Challenges

The challenges to effective global surveillance and response to human disease outbreaks reflect deficiencies in (1) health infrastructure; (2) scientific methods and concepts of operations of infectious disease surveillance programs; (3) human, technical, and financial resources; and (4) international policies.

Health Infrastructure

• Healthcare facilities provide the primary opportunity for detecting cases of unusual diseases or unusual clusters of disease, but healthcare facilities are absent or inadequate in resource-limited countries in Africa, Asia, and other parts of the world. Consequently, these countries do not have adequate domestic disease detection or response capabilities.56
• The absence of health infrastructure in resource-limited countries creates gaps in coverage in regional surveillance systems. The result is a porous patchwork of surveillance systems that is exacerbated by differences in focus, approach, intended audience, and resource base and by inadequate integration and poor coordination between surveillance systems.1
• Establishing de novo healthcare infrastructure is difficult. Because agencies in developed countries often have prerequisites for investing in infectious disease surveillance and response systems, there are few examples of investments in developing countries that have simple or no health infrastructure.
• With the exception of H5N1, there is little coordination or harmonization between human and veterinary sectors of the infectious disease health infrastructure.57,58

Methodology

• There is no consensus on the preferred methodologies, performance characteristics, or outcome measures for surveillance programs.59–63
• There are no clear measures of effectiveness or cost-effectiveness of infectious disease surveillance systems. With the exception of those systems that have as their goals disease eradication or control of vaccine-preventable illness, it is difficult to assess the contributions of the surveillance systems.64,65
• Given current surveillance methods, it is doubtful that infections that spread rapidly (e.g., influenza) or that spread silently (e.g., HIV infection) can be detected before they are widely disseminated. Regional and/or international outbreak responses may be the first response in containment of these infections.26,66

Technical Resources

• Diagnostic tests are essential for rapid screening and confirmatory diagnosis of sick patients in primary care and/or emergency care facilities. Either these tests do not exist for most diseases, or they are too expensive and/or too technical for use in resource-limited health infrastructures. In the absence of an etiologic diagnosis, the opportunity for surveillance and response—including proper medical care treatment, appropriate vaccination, and use of effective infection control procedures—will be lost.67 Despite the essential role of these tests in diagnosis and response, the resources available for the development, manufacturing, and distribution of these diagnostic tests are inadequate. All components of surveillance and response would be enhanced with these tests (see The Role of Rapid Diagnostic Tests).
• The global communication networks necessary to support infectious disease surveillance systems are inadequate. Countrywide deficiencies in the phone and internet systems weaken surveillance, reporting, outbreak investigation, and response.68 Even where electronic reporting systems are available, they are often not used regularly for disease surveillance, in part because information technology personnel are inadequately trained and funded.69
• The accuracy of electronic surveillance systems that use media sources is constrained by both the quality of news reports and the completeness of news coverage. In addition, analytical methods and the number of subject-matter analysts available to assess the credibility of the reports vary across the systems.
• “Real-time” surveillance (used here to mean data available in 24 hours or less) is not possible in most systems, although it has been conducted at special events such as the G8 Summit or the Democratic National Con­vention.70,71 The French Communicable Diseases Computer Network and the European Influenza Surveillance Scheme collect and analyze data at least once per week.72 The QFLU program, piloted in the 2006 influenza season, has the potential for daily reporting; however, that system uses depersonalized data collected from electronic health records, a data source that is not available in most countries.

Financial and Human Resources

• The new IHR 2005 provides a legal framework for global surveillance of and response to human disease, but there are no funds available for implementation. Many resource-limited countries do not have the monies available to establish surveillance and response systems.
• There is no strategic plan to raise the financial resources required for implementing the revised IHR 2005 at the country level. Without identified financial resources to acquire needed technical and human resources, the plans for implementing IHR at the country level are unlikely to be realistic.
• The designated human and financial resources of WHO are inadequate to fulfill the expanded responsibilities stipulated in IHR 2005. The dependence of WHO on volunteer donations and temporary staff weakens the potential of IHR 2005.
• The Global Outbreak Alert and Response Network’s operating budget is not part of WHO’s core budget. Currently, a private philanthropic organization, the Nuclear Threat Initiative, provides some financial resources for initial outbreak assistance. However, all funds required for international response to disease outbreaks are donated at the discretion of World Health Assembly Member States.8

Policy

• Perceived economic consequences due to disruption of trade and travel caused by disease outbreaks deter reporting and delay verification.23 Although health-related regulatory provisions among WHO, the World Trade Organization (WTO), the International Civil Aviation Organization (ICAO), and the Food Agriculture Organization (FAO) are being coordinated to decrease the economic risk to countries that report disease outbreaks, the economic impact of the SARS epidemic suggests that additional measures are necessary.9,73
• IHR 2005 requires that all countries take responsibility for reporting disease outbreaks; this will be a source of friction between the countries involved in bilateral agreements unless memos of understanding are revised and standard reporting procedures are developed between host and sponsoring countries.73