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Access EMERGING INFECTIOUS DISEASES at www.cdc.gov/eid In Index Medicus/Medline, Current Contents, Excerpta Medica, and other databases Editorial Board Editors Electronic Access Abdu F. Azad, Baltimore, Maryland, USA Joseph E. McDade, Editor-in-Chief Retrieve the journal electronically on the Johan Bakken, Duluth, Minnesota, USA Atlanta, Georgia, USA World Wide Web (WWW), through file transfer Barry J. Beaty, Ft. Collins, Colorado, USA Stephen S. Morse, Perspectives Editor protocol (FTP), or by electronic mail (e-mail). Gus Birkhead, Albany, New York, USA New York, New York, USA WWW and FTP: Access the journal at http:// Martin J. Blaser, Nashville, Tennessee, USA www.cdc.gov/eid or from the CDC home page S.P. Borriello, London, United Kingdom Phillip J. Baker, Synopses Editor (http://www.cdc.gov), or download it through Donald S. Burke, Baltimore, Maryland, USA Bethesda, Maryland, USA anonymous FTP at ftp.cdc.gov. The files can Charles Calisher, Ft. 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Heymann, Geneva, Switzerland Johannesburg, Republic of South Africa Walter Hierholzer, Atlanta, Georgia, USA Takeshi Kurata Emerging Infectious Diseases Dagmar Hulìnskà, Prague, Czech Republic Tokyo, Japan Peter B. Jahrling, Frederick, Maryland, USA S.K. Lam Emerging Infectious Diseases is published Suzanne Jenkins, Richmond, Virginia, USA Kuala Lumpur, Malaysia four times a year by the National Center for Mohamed A. Karmali, Toronto, Ontario, Canada Infectious Diseases, Centers for Disease John S. MacKenzie Richard Krause, Bethesda, Maryland, USA Control and Prevention (CDC), 1600 Clifton Brisbane, Australia Bruce R. Levin, Atlanta, Georgia, USA Road, Mailstop C-12, Atllanta, GA 30333, USA. Myron Levine, Baltimore, Maryland, USA Hooman Momen Telephone 404-639-3967, fax 404-639-3075, Stuart Levy, Boston, Massachusetts, USA Rio de Janeiro, Brazil e-mail [email protected]. John E. McGowan, Jr., Atlanta, Georgia, USA Sergey V. Netesov The opinions expressed by authors Patrick S. Moore, New York, New York, USA Novosibirsk Region, Russian Federation contributing to this journal do not necessarily Philip P. Mortimer, London, United Kingdom V. Ramalingaswami reflect the opinions of CDC or the institutions Fred A. Murphy, El Macero, California, USA New Delhi, India with which the authors are affiliated. Barbara E. Murray, Houston, Texas, USA James M. Musser, Houston, Texas, USA Diana Walford All material published in Emerging Infec- Neal Nathanson, Philadelphia, Pennsylvania, USA London, United Kingdom tious Diseases is in the public domain and may Rosanna W. Peeling, Winnipeg, Manitoba,Canada be used and reprinted without special David H. Persing, Rochester, Minnesota, USA permission; proper citation, however, is Richard Platt, Boston, Massachusetts, USA Editorial and Computer Support appreciated. Didier Raoult, Marseille, France Use of trade names is for identification only David Relman, Palo Alto, California, USA Beatrice T. 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Please give us your new address (in the box) and print the number of your old mailing label here__________ Contents EMERGING INFECTIOUS DISEASES Volume 4 • Number 3 July–September 1998 About the International Conference 353 The Emergence of Bovine Spongiform 390 on Emerging Infectious Diseases Encephalopathy and Related Diseases S.A. Morse J. Pattison Explaining the Unexplained in Clinical 395 About Emerging Infectious Diseases Infectious Diseases: Looking Forward Collaboration in the Fight Against 354 B. Perkins and D. Relman Infectious Diseases The Secretary of Health and The Global Threat Human Services Donna Shalala Malaria: A Reemerging Disease in Africa 398 Effective Global Response to Emerging 358 T. Nchinda Infectious Diseases Vaccine-Preventable Diseases 404 C. Broome A. Mawle Addressing Emerging Infectious Disease 360 Travelers’ Health 405 Threats—Accomplishments and Future Plans M. Cetron, J. Keystone, D. Shlim, R. Steffen Global Tuberculosis Challenges 408 J. Hughes Global Surveillance of Communicable Diseases 362 K. Castro Blood Safety 410 D. Heymann and G. Rodier M.E. Chamberland, J. Epstein, R.Y. Dodd, Emerging Infections: An Evolutionary Perspective 366 D. Persing, R.G. Will, A. DeMaria, Jr., J. Lederberg J.C. Emmanuel, B. Pierce, and R. Khabbaz Emerging Infectious Diseases: 372 Confronting Emerging Infections: Lessons 412 A Brief Biographical Heritage from the Smallpox Eradication