ISSUE REPORT ANIMAL-BORNE EPIDEMICS OUT OF CONTROL: Threatening the Nation’s Health TRUST FOR AMERICA’S HEALTH IS F or centuries, humans have been afflicted with diseases that originate in ani- mals. Many of the agents responsible for epidemics throughout human his- tory have their origins in animals: tuberculosis, influenza, bubonic plague, food- A NON-PROFIT, NON-PARTISAN borne illness, and AIDS. Episodes of animal-borne diseases, also referred to as ORGANIZATION DEDICATED TO zoonotic diseases or zoonoses, are increasing around the globe.1 Exotic sounding SAVING LIVES BY PROTECTING ailments, including severe acute respiratory syndrome (SARS), monkeypox, West T H E H E A LT H O F E V E RY COMMUNITY AND WORKING TO Nile virus (WNV), mad cow disease, Lyme disease, and chronic wasting disease MAKE DISEASE PREVENTION A (CWD), a fatal disease affecting deer and elk, have been capturing global head- NATIONAL PRIORITY. lines. Some scientists expect the rise in zoonotic disease episodes to continue.2 Despite the surge in animal-borne diseases cially troublesome given that many of the threatening Americans, the country lacks a potential agents for biological weapons are concerted national program to prevent and zoonotic.4 For instance, anthrax, which can control these illnesses, which can impact be weaponized, has historically been passed humans, animals, and food, in the U.S. and from the soil to farm animals to humans.5 abroad. There is no strong, coordinated This report examines the public health effort or a single federal agency with command response to five of these emerging animal- and control responsibility for managing this ACKNOWLEDGEMENTS: borne diseases: monkeypox, WNV, mad cow growing nationwide health problem. The This report is supported by disease, Lyme disease, and CWD, and con- Centers for Disease Control and Prevention grants from The Pew cludes that the de facto U.S. policy to animal- (CDC) has developed a plan to address ani- Charitable Trusts and the borne disease management has been a gen- mal-borne diseases, but has not received ade- Palmer Foundation. The eral evolution toward cross-agency and inter- quate resources to implement the plan.3 opinions expressed in this state task forces as the diseases progress over report are those of Trust for So, the U.S. is left with a myriad of bureau- time. Yet, the initial ad hoc approach to these America’s Health and do cratic jurisdictions that respond to various health threats delays the development of not necessarily reflect the aspects of the diseases, with little coordina- strong, proactive response and containment views of these foundations. tion and no clear plan for communicating plans. Meanwhile, the diseases continue to with the public about the health threats spread, in growing numbers. AUGUST 2003 posed by animal-borne diseases. This is espe- Consider this. Of the diseases reviewed in this report: I The monkeypox virus entered the U.S. animal health agencies is essential to pre- through imported Gambian giant rats paredness and coordination. The ability sold in the nation’s under-regulated exot- to disseminate and share information ic pet trade. The rats infected pet prairie quickly helps ensure decisions are made dogs, which passed the virus along to with the most current information. humans. The outbreak sheds light on the I The economic impact of mad cow dis- lack of coordinated federal oversight to ease8 in Great Britain has been devastat- prevent future zoonotic disease out- ing. One estimate sets the cost of eradi- breaks, as well as the confusing state and cation and interventions to support farm- federal laws that govern exotic pet trade. ers and markets at over $5 billion (£3.2 I Despite the relatively successful efforts of billion) from 1989 through 2000.9 the public health community to raise Although mad cow disease has not yet awareness about Lyme disease, it is now made an appearance in the U.S., the abil- endemic to the U.S. and the number of ity of the fragmented food safety system to cases has grown significantly. The Centers permanently prevent its entry is uncer- for Disease Control and Prevention tain. If the disease were found here, (CDC) reported 17,730 cases in 2000, the experts predict that the economic impact last year data were available. This number on the $56 billion beef and related indus- represents a notable 28.11 percent tries could be overwhelming.10 increase from the yearly average of 12,745 I Chronic wasting disease (CWD) is a fatal Lyme cases reported from 1991-2000.6 disease striking deer and elk. Left I In the case of West Nile virus, the unmanaged, the disease could potentially pathogen was discovered in the U.S. for devastate deer and elk populations, and the first time in New York City in 1999, incur major economic loss for state gov- where it sickened 62 people, killing seven ernments and private businesses that rely of them. The U.S. General Accounting on hunting for revenue.11 There appears Office (GAO) found that while aspects of to be cooperation and coordination the outbreak investigation worked well, among public and animal health officials the “lack of leadership in the initial in the federal government, and between stages” and the lack of communication the states and federal government with channels among the many agencies respect to CWD. However, because it con- involved prevented information from tinues to be viewed as primarily a wildlife being shared efficiently.7 Rapid and reli- health issue, sufficient funding is lacking able communication between public and to fully control the disease. Why Are Animal-Borne Epidemics Increasing? Humans who come in contact with infected I People are moving into parts of the world animals or disease vectors12 risk contracting a where humans have never lived before, “zoonotic” disease that the animal may be exposing themselves to unknown infectious carrying. The opportunities for such contact agents. are growing steadily: I Air travel and cargo ships allow an infec- I Human and farm animal populations tious person or animal to reach far flung are increasing around the world, and in some parts of the globe in less time than the areas like Southeast Asia, this is bringing more incubation period of many pathogens. humans and animals into close contact. 2 I Importing exotic animals for pets also which are consumed as food. Many public increases the opportunities for the spread health officials now speculate that the virus of zoonotic disease. causing SARS likely jumped from the civets to humans as the animals were handled in I Overlapping animal migration routes markets and during meal preparation.14 introduce birds and other animals into new These individuals fell ill and infected others geographic areas, along with the infectious with the disease. From markets and agents they harbor. kitchens in China, the virus was carried by The emergence of SARS illustrates how infected people traveling to North America, humans can contract diseases through con- Europe, South America, and Africa. tact with animals.13 In China, restaurant Similarly, the AIDS virus is thought to have workers and other individuals handling entered the human population when mongoose-like animals called civets hunters in central Africa killed monkeys for acquired the illness from these animals, food that carried a closely related virus.15 Monkeypox M onkeypox is an infectious, viral disease endemic to Central and Western Africa. In early June 2003, officials in several Midwestern states reported the first human cases of monkeypox contracted in the United States. As of July 2, 2003, over 80 cases of possible monkeypox have been reported in six states: Wisconsin, Indiana, Illinois, Missouri, Ohio, and Kansas. More than 30 of these have been confirmed as monkeypox.16 The monkeypox virus was first discovered in lymph nodes, and exhaustion.20 The illness African laboratory monkeys in 1958, hence lasts two to four weeks. Within one to ten days the name. It belongs to the same of the onset of fever, a rash characterized by orthopoxvirus group of viruses as smallpox, 17 raised bumps and lesions develops, often on though it is less communicable and less the face and trunk. The monkeypox lesions fatal. Human monkeypox outbreaks in then break open and produce scabs or scars, Africa, first documented in 1970, typically similar in appearance to smallpox and produce a fatality rate ranging from one to chickenpox scars. The incubation period ten percent.18 In the recent domestic out- ranges from one to three weeks.21 break, none of the cases have resulted in Currently,the vaccine used for smallpox is death. In past African outbreaks, a weak- 85 percent effective in preventing monkeypox. ened form of the virus has spread from per- CDC has recommended that individuals son-to-person. In the current U.S. outbreak, who have had close or intimate contact with however, no one infected is believed to have individuals or animals with the disease should contracted the virus from another human. be vaccinated with the smallpox vaccine. Humans become infected through a bite or The Public Health Response to contact with an infected animal’s blood, body Monkeypox fluid, or lesions.19 People infected with the monkeypox virus report a range of symptoms, On May 22, a young child in Wisconsin visited including: fever greater than 99.3°F, headache, her physician, exhibiting symptoms consistent muscle ache, backache, chills, cough, swollen with an orthopoxvirus. The child had a high 3 AGENCIES AND ORGANIZATIONS INVOLVED IN MANAGING MONKEYPOX fever and a sore throat that developed after family. In Illinois, as of July 2, 2003, the she was bitten by her pet