REVIEW OF RELATED LITERATURE

There is a need to mobilize the world in terms of how it will respond to the
emerging infectious diseases that are now getting the attention of different
international health organizations. There is also a need to learn from each
other on what works on what and how to work at it. There are many things
that we need to consider in order to become a part of this endeavor. The
World Health Organization (WHO) has already mandated its member nations
to adhere to the policies of creating response teams and organizations in
order to mark the preparedness of each country to these emerging infectious
diseases (EID).

The WHO Template

By the late twentieth century it was noted that there was a rapid increase in
the emergence and reemergence of infectious diseases in almost every part
of the world which is about 30 new diseases including Legionnaires’ disease,
Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency
Syndrome (AIDS), variant Creutzfeldt-Jakob disease (vCJD), Hepatitis C,
several viral hemorrhagic fevers like dengue and also meningococcemia
(Weiss and Michael, 2004). 1 In the beginning of this decade, there had been
significant infectious disease outbreaks that challenged the public health
sector of almost every country affected. These include the Severe Acute
Respiratory Syndrome (SARS) outbreak in 2003 and the new strain of Human
Influenza virus, H1N1 in late 2008 and became a pandemic second quarter of
this year. Kant, an Indian researcher pointed out in his studies that it was
analyzed that the emerging infectious diseases between the year 1940 and
2004 were of majority caused by zoonotic pathogens (60%) and vector borne
diseases (23%). The analysts said that these diseases would be more
concentrated in the lower latitude developing countries and that the next
waves of pandemics would arise from Asia (Kant, 2008). 2

With the onset of these EID colliding with the faster globalization and
international changes, there is an urgent need to strengthen partnerships
and collaboration among different countries. The prevalence and incidence
of affected people and the continuous emergence and reemergence of
infectious disease brought WHO in the revision of the 1969 International
Health Regulations (IHR) at the 1995 World Health Assembly. As early as
2001, there had been a resolution on global health security alert and
response wherein WHO also gave its support in the identification,
verification, and responding to the international public health concerns but
only in 2003 during the SARS outbreak that they prompted to accelerate the
process of revision. In May 2005, the revised IHR was adopted by the 58 th
World Health Assembly and it became the template for all WHO members
(Kimball, et al. 2008). 3 They are required to assess, develop, strengthen and
maintain their country's capacity at a level to meet the minimum core
capacity requirements for disease surveillance and response in order to
strengthen national and regional capacities to detect and be more
responsive to the need. The goal of IHR is to improve the Regional
responsiveness to EID in terms of planning, prevention, prompt detection,
characterization, and the containment and control of these diseases (WHO-
ROWP, 2009) 4 This program was made as a response to the different
research studies done which identified the risk factors of the continuous
emergence of these diseases; find the gap of the existing health systems in
different countries in terms of programs, preparation and surveillance; and
create a more appropriate and responsive action.

Risk Factors for EID Emergence

According to Dr. Jai P. Narain, Director, Communicable Disease Surveillance,

there are many factors that contribute to the emergence and transmission of
these diseases which includes globalization, population growth, urbanization,
international travel, global warming and poor health-care infrastructure. He
added that infectious diseases are a manifestation of a weak public health
infrastructure and there is a need for regional and global collaboration. Some
of the EIDs don’t still have vaccines until now, like HIV, and the efforts of
individual countries are seen to be less effective such that WHO is calling for
a collaboration of different sectors to fight these EIDs. (WHO-SEARO, 2007). 5.

In November 2007, Gayer and colleagues studied multiple risk factors that
may enhance the emergence and transmission of infectious diseases. They
found out that these include inadequate surveillance and response systems,
destroyed infrastructure, collapsed health systems and disruption of disease
control programs, and infection control practices even more inadequate than
those in resource-poor settings, as well as ongoing insecurity and poor
coordination among humanitarian agencies (Gayer, et al. 2007). 6

