Annexe 7 (Continued)

GREP STRATEGIES¹⁷

Mark M. Rweyemamu¹⁸

The Global Rinderpest Eradication Programme is now entering a phase in which intensive focussed action is required to eliminate the remaining foci of rinderpest infection whilst safeguarding those areas already cleared of the disease. The world can be divided into a number of distinct ecological zones for the purposes of GREP (see maps):

(A) AFRICA

1. The infected zone, where rinderpest has occurred since 1994, (consisting mainly of limited foci of infection) - Ethiopia, Sudan, Uganda, Kenya, Eritrea, Djibouti and Somalia

2. Central Africa CAR, Chad, Zaire (north-east)

3. Tanzania, Rwanda, Burundi

4. Countries south of Tanzania

5. West Africa: countries west of Chad

6. North Africa: countries west of Egypt

7. Egypt

ZONE 1 The infected zone (Ethiopia, Sudan, Uganda, Kenya, Eritrea, Djibouti and Somalia)

In the countries which form the last remaining haven for rinderpest on the African continent, and which thereby threaten the gains made in the last 10 years, concerted intensive action is required to focus available resources. This requires:

• an intensive search for residual endemic foci to demarcate areas from which rinderpest could emerge at a later date. These should be given special focussed attention to ensure elimination of infection.

• an intensification of effort to eradicate the persisting endemic foci.

¹⁷ Developed at the GREP Consultative Group Meeting held in Rome in December 1995.

¹⁸ Senior Officer, Infectious Disease Group - EMPRES, Animal Health Service, Animal Production and Health Division, FAO, Rome.

Essentially the strategy proposed is an endorsement of that pursued so effectively in Ethiopia in the last three years. This has accentuated the identification of areas of endemic rinderpest persistence using active disease surveillance supported by targeted serosurveillance. It has predicted the likelihood of extension from these areas through a sound epidemiological understanding, and uses intensive active rinderpest surveillance, an effective and rapid communication network and preparedness for early reaction.

Ethiopia is a central issue in rinderpest eradication from the African continent and the GOE should be counselled to ensure that the activities of PARC Ethiopia are fully endorsed and that there are no impediments to progress.

Within the infected areas where it has been demonstrated that rinderpest infection persists, (identified by the activities listed above i.e. demarcated as requiring immunosterilisation), - a combination of conventional “blanket vaccination” complemented by innovative activities involving vaccine delivery by community-based animal health workers using thermostable vaccine should be promoted. Both approaches should aim at 100% vaccination coverage but implementation must be flexible incorporating the wishes of the targeted communities.

The areas outside those infected should be viewed as constituting mainly unvaccinated surveillance zones within which areas at severe risk of introduction (in the interim period before infection is eliminated) are protected by effective vaccination coverage. Maintaining freedom requires intensive active disease surveillance and ensured early reaction capability.

With respect to Sudan, an intensively vaccinated sanitary cordon should be established to contain infection in the south enhancing the value of the sanitary cordons applicable to Zone 2.

ZONE 2 Central Africa (Central African Republic, Chad, Zaire (north-east))

This zone serves as a buffer between the zone where rinderpest persists in eastern Africa and the increasingly vulnerable countries in West Africa from which rinderpest has been eliminated.

The sanitary cordon established in the east of CAR (virtually the whole country) and CHAD must be strengthened. The strategy indicated for Zone 5, viz. enhanced early warning and early response, should apply throughout, but specifically in the unvaccinated indicator zone between the two parts of the sanitary cordon. A commitment of at least five years to the sanitary cordon and support for the complementary early reaction capability is essential. As the rinderpest situation in the south of Sudan becomes consolidated, the western area of the sanitary cordon in Chad should be withdrawn and replaced with early warning and early reaction capability, i.e. accentuating emergency preparedness. Resources for early reaction to rinderpest outbreaks should be placed in situ. Contingency planning is emphasised.

The sanitary cordon should be extended into the contiguous areas in the west of Sudan and Zaire, both to enhance the protective effect for West Africa and to reduce the area in which rinderpest is free to extend periodically from the area of persistent endemic maintenance. International assistance must not be linked to national situations and issues, as effective implementation of strategies there is vital for food security in the whole of West Africa.

ZONES 3 AND 7 (Tanzania, Rwanda, Burundi; Egypt)

Tanzania (essentially north of the railway line), Rwanda, Burundi and Egypt must replace vaccination with early warning and early reaction capability, as indicated for zone 5 supported by purposive and systematic epidemiological studies.

ZONE 4 and ZONE 6 (countries south of Tanzania and North Africa west of Egypt)

These countries have been free from rinderpest for more than 50 years and are considered free from infection. The OIE Pathway does not apply or an abbreviated process of verification is appropriate.

ZONE 5 (West Africa west of Chad)

All these countries have fulfilled the main criteria necessary for entering the OIE Pathway in that there has been no evidence of disease for seven years or more.

All these countries should immediately cease vaccination and adopt a system of reliance on emergency preparedness, comprising:

1. Early Warning

• A national RINDERPEST OFFICER should be appointed (usually the PARC coordinator). In countries with a federal organisation an additional step would be appointing state rinderpest officers with reporting to the national rinderpest officer.

• A disease reporting system which encourages reporting of suspicious events should be established.

• Structured disease surveillance is required supported by purposive serosurveillance.

• A structured system of monthly reporting to OAU/IBAR PARC of rinderpest absence is required. In addition, disease events which could possibly be rinderpest should be notified immediately followed by details of investigations carried out leading to determination that rinderpest was not the cause.

• Access in-country to a national capability for primary diagnosis must be ensured. Any positive material (and negative material where there is a suspicion of rinderpest) should be forwarded to the regional reference laboratory which must be able to communicate openly and freely with the WRL for Rinderpest. The regional laboratory, which also has an important role to play in training, must be funded by the national PARC programmes.

2. Early Reaction

• Mobilisation of resources must be ensured through practised contingency plans (simulation exercises).

• Countries need to re-examine the structure of their veterinary services and legislative provisions to ensure that they are appropriate to the control of epidemic diseases. OAU/IBAR PARC and GREP together should undertake a systematic programme of assistance to countries in this respect, to pre-empt any problems that could arise later during the inspections required in support of progress to the second step of the OIE Pathway (demonstration of effective veterinary service).

Targeted communication is essential to enhance the objectives. A standard communications package through OAU/IBAR PARC is envisaged to ensure appropriate sensitisation of governments to funding and the required support. The communication project within PARC should address the need for an electronic communication network to ensure effective communication and dialogue at all times, not just in the event of an emergency.

In the event of a rinderpest outbreak

Outbreaks occurring within the first year after cessation of vaccination will almost certainly be indicative of the re-emergence of previously undisclosed disease in the country or close by. After this time any disease would most likely represent incursion from outside. The former will require a complete revision of strategy as an emergency issue, with reversion to a policy of immunosterilisation being envisaged. In the latter event, a single isolated and rapidly-contained outbreak would not prejudice progression along the OIE Pathway. The strategy to be adopted will include stamping out by slaughter (which will require financial support, possibly from contingency funds provided by donors and international agencies), as a preference, combined with standstill and ring vaccination around the outbreak. It is essential that there should be no delays in initiating control. Laboratory confirmation should not be considered a prerequisite when there is a strong indication of rinderpest (the three Ds). Immediate access to the vaccine bank of OAU/IBAR PARC must be ensured.

(B) THE NEAR EAST

(1) Turkey and the north of Iraq

In view of the reported absence of the disease from Turkey after the intensive control programme instituted in 1991 with only one introduction of rinderpest having been detected in 1994, Turkey should designate a rinderpest-free zone consisting of the whole country excluding only the extreme eastern border with Iraq. The remaining area can be maintained as a vaccinated sanitary cordon until it has been shown conclusively that the north of Iraq is free from rinderpest. With respect to the rinderpest-free zone, it is appropriate to cease vaccination, enhance early warning and early reaction capability and embark on the OIE Pathway.

(2) Iraq

Iraq should designate a rinderpest-free zone consisting of the whole country excluding only the 3 northern governorates and embark on the OIE Pathway by ceasing vaccination and enhancing early warning and early reaction capability. Intensive epidemiological investigations are needed to ensure that there are no areas of rinderpest virus persistence within the rinderpest-free zone.