prairie dog. While Department of Public Health had been inves- this was a complex diagnostic determination, tigating 16 confirmed and possible cases.23 the local health department and CDC were Complications in the investigation escalated not notified until June 4 — 13 days later.22 This when a connection was made between the dis- gap delayed the activation of the Emergency ease and pet prairie dogs, specifically a set of Operations Center at CDC, an agency of the pet prairie dogs that were housed with a variety U.S. Department of Health and Human of imported rodents, including Gambian giant Services (HHS). The Emergency Operations rats, which also were being sold as exotic pets. Center is responsible for receiving reports of These rodents are suspected to have carried the suspected infectious disease outbreaks and monkeypox virus from West or Central Africa. launching investigations. While CDC has jurisdiction over national dis- The National Center for Infectious Diseases ease control and prevention, it generally does (NCID), a center within CDC, assumed feder- not have the authority to regulate animals, al responsibility for the monkeypox investiga- agriculture, or food. An effort comprised of tion and management. CDC then worked in industry, government, and academic institu- coordination with state and local public tions operate a system to address emergencies health departments in places where they sus- animals face such as floods, drought and, pected potentially infected people. CDC infectious agents — the National Animal interacts with most of these health depart- Health Emergency System. However, there is ments on a cooperative, voluntary basis, but no corresponding proactive rapid response does not generally dictate how a jurisdiction vehicle to call upon to coordinate health manages disease outbreaks within their local threats that cross both humans and animals. borders. Each state impacted was responsible Instead, the federal Agriculture, Interior, and for dealing with the disease outbreak in its Homeland Security Departments, along with own way. For example, in Wisconsin, the their state and local counterparts, each had to Division of Public Health investigated report- respond to different animal, wildlife, trade, ed cases of monkeypox. The agency also used and security issues, to supplement the efforts its authority to quarantine several individuals of HHS, CDC, and the FDA. The U.S. infected, most notably the child, who had Department of Agriculture’s (USDA) Animal been bitten by her pet prairie dog, and her 4 and Plant Health Inspection Service (APHIS) governing the exotic pet trade, most other helps regulate the exotic pet trade and was states do not.27 called in to investigate the movement of the Efforts to control monkeypox spanned across suspect prairie dogs and Gambian giant rats. the local, state, and federal agencies responsi- On June 11, 2003, HHS imposed a nation- ble for the health of communities, for agricul- wide ban on importing certain rodent species ture, for animal inspections, and for monitor- from Africa, and prohibited the distribution, ing exotic pet trade and commerce. In total, sale, or transport of prairie dogs and six four federal Cabinet Departments, five federal rodent species within the United States.24 agencies, and the corresponding departments CDC and the FDA are in charge of these in each of the impacted states and communi- embargoes, but cannot functionally enforce ties patched together monkeypox contain- the ban without support from the Bureau of ment solutions. Customs and Border Protection, part of the Since the carriers of the virus were found and U.S. Department of Homeland Security, and contained relatively quickly, the human out- the U.S. Fish and Wildlife Service, a division break was able to be largely controlled. of the U.S. Department of the Interior.25 Testing wild rodent populations is ongoing to The states with suspected monkeypox cases detect whether virus has become established then had to devise their own animal con- in domestic or wildlife animals. However, if tainment response. There is a relative pauci- monkeypox were a more virulent and conta- ty of laws governing exotic pet trade. In gious virus, the lack of an effective human- addition, these laws vary greatly from state to animal disease management strategy likely state.26 While two states, Georgia and would have led to more tragic results. California, have fairly comprehensive laws West Nile Virus W est Nile virus (WNV), first identified in Uganda in 1937, infects mosquitoes, birds, humans and horses. WNV is a type of virus that causes encephalitis, or inflammation of the brain. The virus has been confirmed in Africa, Western Asia, the Middle East, the Mediterranean region of Europe and, since 1999, in North and Central America. WNV exists through a transmission cycle In people, most infections produce no symp- involving mosquitoes and birds. Mosquitoes toms, or mild to moderate symptoms. An esti- become infected with the virus when they mated 20 percent of people infected will feed on infected birds, which carry the virus develop West Nile fever. Symptoms may in their blood. Infected mosquitoes can then include headache, fever, and body aches, transmit WNV to humans and animals when often with skin rash and swollen lymph glands. biting. Testing for the virus in humans More severe infections may be marked by high involves collection of blood and cere- fever, neck stiffness, muscle weakness, stupor, brospinal fluid to determine the presence of disorientation, convulsions, paralysis, coma, antibodies to the virus. The incubation peri- and, rarely, death. The elderly and individuals od is generally two to 15 days from the time a with weakened immune systems are most like- mosquito carrying WNV infects an individual. ly to develop severe illness associated with 5 WNV. In 2002, 4,156 people developed West 1999. Several residents of New York City con- Nile fever and 284 died from the illness.28 As tracted encephalitis and soon after, horses on of July 28, 2003, Texas had reported nine Long Island were showing signs of illness. human cases of West Nile virus; Colorado, Originally, the human cases were identified Florida, and South Dakota had reported four as St. Louis encephalitis (SLE), the most human cases each; and Alabama, Iowa, common mosquito-borne disease in the U.S. Minnesota, Ohio, and South Carolina had However, the two seemingly distinct animal reported one human case each.29 The sole and human cases were related. The cause human death attributed to WNV so far in 2003 was West Nile virus, a virus in the same fami- has been an Alabama resident.30 ly as SLE. The U.S. public health communi- ty was shocked at the discovery of WNV, pre- In 2002, there were rare cases of West Nile viously found only in Africa, the Middle East virus infections transmitted to people by and Europe. The outbreak ended in the fall blood transfusions, and even rarer cases of of 1999, but not before 62 people developed organ transplant, breast milk and intrauterine severe encephalitis, including 59 requiring transmission. Virtually all of the nation’s blood hospitalization, and seven who died.32 supply is being tested for WNV. Targeted test- ing of transplant tissue is planned.31 West Nile virus provides an example of how the lack of coordination and communica- There is no specific therapy for treating WNV. tion prevented information from being In more severe cases, intensive supportive ther- shared efficiently among public and animal apy may be necessary such as hospitalization, health officials. Rapid and reliable commu- intravenous (IV) fluids, airway management, nication within and between these commu- respiratory support (ventilator), and prevention nities is essential to preparedness and coor- of secondary infections (pneumonia). There is dination. Sharing information quickly no vaccine to prevent WNV in humans, helps ensure decisions are made with the although a vaccine for horses is available. most current information. Yet public and animal health exist as two distinct fields, sep- The Public Health Response to arated both in organization and culture. West Nile Virus New York City public health officials were Wild birds, especially crows, began dying in not aware of the similarities in the clinical significant numbers in New York in June symptoms occurring in the birds and AGENCIES AND ORGANIZATIONS INVOLVED IN MANAGING WEST NILE VIRUS 6 humans until many days or weeks after the Agriculture, and the Environmental Protection human outbreak began.33 Agency (EPA) are now collaborating to share information to understand the virus better, The West Nile virus outbreak also highlighted monitor WNV activity, and seek ways to prevent the outdated communications systems that future outbreaks.35 The National Institutes of were in place. For example, while an electron- Health (NIH), which is also part of HHS, is ic communication network was available at the involved, too. All of these federal agencies then time of the initial outbreak, not all involved work in connection with state and local depart- agencies and officials were using it. CDC’s lab- ments of public health, agriculture, environ- oratory was not linked to the New York State mental protection, and wildlife. Several states, network. Consequently, the New York State such as Illinois, have also created cross-agency Department of Health had to act as an inter- working groups to coordinate their intrastate mediary in sharing CDC’s laboratory test result agency efforts.36 Mosquito control and moni- with local health departments. Moreover, CDC toring the disease in animals are just two aspects