Where the Gap Lies

In another study done by UPMC (University of Pittsburgh Medical Center) in

November 2007, Hitchcock and colleagues reviewed 14 international
surveillance and response programs and the notion of a global scheme as a
response to EIDs. They cited effective actions like creating new programs or
reviewing pre-existing ones and make them work. However, the four
identified problems which may be considered as gaps or insufficiencies
include the health infrastructure; scientific methods and concepts of
operation; essential human, technical, and financial resources; and
international policies which challenge the global community now (Hitchcock,
et al. 2007) 7
Gayer and colleagues further pointed out that detection and control of these
EIDs will require a functional health system which invests in primary
healthcare infrastructure, human resources, training, and provision of
essential drugs, supplies, vaccines, and equipment (Gayer, et al. 2007).6 And
as the Asia-Pacific Strategy for Emerging Diseases (APSED) stressed that the
threats of new infectious diseases will continue but the challenge lies on how
to develop a more sustainable national and regional or global capacity that
will appropriately and more effectively respond to the need and will really
make a difference (WHO-SEARO, 2007). 5

The Asian Initiative

The effort to control the emergence and reemergence of the infectious

diseases are reinforced in Asia and Africa primarily where possible
pandemics will rise according to some scholar analysts (Kant, 2008). 2 During
the 58th Session of the Regional Committee for South-East Asia, they were
able to create the Asia Pacific Strategy for Emerging Diseases (APSED) which
mainly focuses on strengthening the early response to EIDs which they see
as reducing delays between detecting the disease emergence and the
means to monitor and control it. They have identified several public health
components that play major roles in order to achieve their goal and with
each component is an action plan: establishing a system where they planned
to add more force on strengthening surveillance and the response activities
at all public health levels and to provide training and resources needed;
strengthening the capacity to respond by implementing actions to identify
gaps in the system from baseline mapping and situational analysis; reinforce
information management by developing standard operating procedures to
monitor, record and manage data and to track down the course of the
disease; and a supported communication of risk purported by the EIDs to the
general public like any ongoing outbreaks, unexplained deaths and
emergence of new diseases which aims to build public trust and to empower
the public and other stakeholders to respond. (WHO-SEARO/APSED, 2005). 8

Many Asian countries are now in the process of adopting programs in the
need to control EIDs in the region. In the Review of Regional Work of WHO on
Health Research 2004-2005, there were efforts to assess the national
disease surveillance and response systems including laboratories in South-
East Asian countries like Indonesia and Myanmar and some South Asian
countries like Maldives and Sri Lanka. Others have been documented their
Health Reseach Systems (HRS) with the necessary technical support from
the WHO Regional Office like Bangladesh, India, Nepal and Thailand. 9

In Africa
Africa is considered to be an infectious disease-laden continent which
ironically to say, has also a public health system that does not indeed
address to its needs. Millions of literature and cases have been taken from
this population and still, they are yet to see real movement and effort to
combat both the diseases themselves but also the socio-economic and
political battles that continuously grieve the people. What WHO is presently
up to right now is the identification of diseases that can be prioritized
according to some characteristics like how epidemic-prone is it; the
emerging diseases that are in need or seen as target for eradication and
elimination; and other diseases that are seen to be of more public health
concern. And like what the Asian countries have been doing, they will focus
on how to integrate surveillance of the disease with the new technological
support for the resource-poor areas like sub-Saharan Africa and the
development of early-warning system in Rift Valley for fever surveillance;
and the measures of preparedness, awareness and level of timely response.
This of course will in need of several effective partnerships and
collaborations with the important stakeholders – the government and the
non-governmental organizations (Davis and Lederberg, 2001). 10

In the West

The region focuses on the Emergency Response Teams that cater more
on the health emergencies rather than on the emerging diseases though
they have also programs like in Asia and Africa which is from the WHO.

Canada was able to establish an agency that would manage the

nation’s health emergencies, namely the National Office of Health
Emergency Response Teams (NOHERT) under the Center for Emergency
Preparedness and Response. NOHERT would be integral in the nation’s
attempt to create a coordinated and efficient response to health
emergencies in provincial, territorial and local government levels.1 It should
also be noted that in Canada, disaster stricken areas would call on other
neighbouring provinces, territories, or the federal government for aid. But
NOHERT’s provision of surge capacity to augment the health care resources
and facilities of affected areas that would allow ample countermeasures to
the damages incurred.11 In addition to providing health care, NOHERT is also
involved with training Health Emergency Response Teams (HERT) all over
Canada and is currently the leading Public Health Agency of the nation in
that particular endeavour.11

Multi-disciplinary teams that are summoned whenever health

emergencies emerge characterize the typical HERT. These teams are
composed of medical and emergency response professionals from federal,
provincial and local institutions, NGOs, and private practice.11 These units
should have the necessary skills and resources to react swiftly and
sufficiently to any possible diseases or injuries brought about by natural
disasters, explosions or major chemical, biological, or radio-nuclear incidents.
Up to 185 members make up one team and they may be rapidly sent out to
the front line within 12 to 24 hours upon request of a province or territory
and maintain operations for up to 72 hours before being resupplied.11

Each HERT would be essentially be brought to any area among three

different mission configurations that would cater to variable needs
depending on the situation at hand as noted below.

