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Infectious Disease:
Mitigation through Detection, Research, and Response
Contents
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
I. Introduction and Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
II. Qualitative and Quantitative Cost of Epidemic-Prone and
Zoonotic Emerging Infectious Disease. . . . . . . . . . . . . . . . . . . . . . 11
The Broad-Based Economic Impact of Zoonotic and
Infectious Disease in Humans and in Animals for
Consumption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Economic Impact of Recent Epidemics . . . . . . . . . . . . . . . . . . . . . 18
Quantification of the Economic Impact of Bioterrorism . . . . . . . 20
III. Global Preparedness and Response Capabilities. . . . . . . . . . . . . . 21
IV. Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . 29
Bibliography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
This report sets forth the information required by the terms of the assignment and is prepared in the
form expressly required thereby. This report is intended to be read and used as a whole and not in parts.
Separation or alteration of any section or page from the main body of this report is expressly forbidden and
invalidates this report.
The independent development and publication of this document by Marsh Inc. was funded through an
educational grant from Philips Healthcare.
Executive Summary
Section
Executive Summary
New advances in science and medicine help us gain
ground against certain infectious diseases, yet even
in the twenty-first century other infectious diseases
continue to emerge at a rapid paceand frequently
with significant human and financial costs.
Emerging infectious disease (EID) comprises those
infectious diseases whose incidence in humans has
increased in the past two decades and threatens to
increase in the near future.1 EID includes new or
unrecognized diseases, those that are spreading to
new geographic areas and hosts, as well as those
that are re-emerging. One recent example is Severe
Acute Respiratory Syndrome (SARS), which claimed
nearly 800 lives and imposed a devastating $50
billion in global losses.
WHO (SEARO). Combating Emerging Infectious Diseases. New Delhi, 2005, pg. 1. Emerging infectious
diseases are diseases of infectious origin whose incidence in humans has increased within the
recent past or threatens to increase in the near future. These also include those infections that
appear in new geographic areas or increase abruptly. The new infectious diseases and those which
are re-emerging after a period of quiescence are also grouped under emerging infectious diseases.
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Executive Summary
EID poses major risks to the health and welfare of global human and
animal populations. Human populations are directly at risk from
infection and indirectly at risk through the impact on their food supply.
The risks associated with food supply include economic losses related
to the culling of animals and the unavailability of food due to real or
suspected contamination.2 These risks have the potential to severely
disrupt global supply chains and further harm human health and
welfare.
The life sciences, food and agriculture, and health care industries
face the greatest risk from the impact of EID, but are also uniquely
positioned to mitigate human and financial losses. A global increase of
investment in mitigation strategies is not enough without cooperation
among these three industries, as well as between governments and
global organizations.
Individually and in conjunction with each other, these industries,
governmental bodies, and international organizations should focus on
the following key activities to mitigate EID:
Early detection of high-consequence pathogens responsible for
Moreover, living in close proximity to animals can increase the likelihood of zoonotic infection
when animals become infected.
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Introduction
New or emerging infectious diseases with the potential to cause severe
epidemics or pandemics are increasingly prevalent. What previously
passed for acceptable planning and response has been re-evaluated
in light of the recent SARS experience and in anticipation of an avian
influenza pandemic or other infectious disease event. Preventing EID
from gaining a foothold in new environments is a formidable challenge,
but measures to mitigate its impact on human and animal populations
are possible.
EID is largely a product of societal-based decisions and demographic
changes that are generally considered to be a hidden cost of human
economic development.3 Social, political, and economic factors force
a continual stream of decisions upon governments and relevant
non-governmental authorities. Regardless of whether the need for
decisions is adequately addressed or ignored, unintended consequences
can promote the emergence of infectious diseases, some of which
are referenced in Table 1. The threat of naturally occurring EID is
compounded by other factors including the increased mobility of
humans, the increased import and export of food products, and the
potential deliberate use of pathogenic micro-organisms or toxins for
hostile purposes. These factors have short, medium, and long-term
impacts on populations and economies around the globe.
