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Trends in Infectious Disease Mortality Rates, Spain, 1980–2011

In Spain, as in other industrialized countries, mortality rates decreased overall and for children over the course of the twentieth century, life expectancy increased dramatically. However, other threats to human health related to emergence and reemergence of infectious disease have arisen 7 , mainly because of environmental and climate changes, travel and trade, human behavior, new technologies, microbial adaptation, and host-impaired immunity 8. These continuous threats make specific infectious disease surveillance and control programs even more necessary 8.

All-cause and cause-specific mortality rates, as well as standardized mortality rates, are still good indicators for ascertaining the public health effects of a given disease and assessing trends in incidence. Successive revisions of the International Classification of Diseases ICD have continued to apply an etiologic criterion to pool part of infectious and parasitic diseases in a single group and leaving conditions of infectious origin in other groups.

In Spain, infectious disease mortality rates in the early s were assessed by using similar criteria and resulted in a 3-fold increase in number of deaths related to ICD codes for infectious and parasitic diseases 6 , The purposes of the current study were to determine the magnitude of infectious disease mortality rates rate overall and by sex, age, and the principal causes implicated, and to describe trends during — to clarify surveillance needs and enhance control strategies.

In Spain, the source of mortality rate statistics is the medical death certificate, a compulsory administrative document that is completed by the physician who certifies the death. Data are subsequently forwarded to the regional mortality registries where causes of death are coded according to ICD guidelines. According to World Health Organization recommendations, the cause of death that is ICD coded should be taken as the underlying cause of death We selected deaths caused by infectious causes corresponding to ICD-9 codes for — and ICD codes for — From the ICD-9 and ICD codes, we selected all codes of infectious and parasitic diseases and other infectious causes from remaining groupings Table 1.

We calculated the crude mortality rates by using population data drawn from NSI population projections. Age- and sex-adjusted rates were calculated by using the direct method and the standard European population as a reference. We computed the sex ratio of the adjusted rates to assess sex-related differences. Subsequently, we analyzed the trends of death rates by using a joinpoint regression model to estimate the annual percentage change APC and to identify trend inflection points joinpoints when present. An inflection point was defined as the year representing the final endpoint of 1 period and the initial endpoint of a subsequent period; thus, all periods overlap.

For each period, an APC was calculated. We computed APC for each trend by using generalized linear models and assuming a Poisson distribution This analysis initially assumes that there are no joinpoints and iteratively fits models until a curve with the minimum number of joinpoints is selected by using permutation tests Adjusted rates and SEs were used to fit all joinpoint models, except for analyses by age group, for which deaths and populations under a Poisson model were used.

This method identifies through simulations the minimum number of inflection points i. When the APC is positive and significant, it indicates that the trend is increasing. When the APC is negative and significant, it indicates that the trend is decreasing. Data analyses were performed by using Stata 12 StataCorp. This study was conducted as an activity of infectious disease surveillance at the National Center of Epidemiology, Madrid, Spain. During —, there were , deaths caused by infectious diseases in Spain.

Although the crude mortality rate decreased from The joinpoint method identified 2 inflection points in the trend, the first in and the second in Among men, 4 periods of change were observed. Among women, only 2 periods — and — of change were observed. During —, the male: Sex-specific mortality rates were higher for male patients across all age groups. A notable peak in deaths occurred in — because of AIDS; the population segment most affected was men 25—44 years of age Figure 2.

The study period showed a major decrease in mortality rates among male and female patients across all age groups. Infectious disease mortality rates by sex and age group, Spain, — APC, annual percentage change age-adjusted or age-specific rate ; —, not applicable; AR, age-adjusted rates. The mortality rate for pneumonia showed the largest decrease. Deaths caused by cardiac and renal infections showed mutually opposite trends: Viral hepatitis and intestinal infections had the lowest mortality rates Figure 3.