Campaign P. Drotman W. Foege New and Reemerging Diseases: The Importance 374 The Guinea Worm Eradication Effort: 414 of Biomedical Research Lessons for the Future A. Fauci D. Hopkins Health Policy Implications of Emerging Infections 379 K. Hein Populations at Risk Nosocomial Infection Update 416 New Agents and Disease Associations R. Weinstein Detection and Identification of Previously 382 Opportunistic Infections in 421 Unrecognized Microbial Pathogens Immunodeficient Populations D. Relman J. Kaplan, G. Roselle, and K. Sepkowitz Host Genes and Infectious Diseases 423 J. McNicholl Immigrant and Refugee Health 427 S. Cookson, R. Waldman, B. Gushulak, D. MacPherson, F. Burkle, Jr., C. Paquet, E. Kliewer, and P. Walker Zoonotic and Vector-borne Issues Emerging Zoonoses 429 F. Murphy Influenza: An Emerging Disease 436 R.G. Webster Resurgent Vector-Borne Diseases 442 as a Global Health Problem D. Gubler Global Climate Change and Infectious Diseases 451 R. Colwell, P. Epstein, D. Gubler, M. Hall, P. Reiter, J. Shukla, W. Sprigg, E. Takafuji, and J. Trtanj David Satcher, U.S. Surgeon General; Donna Shalala, U.S. Emerging Zoonoses 453 Secretary of Health and Human Services. J. Childs, R.E. Shope, D. Fish, F.X. Meslin, C. J. Peters, K. Johnson, E. Debess, D. Dennis, and S. Jenkins Cover: T. Moore (1941), Phantasmagoria, oil on board. From the collection of Abdu Azad. Conference photos by Jim Gathany. Contents EMERGING INFECTIOUS DISEASES Volume 4 • Number 3 July–September 1998 Emerging Foodborne Pathogens Bioterrorism as a Public Health Threat 488 New Approaches to Surveillance and Control 455 D.A. Henderson of Emerging Foodborne Diseases Bioterrorism as a Public Health Threat 493 R. Tauxe J. McDade and D. Franz FoodNet and Enter-net: Emerging Surveillance 457 Who Speaks for the Microbes? 495 Programs for Foodborne Diseases S. Falkow S. Yang Emerging Diseases—What Now? 498 Enhancing State Epidemiology and Laboratory 459 G. Alleyne Capacity for Infectious Diseases D. Deppe Summaries from satellite partnership meetings (March 8-12) Communicating the Threat Plague Diagnostic Workshop 501 International Cooperation 461 M.C. Chu J. LeDuc The U.S.-EU Conference on Extension of the 502 Public Health Surveillance and 462 Salm/Enter-net Surveillance System for Human Information Technology Salmonella and E. coli O157 Infections R. Pinner A. Levitt Innovative Information-Sharing Strategies 465 ASM/CDC/NIH Training in Emerging and 504 B. Kay, R.J. Timperi, S.S. Morse, Reemerging Infectious Diseases D. Forslund, J.J. McGowan, and T. O’Brien K. Western Getting the Handle off the Proverbial 467 Pump: Communication Works Letters L. Folkers, M.T. Cerqueira, R.E. Quick, Outbreak of Suspected Clostridium butyricum 506 J. Kanu, and G. Galea Botulism in India Communicating Infectious Disease 470 R. Chaudhry, B. Dhawan, D. Kumar, R. Bhatia, Information to the Public J.C. Gandhi, R.K. Patel, and B.C. Purohit E. Abrutyn Molecular Analysis of Salmonella paratyphi A 507 APEC Emerging Infections Network: 472 From an Outbreak in New Delhi, India Prospects for Comprehensive Information K. Thong, S. Nair, R. Chaudhry, P. Seth, A. Kapil, Sharing on Emerging Infections within D. Kumar, H. Kapoor, S. Puthucheary, and T. Pang the Asia Pacific Economic Cooperation Unrecognized Ebola Hemorrhagic Fever at 508 A.M. Kimball, C. Horwitch, P. O’Carroll, Mosango Hospital during the 1995 Epidemic in S. Arjoso, C. Kunanusont, Y. Lin, Kikwit, Democratic Republic of the Congo C. Meyer, L. Schubert, and P. Dunham M. Bonnet, P. Akamituna, and A. Mazaya Classification of Reactive Arthritides 510 Critical Issues for the Future D.R. Blumberg and V.S. Sloan Controversies in the Prevention and 473 Reply to Drs. Blumberg and Sloan 512 Control of Antimicrobial Resistance J. Lindsay D. Bell Cost of Blood Screening 512 Infectious Causes of Chronic Inflammatory 475 O. Chang Diseases and Cancer G. Cassell Book Review James M. Hughes, Director, Emerging Infections 513 National Center for Infectious B. Mahy Diseases, Centers for Disease Control and Prevention, Atlanta, News and Notes Georgia, USA CDC To Release Updated Emerging 514 Infectious Disease Plan First Congress of the European Society 514 for Emerging Infections, September 13-16, 1998, Budapest, Hungary Foodborne Illness: A Disease for All 514 Seasons, October 27 and 28, 1998, Newark, Delaware December 1998 International Conference 515 on Antiretroviral Therapy Erratum 515 Special Issue About the International Conference