Infectious disease epidemics may last a few weeks or a few months and
can overwhelm the everyday course of society. For this reason, planning
to manage the numerous, complex, and connected impacts of an
infectious disease disruption or disaster has motivated multidisciplinary
strategies across sectors, professions, and functional roles. These
multidisciplinary strategies, when supported by information technology,
bioinformatics, and communications technology, assist in reducing the
lag time between detection of high-consequence pathogens, laboratory
verification, and response.
Such strategies were implemented more widely at the turn of
the twenty-first century with regard to the handling, storing, and
transporting of high-consequence pathogens for research and
development. These steps were taken to preserve the safety and security
of researchers and the general public and to ensure the integrity of
the surrounding environment. Where implemented, multidisciplinary
strategies have increased the effectiveness of biosafety and biosecurity
best practices.
3
Jones, Kate E. et al, Global trends in emerging infectious diseases. Nature, Volume 451, Issue 21,
February 2008, pgs. 990-994.
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Naturally
Occurring
Diseases
Table
1:4 5
6 7
Accidentally
Occurring
Diseases
Deliberately
Occurring
Diseases
While infectious diseases can emerge as a consequence of a host of convergent factors, we have
chosen to define those diseases that occur accidentally as arising directly from unintentional
events, including negligence.
5
Biosafety Levels (BSL) 1-4 are designations provided by the US CDCs BMBL (Biosafety in Microbiological and Biomedical Laboratories) and the WHOs LBM (Laboratory Biosafety Manual). Nomenclature can vary, e.g., pgs. 1-4. Richmond, Jonathan Y. and McKinney, Robert W., ed et al. Biosafety in
Microbiological and Biomedical Laboratories, Fourth Edition. Centers for Disease Control and Prevention
and the National Institutes of Health, 1999. http://www.cdc.gov/od/ohs/pdffiles/4th%20BMBL.pdf.
World Health Organization. Laboratory biosafety manual, Third Edition. World Health Organization,
2004. http://www.who.int/csr/resources/publications/biosafety/Biosafety7.pdf
6
Biosecurity has multiple connotations, and outside of arms control and non-proliferation, biosecurity often refers to food security in terms of access to food, food free from GMOs, and freedom
from disease in the food chain. Biosecurity can also refer to preventive and protective measures
taken against the deliberate acquisition of high consequence pathogenic micro-organisms and
toxins for intentional misuse, and can also broadly include control and response. Trapp, Ralf. Implementing biosafety and biosecurity who, what, why & how. Biological and Toxin Weapons Convention,
2008. http://www.bwpp.org/MX2008Training/documents/TrappMX2008Implementingbiosafetyandbiosecurity.pdf
7
World Health Organization. Biorisk management: Laboratory biosecurity guidance., September 2006.
http://www.who.int/csr/resources/publications/biosafety/WHO_CDS_EPR_2006_6.pdf
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Background
In the first decade of the twenty-first century, the dynamic and often
unpredictable relationship of host-pathogen interactions continues to
challenge researchers and health care professionals.9 The infectious
disease paradigm is shifting as our understanding of the relationship
between host, infection-causing pathogens, and chronic diseases
becomes more nuanced and complex.10 Simultaneously, human
encroachment upon previously uninhabited environments, and the rate
at which people, animals, and cargo traverse the world, has reduced the
time it takes for a highly infectious disease to spread.