and the New York State Department of Health of local West Nile management. laboratory databases were not linked to the database in New York City. Therefore labora- CDC’s Working Group facilitates information tory results had to be manually entered in sharing and coordination of activities among New York City.34 Furthermore, these networks the range of agencies that have some connec- were not linked to laboratories at the tion to disease and wildlife surveillance and U.S. Department of Agriculture’s National mosquito control. The Working Group sched- Veterinary Services Laboratory in Ames, Iowa, ules regular telephone conference calls among which conducted tests of bird samples. the federal agencies and CDC coordinates weekly conference calls with state public health Since the outbreak began, communication and agencies to coordinate national surveillance. coordination has significantly improved. A West Nile Interagency Working Group was In addition, CDC began hosting an annual established and is housed at CDC. It combines conference in 1999, bringing together state the efforts of six federal Cabinet Departments, and local public health officials to share infor- including CDC’s parent agency, HHS. The mation on WNV. The conference proceedings Departments of Commerce, Interior, Defense, form the basis for CDC guidelines on surveil- THE IMPORTANCE OF LINKING DISEASE SURVEILLANCE SYSTEMS There are many disease surveillance sys- Americans. This also prevents the identi- tems. Two examples are FoodNET, which fication of behavioral and environmental the U.S. Department of Agriculture uses factors that may contribute to disease. A to track food-borne illness, and CDC’s Pew Environmental Health Commission Behavioral Risk Factor Surveillance report found that there is little “synchro- System, a phone survey which gathers nization in the collection, analysis and data on behaviors that lead to chronic dis- dissemination of information.”40 In addi- ease. More disease surveillance systems tion, much of the data that is collected is are being created regularly to address a not frequently analyzed or interpreted in particular disease. However, very few of a way that might identify targets for fur- these systems have the capacity to link ther action.41 their data with each other or with other The goal for disease surveillance systems health and environmental and databases. should be the ability to “talk” or interact This prevents public health officials and with each other. Key linkages would be health care providers from obtaining a useful and important for informing dis- full picture of the health status of ease monitoring, control, and prevention. 7 lance, protection, and control of WNV which this information may have been collected but are updated each year after the conference. was not reported at the same time and was not The guidelines are developed with input from available until a year later. Most surveillance sys- a variety of scientists and public health profes- tems continue to operate in this manner. To sionals, including virologists, epidemiologists, help address this lack of coordinated surveil- laboratory personnel, wildlife biologists, and lance, CDC is leading an ad hoc committee of state and local health and agriculture officials. federal, academic, and animal health groups to CDC has also developed tests for use at state discuss a possible framework for developing an laboratories to diagnose WNV in humans, and integrated national zoonotic disease tracking provided training on how to use them. system. The committee met for the first time in August 2002.37 One key feature of the West Nile prevention effort is CDC’s “ArboNET,” an electronic sur- The isolated nature of ArboNET means that veillance system to track and monitor WNV key linkages to other disease patterns and and other mosquito-borne illnesses. CDC contributing health, behavioral, and envi- launched the tracking system in 2000 for states ronmental factors, which are all invaluable to report test results from any animal includ- to effective disease prevention, are not being ing, bird, horse, mosquito, and human test made. Currently, there is not a nationwide results. ArboNET facilitates information shar- health tracking network that coordinates the ing between CDC and numerous state and monitoring of diseases and connects them to local public health agencies across the U.S. possible related factors. This type of infor- mation would help researchers gain a better Disease surveillance is a vital tool in helping understanding about which portions of the public health officials understand how to population are most at-risk as well as the control and prevent disease. ArboNET causes and ways to control diseases. allows states to track crows, wildlife, and any animals impacted by WNV, in addition to As Lowell Weicker, Jr., former three-term humans. Wildlife provide a key indicator for U.S. Senator and Governor from tracking the spread of the disease and Connecticut, stated, “at this point, we know demonstrate the crucial and valuable need more about the health status of dead crows to connect human and animal health efforts. than we do about humans. We should not have to rely on local weathermen’s rain pre- ArboNET represents the first time that surveil- dictions to steer our national West Nile pre- lance data from humans and animals have vention and control strategy.”38 come together in a single system. Prior to 1999, MOSQUITO-BORNE ILLNESSES Beginning in 1912, many states created borne diseases were under control in agencies responsible for mosquito con- North America, resources and funding trol, called mosquito abatement districts, for many state mosquito control pro- to fight mosquito-borne viruses such as grams were cut. New Jersey, for instance, yellow fever and malaria.42 These dis- traditionally had a substantial surveil- tricts were quite successful at implement- lance program to track mosquito-borne ing Integrated Pest Management (IPM) diseases using “sentinel” birds to detect to control mosquito populations and the emergence of diseases. However, decrease the incidence of mosquito- funding for this program dwindled, like borne disease. IPM involves reducing many other programs in several states. mosquito breeding sites, spraying pesti- With the introduction of WNV to the cides on mosquito larvae, and spraying U.S. in 1999, states began to reinvest in adult populations. Once mosquito- mosquito surveillance programs. 8 Health tracking works. ArboNET has ages between surveillance systems that can increased the understanding of how WNV help monitor, control, and prevent disease. spreads. Unfortunately, most disease surveil- After a bumpy start, the public health response lance systems suffer from the lack of national to WNV has evolved into a relatively coordinat- standards and uniform structures, resulting in ed campaign that integrates efforts between a patchwork approach to surveillance. CDC government agencies at the federal, state, and has begun to address this problem with the local levels. The piecemeal and reactive National Electronic Disease Surveillance approach to disease management and preven- System (NEDSS), launched in October 1999.39 tion, however, has meant that the West Nile NEDSS is an important step in the right direc- threat continues to grow and health officials tion, but, by itself, will not provide crucial link- fear that the disease is now endemic to the U.S. Lyme Disease D espite widespread understanding of the cause, history, and symptoms associated with infection, Lyme disease continues to sicken thousands of Americans each year-a number that is growing.43 Thus, there is a strong need for continued pubic health vigilance on this disease. Lyme disease was named in 1977 when Within days to weeks of the transmission, 80 numerous children in Lyme, Connecticut percent of Lyme patients report a red rash in developed arthritis.44 Further investigation the shape of a bull’s-eye at the point of con- revealed that the children had contracted the tact.50 The rash is accompanied by tiredness, bacterium Borrelia burgdorferi45 from the bite of fever, headache, stiff neck, muscle aches, infected black-legged ticks.46 Since the origi- swollen lymph nodes, and general flu-like symp- nal diagnosis, every state has reported cases of toms.51 Some patients develop facial nerve Lyme. The vast majority of infections have palsy, similar to Bell’s Palsy. If untreated, infect- occurred in the northeastern and mid- ed individuals may develop more severe ver- Atlantic regions of the nation.47 CDC report- sions of the early-stage symptoms, as well as ed 17,730 cases in 2000, the last year data were motor and nerve inflammation, encephalitis, available. This number represents a notable arthritis, and, rarely, cardiac problems, includ- increase from the yearly average of 12,745 ing enlargement of the heart and tissue sur- Lyme cases reported from 1991-2000.48 rounding the heart.52 Early-stage patients are Officials estimate actual totals are consistently administered oral antibiotics for three to four higher, due to underreporting caused in part weeks, while later-stage patients often require by Lyme’s asymptomatic tendencies. intravenous antibiotic treatment. Lyme disease is transmitted when immature The Public Health Response to ticks feed on small rodents which are part of Lyme Disease the transmission cycle of Lyme causing bacte- ria. In later stages of development, ticks trans- Since Lyme disease was first reported in 1977, mit the bacteria to humans during the feeding the cases continue to rise. Reasons for the process. This process usually occurs during increase in reported cases