on Emerging Infectious Diseases Stephen A. Morse Centers for Disease Control and Prevention, Atlanta, Georgia, USA More than 2,500 researchers, clinicians, causes of chronic disease, blood safety, host laboratorians, veterinarians, and other public genetics, vaccines, global climate change, and health professionals from all 50 states and more immigration and travel. than 70 countries convened in Atlanta on March In delivering the keynote address, Nobel 8-11, 1998, for the International Conference on laureate Joshua Lederberg reviewed the scien- Emerging Infectious Diseases. The conference, tific basis for the emergence of infectious organized by the Centers for Disease Control and diseases. U.S. Health and Human Services Prevention (CDC), the Council of State and Secretary Donna Shalala and Assistant Secre- Territorial Epidemiologists, the American Soci- tary for Health and Surgeon General David ety for Microbiology, and the National Founda- Satcher, along with representatives from the tion for CDC along with 62 other cosponsors,1 World Health Organization, the Pan American provided a forum for the exchange of ideas and Health Organization, and the U.S. Agency for possible solutions to the problems of new and International Development, and representatives reemerging infectious diseases, including poten- from academia and industry addressed the tial threats presented by bioterrorism. Several national and international ramifications of agencies and organizations sponsored satellite emerging infections. In closing the conference, partnership meetings on March 8 and March 12. James Hughes, director, National Center for More than 85 sessions (12 plenary sessions, 17 Infectious Diseases, CDC, stressed the impor- invited panels, 35 poster sessions, and late- tance of building bridges and forging new breaking abstracts) were presented on surveil- partnerships to prevent and control the lance, epidemiology, prevention, and control of emergence of infections into the next millennium. emerging infectious diseases, as well as emergency In publishing the conference presentations preparedness and response and reemerging or and discussions in this journal, the organizers drug-resistant infectious diseases. Topics included hope to capture the energy expressed by all foodborne diseases, infectious diseases transmitted participants, further disseminate new informa- by animals and insects, nosocomial infections, tion on emerging infections, and stimulate more infections in immunocompromised patients and research and other initiatives against this persons outside the health-care system, infectious important public health threat. 1Alliance for the Prudent Use of Antibiotics, American Academy of Pediatrics, American Association of Blood Banks, American Association of Health Plans, American Cancer Society, American College of Preventive Medicine, American Hospital Association, American Medical Association, American Mosquito Control Association, American Public Health Association, American Sexually Transmitted Diseases Association, American Society of Clinical Pathologists, American Society of Tropical Medicine and Hygiene, American Veterinary Medical Association, Association of American Veterinary Medical Colleges, Association of Schools of Public Health, Association of State and Territorial Directors of Health Promotion and Public Health Education, Association of State and Territorial Health Officials, Association of State and Territorial Public Health Laboratory Directors, Association of Teachers of Preventive Medicine, Burroughs Wellcome Fund, Emory University School of Medicine, Fogarty International Center, Food and Drug Administration, Indian Health Service, Infectious Diseases Society of America, International Life Sciences Institute, International Society for Infectious Diseases, International Society of Travel Medicine, International Union for Health Promotion and Education, International Union of Microbiological Societies, Minority Health Professions Foundation, Morehouse School of Medicine, National Aeronautics & Space Administration, National Association of City and County Health Officials, National Association of State Public Health Veterinarians, National Council for International Health, National Foundation for Infectious Diseases, National Hispanic Medical Association, National Institute of Allergy and Infectious Diseases, National Medical Association, National Oceanographic & Atmospheric Administration, Office of Science