(3) Iran

Iran should continue to maintain a high level of emergency preparedness through effective early warning and early reaction with routine vaccination being appropriate only for the border areas with the Northern Governorates of Iraq and Pakistan/Afghanistan until the persisting foci are eliminated. With respect to the rinderpest-free unvaccinated zone, it is appropriate to cease vaccination and embark on the OIE Pathway.

(4) The Arabian Peninsula

The countries forming this geographical unit are essentially free from rinderpest although trading practices place them, for the time being, at high risk of reintroduction. Whilst there is a need for targeted epidemiological studies to provide reassurance of the rinderpest-free status of the Yemen, it is appropriate for the countries to cease routine rinderpest vaccination except for, as a temporary expedient, specific zones identified as presenting the highest risk, and replace this with effective emergency preparedness by strengthening early warning and early reaction capability. Contingency planning should accent the need to police livestock trade movements. All countries should embark on the OIE Zonal Pathway.

(C) SOUTH-EAST ASIA (countries east of Bangladesh)

All of these countries have been free from rinderpest for at least 35 years and there is, thus, no indication for the use of rinderpest vaccination there. All countries are in a position to declare freedom from rinderpest infection through an abbreviated OIE Pathway. Although the risk of rinderpest reintroduction is low there is no cause for complacency and emergency preparedness must be enhanced.

(D) CHINA WEST/MONGOLIA/CONTIGUOUS PART OF RUSSIA.

These are regions where it is not clear whether the disease is persistent, absent or occurs periodically as epidemic extensions from known of unknown endemic foci. GREP needs to increase surveillance and information gathering in the region through consultancy missions etc. It is also essential that China is made aware of GREP, made to feel a part of the programme and encouraged to become a key player. FAO should undertake this as a matter of some urgency.

(E) CENTRAL ASIAN REPUBLICS

There is no evidence of rinderpest at present, yet these areas must be considered at high risk. Therefore there is an urgent need for enhanced emergency preparedness accentuating training in disease recognition and, outbreak response strategy.

These countries should be encouraged to obtain OIE recognition of freedom from disease.

(F) SOUTH ASIA AND AFGHANISTAN

(1) Bangladesh, Nepal, Bhutan, Sri Lanka, northern Indian states

These should cease vaccination and proceed immediately along the OIE Pathway as there is convincing evidence of their freedom from rinderpest.

(2) Southern India

India should continue short term/time-bound blanket vaccination in the south whilst conducting epidemiological studies to define the reasons for persistence, proceed rapidly towards limited and targeted vaccination to eliminate remaining foci and then proceed along the OIE Pathway (within 5 years.

(3) Pakistan

Pakistan currently constitutes a global emergency situation with respect to rinderpest; the status of the disease in this country threatens the progress made elsewhere towards global eradication and even the historic disease-free status of large parts of the world. We recommend that international aid should be sought now for immediate assistance in advance of a more structured (probably EU) funded programme. Donors should view this as a global priority for enhancing food security. The following actions are required immediately:

• epidemiological clarification to indicate areas of endemic persistence and vulnerability to epidemic extension

• technical assistance for disease recognition, epidemiological investigation and control

• a massive training programme

• use of only quality-assured vaccine

• improving the disease reporting system

• intensive and extensive vaccination for a limited period with quality assured vaccine (not necessarily blanket nation-wide vaccination)

• an intensive communication campaign

This will be a 3 – 4 year phase. During this period it is necessary to identify maintenance factors for disease and apply intensive vaccination in border regions. It will also require Project Management Unit at national level with close links to GREP at all times i.e. professional inputs for control work must be completely integrated with GREP. Contingency funds will be an important element to meet sporadic events, at least initially.

(4) Afghanistan

Continued support to NGOs is required for specific action against rinderpest primarily through vaccination targetted at infected areas and those at high risk of rinderpest introduction from Pakistan. Safeguarding Afghanistan is ultimately dependant on eliminating rinderpest from its neighbour. The short to medium term activity advocated for Afghanistan comprises elimination of existing infected areas combined with enhanced early warning and early reaction to detect and eliminate new introductions.

SURVEILLANCE FOR ACHIEVING GLOBAL POLIO ERADICATION

Maureen Birmingham ¹⁹

BACKGROUND

In 1988, the WHO assembly adopted the resolution to eradicate polio from the entire world by the year 2000. This was preceded by a similar declaration in the Americas in 1985. The Americas demonstrated to the world that global polio eradication was feasible and defined the effective strategies. The last case of polio due to wild poliovirus in the Americas occurred in August 1991. By August 1994, the Americas was certified as polio-free by a Regional Certification Commission. Since then rapid progress is being made in the remaining five World Health Organization (WHO) Regions.

The definition of polio eradication is the complete absence of wild poliovirus throughout the world. What makes polio eradication possible is the lack of a chronic carrier, no natural non-human reservoir, poor survival of poliovirus in the environment, and an effective vaccine (oral polio vaccine) to interrupt wild poliovirus circulation. What makes polio eradication challenging is the inapparent: apparent infection ratio of 200 to 1 and other conditions that manifest similar symptoms to paralytic poliomyelitis, such as Guillain-Barre syndrome and other enteroviruses. These factors make laboratory confirmation critical to achieving the goal.

The four strategies for global polio eradication are: 1) establishment of a strong routine immunization programme through which all children receive 4 doses of polio vaccine during infancy; 2) conduct of National Immunization Days (NIDS) during which all children under 5 years of age in endemic countries receive an extra dose of oral polio vaccine (OPV) during two rounds 4–6 weeks apart, regardless of prior immunization status. Each round is conducted over a period of 1–2 days during the low season of poliovirus transmission ; 3) implementation of effective surveillance for acute flaccid paralysis (AFP) and wild poliovirus through proper specimen collection from each case; 4) conduct of “mopping up” immunization which is intensive house-to-house immunization for all children under 5 years of age in high risk areas. Mopping-up immunization is an end-stage strategy to be implemented when poliovirus is reduced to focal transmission and surveillance can adequately identify these high risk foci.

GLOBAL PROGRESS TOWARDS IMPLEMENTING KEY STRATEGIES

From 1988 to 1990, global coverage with a third dose of OPV in infants increased from 67% to 85%, respectively, and then experienced a slight decline. By 1995, OPV3 coverage had reached a plateau at approximately 83%. Global figures mask variations between and within countries. Several countries experienced a sharp drop in coverage after 1990 when the Universal Child Immunization Goal was attained and donor as well as staff fatigue set in. Countries experiencing downward trends in coverage or “system crashes” are being targeted with enhanced support based on their individual constraints.

By 1995, 67 countries had implemented at least one round of NIDs compared to 1988 when only 16 countries, primarily in the Americas, had implemented them. By the end of 1996, 30 more endemic countries, primarily in Africa, will have implemented NIDs, leaving only 7 endemiccountries where NIDs are still needed. Of note is the initiative “Operation MECACAR”, a three-year initiative which began in 1995. MECACAR is an acronym for the 19 countries involved in the Middle East, Central Asia, Caucasia, as well as the Russian Federation. During Operation MECACAR in 1996, two rounds of OPV are being administered to 69 million children. Also of note were the NIDs conducted in China during 1993-5 in which 83 million children received OPV during each NIDs round. Due to successful implementation of NIDs, China eliminated poliovirus circulation by the end of 1995. Also in 1995, India and Indonesia successfully conducted their first round of NIDs covering approximately one quarter of the world's children. In 1996, 24 African countries declared their intentions to conduct NIDs by launching an initiative “kick polio out of Africa”. This initiative, chaired by President Nelson Mandela, and also including public figures such as Reverend Desmond Tutu, football star, George Wade, and singer, Olomide will involve a huge promotional event for polio eradication during the Africa Cup of Nations.