of Lyme disease are the summer months, when ticks are most likely the result of a true increase in incidence active and humans are most often outdoors.49 from factors such as increased human/tick 9 AGENCIES AND ORGANIZATIONS INVOLVED IN MANAGING LYME DISEASE contact, and more complete reporting result- no boundaries, the public health response to ing from enhanced surveillance.53 disease containment as a state and then a regional problem meant that there was no The response to Lyme disease also shows how strong national strategy for battling what has an early isolated and limited approach to evolved into an expanding health threat. managing the disease has not prevented a rise in the numbers of cases. Instead of being con- Public health efforts toward Lyme disease have tained to the Northeast and Mid-Atlantic U.S., largely focused on prevention efforts and edu- where it originally emerged, it has now been cation. The key federal agency for Lyme related reported in every state. Even though the information is the Division of Vector-Borne spread of infectious disease, not just human- Infectious Diseases (DVBID), part of the NCID to-human, but also animal-to-human, knows at the CDC. This group collaborates with state BIOTERROISM FUNDS AND ZOONOTIC DISEASE In 2002, Congress passed the Public Health However, this approach may not fully take Security and Bioterrorism Preparedness and into account the threats from animal-borne Response Act. The law authorizes the spend- diseases. In Iowa, for example, there are only ing of $4.3 billion to improve public health three million people, but there are 27 million preparedness, enhance controls on deadly pigs, which can be carriers of certain diseases biological agents, and protect the nation’s including some strains of influenza. The food, medication, and drinking water sup- block grants are unlikely to provide states like plies. Included in the legislation is a State Iowa with enough funding to track the health Bioterrorism Preparedness and Response of animal populations.56 Both domestic and Block Grant Program. The funds are helping wildlife animals can serve as “sentinels” or states develop plans for detecting and early warnings for an emerging disease. responding to biological attacks, create train- Without sufficient funding to track animal ing programs, and upgrade hospitals’ and health, the U.S. is missing the chance to other health providers’ ability to serve victims detect a zoonotic disease early, and control, if of a biological attack. Funding is based on not prevent its spread. This is troubling given census population data, a sensible approach. that many bioterror agents are zoonotic. 10 and local public health departments, other fed- ease vaccine approved by the FDA in 1998 was eral agencies such as NIH, Lyme disease-cen- removed from the commercial market in 2002, tered foundations and non-governmental due to poor sales caused by concerns over the organizations, national and international health vaccine’s possible connections to arthritis.55 organizations, and academic institutions to pro- While cooperation now exists between the fed- mote research, awareness, and prevention. eral, state, and local departments and officials Four of the most heavily impacted states, in charge of controlling the disease, Lyme dis- Connecticut, Massachusetts, New Jersey, and ease has become a permanent part of New York, have undertaken invigorated pre- America’s public health landscape. It provides vention projects.54 In northeastern and mid- a warning and example of how an apparent Atlantic states where the disease is endemic, state or regionally-centered problem can grow the CDC hopes to lower Lyme rates to 9.7 to become a national problem. Instead of cases per 100,000 persons by the year 2010. implementing a proactive nationwide animal- borne disease management strategy, the pub- Officials stress the importance of early diagno- lic health response to Lyme disease was left to sis and treatment to prevent the onset of more evolve as the disease spread across the country. serious, late-stage Lyme symptoms. A Lyme dis- Mad Cow Disease “ M ad cow” disease is a fatal illness that strikes the central nervous system of cattle. Formally known as bovine spongiform encephalopathy (BSE), the disease was first diagnosed in Great Britain in 1986. It is now found in 33 countries, including Canada, where the disease was diagnosed in a native cow for the first time in May 2003.57 Scientists are concerned because it appears that humans can contract a related illness, variant Creutzfeldt Jakob disease (vCJD), by eating infected beef. Over 130 cases of vCJD have been reported worldwide.58 However, no cases of mad cow disease impacting cattle or humans have been reported in the U.S. to date. Mad cow disease has an incubation period mal posture, weight loss, and eventually death. from two to eight years in cattle. The incuba- In humans, the symptoms of vCJD include tion period for vCJD in humans is unknown. problems with muscular coordination; However, it is likely that the incubation period impaired memory, judgment, and vision; and ultimately will be measured in terms of many possibly depression or insomnia. As the dis- years or decades.59 The relatively long incu- ease progresses, the patient’s mental capacity bation period of mad cow disease in cattle degenerates further and they eventually lose increases the difficulty of monitoring and pre- the ability to speak, enter into a coma, and die. venting transmission to other cows. There is no known treatment or vaccine to prevent the disease in animals or humans. When symptoms manifest, cattle experience progressive deterioration of the nervous sys- vCJD is one type of transmissible spongiform tem, often leading to erratic behavior, abnor- encephalopathy (TSE) that affects humans. 11 AGENCIES AND ORGANIZATIONS INVOLVED IN PREVENTING THE ENTRY OF MAD COW DISEASE INTO THE U.S. Another TSE in humans is known simply as agent are used to create a high-protein sup- CJD, Creutzfeldt Jakob disease. CJD occurs plement which is then added to cattle feed. spontaneously, striking approximately one in The BSE agent then can be transmitted to one million people and is not caused by eating additional animals that are in turn slaugh- infected beef. While the symptoms of both tered, and the process repeats. Many scien- vCJD and CJD are similar, vCJD affects younger tists believe this is how BSE was spread individuals, average age 29, and CJD strikes through cattle herds in the United Kingdom. older individuals, average age 65.60 There are other TSEs that affect different animals, includ- Public Health Response to Prevent ing deer, elk, sheep, and mink. There is no the Entry of Mad Cow Disease into known treatment or vaccine for these diseases. the U.S. The agent responsible for BSE is generally Mad cow disease demonstrates the complica- believed to be a malformed protein called a tions that can arise because of the gaps prion.61 Prions cause normal proteins in the between animal and human health commu- brain to become deformed, which leads to nities, compounded by adding a possible food sponge-like holes in the brain, called safety factor into the equation. Since mad “spongiform.” These malformed proteins cow disease is transmitted to humans through cannot be deactivated by pasteurization, beef consumption, adding food regulation sterilization, conventional heat, or chemical and monitoring agencies further complicates disinfection. A definitive diagnosis of BSE efforts to control and manage the disease. or vCJD can only be determined from post While there has been no outbreak of mad mortem testing of the brain. cow disease in the U.S. to date, the discovery The origin of mad cow disease is not known of BSE in a cow in Alberta, Canada, earlier definitively, however, evidence suggests that this year raises increased concern that the certain contaminated feed ingredients are disease could cross over into the U.S. the source of the illness in cattle. For There are five federal Cabinet Departments, instance, cattle feed can become contaminat- three offices within the Executive Office of ed when the inedible remains from cows and the President, and three agencies within sheep already harboring the mad cow disease 12 HHS involved in mad cow disease preven- To help prevent mad cow disease from tion. Their efforts are connected through entering the U.S, the USDA implemented an Interdepartmental Steering Committee an import ban on live cattle and “ruminant” for BSE/TSE Affairs. At least a dozen fed- products, such as gelatin and some dietary eral agencies implementing more than 35 supplements, from mad cow-impacted statutes make up the federal part of the food countries in 1989. In 1997, USDA imple- safety system, which is tasked with control- mented another ban - on live ruminant ling food-borne illnesses.62 Twenty-seven imports and most ruminant products from states are also involved in implementing all of Europe. The same year, the FDA food safety regulations. Each agency has banned the practice of feeding remains unique responsibilities in carrying out the from other animals to cattle. nearly three dozen federal laws. To detect mad cow disease in U.S. cattle, the The federal regulatory system for food safe- USDA implemented a surveillance program ty evolved on a piecemeal basis, typically in that conducts post mortem tests for BSE in response to a particular health threat or the brains of cattle that cannot walk and economic crisis. As lawmakers address new those with central nervous system disorders. threats, they typically amend existing laws or The Office of International Des Epizooties enact