Of the 10 first studied diseases, pneumonia showed the largest decrease in mortality rate. Previous studies showed that analysis of infectious disease mortality rates should take into account infectious disease—related ICD codes from groups other than infectious and parasitic diseases in different ICD revisions because relying only on infectious and parasitic diseases will lead to underestimation of infectious disease mortality rates 1 , 6 , 10 , 14 , Using this approach, we showed that 3 times more deaths were caused by infectious disease in Spain in than when only codes for infectious and parasitic diseases were analyzed, which resulted in a reported underestimated rate Our estimated rate was Comparison of mortality rates for Spain with those for other countries in Europe is difficult because no standardized data are available, whether because such data solely take the traditional categories into account or because they refer to different periods.

For , Eurostat data 17 for the European Union 27 member states showed an adjusted mortality rate of 8. Oxford Textbook of Medical Mycology. Local Invasion and Spread of Cancer. The Genetics of Cardiovascular Disease.

Mary Ella Mascia Pierpont. Pregnancy and Congenital Heart Disease. The Eye in Pediatric Systemic Disease. Severe Infections Caused by Pseudomonas Aeruginosa. Clinical Microbiology for Diagnostic Laboratory Scientists. Viral Hepatitis in Children. Helicobacter pylori Biology and Clinical Practice. Current Topics in Complement II. The Surgery of Childhood Tumors. Clinical Use of Anti-infective Agents. Antibiotic and Antifungal Therapies in Dermatology. Clinical Applications of Botulinum Neurotoxin. Bioterrorism and Infectious Agents. Drug Resistance in Leishmania Parasites.

History of Vaccine Development. Reviews of Physiology, Biochemistry and Pharmacology, Vol. Overactive Bladder in Clinical Practice. West Nile Encephalitis Virus Infection. Pathology of Pediatric Gastrointestinal and Liver Disease. Doing so increases sensitivity simply because more conditions are monitored, but as discussed above, increasing the number of syndromes monitored will also increase the number of false positives. Another possibility is to pool data over multiple data streams, perhaps from all hospitals in a metropolitan area or state.

A number of cities are currently doing this. If this results in both the signal and the background increasing proportionally, it will result in a more effective system. Moreover, such an increase would be clear without any sophisticated surveillance system. One can analyze the data for the entire city and for each hospital individually, but with 10 separate analyses, the number of false positives would also increase.

Finally, the data can be analyzed geographically. If there were 18 extra cases of ILI in a city, and all lived in the same neighborhood, that would be more informative than 18 cases scattered throughout the city—it would suggest a biological agent released in that area. This is only effective, however, for a geographically focused bioattack, and would not work if terrorists chose to expose people in an office building or at an airport. It is also less likely to detect seasonal or pandemic influenza, which spreads rapidly before symptoms appear.

The most value, however, may ultimately come from its use in the detection of natural disease outbreaks. More generally, if 21st century syndromic surveillance means effective use of health information technology in identifying cases before they are formally diagnosed, it can supplement traditional public health approaches and improve their effectiveness.

One potential use is in detecting influenza outbreaks. A pandemic, or worldwide outbreak of a new influenza virus, perhaps evolving from the H5N1 avian flu virus circulating in Asia, could dwarf this impact by overwhelming our health and medical capabilities, potentially resulting in hundreds of thousands of deaths, millions of hospitalizations, and hundreds of billions of dollars in direct and indirect costs. Syndromic surveillance systems feature prominently in federal, state, and local plans to prepare the United States for pandemic flu Homeland Security Council, The Centers for Disease Control and Prevention CDC has a number of influenza surveillance systems in place CDC, , yet they do not provide population-based rates of incidence or prevalence rates on a national level because many infected persons are asymptomatic or experience only mild illness and do not seek medical care.

Also, laboratory testing is not common and test results become available late in the course of the illness. Epidemiological characteristics of both seasonal and pandemic influenza, however, suggest that syndromic surveillance and other surveillance systems are likely to make an important contribution beyond the capabilities of existing surveillance systems, and thus enable a more effective public health response.