¹⁹ World Health Organisation, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland

Regarding the third strategy, AFP and poliovirus surveillance, as of June 1996, 118 of 214 Member States had officially implemented AFP surveillance (figure 1). There are 26 polio -endemic countries that still need to establish AFP surveillance. AFP and poliovirus surveillance also requires that stool specimens be collected from each case and processed in a WHO-accredited laboratory. A global polio laboratory network has been established with the primary purpose of tracking the wild poliovirus. The network is organized on a 3-tiered system, with more than 60 national laboratories performing virus isolation and serotyping. Staff at the national laboratories work in close coordination with epidemiologists who investigate AFP cases. The national laboratories are supported by 16 regional reference laboratories which perform intra-typic differentiation, monitor the performance of the national laboratories, supply reagents, provide on-the-bench training, and perform more sophisticated techniques. Six specialized laboratories provide global support by performing molecular sequencing on isolates, maintaining a global strain bank, producing specific reagents, providing global support for research, and developing training materials. Poliovirus surveillance also requires the establishment of a reverse cold chain within each countries so that specimens are maintained at 4–8°C from the time of collection to processing. Considerable logistical support is necessary in countries to properly collect and send laboratory specimens.

Not only is polio surveillance critical for achieving eradication, but also for certification of eradication. The latter will be based on zero incidence of polio with evidence of effective surveillance.

This paper will elaborate on WHO's approach to establishing effective AFP and poliovirus surveillance, including the lessons learned and remaining challenges.

POLIO SURVEILLANCE - WHAT IS IT?

Polio surveillance is comprised of two aspects. Surveillance for acute flaccid paralysis (AFP), and poliovirus surveillance. Ideally, every AFP case should be detected and investigated. Two stool specimens should be collected from the case within 14 days of paralysis onset. Virus isolation, using standard procedures in a WHO-accredited polio laboratory is performed on specimens, and isolated are typed. Poliovirus isolates are then referred to a regional reference laboratory for intra-typic differentiation to determine whether the isolate is wild or Sabin-like. Selected isolates are then submitted to the global strain bank, maintained in the specialized laboratory. Surveillance data are used to track circulation of wild poliovirus, to monitor disappearance of specific genotypes.

NATIONAL ASSESSMENTS OF SURVEILLANCE

To establish global polio surveillance, the development of effective surveillance within countries is the first priority. If the latter is accomplished, then the remaining challenges are relatively more trivial ones involving data transfer between countries. To strengthen country-level surveillance systems, the Expanded Programme on Immunization (EPI) conducted 28 national surveillance assessments between 1993-5 using a standard protocol. Despite the fact that many different consultants from different countries participated in these assessments, there were striking similarities in their recommendations (table 1). These could be summarized into 6 principle recommendations:

1. surveillance should be more action-oriented by linking the reporting of data directly to public health decision-making, for example, immediate case investigations and outbreak containment activities;

2. improve the timely forwarding and dissemination of data, for example feedback to data providers at more peripheral levels and sharing of data with interested parties such as international organizations and the media;

3. standardize and streamline surveillance including case definitions, forms, reporting and investigation procedures, containment activities as well as analyses and performance indicators;

4. designate and enable personnel with appropriate transport, training, specimen kits, access to a reverse cold chain and a means to dispatch specimens; 5) promote local analysis and use of data so that peripheral level staff are not mere “reporting machines”, but actually use the data for local decision-making; 6) ensure teamwork among various team players in surveillance such as epidemiologists, programme managers, laboratory staff and clinicians.

WHO'S ROLES IN STRENGTHENING POLIO SURVEILLANCE

WHO'S current role to strengthen surveillance fall into five principle areas:

1. perform global monitoring and feedback;

2. set standards particular for case definitions and data inputs;

3. distribute appropriate materials and methods;

4. provide technical support to regional and national-level staff; and

5. ensure coordination within WHO, among international organizations involved in surveillance and among surveillance partners within the country.

For global monitoring and feedback, WHO routinely publishes data and articles on progress in WHO's and CDC's weekly bulletins WER and MMWR, respectively, as these bulletins enjoy wide global circulation. In addition, data are published in the quarterly bulletin of the Global Programme on Vaccines and Immunization (GPV). Each of the WHO six regional offices produce monthly or quarterly feedback bulletins that contain data and progress on polio eradication and the quality of surveillance. The launch of the monthly bulletin from the Eastern Mediterranean Region called “PolioFax” was associated with a dramatic improvement in the completeness and timeliness of reporting (Figure 2). All Member States are encouraged to produce their own monthly bulletins. Guidelines on how to produce feedback bulletins are provided during workshops on surveillance.

WHO/GPV/EPI has produced a draft document on recommendations for standardized surveillance for surveillance of EPI target diseases, including polio. This document provides standard case definitions, core variables, performance indicators,

Technical assistance is provided by full-time international staff who work closely with national staff within the ministry of health. Presently, there are approximately 25 CDC-epidemiologists who are detailed to WHO Regional and country offices, particularly in critical countries. National assessments of surveillance system are routinely carried out along with the development of an action plan. Subsequent follow-up ensures implementation of the plan. Inter-country and country-level workshops are held on surveillance systems development and data management.

Numerous materials and methods have been developed by WHO/EPI. These include a detailed field guide on polio eradication (which includes a section on polio surveillance), a protocol to assess surveillance, and generic reference documents for use in workshops on surveillance systems development and data management. As WHO/EPI strongly recommends electronic mapping of polio data, a global inventory of public domain electronic boundary files indicating district boundaries is being developed and provided to Member States. WHO/EPI is currently testing innovative data transfer methods using existing and new technologies, ranging from ground-based data transmission using radios where the telecommunications infra-structure is scant to modem-based transmission using the internet. WHO/EPI also distributes Epi Info and Epi Map, public domain software that was developed jointly by CDC and WHO as a tool for public health practitioners. The menu-driven system, IFA (previously mentioned), that uses Epi Info and Epi Map is also distributed along with Epi Info and Epi Map.

Coordination of surveillance occurs in four domains. First, coordination is necessary within WHO between various programmes involved in surveillance. This is beginning to occur through joint field visits with staff from more than one WHO programmes, an in-house surveillance working group with members from each programme, sharing of materials and methods, and the creation of a manual on WHO recommendations for standardized surveillance that describe the data needs of each programme. Coordination is needed among various international organizations involved with surveillance to ensure that their activities are according to WHO policy and standards. Thirdly is the coordination of the global polio laboratory network. Finally , coordination and teamwork is needed among the various “players” in-country involved with surveillance. These include laboratory staff, epidemiologists and surveillance officers, programme staff, and clinicians.

THE RESULTS

Impact of these efforts are measured by the trends in poliomyelitis incidence and the geographic distribution of poliovirus circulation. In addition, standard performance indicators are used to monitor the changes in the quality of surveillance. Thus far, reported polio incidence has decreased from 35 251 cases in 1988 when the resolution for polio eradication was passed to 6587, representing an 81 % decrease in incidence despite improving surveillance. Geographically, poliovirus is completely eradicated in the Americas (AMR) and rapid progress is being made in other Regions. The only remaining reservoir of poliovirus in the Western Pacific Region (WPR) is in the Mekong Delta Region in Cambodia. The European Region (EUR) has few remaining reservoirs, primarily in Turkey, Caucasia and Central Asia. In the Eastern Mediterranean Region (EMR), most areas of Northern Africa, the Middle East and the Gulf have achieved zero or very low incidence. The remaining reservoirs are in Pakistan, Afghanistan, Iraq, Yemen, Somalia, Djibouti and Sudan. In the African Region (AFR), zero-polio/low incidence areas have been identified in East and Southern Africa. Aggressive efforts are being made to expand these low incidence areas to other parts of Africa. The challenges in this Region are principally in West Africa, particularly Nigeria, Ethiopia, Zaire, and Angola. The most endemic area is South East Asia which account for approximately 65% of all reported polio cases globally. The implementation of NIDs in Indonesia as well as the Indian subcontinent during 1995 should result in dramatic declines in polio in 1996. Data for each performance indicator are not completely available and analyzed globally. The proportion of countries achieving an AFP rate of 1 per 100 000 in children under 15 years of age (an indicator of sensitivity) during 1995 was 4% in AFR, 82% in AMR, 30% in EMR, 6% in EUR, 10% in SEAR, and 21% in WPR. Timeliness of monthly polio reporting (April monthly report received in WHO headquarters by mid-July) was 33% from AFR, 100% from AMR, 87% from EMR, 96% from EUR, 10% from SEAR, and 100% from WPR.