and Technology Policy, Pan American Health Organization, Rollins School of Public Health of Emory University, Society for Healthcare Epidemiology of America, Society for Occupational and Environmental Health, Society for Public Health Education, The Carter Center, The Henry J. Kaiser Family Foundation, The HMO Group, The Robert Wood Johnson Foundation, The Rockefeller Foundation, The World Bank, U.S. Agency for International Development, U.S. Department of Agriculture, U.S. Department of Defense, U.S. Department of State, U.S. Department of Justice (INS), U.S. Department of Veterans Affairs, U.S. Environmental Protection Agency, World Health Organization. Vol. 4, No. 3, July–September 1998 353 Emerging Infectious Diseases Special Issue Collaboration in the Fight Against Infectious Diseases Donna E. Shalala U.S. Secretary of Health and Human Services Two hundred years ago, the U.S. Public Life returned to normal. The great flu was soon Health Service, of which the Centers for Disease pushed off the front pages and out of the public Control and Prevention (CDC) is an essential eye. When avian flu first appeared last year, we part, began as a humble maritime hospital in wondered if perhaps another pandemic had New York City. Its mission was simply to stop begun. An influenza subtype that had never infectious disease from coming in on ships and before produced illnesses or deaths in humans spreading across our country. Today, as we now did. While it appears that the spread of avian celebrate the anniversary of the Public Health flu has halted without the appearance of human- Service, another historic event has occurred. One to-human transmission, the danger is far from of the great detective hunts of the 20th century over because the critical period may be just came to an end. Scientists at the U.S. beginning—this is the start of the traditional flu Department of Defense confirmed that tissue season in Hong Kong. from a woman’s body buried near the Bering The emergence of avian flu points up a Strait contains genetic material from the 1918 broader concern: complacency over infectious Spanish flu virus—the virus that caused the disease. It is easy to assume that modern worst pandemic the world has ever known. This medicine has defeated this enemy once and for discovery will help us map the genetic structure all. Our comfort is a natural byproduct of our of the microbe that sent a wave of death crashing progress and success—the remarkable break- around the globe 80 years ago. throughs in antibiotics and vaccines, thanks to It is hard to believe today that flu could be so the work of scientists and researchers worldwide. nearly apocalyptic. In just 11 months, at least 24 We eradicated smallpox—consigning one of million people died, and most of humanity was history’s deadliest killers from the medical books infected. The infected often never knew what hit to the history books. But infectious disease them; in the morning they felt fine; by night they remains the leading cause of death worldwide could be dead—drowned as the lungs filled with and the third leading cause in the United States. fluid. There was no explanation, no protection, While we may be winning some old battles, we are no cure. The pandemic produced scenes from a struggling with some new adversaries—emerg- gothic horror novel—but it was all too real. In ing infectious diseases such as Ebola, hantavirus Philadelphia alone, 11,000 died of the flu in a infection, new strains of tuberculosis (TB), AIDS, single month. The dead were left in gutters, and and Lassa fever, to name a few. In fact, the World death carts roamed the city in a surreal scene Health Organization (WHO) has labeled the from medieval times. As the deaths mounted all growing threat of infectious disease a global over the world, orderly life began to break crisis. down. Schools and churches closed; farms and The time has come to replace complacency factories shut down; homeless children wan- with a new sense of urgency—to launch a dered the streets; their parents vanished. The renewed, unified, global effort against infectious acting U.S. Army Surgeon General, Victor disease. Nature may have the power to create a Vaughn, calculated that if the pandemic pandemic—but together we have the power to continued its mathematical rate of acceleration, prevent it, to stop it, to overcome it, to cure it. And it soon could spell the end of humankind. there is no time like the millennium. For today, But