WHO. A zoonosis is any disease or infection that is naturally transmissible from vertebrate
animals to humans. Animals thus play an essential role in maintaining zoonotic infections in
nature. Zoonoses may be bacterial, viral, or parasitic, or may involve unconventional agents. As
well as being a public health problem, many of the major zoonotic diseases prevent the efficient
production of food of animal origin and create obstacles to international trade in animal products. http://www.who.int/topics/zoonoses/en/
9
Forum on Microbial Threats. Ending the War Metaphor: The Future Agenda for Unraveling the HostMicrobe Relationship. Board on Global Health, Institute of Medicine of the National Academies,
March 2005. http://www.iom.edu/?id=24454
10
Knobler, Stacey L. ed. et al. Obstacles and Opportunities for Framing Future Research. The National
Academies Press, 2005. http://books.nap.edu/openbook.php?record_id=11026&page=135
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11
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ZOONOSES
13
Data found to support this diagram can be found on the WHO, CDC, FAO, OIE, and other websites. See also: WHO (in collaboration with the Health Council of the Netherlands). Report of the
WHO/FAO/OIE joint consultation on emerging zoonotic diseases. May 2004. http://whqlibdoc.who.int/
hq/2004/WHO_CDS_CPE_ZFK_2004.9.pdf
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14
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15
10
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11
SARS
China, Hong Kong,
Singapore, Canada
$50bn+
$50bn
$40bn
$30bn
$20bn
BSE, UK
$10 -13bn
$10bn
Lyme disease
US, $2.5bn
Swine Flu,
Netherlands
Foot & Mount Disease
$2.3bn
Taiwan, $5-8bn
Nipah, Malaysia
$350- 400m
$0
BSE, Canada
$1.5bn
Avian Flu
Asia, US, Canada
$10bn
Avian Flu, EU
BSE,
Japan $500m
$1.5bn
BSE, US
$3.5bn
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
17
Permission to reprint image granted by Bio Economic Research Associates, LLC ., 12 August
2008. SARS and the New Economics of Biosecurity, 2003.
12
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13
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Plague in India:
The 1994 plague outbreak
in Surat, India and
resulting panic brought
about a sudden exodus of
0.5 million people from the
region and led to abrupt
shutdowns of entire
industries, including
aviation and tourism.
Several countries froze
trade, banned travel from
India, and sent some
Indian migrants home.
The WHO estimated the
outbreak cost India some
$2 billion.
18
Fielding R, et al. Avian influenza risk perception, Hong Kong. Emerg Infect, May 2005.
http://www.cdc.gov/ncidod/EID/vol11no05/04-1225.htm
19
Avian Flu Diary: The Return Of The Nipah Virus EMERGING DISEASES: Malaysian Researchers Trace
Nipah Virus. www.sciencemag.org/cgi/content/full/sci;289/5479/518
20
Campbell G L and Hughes JM. Plague in India: A New Warning from an Old Nemesis. Editorial.
Annals of Internal Medicine, 15 January 1995. Volume 122, Issue 2, Pages 151-153. http://www.annals.
org/cgi/content/full/122/2/151 See also: WHO, SEARO. Plague Surveillance and Outbreak Response.
Report of an Informal Intercountry Consultation. Bangalore, India, 15-17 July 2002. New Delhi.
http://whqlibdoc.who.int/searo/2002/SEA_PLAGUE_20.pdf
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15
SARS in Canada:
Research suggests a loss in
national economic activity in
2003 of roughly $1.5 billion,
representing 0.15 percent of
Canadas real GDP. Real GDP
in the City of Toronto itself was
lowered by $950 million, or 0.5
percent, with about $570 million
of this total concentrated in the
travel and tourism sector.
Cholera in Peru:
The outbreak of cholera
in 1991 cost the
Peruvian fishing
industry an estimated
$775 million
in lost tourism and trade
because of a temporary
ban on seafood exports.
21
16
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24
Debarati Guha-Sapir, Willem G. van Panhuis, World Health Organization Collaborating Centre
for Research on the Epidemiology of Disasters, Armed Conflict and Public Health, 2002,
http://www1.cedat.be/Documents/Publications/rocpressweb.pd
25
WHO. Global tuberculosis control surveillance, planning, financing. Global TB report 2008.
http://www.who.int/tb/publications/global_report/en/index.html
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17
Order of the Centers for Disease Control and Prevention, Department of Health and Human
Services: Notice of Embargo of Civets, (Centers for Disease Control and Prevention, May 2005).
http://www.cdc.gov/ncidod/sars/civet_ban_exec_order.htm.