The task ahead to establish effective global polio surveillance is enormous and becoming increasing urgent. Efforts are rapidly accelerating to make these systems effective. Some of the principle obstacles remain. These include the difficulties in working with some existing national surveillance systems which are already overburdened, stagnant and largely dysfunctional; the many “players” involved in surveillance and difficulties in coordination and teamwork among them; inadequate human and/or financial resources as well as inadequate political commitment in some countries; difficult logistics to dispatch specimens and maintain a reverse cold chain; and political unrest. Nevertheless, experience has shown that these obstacles can be overcome. We can then look forward to the day when parents no longer fear this dreaded disease that may cripple or kill their children.

Figure 1. Countries conducting AFP surveillance as of July 1996.

Figure 2. Impact of the feedback bulletin “PolioFax” on timeliness of monthly AFP and polio reporting, Eastern Mediterranean Region, 1993-4.

CONTINGENCY PLANNING AND EMERGENCY PREPAREDNESS

Gareth Davies²⁰

We are contemplating a world where Rinderpest has been eradicated and it no longer scourges the cattle populations of Africa and Asia.

This is a measure of the progress that has been made in controlling and eradicating the major epidemic diseases of livestock during the last few decades. Unfortunately this progress has been achieved at the expense of an increasing risk of major pandemics. What was previously an endemic situation is now largely an epidemic situation in which disease occurs occasionally, but in a devastating form. It is the measures that we must take to meet these occasional but catastrophic events that this paper will address.

The Increasing Risk of Epidemics

A combination of factors have increased the risk of epidemics:

• the rarity of many of the major epidemic diseases which means that they may be unrecognised when they first strike a population.

• the increasing mobility of human and livestock populations.

• a shortage of resources.

The increasing rarity of the more serious epidemic diseases means that veterinarians and livestock owners are often unaware and are certainly not alert to the signs of these diseases. Only four members of the Greek veterinary services had ever seen Foot and Mouth disease (FMD) before the epidemic of 1993-94. Fortunately, one of the four recognised it and so aborted what could have been a disastrous epidemic. This is a major problem for veterinary services in Europe, North America and the Antipodes.

Livestock populations are increasingly mobile partly as a result of developments in world trade, but also due to social and political upheavals. The collapse of the command economies in Russia and Central Europe left their borders open to traffic in animals and this traffic has been stimulated by the price differentials between the ex.Russian states and the European Union. In Africa the Rwanda conflict resulted in the migration of thousands of people and their livestock at a time when border controls and movement checks were in some disarray.

The shortage of resources to fight disease control campaigns is due to a number of factors. Many developing nations are desperately poor and their public sector is increasingly under-resourced. Despite this high unemployment rates have led the authorities to maintain large labour forces in the public sector and one consequence has been that many veterinary services have an abundance of staff, but not the material resources such as transport and other equipment to allow them to do their work. A relatively recent response to the problem of funding the public sectors has been to transfer the services to the private sector and veterinary services are struggling to come to terms with this development.

²⁰ Veterinary epidemiologist, UK; formerly MAFF, UK, and EC, Brussels.

These “risk factors” have led to a situation where there have been major pandemics of Rinderpest and Contagious Bovine Pleuropneumonia in Africa, Rinderpest has spread in the Middle East and Asia and Western Europe has suffered incursions of Foot and Mouth disease.

The Measures That Must Be Taken

We have to come to terms with the phenomenon of long distance transport that may result in infected animals penetrating deep into previously disease free territory. We must also acknowledge that national governments and aid agencies are unlikely to continue funding large ‘standing armies’ in the veterinary services. We have to make the best use of the resources provided replacing the ‘standing army’ with a ‘task force’. This is a process that is occurring in the armed forces of many countries which have created rapid reaction forces in response to the episodic nature of modern warfare.

To make the best use of available resources and to do so in a way that meets sudden emergencies, we must develop forward planning or contingency planning.

Contingency Planning

A contingency plan should ensure that:

• resources are available to meet sudden emergencies.

• the resources can be deployed rapidly.

• the resources are used efficiently.

The European Union has already faced many of the problems that are described above. Many veterinarians in the Union have little experience of ‘exotic disease’ and disease eradication campaigns. External borders to the east and the south have not always been fully under control and the emergence of a single continental market in goods and services has led to the development of rapid and long distance traffic in animals and animal products.

The response to the European Commission was to develop the concept of contingency planning by producing a model plan as a basis for planning by the Member States. The Food and Agriculture Organisation (FAO) adopted and developed the model for wider use.

The Community plan outlines the resources that must be available to meet the possibility of an FMD epidemic. It is couched in general terms and so it also serves as a plan for other OIE List A diseases, such as Rinderpest. But it is not a set of instructions and we need to develop the contingency concept to ensure that the plan has two elements:

• A plan to ensure that the proper resources are available - A Resource Plan

• A set of instructions so that everybody knows what to do in an emergency - An Action Plan

The Resource Plan

The resources to be defined in the plan are set out in Appendix 1.

First of all it is essential that legal powers are in place and are actively exercised so that controls can be enforced during emergencies.

Secondly, there have to be adequate financial provisions. This means not only the budget to fund staff and equipment, but also provision for rapid access to additional finance in times of emergency. This is a major problem for some countries and has led supranational authorities to set up trust funds that cover regions or continents.

The next requirement is a command structure that is effective in delivering the rapid responses required in controlling epidemics. The European experience is that a unified structure with a short chain of command from the national headquarters to the veterinarians in the field is the most appropriate even though it may run counter to regionalisation and other political developments.

The task force approach is met by setting up expert teams. The composition of such teams varies from country to country, but the essence is that there is a cadre of staff that is highly trained in disease diagnosis and in disease eradication measures. These are the people who deal with the first outbreaks of disease in an epidemic and who can advise the director of veterinary services thereafter.

The control of a large epidemic requires personnel to carry out the routine tasks of quarantine, stamping out, surveillance, movement controls, tracing and vaccination. These tasks are labour intensive and it is imperative that every available person is brought in to help. Veterinary services need to develop on-call arrangements for veterinarians in the private sector.

Effective control depends on the availability of adequate material resources such as transport, sanitation equipment, facilities for killing animals and dispensing of the carcases and diagnostic aids. These resources should be distributed throughout the national territory.

The vital initial action in a disease epidemic is the recognition of the first outbreak and this requires an effective surveillance system linked to properly equipped and skilled diagnostic laboratories. Publicity and disease awareness campaigns are essential to ensure that veterinarians and stock owners are alert to the first signs of disease.

The other resource that may be required is vaccine and vaccination equipment and here again supranational authorities are serving regional needs by organising vaccine banks.

The Action Plan

The EC/FAO contingency plan details two items that properly fall into an action plan. They are:

• a set of instructions that covers every aspect of the controls implemented during an epidemic from the first suspicion of disease to the final eradication.

• a plan for the deployment of vaccine either in a ring vaccine zone or by blanket vaccination.

“Model” plans to cover these two aspects of action during an emergency would be of immense value to the many countries that are reorganising their veterinary services.

The European Experience of Contingency Planning

It is now some five years since the Member States of the European Union drafted contingency plans for FMD. During this time there have been major epidemics of FMD in Italy and Greece.

Have the plans been effective? The answer is yes and no.

YES the plans have ensured that the veterinary authorities have a coherent approach to resource planning.

NO the epidemics have revealed certain weaknesses.

The major weakness has been that there is no check system in place to ensure that the plan is operational. There should be an annual audit that specifies how many staff have been trained, that equipment has been checked and above all that the diagnostic laboratories are operating testing systems that are valid. A further occasional check should be carried out to ensure that staff manuals are up to date.

Another weakness is that disease awareness in the veterinary services is unsatisfactory. More needs to be done to educate veterinarians in the signs, symptoms and epidemiology of the so called exotic diseases.

A further problem common to European and other countries is that their command structures are changing in response to political pressures. Most European countries now have decentralized political structures that are quite unsuitable for fighting diseases that know no boundaries.

Financing a major campaign requires open-ended budgets and few of the less wealthy nations can afford this - yet it is vital that transport and equipment is immediately available and that compensation for slaughtered livestock is paid promptly. We have to develop the concept of a common i.e. supranational trust fund.

We must also develop vaccination strategies. Many countries do not have access to vaccine banks or call-off arrangements with commercial vaccine producers. In the case of FMD a decision to vaccinate not only has a cost, but has major implications for the export trade. Inevitably a decision to vaccinate at some stage of the epidemic will be followed by a pause during which vaccine is obtained and prepared for the field and delivered to the infected area. This may take some weeks and during that time the epidemic may be out of control. These are all aspects of a vaccination strategy that should be addressed by forward planning.