then, as silently, as mysteriously, as history and human progress have created an quickly as it came, the terror began to fade away. “ironic contradiction” in the fight against People stopped dying. The victims were buried. infectious disease: some of the same forces that Emerging Infectious Diseases 354 Vol. 4, No. 3, July–September 1998 Special Issue invite pandemics can also be harnessed to fight the first antibiotic to fight a new generation of pandemics. With the globalization of travel and “super bugs,” Synercid, won limited approval trade, immigration, communication, and indus- from a Food and Drug Administration (FDA) trialization, we have a smaller world with porous advisory panel. If it wins full approval, it will be borders. Nations are more interconnected, people the first drug in a new arsenal of weapons. FDA are more interdependent, and humanity is less continues to work with drug manufacturers to divided by what the Indian poet Tagore called our bring new antibiotics to market as safely and “narrow domestic walls.” So the bad news is that rapidly as possible. we have fewer barriers against the spread of Antibiotic resistance is not just a medical infectious disease; yet the good news is that those problem; it is also a behavioral problem. Patients fewer barriers mean new avenues to progress and too often demand antibiotics for every illness— the potential for sharing information and efforts even for viral infections (like the flu) that do not to stop infectious disease. respond; patients often do not finish the course of We now have the power to push infectious medication, allowing the remaining bacteria to diseases off the world stage but only if develop resistance; many doctors overprescribe; governments, world health organizations, the and the pharmaceutical industry has limited its private sector, scientists, and researchers work antibiotic development because of cost. The together with a global strategy. How do we widespread use of antibiotics in farm animals successfully wage this global battle against may also be helping the spread of drug-resistant infectious disease? The answer lies in what we genes. Given the consequences, we must act now to can learn from the 1918 pandemic; it provides combat the diminishing effectiveness of antibiotics. three important lessons—challenges for all of us. That is why CDC is strengthening surveillance and The first lesson is that we must assume it implementing education campaigns about the could happen again. Influenza pandemics have problem, why the National Institutes of Health regularly swept the world every 10 to 40 years, (NIH) is studying resistance, and why FDA is and it has been 30 years since the last influenza promoting judicious antibiotic use. But this is not pandemic, Hong Kong flu, killed 700,000. Nature is a job for government agencies alone. Each and creative, and the flu has great potential for every one of us who understands the risks needs mutating. If a strain changes dramatically, we to spread the message that antibiotics are being could suddenly have a virus for which we may misused, abused, and overused. have no immunity, no vaccine, and no cure. The The next pandemic could also result not from threat is not just the flu—the spectrum of new a mutating bug or ineffective antibiotics but from infectious diseases is constantly expanding, an act of bioterrorism. Whether bioterrorism is while old diseases, such as TB, have evolved into state sponsored or undertaken by a lone terrorist, entirely new killers because they developed it is not just a problem for the military or law antibiotic resistance. enforcement; it is also a challenge for the entire The advent of antibiotics in the 1940s was one public health community. If a specific threat is of the chief reasons we began to defeat infectious issued—perhaps someone claims to have released a disease. However, almost as soon as antibiotics toxic agent in a public place—trained public health were available, microbes mutated and developed officials must first verify that an incident has resistance. In the 1950s to 1970s, we produced so occurred. They may need to decontaminate the many new antibiotics that there was always an area, identify exposed populations, and deliver alternative medication; today, the flood of new preventive measures and treatments. Too often, antibiotics has diminished to a trickle, while the a threat is not issued, no warning is given. In such microbes have continued