new ones without updating previous (the animal health equivalent to the World statutes. The organizational and legal Health Organization) sets recommended patchwork results in divided jurisdictions cattle testing levels based on the size of the for specific food items among different adult cattle population. Since 1994, the U.S. agencies, which then have different author- has complied with these levels. However, ities and responsibilities.63 because testing is not performed on healthy animals, the percentage of total animals that Food safety problems occur in part because are slaughtered each year is small. Only responsibilities are still divided among sev- about 20,000 out of the 36 million cattle eral agencies, and each of these agencies processed for food in the U.S. were tested operates independently with different regu- for BSE in 2002.68 Considerable resources latory approaches.64 are involved and testing a much higher per- For instance, FDA regulates frozen pizza. centage of cattle would be costly. However, if the pizza is topped with two per- A study by the Harvard Center for Risk cent or more of cooked meat or poultry, the Analysis found that mad cow disease or a USDA (Food and Safety Inspection Service) similar disease is unlikely to be introduced regulates it. Inspections at pizza production in this country.69 This is largely a result of facilities follow two sets of guidelines, one a relatively early, proactive response to pre- issued from FDA and one from USDA.65 vent mad cow disease from entering U.S. A range of legislators, consumer groups, the shores by banning live cattle and feed U.S. General Accounting Office (GAO), from countries that have already been and the Institute of Medicine (IOM) at the afflicted and by issuing cattle feed rules. National Academies of Science (NAS) have The Interdepartmental Steering called for a change from the current Committee for BSE/TSE Affairs demon- Byzantine federal food safety system to a sin- strates that once created, coordinated gle, independent food safety agency.66 interagency, interstate groups dedicated to Other countries, including Canada, containing and preventing animal-borne Denmark, Great Britain, and Ireland, each diseases can be effective. have single agencies that are responsible for the full range of food safety activities.67 13 Chronic Wasting Disease C hronic Wasting Disease (CWD) is a progressive, fatal disease affecting the central nervous system of elk and deer, including white-tailed, black-tailed and mule deer. CWD was first diagnosed in Colorado deer in 1967 and is now found in ten states and two Canadian provinces.70 CWD is a one of several TSEs that attack the nervous system of various species. Other TSEs include mad cow dis- ease in cattle and CJD and variant CJD (vCJD) in humans. As noted previously, TSEs are fatal and there is no known treatment or vaccine. CWD primarily occurs in adult animals. Clinical non-infected animals. Excreta from infected ani- signs are similar to other conditions such as mal- mals may be another route of transmission, espe- nutrition, but the most apparent and consistent cially in captive herds of deer and elk. Scientists symptom is steady weight loss. Other signs have not yet understood the role of environ- include listlessness, decreased interaction with mental contamination in wild populations. other animals and repetitive walking in a set pat- tern, loss of muscle control, and eventual death. Public Health Response to Prevent the Potential Threat CWD May While no known cases have been transmitted to Pose to Humans humans to date, public health officials are con- cerned that eating deer or elk infected with In 2001, a working group was formed to CWD could lead to vCJD. A small number of address the disease, the national CWD Task individuals living primarily in the United Force. Co-chaired by the Department of the Kingdom who ate beef infected with BSE devel- Interior and USDA, the Task Force includes oped vCJD. It is not known definitively whether state and federal officials, CWD experts from eating CWD infected animals will cause vCJD in academia, and non-governmental institu- people. While there has been no causal link tions. The Chairman of the CWD Task formally established between CWD and vCJD, Force’s strategic plan committee estimates states with affected deer and elk are conducting that if Congress fully funded the plan, the dis- surveillance and testing to identify the disease. ease could be fully controlled in five years.72 Similar to mad cow disease, scientists generally The CWD public health response involves five believe that malformed proteins called prions federal Cabinet Departments and at least 12 cause CWD. The agent does not elicit any federal agencies. The corresponding state and detectable immune or inflammatory response in local health, wildlife, agriculture, and environ- the infected animals. Testing for CWD is mostly mental protection agencies are also integrated conducted through a post mortem examination into the prevention effort. Federal and state of brain tissue. A test on live-animal tonsilar tis- law gives states primacy and policymaking sue has been developed. However, the test seems authority regarding wildlife management. to only work for deer and not elk.71 Nearly all states have adopted regulations that Animals born both in captivity and in the wild aim to stop the spread of CWD. State govern- have contracted the disease. Unlike mad cow ments, with assistance from the federal govern- disease, transmission of CWD has not been ment, are conducting research, surveillance, ani- linked to any feeding practice in farmed elk or mal transport prohibitions, quarantine, destroy- deer. The precise transmission mechanism of ing infected herds, farmer compensation for CWD is not fully understood, although evidence destroyed animals, and public education to man- 14 points to direct contact between infected and age CWD in wild and captive animals. Some states have launched aggressive programs and elk.74 In addition, many state governments to reduce deer densities where CWD has been and private businesses rely on hunting and found. Nearly all states with CWD are random- wildlife associated tourism for revenues. For ly testing hunter-killed animals. USDA has a example, Colorado’s Division of Wildlife esti- program to reimburse elk farmers up to $3,000 mated that deer and elk hunters generated for animals that are destroyed.73 Farmers who $599 million for the state’s economy in 2001.75 chose to participate in the program must agree If uncontrolled, CWD has the potential to dev- to restock their land with animals other than astate deer and elk populations, resulting in deer or elk (cattle, swine, and sheep). Carcass major economic losses for state governments disposal is also being performed at controlled and private businesses that rely on revenues landfills and incinerators to avoid possible con- from hunting and wildlife associated tourism. tamination through water or air. The CWD Task Force, which evolved in Although there is no scientific evidence that response to a health threat, has been success- CWD can be spread to humans by contact with ful in learning how to control, contain, and infected animals or through eating infected possibly in the future eliminate this animal- meat, it is unknown if such transmission can borne disease and avoid its spread to humans. occur. States are therefore advising the public The lessons from the task force are beginning to take several precautions. For example, to cross over into another area by working with hunters are warned not to eat the brain, eye- the Interdepartmental Steering Committee balls, spinal cord, spleen, or lymph nodes of for BSE/TSE Affairs, which focused on mad the deer they shoot, and they should not han- cow, a related disease. However, coordination dle or eat any part of a deer that appears ill. between other types of animal-borne disease response efforts is virtually absent. The CWD Public health and wildlife officials are con- Task Force and Interdepartmental Steering cerned about CWD’s ability to spread from Committee for BSE/TSE Affairs, and the West states with the first diagnosed cases, Colorado Nile Interagency Working Group all evolved and Wyoming, to states east of the Mississippi from the need to coordinate efforts across River, including Wisconsin and parts of Illinois. agencies and state lines. The knowledge The concerns are often related to the econom- gained from working to prevent individual dis- ic impact of the disease. Nearly 11 million indi- eases typically remains separate and distinct viduals spend over $10 billion on equipment from other preventive efforts. and related costs to hunt big game such as deer AGENCIES AND ORGANIZATIONS INVOLVED IN PREVENTING THE POTENTIAL THREAT CWD MAY POSE TO HUMANS 15 Conclusion and Recommendations T his country has faced a rash of the emerging infectious diseases in the past ten years, many involving animal-borne agents. Unfortunately, we have failed as a nation to strategically combat these serious health threats, leaving us vulnerable to new and emerging zoonoses. A crisis mentality in dealing with these diseases has evolved by default. We pour resources into the latest disease outbreak with few plans for addressing zoonoses from the broader perspective they require. In reviewing these recent epidemics from a This absence of leadership leaves federal, state, public health perspective, Trust for and local governments without the direction, America’s Health identified a number of sys- resources, and effective strategies necessary to temic concerns. The issues range from protect the American