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The Swine AcCHORDS: Infectious Disease Surveillance in the 21st Century

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Mexican Health Minister Jose Angel Cordova recently noted at a news conference that the current outbreak of H1N1, commonly referred to as swine flu, appears to be tapering off. Mr. Cordova indicated that infected individuals are currently passing the virus along to approximately 1.4 to 1.8 people, lending credence to the idea that perhaps this strain may be only a little more contagious than seasonal influenza. While this may result in health organizations across North America lowering public alert levels, widespread incidence of the flu remains: on Sunday there were 226 cases spread across 30 US states -- as of Monday that number moved up to 286 cases reaching 6 additional states. Moreover, the World Health Organization (WHO) cited 1,085 cases across 21 countries -- up 3 additional nations considered infected as of Sunday. While previously alarmist characterizations of the threat may be on the decline, the increasingly ubiquitous nature of biological threats demands that there be a renewed, sustained and proactive disease-surveillance posture implemented across the globe, in order to best deal with possibilities of a larger scale pandemic.

In his first overseas trip as President in April 2009, Barack Obama, at a town hall meeting in France, acknowledged the urgency of the situation by saying, "If you have no health facilities whatsoever in countries in Africa, these days a pandemic can get on a plane and be in Strasbourg or New York City or Chicago overnight. So we better think about making sure that there are basic public health facilities and public health infrastructure in those countries, because we can't shield ourselves from these problems." The dire need to roll out smart infrastructure on a global scale is further compounded, given sentiments from WHO Deputy Director General Dr. Keiji Fukuda that, "We're not quite certain about how this is going to evolve. There is always uncertainty when it comes to a new disease."

Yet, as countries attempt to navigate the murky terrain ahead, one thing remains clear: cross-border cooperation among decision makers and health officials functions as the cornerstone of the first line of smart defense against infectious diseases. While a premium has often been placed on threats this homeland faces from hostile entities abroad, this Administration must immediately prioritize and enact a health imperative, as part of their broader Homeland Security goals, in order to ensure the United States and the world remains vigilant of what things may come.

Answering this call to action begins by bolstering the mechanisms of individual countries along three key areas: developing their sub-national (and regional response) capacities, ensuring awareness of and compliance with international disease-response protocol, and the promotion of economic development within nations. According to Dr. Katherine Bond, an Associate Director of trans-boundary disease control with The Rockefeller Foundation, "Internal economic development functions as a form of soft-power for developing countries, and all nations interested in strengthening their line of defense against outbreaks. More capital [that flows into public health infrastructure] can yield better skilled people, better communication and better collaboration. This impacts everything from maintaining an adequate response time to monitoring the health of livestock to having sufficiently developed isolation and quarantine methods." To this end, President Obama has acknowledged the need for capital infusions, stating at the aforementioned town hall session that "developed countries have to increase aid, but it also means that the countries who are receiving aid have to use it wisely." The Executive Branch should make good on its insistence to fund the development of this sort of infrastructure, by authorizing money that (a) helps forge clear links between health care providers, agencies and hospitals; (b) makes available cutting edge communication tools for decision makers and (c) conducts thorough dress-rehearsals anticipating both natural and man-made biological attacks, in order to ramp up rapid-response for real-time crises. Funding projects around these themes ensures a wise allocation of resources, empowers our neighbors to be better organized when it comes to detection, and meets the homeland security goals of an Administration weary of the need of a health imperative.

But that is only the first step.

A world ready to confront biological threats of the 21st century is not solvent solely by strengthening the capacity of individual states. Instead it requires that regional disease surveillance networks be established -- both among developing countries and developed ones -- in order to improve the quality of detection and control across borders.

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Steps toward building and sustaining such global networks have been pioneered by the Nuclear Threat Initiative's (NTI) biological program, the Global Health and Security Initiative (GHSI). After a Winter 2007 conference in Bellagio, Italy convened epidemiologists, experts in health informatics and representatives from Africa, the Americas, Asia, Europe and the Middle East, a call for action was published -- determining the optimal practices required for enhancing our global wherewithal in public health surveillance. Last week, GHSI officially launched a vehicle to implement those recommendations through a process entitled Connecting Health Organizations for Regional Disease Surveillance (CHORDS).