to grow resistant. a situation, public health officials must first Antibiotic-resistant bacteria are becoming more quickly determine the deadly agent, the route of common in hospitals and among patients with exposure, and the likely source. depressed immune systems. In Japan in 1996 and The U.S. Department of Health and Human in the United States last year, we started to see a Services (DHHS) is coordinating with our strain of staphylococcus infection, the most partners in other agencies and the military to common hospital-acquired infection, which could ensure the proper training of state and local sometimes withstand vancomycin—our most health officials, the availability of vaccines and potent treatment. But almost simultaneously, drugs, and the enhancement of our surveillance Vol. 4, No. 3, July–September 1998 355 Emerging Infectious Diseases Special Issue capacity and expertise. There is also an monitoring and surveillance system needed administrationwide effort to train emergency worldwide is the excellent system that stopped response teams and health-care providers in 120 the avian flu outbreak in Hong Kong. On a cities. We must enhance our ability now to routine basis, officials collect throat swabs from address the growing threat of bioterrorism. people with flulike symptoms. The samples are The second lesson concerns preparation for a analyzed, and if suspicious, they are immediately potential pandemic. We cannot wait until the sent to CDC, which functions as one of the WHO next deadly microbe appears on the world stage. International Reference Laboratories for East Therefore, since 1993, HHS has been leading a Asia. When the first known case of avian flu was federal, state, and local effort to develop a diagnosed in a 3-year-old boy, warning bells went “pandemic influenza plan.” As a result of the off immediately. When a second case appeared in avian flu episode, we have sped up the process to November, health officials around the world went complete the plan and pursue its full implemen- on alert, and a team from CDC left for Hong Kong. tation. Meanwhile, CDC is studying the impact of Over the next 2 months, work continued to define antiviral medications and alternative ways to the extent of the outbreak, including who was produce vaccines. NIH is working with the becoming ill, why they were becoming ill, and pharmaceutical industry to develop and test whether the virus could spread from person to innovative vaccines, including a nasal spray that person and cause a pandemic. The slaughter of delivers an inoculation dose of the virus. FDA is more than one million chickens seems to have issuing new drug permits for experimental halted the virus at least for now. influenza vaccines. With new viruses knocking at Hong Kong’s surveillance system proved that the door, we cannot afford to be caught unprepared. early detection of infectious diseases can prevent Because only in the movies can we save the world their spread. David Heymann of WHO once asked from a deadly disease in just 24 hours. a provocative question: What would have We need commitment in responding to all happened if we had had an excellent surveillance emerging infectious disease. We need a world- system in place in Africa when the AIDS outbreak wide “surveillance and response network” that first occurred? Perhaps we could also have halted can quickly identify and stop an outbreak. We that virus in its tracks. Perhaps we would have have already laid the groundwork for such a spared ourselves the second great pandemic of system with bilateral and multilateral talks on the 20th century. AIDS taught us that regardless disease monitoring with our partners in Europe, of a person’s sexual orientation, color, wealth, or Japan, Asia, and Africa. For example, at the home, if we hesitate in our fight against Denver Summit in 1997, the group of eight infectious diseases and fail to detect and track industrialized nations, including the United them early, they will eventually affect us all. States, pledged to help develop a global disease We cannot simply deal with each potential surveillance network and coordinate an interna- pandemic as it arises. We must also look over the tional response to infectious disease. Working horizon and seize new possibilities to head off through the Trans-Atlantic Agenda with the infectious diseases before they can occur. We European Union (EU), the United States and EU must fully harness this golden age of global countries have begun to share surveillance data telecommunications (from satellites to the on Salmonella infections. Additionally, through Internet) to create a truly global surveillance and the U.S.