Simulation studies have shown that unless a bioterrorism outlook is exceptionally large, syndromic surveillance detection algorithms take days to be detected Stoto et al. This time frame is longer than some proponents of syndromic surveillance as a tool to detect bioterrorism suggest is needed Wagner et al. Compared to the current influenza surveillance systems, however, a one-week lead time would provide valuable information, and this is likely to be achievable for syndromic surveillance.

Furthermore, a number of studies have demonstrated the potential that syndromic surveillance of ILI offers at the national, state, and local levels. Sebastiani and colleagues have shown that children and infants presenting to the pediatric emergency department ED with respiratory syndromes are an early indicator of impending influenza morbidity and mortality, sometimes by as much as three weeks. With similar data, Olson and colleagues note that age-stratified analyses of ED visits for fever and respiratory complaints offer the potential for more precise quantification of the burden of illness, earlier warning of the arrival of epidemic influenza, and greater sensitivity for detecting the characteristic age shift of pandemic influenza.

Given a built-in delay of about two weeks in the CDC system, this is a substantial advantage. In normal flu seasons, laboratory analysis to determine whether a case is truly influenza, or to identify the viral strain, is rarely done.

The rodent importer in Texas did not reimburse government agencies for the millions of dollars spent on the response to monkeypox in the United States. Variant Cretzfeldt-Jakob disease death, United States. Your display name should be at least 2 characters long. Who should be under surveillance and for what are most critical. The threat of pandemic influenza:

Testing, however, is critical for identifying pandemic influenza, in which an antigenic shift results in a new viral strain to which few people are immune by virtue of previous exposure. Syndromic surveillance of flu-like symptoms might trigger more laboratory analysis than is typically done and in this way hasten the public health response. In a normal flu season, Labus has reported that early identification of the start of the influenza season using syndromic surveillance in Clark County, Nevada, enabled the notification of the medical community.

Physicians were encouraged to submit specimens for culture, and the county health department provided kits to help them do this, which allowed for rapid identification of the major circulating strain. In — a period with a marked increase of early season influenza and deaths in children in other parts of the country this syndromic surveillance system allowed for better tracking, and provided data for daily reports to decision makers and the media. Because of their focus on the early detection of bioterrorist events, most syndromic surveillance systems are designed to detect large increases in the number of people with common symptoms such as ILI.

As a result, they cannot be expected to detect small numbers of cases, even if very unusual. One reason is that in a small disease outbreak or the early stages of a larger one, each case will be seen by only one physician. The natural tendency of physicians who see only one case, however suspicious it may be, is to discount it. Modern health informatics systems provide the potential to identify the presence of small numbers of cases of concern before they are formally diagnosed. For example, automated systems can aggregate data for a metropolitan area, spanning local reporting jurisdictions, to identify, say, cases of rash and fever, which would suggest smallpox.

Systems can also be set up to enable and encourage early reporting of cases based on symptoms only. For example, the Syndrome Reporting Information System SYRIS system, now operating in Lubbock, Texas, and elsewhere, enables physicians to report suspicious cases to the local health department without waiting for laboratory confirmation, and encourages them to do so by providing feedback in the form of information about practice guidelines and other similar cases Lindley and Ward, Real-time access to prediagnostic data can also help health authorities respond to public health threats.

If person-to-person transmission of avian flu virus is documented in Asia, for example, health departments in Europe and the United States might want to identify and follow up on local cases of people hospitalized with flu-like symptoms, and syndromic surveillance systems could be designed to identify them. If an environmental sensor detects signs of the terrorist agent tularemia, syndromic surveillance systems can be checked for cases with appropriate symptoms. This actually occurred in Washington, DC in , and the lack of cases in area emergency rooms reassured local officials that the alarm was false.