The first mission configuration is designated as the HERT Mass

Casualty Unit or MCU. This would mostly address a typical surge capacity
scenario wherein they would provide direct support to Emergency Rooms
through deployment of medical professionals from their unit in order to
augment staff and resources wherever necessary as they offer their skills
and equipment to support hospitals that require them. Each MCU would have
three component teams namely, the Rapid Response Team, Medical
Response Team, and Mission Support Team.11

The second HERT mission configuration is classified as the Specialized

Unit (SU). These SUs would be made up of specialized teams of primary
health care workers trained to deal with specific medical situations from
either epidemic or chemical, biological, radiological, or nuclear incidents.
They may be deployed as a team with a single health care worker or a team
of experts, depending on the nature of the situation’s needs. Being relatively
smaller and more specialized, SU team would most likely not require the
HERT Rapid Response Team or Mission Support Team components.11

And lastly, the third HERT mission configuration is the Air Mobile Unit
(AMU) that is tailored for expedious deployment by air to far flung areas of
the country. These units would only have a smaller Medical Response Team
and Mission Support Team with a smaller equipment load but will have
enough resources to maintain their services for up to 72 hours before
requesting for additional supplies.11

Another method for responding to disasters is America’s Emergency

Management Assistance Compact (EMAC), which is an interstate mutual-aid
agreement that allows different states to share personnel, equipment, and
other resources among each other during emergencies and disasters in a
coordinated system. Although initially used by the National Guard and other
emergency management assistance, EMAC was able to demonstrate
exceptional performance in providing public health and environmental
assistance during the 2005 hurricane season. It is also given daily in
administrative and technical support by the National Emergency
Management Association as it performs its operations and educational
activities.12

Several of the benefits that EMAC can offer during emergency

response situations includes a sound legal framework and its ability to tackle
crucial issues in aspects of worker’s compensation, liability and immunity,
credentialing and licensure, and reimbursement. It can also allocate funds
for interstate emergency response efforts. This is an important consideration
as all states intend to have their emergency response assistance expenses
to be reimbursed during an incident.12 It also has a system to facilitate
interstate mutual aid prepared to either act before or supplement federal
assistance. As such, EMAC encourages greater collaboration among states to
provide mutual-aid services between one another especially when faced with
disasters bearing unexpectedly grave consequences that require greater
cooperation and assistance than what a particular state is used to encounter.
But it should also be noted that EMAC does not replace the existing federal
assistance or support programs and it cannot interfere with existing mutual-
aid aggreements.12

Overall, EMAC is a beneficial means of providing a methodology for

obtaining assistance by using a formal organizational structure and standard
operating procedures. This system offers predetermined and understood
roles that are specifically tailored to meet certain needs should an incident
arise. This is the reason for the EMAC’s success in the calamitous events
such as Hurricane Katrina.12

On a more local and community-oriented level, the creation of

Community Emergency Response Teams (CERT)have given a certain level of
awareness to members of a neighbourhood or workplace that wish to be
educated and prepared for possible disastrous incidents that may threaten
their community.13 CERT programs were originally designed to address
problems of communities affected by major disasters particularly by giving
aid during the aftermath of such incidents especially when the initial
responders were overwhelmed or not able to take action due to
communication or transportation difficulties.3 But with the expansion of
CERT’s programs all over America, it has now become a vital constituent to
the preparedness and response capabilities of communities all over the
nation.13 As such, they have become a prized investment by the different
local governments’ time and resources. In addition, program sponsors
provide capital by viewing CERT members as active volunteers that may aid
in the local public safety activities and volunteer from the communities
themselves can take part in the endeavour, further allowing better
interaction of the program with the communities that they serve.13