Looking to the input from varying countries and regional concerns, CHORDS pools together community practice standards for surveillance by streamlining the sharing and distribution of common knowledge. This can, in effect, function as a blueprint for the Administration and the world to communally establish best-practiced standards for infectious disease monitoring. Moreover, by tapping into the insights of those in the animal, human and agricultural sectors across the world via interactive problem solving, experts are able to shed light on matters that may impact one part of the world, but haven't come to fruition in another, thereby boosting the preventative capacity of differing nations. CHORDS can also make it possible to boost cross-border communication and connectivity through cutting edge technologies (i.e. FluChip, SMS alerts, etc.) as well as with public-private partnerships. One such network in the Middle East established in 2003 (known as the Middle East Consortium on Infectious Disease Surveillance or MECIDS) was able to harness the efforts of IBM and NTI to utilize a technology that standardizes the sharing of health information and automates analysis of infectious outbreaks. The system known has the Public Health Information Affinity Domain (PHIAD) has been deployed regionally, but with an organizational vehicle such as CHORDS, a push could be made to deploy such technology internationally, putting various agencies on the same page and boosting collaboration among countries when cross-border responses are a matter of life and death.

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Finally, CHORDS has the capacity to build upon networks, forming conduits that link equipped societies to societies in need. As Terence Taylor the Vice President for Global Health & Security at NTI noted at a press conference last week, "an organizational push to connect countries through the monitoring and sharing of information does not just help existing networks, but has the potential to build new ones." While the efforts can further strengthen national and global capacity through electronic tools and joint exercises, it can also go a long way in promoting the development of new capacities in areas of particularly dire need such as Africa and South Asia. Since the late 90's, NTI has worked with governments and health officials to develop regional partnerships to confront viral threats that respect no boundaries. From MECIDS-a collaboration between Israel, Jordan and the Palestinian Authority -- to the Mekong Basin Disease Surveillance Network (MBDS) -- a collaboration of 7 Southeast Asian countries -- communities that may not have always been on the same side of the political coin have coalesced to confront the complex threats of biological agents. Full endorsement from President Obama, and other G20 leaders for a program like CHORDS will help different actors work in tandem all over the world, and can assist all participating countries meet their legal obligations under the 2005 International Health Regulations -- ensuring that organizational response and accountability.

Support and implementation of such an endeavor is critical for an Obama Administration that strives to protect citizens at home and of the world from biological attacks and infectious disease outbreaks. A champion of reducing biological, chemical and nuclear proliferation threats, former Senator Sam Nunn (D-GA) and current co-chairman of NTI recently explained that "one fact is in our favor: many of the most effective steps for fighting infectious diseases are also steps needed to protect against...attacks. Our response to a biological outbreak -- whether caused by nature or by the deliberate act of man -- will depend on our public health doctors, nurses, labs, hospitals and networks -- not on our ships or planes or tanks." By both investing in smart health infrastructures, and working with CHORDS in promoting new cross-border networks, President Obama would be uniquely able to define the strategic goals and priority investments in bioterrorism.

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At the same time, by facilitating a collaborative approach in establishing these surveillance networks, several different countries are provided a democratic opportunity to outline what concerns impact their region most. According to Dr. Louise Gresham, the Director for Health Security and Epidemiology for NTI's GHSI, "Empowering collective action to build and share resources regionally, makes way for equitable solutions." While not every country will bring the same sorts of academics or technologies to the table, a program like CHORDS ends up enhancing global capacity, by affording an equitable stake in problem solving. This also allows for flexibility in regional problem solving, as challenges are addressed with tailored solutions -- as opposed to a one-size fits all approach.

Investment and support for the CHORDS program by the Administration would help enact a human health imperative consistent with larger Homeland Security promises set up by the Obama campaign, restoring faith in American leadership via truly global partnerships. By developing surveillance practices and standards through these methods, we are not only better prepared to deal with outbreaks, but the world is much more in sync with what health problems people of the 21st century are facing. Much of the collaboration we are witnessing in real time by North American countries and the WHO in response to swine flu, is the result of years of preparation and exercises. If such collaborative networks can be developed and implemented across the globe, we can collectively ease the world of the burden of infectious diseases, efficiently share information critical to saving lives, and not have to worry about wearing masks on summer vacation.