The weaknesses outlined above are not unsurmountable, but they do need attention at times when the prospect of an epidemic seems distant. To attend to them during an emergency will be too late.

Appendix 1

CONTINGENCY (RESOURCE) PLANS - THE MAIN ELEMENTS

1. Legal Powers

2. Financial Provisions

3. National Disease Control Centres

4. Local Disease Control Centres

5. Expert Teams

6. Personnel

7. Equipment and Facilities

8. Instructions For Dealing With Outbreaks

9. Diagnostic Laboratories

10. Contingency Plans for Vaccination

11. Disease Awareness

SUSTAINABLE VETERINARY STRUCTURES

Yves Cheneau ²¹

First, I should like to touch on the terminology. Thus, the term veterinary structures includes all of the infrastructures that contributes to delivering veterinary services to farm animals; hence the public veterinary services, part of the private services and ancillary infrastructures.

The term sustainable carries with it the notion of justifiability, endurance, and selfsufficiency; probably in that order. The cost of maintaining an infrastructure that is to deliver a set of services must first be justifiable in socio-economic terms; it should then be able to last - as long as the services are needed - and withstand threats of various nature, particularly political; finally, it should become self-sufficient in the sense of being able to recover an increasing portion of the costs.

Second, it is not my purpose to describe today what a sustainable veterinary structure responsible for the full spectrum of veterinary activities should be; instead I wish to concentrate on the structures responsible for the control/eradication of transboundary contagious diseases.

This presentation, to some extent, overlaps with those of Jeffrey Mariner and of Tim Leyland which described in detail the community-based approach for outreaching to marginalized communities and inaccessible areas. I wish to congratulate them very warmly for the substantial efforts they have made in these regions and for the excellent papers they have produced and presented here. No doubt that the Animal Health Service team in Rome and our colleagues working with control/eradication programmes and projects in the field will use their approach and advise; their work is being considered as a model.

Within the context of animal disease control and eradication campaigns such as GREP, there is a general tendency for producers and the livestock industry to play a growing role in both the financing and the logistics of such programmes. The tendency is welcome but I wish to point out that governments should not, in my view, wash their hands of this primary responsibility. For many reasons, including international liability in the control of transboundary diseases, governments should ensure adequate funding of public veterinary services and their authorized agents or structures.

In recent years, the concept of a veterinary structure delivering services as a commodity has made considerable progress. If seen as a commodity, it is paradoxical that some services should be “free” to the beneficiary while other services should be directly remunerated by him/her. I am putting the word free in quotes because such “free” services are also being paid for, but by society at large rather than by the direct beneficiary (livestock producer/industry). Now, the latter (the direct consumer of the services) is being asked to pay for more and more of the direct cost of such services - and rightly so. One can argue that the government's budget is fed by the money of the tax-payers and that the “citizen-herder” will pay twice if he has to contribute both directly and indirectly to vaccination campaigns!

A well balanced policy is needed when it comes to share the costs between the public interest and the private interest. The same balanced attitude should prevail when the sharing of responsibilities between the public and the private veterinary services is under discussion. Let me show you an illustrative normogram for a national veterinary structure which was recently proposed by my colleagues of the Infectious Diseases Group (Figure 1).

²¹ Chief, Animal Health Service, Animal Production and Health Division, FAO, Rome, Italy; with collaboration of Roger Ruppanner and David Ward, Veterinary Services Group, Animal Health Service.

^* To include all organisations (predominantly private) set up for the provision of clinical services even if for “temporary” socio-economic reasons there may be a need for direct governmental participation.

Figure 1: AN ILLUSTRATIVE NORMOGRAM FOR A NATIONAL VETERINARY STRUCTURE ²²

²² from: Report of the Joint FAO EMPRES and OAU IBAR Regional Workshop on Contagious Bovine Pleuropneumonia (CBPP) Prevention and Control Strategies in Eastern and Southern Africa, held in Arusha, Tanzania, 4 to 6 July 1995.

It can be seen that most of the functions concerned with control/eradication programmes can be contracted to the private veterinary sector. The concept is gaining momentum and acceptance but the fundamental issue remains: whatever services are provided by the public and/or the private sector, somebody will have to pay for it!

It is not my intention to be provocative, but let me provide the recent example of an epidemic transboundary disease which illustrates the precariousness of the notion of sustainability of veterinary interventions and services: the ongoing upsurge of foot-and-mouth disease in Central Europe. The situation is so serious that the governments concerned as well as the governments of the European Union are not at all questioning the need for disbursing public money; they are not asking any financial contribution from the livestock owners, on the contrary, they are providing compensation. It is understood that what is in danger is the European livestock industry and trade as a whole and the sustainability of the veterinary infrastructures is no longer the priority concern.

Public versus private funding of animal disease control programmes has been a matter of debate for a long time. Suffice it here to recall that among the various measures to control and eradicate infectious diseases are those not always visible during the actual vaccinations campaigns such as say against rinderpest or FMD. They include quarantine to stop movement of possibly infected animals; testing and examination to detect infection; destruction of infected animals to prevent further disease spread; and cleaning and disinfection of contaminated premises, etc.

These activities can be as costly as, or more costly than, the vaccination campaign itself which also carries with it a number of invisible costs - mainly paid for by the taxpayer. These costs are those associated with quality control, pre-vaccination surveillance and post vaccination monitoring. Already, in some countries, the producers and livestock industry are actively participating, if not initiating and promoting, certain animal disease eradication strategies. This is the case for FMD eradication in Latin America and should be taken as an example of things to come.

The “International Conference on perspectives for the eradication of foot-and-mouth disease in the next millennium and its impact on food security and trade” took place only ten days ago in Brasilia and one of the main outputs is the decisive role the livestock herders associations and the industry will play in the final assault against FMD in South America.

Various modes of funding are being explored. Professional associations, producers groups, feeder associations, trade federations and other constituent bodies are being requested to contribute through their membership and are responding positively in many countries. In other countries, “livestock development funds” fed by internal taxation, are being set up. Furthermore, as you have already heard, partial or total cost-recovery for rinderpest vaccination is advocated by the those promoting participatory rural appraisal and community animal health workers. If I understood them well, it is not only a matter of payment for services rendered (“financial sustainability”), it is also a question of “ownership”. Can we expect more?

In addition to their regulatory functions, the role of the official (national) veterinary services becomes one of strategic planning, marketing (communication, dialogue, promotion), monitoring and quality control. It seems that this concept is now accepted; leaving the other services to the private sector.

Let me briefly elaborate on these functions:

• strategic planning: we dispose, at international level and more and more at national level, of very powerful tools (PCR, ELISA, …) which allow for sound strategies and decisions. We should make full use of them and promote their adoption where the problems are.

• communication, dialogue, promotion: the OAU-IBAR PARC team, FAO and the EU recognized early on that special “marketing” efforts needed to be oriented towards the politicians and decision makers, the local authorities and community representatives, and the livestock owners. Now that rinderpest endemic foci are mostly restricted to remote, marginalised areas and communities, we should increase our efforts and strengthen the structures responsible for this successful approach.

• monitoring and quality control: these activities can be seen in the broader context, from supervision of field operations to QC of the vaccine used in the campaigns, or from setting up time bound programmes to the thorough evaluation of what was really done. The successes already achieved by PARC are certainly due to such requirements as QC during vaccine production to guarantee a safe and potent vaccine; QC of vaccine delivery in the field through post-vaccination sero-monitoring to guarantee its performance. What remains to be fully put in place are validated and quality-controlled socio-technical interventions for case finding and disease surveillance.

Quality control is the one cost item that could be most easily “transferred” to the direct beneficiary of a vaccination campaign: the livestock producers. Delivering a veterinary service of high quality and proven effectiveness is certainly the best contributor to sustainability.

Controlling or eradicating an infectious disease already present in a country is, however, only one band of the spectrum of the activities of a sustainable veterinary structure that contributes to the growth of the GDP. Denying foreign infectious animal diseases to enter or to establish themselves in a country also has its benefits, namely the benefits of avoided potential costs. These benefits are less visible than seeing that your herd has been protected by vaccination while your neighbour's herd has been decimated because of failure to vaccinate. How could these less visible benefits be measured and brought to bear on the political decisions made?