public from these threats. balkanized government responsibilities, TFAH calls on the Senate Committee on inadequate disease tracking and communi- Governmental Affairs and the House cation systems, minimal legal oversight or Committee on Government Reform to con- enforcement in preventing hazardous vene hearings on this issue. The hearings health conditions, and insufficient numbers should examine how best to create a systematic of health professionals trained or dedicated approach to managing animal-borne diseases, to battling emerging infectious diseases. including how to integrate and balance these These gaps needlessly leave Americans, requirements with the need to modernize and their families, and communities at risk. revitalize the overall public health infrastruc- ture. In particular, the hearings should consid- To address the current problems in control- er the lack of leadership in managing, prevent- ling and preventing animal-borne illnesses, ing, and controlling these diseases. These TFAH offers the following recommenda- committees should coordinate with other tions to federal policymakers: Congressional committees that have begun reviewing different facets of the zoonotic dis- Congressional Hearings on the Need for ease issue. For example, the Senate Committee Improved Leadership in the Fight Against on Environment and Public Works recently Animal-Borne Diseases held a hearing on the importation of exotic TFAH research found over 200 different gov- species and the impact on human health and ernment offices and programs engaged in the safety. It is now time to build on those efforts. response to just these five diseases, which creates Leadership is needed ensure that the various gov- a literal public health maze. As many as seven ernmental agencies — at the federal, state and cabinet-level agencies are involved in efforts to local level — are coordinated, well-functioning, research, track, and manage the diseases dis- and capable of responding rapidly across juris- cussed in this report. Hundreds of state and dictional boundaries. Just as the Department of local public health agencies, along with state Homeland Security coordinates different aspects departments of agriculture and environmental of national security, there must be a concerted protection agencies, also play critical roles. effort to ensure that we, as a nation, attack ani- No one agency has clear leadership to oversee mal-borne diseases in a high-priority, unified, the nation’s response to animal-borne diseases. coherent, streamlined, and well-managed way. 16 Improving Preparedness to Respond to Fixing the public health system requires Animal-Borne Disease Threats Must Be recruiting qualified public health profes- Better Integrated into Overall Efforts to sionals, upgrading communications capacity, Modernize the Entire Public Health System repairing public health laboratories, increas- ing the public health service’s legal authori- The public health system includes the network ty, and establishing a coordinated, compre- of local, state, and federal health agencies that hensive nationwide health tracking network. collectively are responsible for disease preven- tion, response, and control. This system man- Managing animal-borne diseases effectively, ages and responds to a wide-range of health calls for, at a minimum, ensuring that public threats, including infectious diseases, chronic health professionals are well-trained and diseases, and threats of potential chemical, understand the public health threats and radiological, and biological terrorism. special nature of these diseases; increased training for medical students in zoonotic The overall public health infrastructure “is diseases; coordinating the activities of pub- still structurally weak in nearly every area,” accord- lic health and diagnostic veterinary labora- ing to the CDC’s 2001 report Public Health tories; reviewing laws impacting animal and Infrastructure. The report calls for a system of wildlife control and commerce, with special “public health armaments,” including a attention to public health concerns; “skilled professional workforce, robust infra- strengthening food protection statutes and structure and data systems and strong health regulation; and integrating the tracking of departments and laboratories.”76 America’s animal-borne diseases into a comprehensive public health system was once a world leader disease surveillance system. in stamping out diseases like smallpox, influenza and yellow fever. Today, however, Create a Nationwide Disease Tracking the system lacks the resources it needs to tack- Command Center at CDC le current public health threats. Decades of under-investment have left our public health As TFAH’s snapshot of five animal-borne dis- system with a shortage of qualified workers eases reveals, health officials utilize disease and outdated technology. tracking systems that are seldom connected to other disease surveillance networks. Like Moreover, animal-borne diseases present a the military’s early warning systems, public new set of complexities to the nation’s health must have integrated, effective track- already limited public health system. These ing systems to rapidly identify, control, and diseases call for different prevention and prevent health threats. Without such funda- control strategies than infectious diseases mental tools, health officials are virtually spread only through human contact. For working in the dark, leaving them unable to example, many different scientists with quickly spot developing health crises and highly specialized knowledge must be respond effectively. Tracking an emerging involved, including wildlife biologists, ecolo- health threat, like a new animal-borne dis- gists, medical entomologists, epidemiolo- ease, allows health officials to identify its ori- gists, and virologists.77 Animal and public gin, understand how to diagnose and treat health, however, exist as two distinct fields, patients, and find ways to contain its spread. separated both in organization and culture. TFAH found that most animal-borne dis- Without better integration and coordina- eases are tracked on an ad hoc basis, or at a tion of these two fields, the special needs state level without formal interstate coordi- and responses to these diseases will contin- nation. While CDC is leading an effort to ue to be managed only on a piecemeal and plan an integrated zoonotic disease tracking an emergency one-disease-at-a-time basis. system, funding for it will likely be a chal- For instance, it is entirely likely that new ani- lenge. This could leave the implementation mal outbreaks will first be detected and ana- of the system uncertain. lyzed in diagnostic veterinary laboratories. 17 CDC has established the independent ability to understand the interconnections ArboNET surveillance system that identifies between diseases and possible causes. cases of mosquito-borne illnesses, including Starting in 2002, Congress began an invest- West Nile virus. ArboNET, however, does ment toward strengthening the nation’s dis- not connect to other health tracking efforts, ease tracking capacity. As the U.S. Senate such as chronic diseases, that may be linked Appropriations Committee on Labor, to similar vectors or environmental factors. Health and Human Services and Education These connections can be crucial to recog- recently stated, health tracking should be nize and understand new diseases. For “compatible and integrated with other CDC example, it was the identification of the sud- and government tracking systems that focus den rise in arthritis in children in Lyme, on other environmental factors that may be Connecticut that led to the discovery and related to health effects, such as infectious diagnosis of Lyme disease. Tracking West agents, behavioral risks, ultraviolet radia- Nile virus in isolation, without the ability to tion, tobacco smoke, food-borne illness, nat- track a range of diseases and make connec- urally occurring substances, natural disas- tions to possible contributing factors, ters, and temperature extremes.”78 severely limits the ability to gain necessary insights into causes and ways to better con- Congress has started in the right direction trol and prevent disease. Being able to by appropriating $17.5 million in FY 2002 share and compare information across state and $28 million in FY 2003 to initiate a and local boundaries is also essential to Nationwide Health Tracking Network in sev- effective disease tracking, particularly in the eral states and cities, overseen by the CDC. case of animal-borne disease, since bugs Yet, the cost of an integrated, comprehen- know no boundaries. sive Nationwide Health Tracking Network is estimated at $275 million a year. The U.S. needs a tracking system that can address significant emergencies, like SARS TFAH recommends Congress provide the and monkeypox, as well as looming threats mandate, resources, and support to establish that have the potential to strike at any time. a centralized disease tracking center within Because of the current “disease du jour CDC for nationwide health tracking. This approach,” CDC risks establishing hundreds would include tracking animal-borne dis- of different databases that are not directly eases, infectious diseases, chronic diseases, linked, integrated and may be redundant. It such as cancer and asthma, events related to also limits the public health community’s bioterrorism, and environmental factors. 