27
Summary of probable SARS cases with onset illness from 1 November 2002 to 31 July 2003, (Epidemic and Pandemic Alert and Response (EPR), September 2003). http://www.who.int/csr/sars/country/
table2003_09_23/en/
28
Asian Development Bank, Assessing the Impact and Cost of SARS in Developing Asia. Asian
Development Outlook 2003 Update, 2003. http://www.adb.org/documents/books/ado/2003/update/
sars.pdf
29
Darby, Paul. The Economic Impact of SARS. The Conference Board of Canada, May 2003.
30
Corporate Pandemic Preparedness: Current Challenges to and Best Practices for Building a More
Resilient Enterprise, (Marsh Inc. and The Albright Group, LLC, 2007).
31
Maunder et al. Factors Associated With the Psychological Impact of Severe Acute Respiratory
Syndrome on Nurses and Other Hospital Workers in Toronto. Journal of Psychosomatic Research,
Volume 66, pgs. 938942, 2004.
32
Styra et al. Impact on healthcare workers employed in high-risk areas during the Toronto SARS
outbreak, Journal of Psychosomatic Research, Volume 64, pgs. 177-183, 2008.
18
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global economies could top $1.25 trillion, and the pandemic could kill
as many as 150 million people worldwide. 33, 34
To date, current strains of avian influenzathe anticipated source of
pandemic influenzahave killed tens of millions of domestic birds
(poultry) and wild birds worldwide.35 This has amounted to billions
of dollars in losses for economies in Asia, which have been hit the
hardest.36 As avian flu spreads throughout the worlds poultry food
supply, it is causing import/export bans as it did in France in 2006 and
in the U.S. in 2008.37
Once the virus becomes capable of efficient human-to-human
transmission, the potential disruption to industry, services, and
government is anticipated to be enormous. Stockpiling of vaccines
and antiviral medication is happening on a global basis and massive
planning efforts are underway to mitigate the effects of the pandemic.38
The sufficiency of these measures is currently being evaluated. Access
to the existing standard of care, however, will remain a concern when a
pandemic strikes.39
Bovine Spongiform Encephalopathy (BSE)
BSE, a zoonotic neurodegenerative disease found in cattle also known
as mad cow disease, can be transmitted to humans through the
consumption of infected cattle products. In humans, it is known as
Variant Creutzfeldt-Jakob disease (vCJD), a long incubation disease
that is fatal and has killed 204 people.40
By far, the greatest impact of BSE has been economic. In the UK, more
than 4.4 million head of cattle were destroyed to stop the spread of a
BSE outbreak. The combined effects of a fall in consumer confidence
throughout the UK and Europe, and the subsequent bans and
33
Press Conference by UN System Senior Coordinator for Avian, Human Influenza, (United
Nations Department of Public Information, New York News and Media Division, September 2005).
http://www.un.org/News/briefings/docs/2005/050929_Nabarro.doc.htm
34
Frielink, A. Barend. Joint OIE-ASEAN/ADB Inception Workshop on HPAI Control and
Eradication in ASEAN. Asian Development Bank, October 2006. http://www.adb.org/documents/
speeches/2006/sp2006047.asp
35
Polet, Yvan, Avian Influenza: Impact of Outbreaks on European Poultry and Meat Markets. GAIN
Report, March 2006. www.fas.usda.gov/gainfiles/200603/146187030.doc.
36
Ibid.
37
Tyson bird flu find curbs exports to Japan, Russia. Nathan Becker. Marketwatch,
June 4, 2008 http://www.marketwatch.com/news/story/tyson-bird-flu-find-curbs/story.
aspx?guid=%7B1E8A9C17-A8D9-4A21-98B8-414EDE665032%7D&dist=msr_1
38
CDC chief says that avian flu is the biggest threat, (CIDRAP News, Center for Infectious Disease
Research and Policy, February 2005), http://www.cidrapsummit.org/cidrap/content/influenza/avianflu/news/feb2105gerberding.