Veterinary structures, be they public or private, need to find ways and means by which to estimate the costs avoided because of the effectiveness of the preventive services delivered. Whether these benefits are considered important by the decision makers depends to a large extent upon the priority ranking of public goods in a given country. If economic growth, poverty alleviation and food security are the main concerns of the country policy, then the benefits derived from the interventions of the veterinary infrastructure can easily be argued to make a significant contribution to the GDP. If, however, the main concern of the government is security, then the benefits derived from keeping out epidemic diseases are less likely to be appreciated as contributing to the GDP and government priorities.

Highly infectious transboundary diseases such as rinderpest ought to lend themselves well to the type of analysis proposed above. If data can be collected/generated to feed an economic analysis of the benefits of keeping such diseases out, a strong argument could be developed to incite governments to allocate a larger proportion of the public spending to the veterinary infrastructure. Indeed, the livestock producers/industry could be made aware that investing in prevention beyond country boundaries could also be of benefit to them; and their lobbying, in-turn, would help the cause of more adequately resourcing the veterinary infrastructure.

OIE STANDARDS FOR EPIDEMIOLOGICAL SURVEILLANCE SYSTEMS FOR RINDERPEST

Alain Provost²³

An OIE Experts Consultation on Rinderpest Surveillance Systems held in Paris in 1989 outlined a series of steps that countries must undertake in order to obtain official recognition by OIE that they are free of RP and its causative virus. These steps became known as the 'OIE Pathway' (Figure 1) and were ratified by the 59th General Session in 1991. The description of the pathway contained in the OIE report of that consultants meeting is given below.

Figure 1 OIE Pathway.

²³ Expert en péripneumonie contagieuse bovine (PPCB), 2, rue Fontaine, Ezy-sur-Eure 27530, France; representing OIE.2

STEPS TO BE TAKEN TO DECLARE A COUNTRY TO BE FREE FROM RINDERPEST

Since the current national and regional RP control campaigns have the ultimate aim of achieving global eradication it is necessary to institute a system of verifying the steps towards these short and long term aims, and to assist countries which wish to trade in livestock and livestock products, but face difficulties due to the presence or past occurrence of RP.

A three-stage process of achieving and proving freedom from RP is therefore envisaged. Once a country is satisfied that it is free from RP and that the disease is unlikely to be reintroduced, the country can declare itself provisionally free from disease provided it is satisfied it meets the criteria listed below.

Subsequent steps are then subject to international verification under the auspices of the OIE. At least three years after a country has declared itself provisionally free from disease, it may be declared by the OIE to be free from disease if it meets the criteria stated below. At least one year later, a country which meets more stringent criteria with regard to RP may be declared free from infection.

The specific criteria proposed for each stage of this process are as follows:

1. Provisional freedom from disease

For a country to declare itself provisionally free from rinderpest, it must fulfil certain conditions, which are:

• No clinical disease should have been detected for at least two years;

• There is an effective veterinary service which is able to monitor the animal health situation in the country;

• The service investigates all clinical evidence suggestive of RP;

• There is an effective reporting system, both from the field to the central veterinary authority, and by that body to the OIE;

• There is a reliable system of preventing the introduction of infection which is carried out by proper border control, quarantines, etc.;

All vaccinations against RP will cease by the date of declaration. The OIE and the neighbouring countries must be notified of this decision (in writing), giving the date from which vaccination ceased.

2. Freedom from disease

A country which has declared itself to be provisionally free from RP may upon application to the OIE be declared free from disease provided that the following criteria are met:

• No clinical RP has been detected for at least five years;

• No RP vaccination has taken place for at least three years;

• The county operates both clinical surveillance and disease reporting systems for RP, adequate to detect clinical disease if it were present;

• All clinical evidence suggestive of RP is investigated by field and laboratory methods (including serological assessment to refute a possible clinical diagnosis of rinderpest);

• There are effective measures in force to prevent the re-introduction of the disease.

The Expert Panel for the Verification of Disease Status of the OIE shall evaluate the application and decide whether or not to approve it. In coming to its decision the Expert Panel will consider evidence presented by the country and will gather information on the extent to which the criteria have been met. This information-gathering will usually include sending members of the Panel to make a field visit to the country. The Expert Panel will report its findings and its conclusion to the OIE Foot and Mouth Disease (FMD) and Other Epizootics Commissions, which will have the power to make the declaration on behalf of the OIE. The Commission will report its actions annually to the International Committee.

To maintain this status, a country must continue to meet these requirements until it is declared free from infection and must annually report a summary of developments to the OIE. If it is not practical to achieve national freedom from disease in a single step, a country may apply to the OIE for zones within the country to be declared free from disease provided that:

• Each proposed zone has well-defined boundaries;

• No clinical RP has been detected within the zone for at least five years;

• No RP vaccination has taken place within the zone for at least three years;

• The country operates within the zone both clinical surveillance and disease reporting systems for RP, adequate to detect clinical disease if it were present;

• All clinical evidence suggestive of RP within the zone is investigated by field and laboratory methods (including serological assessment) to refute a possible diagnosis of RP;

• There are effective measures in force to prevent the re-introduction of the disease into the zone from the remainder of the country and from other countries.

The Expert Panel for the Verification of Disease Status of the OIE shall evaluate the application and decide whether or not to approve it. In coming to its decision the Expert Panel will consider evidence presented by the country and will gather information on the extent to which the criteria are met. The Expert Panel will report its findings and its conclusion to the OIE FMD and Other Epizootics Commission, which will have the power to make the declaration on behalf of the OIE. The Commission will report its actions annually to the International Committee.

The declaration of zones to be free from RP will not remove the requirement for the country to subsequently meet the criteria for declaration of freedom from disease for the country as a whole; if it wishes to achieve that status, it will have to meet all the requirements specified earlier before it can apply for a declaration of freedom from disease for the entire country.

Should there be a localized temporary outbreak of disease due to re-introduction of RP to a country which is within two years of meeting the requirements for declaration of freedom from disease, that country may take special measures (including limited ring vaccination) to eradicate the outbreak. In such circumstances, it will then require at least one year from the date of the last case or the last vaccination (whichever occurs later) before the country becomes eligible to apply for a declaration of “freedom from disease”.

In making such an application under these special circumstances, the country must satisfy the Expert Panel that the outbreak did not represent endemic infection and that the disease has been eradicated by the actions taken.

3. Freedom from infection

A country which has not vaccinated against RP for at least ten years and throughout that period had no evidence of RP disease or RP virus infection may be declared free from rinderpest infection by the OIE based on conclusions of the Expert Panel on Verification of Disease Status, provided that throughout that period the country had maintained permanently an adequate disease reporting system.

A country which has either vaccinated against RP within the last ten years or has had clinical evidence of RP, may be declared by the OIE to be free from infection if the following criteria are met:

• It should have been declared free from disease at least one year earlier, and continues to meet the requirements for this status.

• There should have been an effective serosurveillance system in operation for a period of at least two years, and the findings must have been consistent with freedom from infection. This serosurveillance must include other susceptible domestic stock as well as cattle.

• Investigations into infection in wild susceptible species must be carried out where these species occur in significant numbers. Where there are opportunities, sampling should be done when possible. Additional strategic sampling of domestic stock should be done in areas adjacent to large game populations to enhance the possibilities of finding any evidence indicating the presence of rinderpest virus in the game. The findings must be consistent with freedom from infection.

On meeting these criteria, a country may apply to the OIE to be declared free from infection. The Expert Panel for the Verification of Disease Status of the OIE shall evaluate the application and decide whether or not to approve it. In coming to its decision, the Expert Panel will consider evidence presented by the country and will gather information on the extent to which the criteria have been met This information-gathering will usually include a field visit to the country by members of the Panel. The Expert Panel will report its facts and its conclusion to the FMD and Other Epizootics Commission which will have the power to make the declaration on behalf of the OIE. The Commission will report its actions annually to the International Committee of the OIE.

Declaration of freedom from infection can only be made for the country as a whole, and not for zones within a country. Should there be a localized, temporary outbreak of disease due to reintroduction of RP to a country which is within one year of meeting the requirements for declaration of freedom from infection, that country may take special measures to stamp out the outbreak (excluding the use of vaccine). In such circumstances, the country must wait at least six months from the date of the last case before it becomes eligible to apply for declaration of freedom from infection. In making such an application under these special circumstances, the country must satisfy the Expert Panel that the outbreak did not represent endemic infection and that the disease has been eradicated by the actions taken. In order to maintain this status, the country must continue to operate an efficient disease reporting system which would detect RP if it occurred.