Syndromic surveillance systems can also be queried to determine background rates when it is not clear whether a reported cluster of cases is unusual. H57 outbreak in the New York City area in late provides an example of how syndromic surveillance could have been used for case finding. The outbreak came to light on November 17 when the first case was reported to a local health department in New Jersey.

By November 27, 11 cases were reported in that jurisdiction. Three days later the Taco Bell restaurant, where people in 9 of the 11 cases had eaten closed voluntarily. On December 1, a similar case originally attributed to another cause was reported to a local health department in New York state, and it turned out that this person and three others in that jurisdiction had eaten at a different Taco Bell restaurant.

By December 4, all Taco Bells in the New York metropolitan area were closed, and two days later a particular food item, green onions, was identified as the likely source of contamination. By December 9, more than 61 E. H57 cases in at least four states were reported CDC, d. Although a number of syndromic surveillance systems were operating at this time in New York City and the surrounding jurisdictions, there were too few cases in any location to detect.

However, once the outbreak was identified in New Jersey, an advanced syndromic surveillance system could have searched emergency department admissions for cases of bloody diarrhea and abdominal cramps in the entire metropolitan area. Cases so identified could have been interviewed to take a food history, and lab samples obtained to test for E.

In addition, health departments could have initiated active surveillance by physicians in the area, searched data from surrounding states to identify additional cases for follow-up and to confirm lack of cases elsewhere. If these steps had been taken, it is possible the restaurant chain and green onions could have been identified and remedial steps taken earlier—either closing the restaurant or removing the green onions.

It is also likely that the additional data from syndromic surveillance systems could have resolved the uncertainty about what was happening and thus diminished public concerns. Using syndromic surveillance—essentially, prediagnostic health information in existing electronic databases—as these examples suggest requires flexible and easily accessible IT systems, as well as a relationship between data providers and health departments that enables the systems to be used when needed.

A benefit of developing these relationships may be improved communications between health-care providers and public health, which is essential to responding to any health emergency. Any careful review of the development of syndromic surveillance in the past five years would have to conclude that much impressive work has been done with respect to information technology, including the real-time integration of many disparate data streams, and analysis—the development of statistical models, detection algorithms, and methods to visualize syndromic data.

From a public health practice point of view, however, the value of syndromic surveillance for detecting bioterrorist attacks has not yet been demonstrated. There are two major reasons for this conclusion. First, in statistical terms, there is a relatively narrow window between what can be detected in the first few days and what is obvious. Second, better integration with public health systems is needed before information generated is useful in guiding a public health response.

The analysis in this paper, however, suggests that the most important contribution of syndromic surveillance to public health practice may be for natural disease outbreaks, such as seasonal and pandemic flu, and as a tool to monitor outbreaks and guide the public health response. Realizing this potential will require designing systems that focus on these uses rather than being optimized for timely detection of large-scale bioterrorist attacks.

Trends in Infectious Disease Mortality Rates, Spain, 1980–2011

Instead of automating the process of detecting outbreaks with statistical detection algorithms, it might be more useful to build flexible analytical tools into syndromic surveillance systems so they can monitor ongoing bioevents and facilitate epidemiological analysis. Any discussion must begin with some formal definition of these terms.

Real-time computing systems are required for time-critical applications where the result of a computing process is time critical. Examples with which most everyone is familiar are video games where a split-second delay could change the result of an outcome, or the use of antilock brake systems in cars to provide immediate feedback and response to avoid a collision. The Encarta Microsoft Encarta, definition includes:. Batched reporting of surveillance data, however, can mean a variety of things.

The following are just a few:. This is usually the first step in the surveillance process. These algorithms can be used to convert unstructured text data into structured data, for the identification of abnormal trends in the data, or for transforming data and information to be viewed in a manner that would permit easy interpretation by a variety of users. Batched reporting is also used to refer to the actions needed to present data and algorithm outputs to the users of surveillance systems.