-South Africa Bilateral Commission, our monitoring network and find new ways to two countries are training health personnel in prevent, stop, overcome, and cure infectious South Africa in surveillance and applied disease. That is one of the reasons that President epidemiology. I look forward to working closely Clinton proposed the 21st Century Research with WHO to further globalize our approach to Fund—a historic national effort to spur the best surveillance and response. minds of this generation to unlock scientific U.S. agencies are already supporting the discoveries, unravel scientific mysteries, and efforts of WHO to improve communications uncover scientific advances. Today, the pace of networks and to build regional centers for medical discovery is not limited by science or monitoring disease. CDC and WHO jointly run 12 imagination or intellect but by resources. Thus, world monitoring stations for the flu alone. the research fund will provide a US$1.1 billion Perhaps the best example of the kind of budget increase for NIH next year. It is the first Emerging Infectious Diseases 356 Vol. 4, No. 3, July–September 1998 Special Issue down payment on an unprecedented 50% If we truly want to end the threat of infectious expansion of NIH over the next 5 years. This diseases, we must do even more together. We funding will enable NIH to do more to develop must inject into global gatherings—no matter new ways to diagnose, treat, and prevent disease. where they are, no matter what the subject—the We are also seeking a boost in CDC funding to urgency of working together to defeat infectious step up our ability to identify and investigate disease. We must never let research into infectious disease outbreaks, including foodborne infectious disease become a forgotten step-child. outbreaks. CDC will play a key role in a new We must continue to invest in vaccine research initiative by the U.S. Agency for International and development and ensure that preventive Development to develop programs in targeted vaccines are available, affordable, and effective countries to fight the growing threat of bacterial everywhere. We must work with all our resistance, TB, and malaria. This new American partners in the private sector to ensure that investment in fighting infectious disease will not drugs, vaccines, and tests are available during only pay off in America, because in this world an infectious disease emergency. We must without borders, a discovery by any one nation ensure that all urban populations have access to will benefit us all and brings us a little closer to essential facilities, especially clean water, preventing the next pandemic. because vaccines and medicines can do little if The third lesson of the great pandemic of water is unclean. We must work together to deal 1918 is that we have the power to prevent the with urban overcrowding, poverty, and poor next pandemic and defeat emerging infectious sanitation, which are spreading infectious disease diseases, but only if our nations step up the fight in many parts of the world. Finally, we must pool together. Because diseases recognize no borders, our greatest resources—our imagination and in our fight against them, neither can we. Or as intellect—to fight this collective fight. For as Dr. Bruntland of WHO has stated, when it comes Joshua Lederberg once noted, “Pitted against to public health, “solutions, like the problems, microbial genes, we have mainly our wits.” have to be global in scope.” That is why U.S. and Let us pit our wits (and our will) to this battle, Japanese scientists have held three international together, to heed the lessons of the great conferences together on infectious diseases and pandemic and so ensure that it does not happen research. It is why some members of the Asian- again, that we are prepared, and that we always Pacific Economic Cooperation Area, including work together. If we do, our children—the children Thailand, Indonesia, and the Philippines, have of the millennium—will remember the 21st century developed a communications network to track cases as a time of health and hope, a time of promise and of multidrug-resistant TB. And it is why CDC, FDA, possibility, a time of medical miracles and and other U.S. agencies are providing assistance to scientific