18 FEDERAL AGENCY RESPONSIBILITIES BY DISEASE Department of Agriculture CHRONIC WASTING DISEASE U.S. agency involved in a myriad of food • Funds disease testing and monitoring efforts. and health-related responsibilities, • Runs reimbursement program for elk farmers. including food safety, anti-hunger, food • Co-chair of CWD Working Group, in charge of studying disease and making rec- and plant research, and conservation ini- ommendations for its management. tiatives. Includes Food Safety Inspection Service, Animal and Plant Health • Conducts research and assists with disease management in states. Inspection Service, and the Animal LYME DISEASE Research Service. • Develops programs to reduce numbers of ticks on deer. MAD COW DISEASE • Enforces regulations on animal importation into the U.S. including a ban on importation of live ruminants and most ruminant products like protein supple- ments from countries with BSE or at high risk of BSE. • Inspects all domestic cattle prior to slaughter; cattle showing signs of central nerv- ous system disorders are not allowed to enter the human food supply. • Conducts research on BSE. MONKEYPOX • Assists state agriculture departments with tracing exotic pets involved in the out- break. • Responsible for inspection, detention, and quarantine recommendations. WEST NILE VIRUS • Member of Interagency Working Group. • Tracks West Nile’s impact on U.S. livestock and poultry. • Conducts research to develop methods for surveillance, monitoring, prevention and control. Department of Commerce WEST NILE VIRUS National Oceanic and Atmospheric • Conducts research with public health officials on the impact of climate patterns Administration involved is the key oper- on mosquito populations, and helps develops plans for controlling mosquitoes. ating division relevant to this report. • Member of Interagency Working Group. Department of Defense CHRONIC WASTING DISEASE Mission is to provide military forces • Conducting prion research for CWD. needed to deter war and protect the MAD COW DISEASE security of our country. The U.S. Army • Member of Interdepartmental Steering Committee for BSE/TSE Affairs. Medical Research Institute of Infectious Diseases, the Armed Service Blood WEST NILE VIRUS Program Office, and the Global • Works on research and testing initiatives to prepare and treat the military and Emerging Infections Surveillance and general public. Response System are among the rele- • Tests the impact on the Armed Service Blood Program Office. vant components for this report. Environmental Protection Agency CHRONIC WASTING DISEASE Works for a cleaner, healthier environ- • Researches and partners with local and state agencies to assess environmental ment for America’s air, water, land, and impact of disease and resultant prevention efforts. people WEST NILE VIRUS • Member of Interagency Working Group. • Researches and tracks the impact of pesticides used in prevention efforts. 19 FEDERAL AGENCY RESPONSIBILITIES BY DISEASE Department of Health and Human CHRONIC WASTING DISEASE Services • FDA works to minimize exposure to TSE in food products and blood supply. As part of its health mission, engages in • FDA created TSE Advisory Committee. research, service delivery, treatment, LYME DISEASE prevention, and public safety measures to ensure national health and well-being. • CDC oversees federal control and tracking efforts. Operating divisions include Centers for • CDC helps to fund prevention projects in endemic states. Disease Control and Prevention (CDC), • FDA tests effectiveness and safety of potential Lyme vaccines and drugs. Food and Drug Administration (FDA), • NIH conducts research and testing to learn more about the disease and encour- and National Institutes of Health (NIH). age effective treatment and eradication. MAD COW DISEASE • CDC conducts surveillance for any cases of vCJD among humans through analysis of death certificate data. • CDC undertakes research to improve understanding of TSEs. • FDA regulates animal feed - bans feeding mammalian protein to ruminants, includ- ing cattle, sheep and goats. • FDA conducts inspections in commercial feed mills to ensure compliance with the feed ban. • NIH conducts research on human TSEs (vCJD and CJD). MONKEYPOX • CDC coordinates emergency response, management, and investigation measures. • CDC develops recommendations for controlling infections and organizes enforce- ment efforts. • FDA enforces embargoes of imported African rodents and prairie dogs. • FDA manages potential impact on blood and plasma supply. WEST NILE VIRUS • CDC is in charge of initial investigation, tracking and diagnosis efforts. • CDC operates ArboNET, the electronic surveillance system for tracking mosqui- to-borne infectious diseases. • FDA protects against risk of contaminating nation’s blood supply. • NIH engages in research and testing of the virus and seeks related treatments. Department of Homeland Security MAD COW DISEASE Responsible for preventing terrorist • At ports of entry, reviews passenger declarations and cargo manifests to target attacks within the United States and mini- high-risk. agricultural shipments that originate from BSE affected countries. mizing the damage from potential attacks MONKEYPOX and natural disasters. Divisions relevant to • Enforces African rodent and prairie dog embargo via Bureau of Customs and this report include the directorates Border Border Protection. and Transportation Security and Emergency Preparedness and Response. Department of the Interior CHRONIC WASTING DISEASE Duties include research, stewardship of • Responsible for research and management efforts in protected national land. our land and resources, and conservation MONKEYPOX of national parks and protected regions. • Enforces African rodent and prairie dog embargo via U.S. Fish and Wildlife Service. Relevant bureaus include the U.S. Fish and Wildlife Service, the Bureau of Land WEST NILE VIRUS Management, National Park Service and • Assists states with diagnosis of wildlife infections. the U.S. Geological Survey. • Member of Interagency Working Group, responsible for, among other things, con- trol and prevention measures on National Park land. 20 ANIMAL-BORNE EPIDEMICS OUT PEER REVIEWERS OF CONTROL: THREATENING The opinions expressed in this report are those THE NATION’S HEALTH of Trust for America’s Health and do not nec- essarily reflect the views of the Peer Reviewers. REPORT AUTHORS Michael Osterholm, PhD, MPH Georges Benjamin, MD, FACP Director, Center for Infectious Disease Research Executive Director and Policy, and American Public Health Association Professor, School of Public Health University of Minnesota Patti J. Unruh Minneapolis, Minnesota Senior Communications Associate Trust for America’s Health Emi Kate Saito, VMD, MSPH West Nile Virus Surveillance Coordinator Michael J. Earls Department of the Interior Communications Specialist U.S. Geological Survey Trust for America’s Health National Wildlife Health Center Shelley A. Hearne, DrPH Madison, Wisconsin Executive Director Mark L. Wilson , ScM, ScD Trust for America’s Health Associate Professor of Epidemiology, and Director, Global Health Program University of Michigan Ann Arbor, Michigan Endnotes 5 Ibid. 6 “Telebriefing Transcript, MMWR Lyme Disease - 1 Murphy, Frederick A., “Emerging Zoonoses,” 2000,” Centers for Disease Control and Emerging Infectious Diseases. Volume 4, Prevention. <http://www.cdc.gov/od/oc/media Number 3. July-September 1998. /transcript/+020117.htm 17> January 2002. 2 Interview with Dr. Frederic A. Murphy, DVM, 7 “West Nile Virus Outbreak, Lessons for Public UC-Davis. 24 June 2003. Health Preparedness,” GAO/HEHS-00-180, U.S. 3 In 1994 the Centers for Disease Control and General Accounting Office, September 2000. Prevention (CDC) issued a report, Addressing 8 The scientific name for mad cow disease is Emerging Infectious Disease Threats: A bovine spongiform encephalopathy (BSE). Prevention Strategy for the United States. This For the purposes of this report, the name report contained recommendations to strength- mad cow disease is used. en and integrate programs to monitor, control 9 Cowen, Peter and Morales, Roberta A., and prevent emerging vector-borne and zoonot- “Economic and Trade Implications of Zoonotic ic diseases. In 1998, CDC updated those recom- Diseases.” The Emergence of Zoonotic mendations in Preventing Emerging Infectious Diseases: Understanding the Impact on Diseases: A Strategy for the 21st Century. The Animal Health - Workshop Summary (2002). report calls for enhanced surveillance for National Academies of Sciences. Conversion of zoonotic diseases, applied research to diagnose pounds to dollars calculated using xe.com these diseases, increased infrastructure and Universal Currency Converter and July 2003 training, and better prevention and control. exchange rates. <http://www.xe.com/ucc/> While a few of the recommendations have been 10 Mad Cow Disease: Improvements in the implemented, most have not. A lack of resources, funding and clear directive from Animal Feed Ban and Other Regulatory Congress and various Presidential administra- Efforts Would Strengthen U.S. Prevention tions has prevented CDC from fully acting on its Efforts, GAO-02-183. U.S. General plan to prevent and control zoonotic diseases. Accounting Office. February 2002. 4 Franz, David R., “The Potential ‘Bioweaponization’ of Zoonotic Diseases,” National Academies of Sciences. The Emergence of Zoonotic Diseases: Understanding the Impact on Animal Health - Workshop Summary (2002). 