Collection and processing of data do not occur at the same time as when data and results are being made available to the user. Batched health data may be reported to users as soon as it is processed, or it may be delivered at regular intervals, or accessed on demand. Reports of animal diseases occurred monthly in some jurisdictions for those diseases that are reportable, but do not pose an immediate threat. Figure presents an example of a generic disease surveillance system. Data acquisition occurs on the left of the figure.

User interfaces are on the right, and archiving and analytic processes are in the center. Possible sources of early indicators of population health include calls, emergency medical services, emergency department chief complaints, over-the-counter self-medications, etc. Some of the indicator data can be made available in real time while others can not.

Only data that is captured in real time can be made available for surveillance in real time. Several large retailers of over-the-counter medications capture their sales in real time so they can keep track of inventory in each store. Schools track absenteeism on a daily basis and not throughout the school day. School nurses could potentially track every student visit as it occurs. These systems provide a comprehensive framework for the exchange, integration, sharing, and retrieval of electronic health information. Such information includes the instruction of orders; clinical observations and data, including test results; admission, transfer and discharge records; and billing information.

HL-7 has become a standard for the interfacing of clinical data for many large hospitals Health Data Standards: Monitoring an HL-7 data stream provides hospital record data as close to the time they are created as possible. Electronic health monitoring components. To preserve the timeliness of HL-7 records, many developers and surveillance system users believe the records need to be transmitted to the automated surveillance system as quickly as they are created. One method for preserving this timeliness is to provide continuous transmission of HL-7 records between the hospital and the surveillance system.

Most state and local health departments have varying requirements for the timeliness in which data are provided for surveillance. Many health departments believe that receiving data once a day may be sufficient, while others believe that real time is mandatory. The Department of Health and Human Services for Montgomery County, Maryland, has implemented its data collection surveillance component so it can acquire data at higher rates during times when the department is concerned about a possible health risk.

Once the data are acquired and archived by the surveillance system several processing steps could occur. Initial processing is needed to reduce entry and transmission errors.

Automated surveillance systems employ a variety of algorithms 4 to process data for early detection of a health event. If the datasets are large or diverse, or come from many different sources, the signal processing steps can require several minutes to hours of computing time. Certain algorithms, such as those for spatial analysis e.

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Processing is initiated and results are provided after well-defined periods, such as every four hours. Some surveillance systems are interactive and allow the user to invoke specific processes to get an immediate result. These systems permit the user to analyze and view data as they are being received. Data are processed at regular intervals and results available for display, but they are also available for user-defined analysis as soon as they are received, archived, and preliminary processes are completed. Many advanced disease surveillance systems take advantage of modern Internet technology.

Most modern disease surveillance systems provide outputs to users as soon as the signal processing phase is complete. Users log on to the surveillance system and view the alerts or data. Most modern disease surveillance systems have multiple processes that must be completed before the data are provided to users. Collecting data in real time while processing it in batch due to the constraints in computing time does not make for a real time system. Going through the extra expense of maintaining a VPN to collect HL-7 hospitals as they are being created makes little sense unless these data can be processed and made available to the analyst also in real time However, the question remains whether real time is even needed by public health.

The total throughput or time delay of the current BioSense processing steps is not known to the author, but it can safely be estimated to be greater than 15 minutes.

The BioSense data feed is batched, but more timely than systems claiming to be real time. Given constraints on time and resources, one could envision two modes of operation for electronic surveillance systems: For routine monitoring purposes, it will be of paramount importance to keep alert rates to a manageable level. The focused monitoring of perceived threats should be a rare occurrence, but essential information should be obtainable in sufficient time to mount an effective response to an emerging crisis. The benefits of real-time data collection are only realized if all other components of a surveillance system satisfy the real-time criteria.