marvels. I have absolutely no doubt that the Russian Federation and the Newly Indepen- we can do it, that we must do it, that we will do it. dent States, which have faced a large increase in infectious disease in the post-Soviet era. Vol. 4, No. 3, July–September 1998 357 Emerging Infectious Diseases Special Issue Effective Global Response to Emerging Infectious Diseases Claire V. Broome Centers for Disease Control and Prevention, Atlanta, GA, USA To discuss the global efforts needed to detect reagents had to be available and the reference and control emerging infections, I will begin with laboratories had to be able to make a definitive a personal experience. In 1987, a large epidemic identification, not just of that initial strain, but of of meningococcal meningitis occurred during the the hundreds of other strains evaluated. In this haj, the annual pilgrimage of Moslems to Mecca. case, H5 reagents (the result of National The Centers for Disease Control and Prevention Institutes of Health [NIH] research) had been (CDC) sent a team of epidemiologists and distributed (by CDC) to reference laboratories laboratorians to Kennedy Airport to meet the internationally. The capacity to respond to thousands of pilgrims returning to the United potential outbreaks with expert epidemiologic States. Returning pilgrims were given chemopro- investigation also had to be in place. The team phylaxis; nasopharyngeal cultures showed that that went to Hong Kong consisted of epidemiolo- 11% of the pilgrims carried the epidemic strain of gists, laboratorians, a public affairs specialist, group A Neisseria meningitidis, the causative and an expert in animal influenza. The team agent. Only 25% of the returning pilgrims were worked closely with Hong Kong colleagues to intercepted and treated; thousands of others detect new cases by implementing an enhanced dispersed throughout the country (presumably surveillance system. They targeted not only with the same 11% carriage rate of this highly hospitals but also outpatient settings. Most virulent strain). Were U.S. surveillance systems importantly, they designed studies to rapidly adequate to rapidly detect any subsequent determine whether the strain could be transmit- outbreaks? We were completely dependent on ted from human to human. Would the H5N1 local physicians to diagnose cases, on laboratories isolates share the pathogenic potential of human to isolate and serotype the organism, on the influenza, which is so readily transmissible from notification systems to inform the state and human to human, or was this strain relatively federal agencies. In this instance, the United limited in its ability to spread? The kind of rapid States was fortunate and did not see any but rigorous epidemiologic studies undertaken by secondary outbreaks. Other countries were not so the outbreak response team were invaluable in fortunate; large epidemics occurred in Chad, answering this question; fortunately, the strain Kenya, and Tanzania as a result of the same had limited potential for human-to-human virulent clone of N. meningitidis. The importa- transmission. Still, we cannot become compla- tion of this epidemic clone illustrates the central cent; given the genetic recombination potential of importance of local capacity to diagnose, report, influenza viruses, we need to maintain and and control emerging infectious diseases. enhance our surveillance systems worldwide. A more recent example is the 1997 influenza Through the U.S. emerging infections H5N1 outbreak in Hong Kong: the outbreak initiative, the number of laboratory surveillance illustrates what systems are needed to detect a sites supported to look for new influenza strains new organism and to respond appropriately. has been increased. In China, sites had been First, the Hong Kong public health system had to expanded from 6 to 12, which improved the have the capacity to isolate the organism and to ability of the World Health Organization (WHO) recognize that it was not an ordinary influenza system to monitor evidence of dissemination of strain. Because infections emerge at the local this strain on the Chinese mainland. Through level, the capacity to detect new threats when the CDC WHO Collaborating Center on they arise should be available throughout the Influenza, we made diagnostic kits based on the world. Secondly, the specialized diagnostic NIH H5 reagents available to reference Emerging Infectious Diseases 358 Vol. 4, No. 3, July–September 1998