GLOBAL EARLY WARNING SYSTEM AGAINST RINDERPEST AND OTHER MAJOR EPIDEMICS

Bill Geering²⁴

In dealing with serious epidemic livestock diseases, such as rinderpest, time is of the essence. If a new disease outbreak, particularly in a previously free area or country, can be recognised early and dealt with effectively whilst it is still localised the prospects of its eradication with a minimum of production losses are excellent. Conversely, if there are substantial delays in either of these elements the disease may become widespread and very difficult and costly to control and eradicate. Regrettably, the latter has occurred too often in the past in many countries. It would be invidious to cite specific examples of these failures. Rather, I would prefer to cite a case study of what can be achieved when there is early warning and early reaction to a new disease. This is from my own country, and relates not to rinderpest but to another morbillivirus disease.

In September 1994, a new and highly acute and fatal pneumonia occurred in horses in a racing stables in Brisbane. There were 20 cases, with 13 deaths, over a three week period. Furthermore, the trainer and a stablehand became acutely ill, with the former dying. This was a potentially explosive situation as the outbreak occurred in an area of both high equine and human population density. A well proven national emergency disease contingency plan was implemented immediately and effective control action was taken even in advance of a definitive identification of the aetiological agent. This consisted of quarantine and disinfection of the affected premises, movement restrictions over a wide area (including cancellation of horse races) and traceback and traceforward of horses that had been in contact with affected horses over the critical period. The latter resulted in quarantine of properties in other States. Within weeks the causative virus had been identified (equine morbillivirus), serological tests developed and comprehensive serological surveys had been completed in horses and people over quite a wide geographical area. in less than six months it was possible to prove that this particular outbreak had been eradicated without extension of infection from horses belonging to the original training stables.

Early warning of and early reaction to serious epidemic livestock diseases are at the very core of the EMPRES philosophy. These are seen as indivisible as it is axiomatic that the collection of disease information which is not action oriented and used for decision making and/or disease control responses is a virtually worthless activity. As the Assistant Director General has reminded us in his opening speech, we are in a particularly critical phase of the global rinderpest eradication programme.

Rinderpest is now restricted to relatively small areas, which are surrounded by increasingly susceptible populations of cattle, buffaloes and wildlife. This is a potentially dangerous situation, which will require an even greater attention to active disease searching and early warning of new rinderpest outbreaks. As rinderpest eradication programmes approach their successful conclusion, strict adherence to the OIE pathway for proof of rinderpest eradication will be paramount. To do otherwise will be to repeat the costly mistakes of the past.

In line with its responsibilities for technical coordination of the Global Rinderpest Eradication Programme and for other serious epidemic livestock diseases, FAO plans to establish a global early warning system within its EMPRES-livestock programme for the six EMPRES high priority diseases. Rinderpest will be used as the model disease to trial systems.

²⁴ Visiting Scientist, EMPRES-Livestock Programme, FAO Animal Health Service, Rome

It is hoped to establish a central early warning unit within FAO EMPRES headquarters, with responsibility for collection, collation and dissemination of information relevant to disease control campaigns for EMPRES priority diseases, epidemiological analyses and training programmes. Its activities will be closely linked to those of a parallel central early reaction unit. At a regional level, it is planned to appoint FAO regional epidemiologists, initially to cover Africa; the Near East and Central Asia; and South East Asia to promote and coordinate EMPRES early warning and reaction activities in the countries within their regions.

The principles of the EMPRES Global Early Warning System are that it should be:

• FOCUSED (on EMPRES diseases)

• ACCURATE

• TIMELY

• VALUE ADDED (through epidemiological analysis)

• WELL PRESENTED

• ACCESSIBLE

• ACTION ORIENTED
  (by linkage with FAO emergency response mechanisms).

One of the main tasks of the Global Early Warning System will be to develop and implement a workable information network between the international/regional agencies that are concerned with control and eradication of EMPRES priority diseases. Rinderpest will be used as the model, but the system should be robust enough to be transportable to the other diseases. The rapid flow of epidemiological information is seen as being of high priority for the coordination of GREP, and FAO would therefore like to develop this information network over the next 6-12 months, in collaboration with its international partners.

It is anticipated that FAO/EMPRES would have a hub role in this network by:

1. acting as a clearing house for receipt of and redistribution of epidemiological information to other partners;

2. undertaking overall epidemiological assessments based on information from all sources. This would include, inter alia, disease mapping and a GIS approach; and risk analyses;

3. maintaining a databank;

4. identifying gaps in information and developing strategies to rectify these.

The potential international participants in this network include OIE, the World Reference Laboratory for Rinderpest, EMVT, IAEA, regional rinderpest coordination groups including PARC and SAREC, EMPRES regional epidemiologists (when appointed) and FAO Regional Offices.

It is anticipated that another main focus for the proposed EMPRES global early warning system will be in assisting FAO member countries to adopt the principles of early, effective disease control responses and soundly based eradication programmes based on active disease surveillance, good reporting systems, epidemiological analysis and close collaboration with international reference laboratories and other agencies.

FAO/EMPRES will continue to play a catalytic role in this process through training programmes, publications, technical cooperation programmes (TCP) and personal contact through its EMPRES Regional Epidemiologists.

In particular, attention needs to be focused in the following areas:

• farmer awareness programmes for high-threat epidemic livestock diseases;

• training of field veterinary and paraveterinary staff on the clinical and gross pathological recognition of rinderpest and the other serious epidemic livestock diseases; collection and transportation of diagnostic specimens; and the need for prompt action;

• active disease surveillance, rather than passive monitoring, based on close coordination between field and laboratory veterinary services, and use of techniques such as serological surveys and abattoir monitoring to supplement field clinical searching for disease;

• disease tracing capabilities, including livestock identification systems;

• emergency disease reporting mechanisms to national veterinary headquarters;

• enhancement of laboratory diagnostic capabilities for EMPRES priority diseases within provincial and national veterinary laboratories;

• improving linkages between national laboratories and world and regional reference laboratories, including the more routine sending of outbreak virus isolates to the latter for specialised antigenic and epidemiological characterisation;

• strengthening of national epidemiological capabilities to support disease eradication campaigns;

• prompt and comprehensive international disease reporting to OIE etc.;

• contingency planning and other emergency preparedness for epidemic livestock diseases.

GLOBAL EARLY REACTION AGAINST RINDERPEST AND OTHER MAJOR EPIDEMICS

Peter Roeder²⁵

THE NEED FOR EARLY REACTION

Major epidemic diseases have the potential to cause catastrophic production losses, adversely affecting food security, disrupt livestock trade and even, for the zoonoses, directly harm human wellbeing. Their control is, thus, essential to supporting and safeguarding all developmental activities. Managing these epidemic diseases on a global scale can be approached in two generic directions:

• The “live with the risk” approach, addressed at individual diseases, relying heavily on the indefinite maintenance of a high level of herd immunity through institutionalised immunisation programmes to prevent the disease taking hold should it be introduced;

• risk management through maintaining emergency preparedness with an effective early warning system to detect introduction and ensured early reaction capability to bring about rapid containment and elimination.

The former is inordinately expensive, has no time limit and addresses only one disease. The latter is an adjunct to global, or at least regional, eradication strategies which are time-bound programmes. Specific diseases may be targetted yet it has the advantage of being applicable to all epidemic diseases - clearly a more cost-effective activity.

Another paper has presented concepts of an EMPRES global early warning system and it is self-evident that early warning is not an end in itself; early warning demands early reaction. Without early reaction, early warning is merely an academic exercise and, without early warning there can be no effective early reaction.

There is no shortage of examples to illustrate the fact that a lack of timely and decisive intervention (i.e. early reaction) after epidemic disease introduction to a country, especially when exacerbated by prior deficits in early warning, leads to great expense and extreme difficulty in control, let alone eradication, although it must be admitted that full economic appraisals are severely lacking.