Receiving and processing health indicator data several times an hour should be more than adequate for public health needs, even during public health emergencies. Consumers should attempt to understand the actual system characteristics rather than relaying the misuse of terms by vendors of surveillance systems. Outbreaks of avian influenza, severe acute respiratory syndrome SARS , Ebola hemorrhagic fever, bovine spongiform encephalopathy mad cow disease , and other emerging diseases are surprising the public, disrupting globalization, resulting in massive economic losses, and jeopardizing business and diplomatic relations.

These diseases, which are able to cross the Darwinian divide between animals and people, do not depend on humans for their survival and easily live far from the reaches of most medical interventions. Their competitive advantage in this regard demands that we revisit basic strategies for disease control, including the assumptions from the s declaring the chapter on the threat of infectious diseases closed. Not only was this narrow, urban human health point of view premature, but it diverted resources away from preparedness for dealing with the modern-day world of rapid travel and transportation of both goods and people, higher human population densities, and a growing dependence on intensified livestock production.

For much of the world, there are no systems of inspections for these markets, and few people have access to good health care, education on hygiene, common vaccinations, or antibiotics. The global transport of animals and animal products, which includes hundreds of species of wildlife Karesh et al. Surveillance of infectious diseases is most useful when it occurs as close to the source as possible, rather than waiting to measure morbidity and mortality in distant lands.

This requires a new approach, one that engages people around the world to work together in earnest and share findings in a timely manner. Currently, no government agency is responsible for, or capable of, the surveillance and prevention of the myriad diseases residing around the world. None are given the responsibility for robustly pursuing the simplest of concepts— the health of people, animals, plants, and the environment in which we all live are inextricably linked.

The great gains from specialization in the fields of human health, public health, livestock health, and wildlife health have unfortunately resulted in academic hubris and reduced communication across disciplines by the end of the 20th century. Radar screens are set to blink when livestock are threatened. Even the more recent concerns of agroterrorism have not done enough to support the global outreach necessary to understanding and reducing diseases overseas before they reach U.

Emerging Tickborne Diseases

The wildlife services branch of USDA traditionally was focused on wildlife control and eradication in order to protect livestock. It is rapidly trying to remake itself in a modern world that is recognizing the cultural, ecosystem, and economic value of wildlife itself. But developing an effective program, building a reputation and trust among the wildlife community, and developing expertise in wildlife surveillance will take a long-term commitment that may or may not be on the horizon or appropriate, in all fairness for a federal agency focused on agricultural production and markets.

Traditionally, few resources were devoted to exploring the linkages of the health of wild plants and animals with their domesticated cousins. This has changed since , and a small program was begun in collaboration with the WCS to coordinate responses and investigations of highly pathogenic avian influenza virus in wild birds.

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In the past two years, they have formed a parallel committee to address zoonotic and emerging diseases but the two committees are not linked to one another. The World Health Organization WHO is directed at human health, but until the change in the International Health Regulations IHRs that took effect this year, they could only respond on official invitation from a country that may or may not know about, or want to reveal, the presence of a disease.

The changes in scope will allow for gathering of information without going through official channels. This could help significantly in global response time, but the IHRs are still institutionally entrenched in a world of human disease. Centers for Disease Control and Prevention CDC has the responsibility to prevent human diseases in the United States, and extend their reach around the world, but also only when invited.

No government agency or multilateral organization is charged with uniting knowledge and efforts that span the diversity of disease threats to people, domestic animals, and wildlife. No one is ensuring that health solutions are based on the input of expertise from human, domestic animal, and wildlife health professionals and equally important, communicated across disciplines in terms that effectively motivate all stakeholders and demonstrate common goals.

Clearly, there is an urgent need for a new health paradigm that not only integrates the efforts of disparate groups, but possibly more important, balances their respective influences to prevent both the gaps and the biases that we are now coming to recognize. The failure to recognize and aggressively address the broad range of diseases that have no respect for hundreds of years of earnest scientific classification, places animals and people in great danger.