39
Ability of regional hospitals to meet projected avian flu pandemic surge capacity requirements.
Prehospital Disaster Medicine. 2008 Mar-Apr;23(2):103-12.
40
Variant Creutzfeldt-Jakob Disease, Current Data (April 2008), (The National Creutzfeldt-Jakob
Disease Surveillance Unit, April 2008), http://www.cjd.ed.ac.uk/vcjdworld.htm . See also fact
sheets from WHO on BSE, http://www.who.int/mediacentre/factsheets/fs113/en/ and vCJD, http://
www.who.int/mediacentre/factsheets/fs180/en/, as well as from CDC on vCJD, http://www.cdc.
gov/ncidod/dvrd/vcjd/factsheet_nvcjd.htm and EUCDC on vCJD, http://www.cjd.ed.ac.uk/.
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19
restrictions on beef trade, caused the British cattle and beef market to
collapse, costing nearly $6 billion.41 In Canada, a single cow infected with
BSE led to the ban of Canadian beef imports in the United States, costing
an estimated $5 billion.42
Buzby Jean C and Detwiler Linda R. BSE Anatomy of A Crisis - bovine spongiform encephalopathy
- Statistical Data Included Choices: The Magazine of Food, Farm and Resource Issues, Spring, 2001.
42
Beef ban cost producers up to $5B: BMO economist, CBC News, November 29, 2004. http://www.
cbc.ca/money/story/2004/11/29/beefbancost-041129.html.
43
Roffey, R. G8 Global Partnership: State of play of efforts against CB-weapons. Swedish Defense Research
Agency, June 2005. http://www.delegfrance-cd-geneve.org/declarations/declafrancaises/armes%20
bio/Roffey%2080th%20GenevaProtocol%20G8GPCBW%2010June2005.pdf
44
As of 2004 the original G8 partners have pledged $17 billion to the effort Center for Strategic
and International Studies. Global Partnership Scorecard, May/June 2004. Strengthening the Global
Partnership, 2004. http://www.sgpproject.org/GP%20Scorecard.pdf.
45
Since the 2001 terrorist attacks on the United States, the U.S. government has spent or allocated
nearly $50 billion among 11 federal departments and agencies to address the threat of biological
weapons. For Fiscal Year 2009 (FY2009), the Bush Administration proposes an additional $9 billion in
bioweapons-related spending, approximately $2.5 billion (39%) more than the amount that Congress
appropriated for FY2008. The Center for Arms Control and Non-Proliferation. Federal Funding for
Biological Weapons Prevention and Defense, Fiscal Years 2001 to 2009. Brief published on 15 April
2008. http://www.armscontrolcenter.org/media/fy2009_bw_budget.pdf
46
Kaufmann AF, Meltzer MI and Schmid GP. CDC. The Economic Impact of a Bioterrorist Attack:
Are Prevention and Postattack Intervention Programs Justifiable? Emerging Infectious Diseases, Vol 3,
No 2. April-June 1997. http://www.cdc.gov/ncidod/EID/vol3no2/kaufman.htm.
20
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21
Life Sciences
clinical settings
Networked communication within local and regional
Food and
Agriculture
Health Care
47
Burroughs, Tom, Knobler, Stacey, Lederberg, Joshua. The Emergence of Zoonotic Diseases:
Understanding the Impact on Animal and Human Health. The National Academies Press, 2002.
22
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Following the
detection of a pathogen,
confirmatory tests are
needed to demonstrate
the presence or absence
of disease during an
outbreak.
48
Smolinski, Mark S., ed. et al. Microbial Threats to Health: Emergence, Detection, and Response. The
National Academies Press, 2003.