21 11 Chronic Wasting Disease Coalition Letter to 24 “HHS Bans Rodent Imports from Africa; Senator Conrad Burns and Senator Byron Prohibits Domestic Commerce in Rodents Dorgan on FY 2004 Appropriations for the and Prairie Dogs,” U.S. Department of Department of the Interior and Related Health and Human Services. Agencies, <http://www.cwd-info.org/docs/ <http://www.hhs.gov/news/press/2003pres CWD%20Funding%20Appropriations%20 /20030611a.html> 11 June 2003. Letter%20-%20April,%2018,%202003.doc> 18 25 “Interim Questions and Answers on April 2003. Embargo and Prohibition of Certain 12 A vector is a disease carrier that spreads the Rodents and Prairie Dogs,” Centers for disease from an infected animal to an unin- Disease Control and Prevention. fected human or animal. <http://www.cdc.gov/ncidod/monkeypox/e 13 More information on severe acute respirato- mbargoqa.htm> 19 June 2003. ry syndrome (SARS) and the U.S. public 26 Madigan, Erin, “Monkeypox Outbreak health response can be found in Trust for Reveals Gaps in State Laws,” Stateline.org. America’s Health May 2003 report, SARS 25 June 2003. and Its Implications for U.S. Public Health 27 “Captive Exotics and Wild Animals as Pets,” Policy: We’ve Been Lucky, co-authored by Humane Society of the United States. Drs. Margaret Hamburg and Shelley <http://www.hsus.org/ace/12055?pg=3> Hearne. <http://healthyamericans.org/ 28 “West Nile Virus 2002 Case Count,” Centers resources/files/SARSreport.pdf> 14 Field, Hume, “The Role of Animals in the for Disease Control and Prevention. <http://www.cdc.gov/ncidod/dvbid/west- Transmission of SARS,” World Health nile/surv&controlCaseCount02.htm > 7 July Organization Global Conference on SARS. 2003. <http://www.who.int/csr/sars/conference/j 29 “West Nile Virus: Statistics, Surveillance, and une_2003/materials/presentations/en/role- ofanimals.pdf > 17 June 2003. Control.” Centers for Disease Control and 15 Elizabeth Bailes, Feng Gao et. al., “Hybrid Prevention. <http://www.cdc.gov/ncidod/ dvbid/westnile/surv&controlCaseCount03.h Origin of SIV in Chimpanzees,” Science, 300 tm> 29 July 2003. (5626) 1713. 13 June 2003. 30 Ibid. 16 “Questions and Answers About Monkeypox,” 31 McNeil, New York Times, 10 June 2003. Centers for Disease Control and Prevention. <http://www.cdc.gov/ncidod/monkeypox/q 32 Ibid. a.htm.> 19 June 2003. 33 “West Nile Virus Outbreak, Lessons for 17 A genus of complex viruses that cause a gen- Public Health Preparedness,” GAO/HEHS- eralized infection with rash in mammals. 00-180, U.S. General Accounting Office, Includes camelpox, cowpox, ectromlia, September 2000. Monkeypox, vaccinia, and smallpox. 34 Ibid. Information from CDC website at 35 Testimony of James M. Hughes before the U.S. www.cdc.org. 18 Altman, Lawrence K. and Wilgoren, Jodi, House Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human “Less Lethal Cousin of Smallpox Arrives in Resources. 3 October 2002. U.S.,” The New York Times. 9 June 2003. 36 Testimony of John R. Lupmkin before the U.S. 19 “Fact Sheet: Basic Information about House Government Reform Subcommittee on Monkeypox,” Centers for Disease Control and Criminal Justice, Drug Policy, and Human Prevention. <http://www.cdc.gov/ncidod/ Resources. 3 October 2002. monkeypox/factsheet.htm.> 12 June 2003. 37 “Conceptual Framework for and 20 “Updated Interim Case Definition for Implementation of an Integrated National Human Case of Monkeypox,” Centers for Zoonotic Disease Surveillance System,” Ad Disease Control and Prevention. Hoc Committee of Academic Institutions, <http://www.cdc.gov/ncidod/monkeypox/c CDC, American Association of Zoo Vets, U.S. asedefinition.htm> Departments of Health and Human Services 21 Ibid. and Homeland Security, et al. 23 July 2003. 22 Mitchell, Steve, “Monkeypox Shows Gap in 38 Remarks by the Honorable Lowell Weicker, Bioterror Readiness,” United Press Jr., Trust for America’s Health Community International. 12 June 2003. Workshop. 4 February 2003. 23 “Monkeypox Home Page,” Illinois 39 “National Electronic Disease Surveillance Department of Public Health. System,” Centers for Disease Control and <http://www.idph.state.il.us/health/infect/ Prevention. monkeypox_data.htm> 2 July 2003 <http://www.cdc.gov/nedss/index.htm> 22 40 Transition Report to the New 57 “Consumer Questions and Answers about Administration: Strengthening our Public BSE,” U.S. Department of Health and Health Defense Against Environmental Human Services, Food and Drug Threats, Johns Hopkins School of Public Administration. <http://vm.cfsan.fda.gov/ Health. 17 January 2001. ~comm/bsefaq.html.> May 2003. 41 Ibid. 58 “Bovine Spongiform Encephalopathy Fact 42 Testimony of Joseph M. Conlon, American Sheet,” World Health Organization, Fact Mosquito Control Association, before the sheet No. 113. Revised November 2002. U.S. House Committee on Transportation <http://www.who.int/mediacentre/fact- and Infrastructure Subcommittee on Water sheets/fs113/en/> Resources and The Environment. 59 “New Variant CJD: Fact Sheet,” Centers for <http://www.mosquito.org/TACongress02.h Disease Control and Prevention. 21 May tml> 10 October 2002. 2003. <http://www.cdc.gov/ncidod/dis- 43 Reuters, “Lyme Disease Cases Reach Record eases/cjd/cjd_fact_sheet.htm> High, Experts Say,” The Washington Post. 60 “Creutzfeldt Jakob Fact Sheet,” World Health 18 January 2003. Organization, Fact Sheet No. 180. Revised 44 “CDC Lyme Disease Home Page,” Centers November 2002. <http://www.who.int/ for Disease Control and Prevention. mediacentre/factsheets/fs180/en/> <http://www.cdc.gov/ncidod/dvbid/lyme/i 61 Note that the cause of BSE is still under ndex.htm> 25 June 2003. debate. Some scientists believe the BSE 45 A helical shaped bacteria that naturally lives agent is a virus-like organism carrying genet- in some small rodents. Information from ic information. CDC website at www.cdc.gov. 62 “Ensuring Safe Food,” National Academies 46 “CDC Case Count 2002,” Centers for Disease of Science, 1998. Control and Prevention. 25 June 2003. 63 Robinson, Robert A., “Food Safety and <http://www.cdc.gov/ncidod/dvbid/west- Security, Fundamental Changes Needed to nile/surv&controlCaseCount02.htm> Ensure Safe Food,” GAO-02-47T, U.S. 47 “Telebriefing Transcript, MMWR Lyme General Accounting Office. 10 October 2001. Disease - 2000,” Centers for Disease Control 64 Ibid. and Prevention. 65 “Ensuring Safe Food,” National Academies <http://www.cdc.gov/od/oc/media/tran- of Science, 1998. script/+020117.htm 17> January 2002. 66 See Dyckman, Lawrence J., Food Safety: U.S. 48 Ibid. Needs a Single Agency to Administer a 49 “Lyme Disease Questions and Answers,” Unified, Risk-Based Inspection System, Centers for Disease Control and Prevention, GAO/T-RCED-99-256, U.S. General <http://www.cdc.gov/ncidod/dvbid/lyme/q Accounting Office, 4 August 1999, and a.htm> 25 June 2003. “Ensuring Safe Food,” National Academies 50 Ibid. of Science, 1998. 51 Ibid. 67 Robinson, Robert A., Food Safety and Security, Fundamental Changes Needed to 52 Ibid. Ensure Safe Food, GAO-02-47T, U.S. General 53 “Surveillance for Lyme Disease - United States, Accounting Office. 10 October 2001. 1992-1998,” Morbidity and Mortality Weekly 68 Number of cattle tested for BSE: “USDA Report, Vol. 49, No. SS-3, Centers for Disease Marks Progress on BSE Prevention Action Control and Prevention. 28 April 2000. Steps, Triples Number of Tests for BSE,” 54 “Telebriefing Transcript, MMWR Lyme U.S. Department of Agriculture, Press Disease - 2000,” Centers for Disease Control Release No. 0012.03, and Prevention. <http://www.usda.gov/news/releas- <http://www.cdc.gov/od/oc/media/tran- es/2003/01/0012.htm> 15 January 2003. script/+020117.htm 17> January 2002. Number of cattle processed for food: 55 Officials have not demonstrated a statistical “Livestock Slaughter” report, U.S. Department of Agriculture, National linkage between the LYMErix Lyme disease Agricultural Statistics Service. vaccine and elevated rates of arthritis. <http://jan.mannlib.cornell.edu/reports/n 56 Interview with Mary Gilchrist, Director, assr/livestock/pls-bb/2003/lstk0103.txt> 24 University Hygienic Laboratory, University January 2003. of Iowa. 23 July 2003. 23 69 Cohen, Joshua T, Duggar Kieth, et. al., 74 2001 National Survey of Fishing, Hunting Evaluation of the Potential for Bovine and Wildlife-Associated Recreation, Spongiform Encephalopathy in the United Department of the Interior, U.S. Fish and States. Harvard Center for Risk Analysis, Wildlife Service, October 2002. Harvard School of Public Health, 75 Chronic Wasting Disease Coalition Letter to November 2001. Senator Conrad Burns and Senator Byron 70 The 10 states are Colorado, Wyoming, Dorgan on the FY 2004 Appropriations for the Montana, South Dakota, Nebraska, Kansas, Department of the Interior and Related Oklahoma, Wisconsin, Illinois and New Agencies, < http://www.cwd-info.org/docs/ Mexico. The 2 Canadian provinces are CWD%20Funding%20Appropriations%20Lett Alberta and Saskatchewan. er%20-%20April,%2018,%202003.doc> 71 “CWD: A Synopsis of the 2002 National 18 April 2003. Symposium,” Chronic Wasting Disease 76 “Public Health’s Infrastructure: A Status Alliance, <http://www.cwd- Report Prepared for the Appropriations info.org/index.php/fuseaction/resources.sy Committee of the United States Senate.” mposiumsynopsis> 6-7 August 2002. Centers for Disease Control and Prevention. 72 Interview with Bruce Morrison, Chair of the 2001. National Chronic Wasting Disease Strategic 77 Murphy, Frederick A., “A Perspective on Plan Implementation Committee. 18 June Emerging Zoonoses,” National Academies of 2003. Sciences. The Emergence of Zoonotic 73 “USDA Requests Public Comment on Diseases: Understanding the Impact on Indemnity for Chronic Wasting Disease in Animal Health - Workshop Summary Cervids,” U.S. Department of Agriculture, (2002). Animal and Plant Health Inspection Service 78 Fiscal Year 2004 Report, Senate Press Release Appropriations Subcommittee on Labor, <http://www.aphis.usda.gov/lpa/news/2002 Health and Human Services. July 2004. /02/chrwasdi.html> 7 February 2002. 24