The immediate effects of the diseases themselves are often the least of the worries. Analyses indicate that more than 60 percent of the over 1, infectious diseases currently known to modern medicine are shared between humans and animals Taylor et al. From an anthropocentric point of view, most of these infectious agents are labeled zoonotic, or diseases of animals that infect people. Anthrax, Rift Valley fever, plague, Lyme disease, and monkeypox are just a few examples. Receiving less attention is the other group that moves across species boundaries, the anthropozoonotic diseases.

These infectious diseases are typically found in humans but can, and do, infect animals. Human herpes virus, human tuberculosis, and human measles are all transmissible to a variety of animal species, with devastating consequences. This traditional division of infectious agents into two groups is convenient for teaching purposes, but lacks the broader and critically important concept that these diseases can move back and forth, and change characteristics in the process.

Avian influenza is but one disease that is teaching the medical world about the need for a more holistic point of view. Recent Ebola hemorrhagic fever outbreaks in humans in Africa have a similar history. The disease was first recognized by the western world when it appeared in the Democratic Republic of Congo in , around the Ebola River. The virus infects people, gorillas, chimpanzees, and monkeys Leroy et al. It causes severe internal and external hemorrhaging, and can be extremely deadly, killing up to 90 percent of its human victims.

Infection spreads quickly, especially via caregivers and by those who flee to escape the illness. But it is clear that both people and nonhuman primates suffer equally from the disease. Outbreaks have caused declines in lowland gorillas and chimpanzees in Gabon and the Republic of Congo, and chimpanzees in western equatorial Africa. Other forest animals, such as duikers—small antelopes—and bush pigs may also be affected. When subsistence hunters discover a sick or dead animal in the forest, they view it as good fortune and bring it home to feed their families and trade with neighbors.

The Ebola virus then easily infects those handling the meat, and a chain of contacts and infections ensues. Each human outbreak in central Africa during the late s and the first years of this century was traced to humans handling infected great apes. The SARS coronavirus has been associated with the trade in small wild carnivores. People began complaining of high fever, cough, and diarrhea, and eventually developed severe pneumonia. It was an unknown disease, and it was very contagious. Within a matter of weeks, it spread via a hotel visitor in Hong Kong to five continents.

By July , WHO had tallied 8, cases, with deaths. A coronavirus a family of viruses found in many animal species was finally discovered to be the culprit, and it was also detected in masked palm civets that were farmed in the region and sold for human consumption. Later, evidence of the virus was also found in raccoon dogs, ferrets, and badgers in the wildlife markets, as well as domestic cats living in the city and a closely related coronavirus in bats commonly sold in the same markets.

Epidemiological studies have concluded that the first human infections did indeed come through animal contact, though the exact species has not been definitively identified Tu et al. Within 10 days, nearly a million animals were confiscated, many brought in from other parts of the world with their exotic viruses and bacteria, demonstrating that law enforcement can in fact be used to reduce or control the trade in wildlife and wildlife products.

If a virus or bacteria was hoping to win the big lottery of jumping among species, going to the markets of Guangdong would be like buying a million lottery tickets.

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The profits from the wildlife trade in China pale in comparison with the estimated U. The inadvertent movement of infectious agents due to wildlife handling and trade, as well as domestic animal movement, is not limited to human pathogens, but also extends to those that can devastate native wildlife, which serve as biological linchpins for environmental integrity and provide a range of cultural and quantifiable economic values Karesh et al.

In , H5N1 Type A influenza virus was isolated from two mountain hawk eagles illegally imported from Thailand in airline cabin carry-on baggage to Belgium OIE, Tuberculosis originating from domestic cattle has now infected wild herds of bison in Canada, deer in Michigan and Wisconsin, and Cape buffalo and lions in South Africa. Surveillance of these wild populations is now needed not only to assess risk for humans and livestock, but for the wild animals themselves. In one swift outbreak of rinderpest, a disease originally introduced to Africa by the importation of domestic cattle, more wild buffalo died in Kenya in than were killed by illegal poaching during the previous two decades.