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23
presence of pathogen
Life Sciences
Food and
Agriculture
processes
Trained personnel to read samples and determine
safety
Use of microbiology laboratory (on site or shared
Health Care
Response
Effective measures to mitigate or prevent spread of a disease in the field using
a mixture of practices including patient isolation, quarantine, therapeutic
interventions, prophylaxis, culling of animals, and food recall practices.
While it is not possible to fully anticipate infectious disease incidents
of international public health concern, it is possible to prepare for
response and recovery, whatever the origin of the outbreak. Initial
efforts taken to control the spread of infectious diseases, prior to
pathogen verification, will follow a similar set of practices aimed at
isolation, quarantine, and travel controls.49
If an event is determined to be an act of bioterrorism or sabotage, there
are particular implications for which agency (e.g. law enforcement,
49
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public health, etc.) will assume the lead in the disease investigation.
Regardless of origin, the ultimate goalcontrolling the spread of
diseaseremains the same. In the event that prior intelligence
or prior verification was received, appropriate prophylaxis can be
provided to prevent further exposure of employees and the general
public. Preparing to recover from an infectious biological event
necessitates that preparedness and response procedures are tested
and evaluated for their applicability and potential efficacy. No singular
set of characteristics exists for an infectious biological incident or
contamination. Managers may use a combination of pathogen-specific
plans as well as more flexible approaches for isolation and quarantine
in the case of unidentified or unverified diseases. Planning for
prevention and planning for response are parallel efforts.
Life Sciences
Food and
Agriculture
infected
Product recall of suspected or known contaminated
Health Care
* 50
Managing the Infectious Disease Risk: Research Facilities
Because modern epidemic-prone infectious diseases can be novel (e.g.
SARS) or constantly evolving (e.g. seasonal influenza), research
50
The U.S. National Institutes of Health (NIH) and the U.S. Food and Drug Administration (FDA)
have both recently initiated programs to encourage the use of modern research tools as part
of a focus on translational research, the goal of which is to accelerate the transfer of medical
discoveries to the clinical environment. Examples of these tools include genomics and proteomics,
imaging, and bioinformatics. See the FDAs Critical Path initiative http://www.fda.gov/oc/initiatives/
criticalpath/initiative.html. See also, The NIHs New Pathways to Discovery initiative http://
nihroadmap.nih.gov/newpathways/.
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51
26
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History of Quarantine, (Centers for Disease Control and Prevention, February 2007),
http://www.cdc.gov/ncidod/dq/history.htm.
54
Marsh Inc. and The Albright Group, LLC. Corporate Pandemic Preparedness: Current Challenges to
and Best Practices for Building a More Resilient Enterprise. Marsh Inc. and The Albright Group, LLC, 2007.
55
WHO with the cooperation of FAO. The International Food Safety Authorities (INFOSAN) Users Guide.
October 2006. http://www.who.int/foodsafety/publications/fs_management/INFOSAN_User_
Guide_Final.pdf.
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56
Asian Development Bank Economic and Research Department, Potential Economic Impact of an
Avian Flu Pandemic on Asia. November 2005. http://www.adb.org/Documents/EDRC/Policy_Briefs/
PB042.pdf.
57
Avian and pandemic influenza: developments, response and follow up, and applications of
International Health Regulations (2005), (World Health Organization, January 2007), http://www.
who.int/gb/ebwha/pdf_files/EB120/b120_id3-en.pdf.
58
FAO and OIE (in collaboration with WHO), A Global Strategy for the Progressive Control of Highly
Pathogenic Avian Influenza (HPAI), FAO and OIE, May 2005. http://www.fao.org/ag/againfo/resources/
documents/empres/AI_globalstrategy.pdf.
28
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Failure to jointly
pursue these goals in
a balanced approach
will only contribute to
new, re-emerging, and
therapeutically resistant
pathogens.
interventions;
the global food supply chain; and
the operational resilience of the delivery of health care services.
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29
30
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Notes
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Notes
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Notes
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Marsh
45
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