A devastating pandemic of rinderpest swept through Africa from the Horn to the West African coast in the 1980s when epidemic extensions developed from the remaining isolated residual endemic foci as herd immunity levels fell following the termination of Joint Project 15. This clearly demonstrated that the threat of cattle plagues had not diminished. The pandemic is estimated to have cost around US$ 2 billion and could be conceived as a direct result of Joint Project 15 failing to establish an appropriate preventive mechanism. Events in Africa were mirrored in India after support for the largely successful All-India National Rinderpest Campaign faltered in the 1970s. It is clear that long-term maintenance of risk management through extensive vaccination campaigns is not sustainable.

Contagious bovine pleuropneumonia (CBPP) expansion in eastern, central and southern Africa is a more recent case in point. Invasion of Tanzania occurred in 1990 by movement across the Kenyan border of one heifer. Stamping out at that time would have cost very little but this was not done and in the next year some 136,000 cattle (8 per cent of the cattle population in the immediate vicinity), valued at US$ 9.5 million, are estimated to have died in Mara and Arusha Districts. Further expansion southwards from the infected area occurred from 1994 and more than 15,000 cattle, valued at in excess of US$ 1 million, have died. FAO alone has spent more than US$ 400,000 on control in addition to emergency funds of US$ 86,000 released by the Government of Tanzania and vaccine purchased to the value of US$ 42,000 by the EC. The true cost to Tanzania, and other countries affected by this one epidemic event, is surely far greater than the mere summation of these figures. Complementary action by FAO to try to prevent further transboundary spread from this and related CBPP epidemics in eastern and central Africa exceeds a further US$ 1 million to date. Similarly, in Botswana, introduction of CBPP in 1995 from Angola/Namibia could have been terminated rapidly at modest expense but failure to do so has now involved the Botswana Government in spending on control, so far, the staggering sum of more than US$ 100 million and FAO US$ 84,000.

²⁵ Animal Health Officer (Infectious Disease Emergencies), EMPRES, Animal Health Service, FAO, Rome

In contemplating the world without rinderpest we must be fully prepared for the fact that to reach this state we must pass through a time of steadily increasing vulnerability to epidemic recrudescence as the disease is progressively eliminated from the remaining foci of persistence and prophylactic vaccination ceases, whether by design or default. The prospect of a return to the time of rampant cattle plague is very real. In recognition of this fact a GREP Consultative Group Meeting, held in December 1995 in Rome, concluded that global rinderpest control had reached a point where “The appearance of rinderpest in any country is an emergency and requires an immediate response.” Nowhere is this more true than those African countries which lie outside the endemic area of eastern Africa and have been free from rinderpest for at least eight years, some for much longer. We must take heed of the devastating African pandemic of the 1980s. This could easily occur again in Africa and a similar scenario applies to the other rinderpest theatres in the world. For example, in 1969 rinderpest swept through Iran into the Middle East developing into a pandemic which reached the Mediterranean littoral, affecting most countries in the region and persisting until 1983. Again in 1985 another pandemic resulted from the introduction of rinderpest into Iraq in a consignment of buffaloes conveyed by sea from the Indian sub-continent. The region still suffers from the aftermath of these events and rinderpest persists there to this day, so far evading all attempts at total elimination although most countries are free once again. The risks from endemic areas may be reducing but essentially little has changed to prevent such events occurring again. Had a mechanism for effective early warning and early reaction existed at these times, these pandemics could have been aborted. We still lack a mechanism of early reaction to safeguard the very real gains made so far.

Rapid detection, containment and elimination of epidemic extensions from the endemic foci is clearly needed to avoid wide dissemination of infection and the attendant catastrophic losses but also, and perhaps more importantly in the long term, to preempt the generation or re-establishment of persisting endemic foci. These commonly involve marginalised rural communities and are extremely difficult to eliminate. It is obvious that we need to transit rapidly through this period of high and increasing vulnerability to reach global rinderpest-free status and, thus, zero risk of recrudescence. For reasons presented elsewhere this acceleration of progress towards global eradication is considered to require rapid entry onto the OIE Pathway, leading to a validated status of freedom from rinderpest infection, for which a pre-requisite is cessation of vaccination. Lack of progress towards this goal, for example in West Africa but also in most of the rest of the world formerly affected by rinderpest, is evident and one of the reasons for this, if not the prime reason, is that government veterinary authorities are reluctant to abandon prophylactic vaccination in the absence of a safety net of assured assistance should rinderpest outbreaks recur.

Experience indicates that the existing global early reaction capacity, including that of FAO itself, will not suffice. Conventional programmed activities of all organisations are constrained by procedures which can result in very damaging delays even if contingency funds were to be a significant element of budgetary provisions. By early reaction we must really understand immediate reaction, or as near to immediate as is possible, for the possibility of containing epidemics obviously reduces the later that measures are applied, just as the cost increases. That cost rapidly escalates to a point where all possibility of obtaining funds rapidly disappears and years must be spent in devising and obtaining funding for large scale campaigns.

It is intended that EMPRES should meet the challenge of enhancing global emergency preparedness by:

1. working with national authorities to bring about a sea change in attitudes to ensure that the provision of national early reaction capability is accorded appropriate priority in livestock production planning; and

2. establishing a greatly enhanced international capacity for early reaction, with the GREP element being of paramount importance initially.

THE NATIONAL EARLY REACTION COMPONENT

The reality is that in many of the countries in the three regions (Africa, the Near East and Asia) emergency preparedness is non-existent. To put this deficit in perspective one should appreciate that formal emergency preparedness has only been instituted within the last five years in EU countries and Australia, among the leaders in managing epidemic disease risks. Changing the status quo will require a combination of formal training, aided by extension activities, and continuous informal dialogue. From a relatively modest start the potential impact is already apparent.

The national early reaction capacity to be aimed for will consist of:

• contingency planning, both generic and for specific identified high risk diseases, tested and refined through simulation exercises; contingency fund availability assured

• arrangements made for national and local disease control headquarters, with rapid communication facilities between these and field and laboratory staff: disease emergency and epidemiology teams identified, trained and prepared

• diagnostic capabilities for all high threat diseases fully developed and tested in national and, where appropriate, provincial diagnostic laboratories: linkages established with World and Regional Reference Laboratories

• arrangements made for involvement of the private sector (e.g. farmer groups, veterinary practitioners and commercial livestock groups)

• vaccine banks in place and/or source of high quality vaccines identified

• epidemic livestock diseases included in national disaster plans so that police, army and other services can be involved on a needs basis

• legislative and administrative frameworks prepared to permit all necessary disease control actions to be implemented without delay

• veterinary services structured in such a way as to allow a nationally coordinated disease control/eradication campaign to be implemented without delay in an emergency

• communication channels to EMPRES ensured through an appointed and empowered National EMPRES Officer; operational involvement of FAO EMPRES planned including early reaction assistance where needed

THE GLOBAL AND REGIONAL EARLY REACTION COMPONENTS

An enhanced central Global Early Reaction Unit is required to:

• coordinate global early reaction activities

• establish a global contingency plan for disease emergencies which will ensure the immediate availability of global early reaction assistance teams, trained and prepared

• prepare communication literature, audiovisuals, manuals

• conduct regional training/workshops

• ensure functioning of World Reference Laboratories

• be closely coordinated with the EMPRES Global Early Warning System

It is intended to enhance the impact of headquarters capacity by working through Regional EMPRES Units (initially three - for Africa, the Near East with Central Asia, and South/South-east Asia) which will need to have direct and frequent contact with national EMPRES liaison officers in each country and be able to provide immediate assistance with analysis and coordinating any additional inputs required for immediate definition, containment and elimination of outbreaks. They require guidance and assistance from the Central Early Reaction Unit. A Regional unit would be responsible for:

• providing training, assisting with contingency planning, guiding epidemiological prioritisation and veterinary service structure development

• ensuring that a regional contingency plan is in place with resources available, Regional Disease Emergency Teams are trained and prepared and that agreements with countries are made for staff access/collaboration/ release

• assisting national counterparts with active investigation of suspicious disease events

• ensuring the functioning of National Diagnostic Laboratories

• ensure the functioning of the Regional Reference Laboratories

• developing regional epidemiological understanding

• being the eyes and ears of the central EMPRES Unit with ensured, constant, rapid communication

If the regional element develops as anticipated it is to be expected that regional organisations and regionally-based donors will assume responsibility for an increasing proportion of the required support. The central unit will require extra-budgetary resources as will the regional units initially.