Exact quantification of the global wildlife trade is impossible because it ranges in scale from extremely local to major international routes, and much is illegal, or through informal channels. WCS figures compiled from a variety of sources for just the live wildlife trade indicate that each year, roughly 40, live primates, 4 million live birds, and , live reptiles are traded globally Karesh et al. Daily, wild mammals, birds, and reptiles flow through trading centers where they are in contact with humans and dozens of other species before being shipped to other markets, sold locally, and even freed back into the wild with new potential pathogens as part of religious customs such as merit release or because they become unwanted pets.

Conservative estimates indicate that in east and southeast Asia, tens of millions of wild animals are shipped regionally and from around the world annually for food or use in traditional medicine. The estimate for trade and local and regional consumption of wild animal meat in Central Africa alone is more than 1 billion kg per year Wilkie and Carpenter, In Central Africa, estimates of the number of animals consumed by humans annually vary, but a figure of million has been proposed.

Estimates for consumption in the Amazon Basin range from 67 to million kg annually, comprising, for mammals alone, between 6. Hunters, middle marketers, and consumers make some type of contact with each animal traded. Additionally, domestic animals and wild scavengers in villages and market areas consume the remnants and wastes from the traded and to-be-traded wildlife. These numbers combined suggest that at least some multiple of 1 billion direct and indirect contacts among wildlife, humans, and domestic animals result from the handling of wildlife and the wildlife trade annually.

In addition to the direct health effects of the pathogens on people and animals, animal-related disease outbreaks have caused hundreds of billions of dollars of economic damage globally, destabilizing trade, and resulting in devastating effects on human livelihoods. The costs are rarely borne by the same individuals that profit from the movement of animals and their pathogens. Wildlife market traders did not bear the costs of the SARS outbreak.

The rodent importer in Texas did not reimburse government agencies for the millions of dollars spent on the response to monkeypox in the United States. Hundreds of millions of public dollars will be spent in attempting to remove tuberculosis and brucellosis from wildlife populations infected by domestic animals.

In early , FAO reported that more than one-third of all global meat trade was embargoed as a result of mad cow disease, avian influenza, and other livestock disease outbreaks. The projected growth of industrial livestock production in developing countries to meet rising global protein demand will increase both the economic and the food security impacts of future disease outbreaks, and the global economic impacts do not adequately reflect the local, direct effects.

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Preventing and controlling infectious diseases in the modern world requires a far broader range of expertise than needed for previously isolated systems in highly developed countries. The challenges seen in controlling avian influenza in Asia and Africa are just one example of the multispecies disease dilemma. Most of these diseases threaten local people directly, as well as their livestock and their livelihoods. They decimate wildlife and undermine ecosystem stability and services, and with modern travel and transport, they can quickly pose a threat to any nation.

Fear, understandably founded on a lack of information, can drive global responses and economic reactions far beyond the actual cost of disease control. Currently, it appears that a few people in some of the most remote places on earth, many from nongovernmental organizations NGOs and many working at local government levels but unlinked to larger formal networks, are working to fill the intersectorial gaps in health care as they relate to emerging diseases and wildlife.

The work is directed where rare infectious diseases are least understood and local institutions have the fewest capabilities to effect prevention and control. Our staff and partners routinely encounter diseases such as anthrax, avian influenza, monkeypox, and Ebola where they naturally occur.

We build local capacity to conduct surveillance and reporting networks at very low costs. When attention was being misdirected at wild birds in efforts to control the current avian influenza outbreaks in Southeast and East Asia, these new, but informally recognized participants in health discussions, were the first to point out that migratory routes and seasonal timings did not correspond with the regional spread of the disease as posited by articles in prestigious scientific journals—it was the largely uncontrolled movements of domestic birds that were spreading this disease, not wildlife.