Being a volunteer program that encourages participation from the

community members, the limits of their service and capabilities must be
taking into consideration. The most reliable source of help in an emergency
or disaster should still be the paid or volunteer professional tasked to
respond in such situations but they may not be able to provide their
expertise in immediate life-saving needs or protect property.13 This is where
CERT members can offer aid as they may be present within the community
the moment disasters strike and provide immediate help. They are not
however intended to take over and replace existing community response
capabilities but are there to give supplemental aid when the need arises.13

On an institutional level, certain hospitals such as that of the University

of Wisconsin (UW) School of Medicine and Public Health have heeded the call
for emergency response teams though its emergency transportation services
program. Their critical care services work in line with physicians, hospitals
and emergency services in providing round-the-clock life-saving critical care
daily.14

Their Critical Care Transport is privileged with a well-equipped team

with state-of-the-art ground transport unit as well as Med Flight helicopters
capable of transporting severely ill and injured children rapidly to health care
teams that may properly assess and treat their condition. UW’s pediatric
I.C.U. nurses and staff in the Critical Care Transport team have also been
given special training to address the requirements of emergency and trauma
situations.14

With regards to providing more organized and efficient method for

coordinating citizen, government and emergency response entities, certain
companies offer their technological innovations such as MIR3 Intelligent
Notification’s inEnterprise platform.15 “The MIR3 platform provides the
capability to quickly and cost-effectively reach citizens by disseminating
important information to a wide range of commonly used modality
technologies. Featuring MIR3's Enterprise Access Control (EAC), designated
users (defined by their role and associated security attributes) are able to
send time sensitive communications to pre-determined departmental zones,
operational groups, customers or other employees based on pre-defined
security access.”15

References:
1
Weiss, R. McMichael, A. Social and environmental risk factors in the
emergence of infectious diseases. Perspective Nature Medicine. 2004 Nature
Publishing Group http://www.nature.com/naturemedicine (retrieved from:
http://www.sage.wisc.edu/courses/400Patz/WeissMcMichael.pdf. October 19,
2009)
2
Kant, Lalit. Combating emerging infectious diseases in India:
Orchestrating a symphony. Indian Council of Medical Research, New Delhi
110 029, IndiaJ. Biosci. 33(4), November 2008, 425–427, © Indian Academy
of Sciences. http://www.ias.ac.in/jbiosci/nov2008/425.pdf
3
Kimball, AnnMarie MD, MPHa,b, MelindaMoore, MD, MPHc,
HowardMatthew French, MPHd,YuzoArima, MPHa,
Kumnuan Ungchusak, MD, MPHe, SuwitWibulpolprasert, MDf,
TerenceTaylor, BAg, Sok Touch, MDh, Alex Leventhal, MD, MPH,MPAi.
Regional Infectious Disease Surveillance Networks and their Potential to
Facilitate the Implementation of the International Health Regulations
http://download.thelancet.com/flatcontentassets/H1N1-
flu/surveillance/surveillance-2.pdf

4 WHO-Regional Office for the Western Pacific. Communicable Disease and

Surveillance. http://www.wpro.who.int/sites/csr/

5 WHO-SEARO. Second Meeting of the Asia-Pacific Technical Advisory Group

on Emerging Infectious Diseases. Report of the Bi-regional Meeting. SEARO,
New Delhi, 18–19 July 2007.
http://www.searo.who.int/LinkFiles/Publication_CD_169.pdf

6 Gayer, Michelle, Dominique Legros, Pierre Formenty, and Maire A.

Connolly. Perspective. Conflict and Emerging Infectious Diseases. World
Health Organization, Geneva, Switzerland. Emerging Infectious Diseases.
Center for Disease Control and Prevention. Volume 13, Number 11–
November 2007. http://www.cdc.gov/EID/content/13/11/1625.htm

7 Hitchcock, Penny, Allison Chamberlain, Megan Van Wagoner, Thomas V.

Inglesby, and Tara O’Toole. Center Articles and Publications. Challenges to
Global Surveillance and Response to Infectious Disease Outbreaks of
International Importance Biosecurity and Bioterrorism. Volume 5, Number 3,
2007. © Mary Ann Leibert, Inc. Reprint with
permission. DOI: 10.1089/bsp.2007.0041.
http://www.upmc-biosecurity.org/website/resources/publications/2007_orig-
articles/2007-09-15-challengestoglobalsurveillanceandresponse.html

8 WHO-SEARO. Asia Pacific Strategy for Emerging Diseases.

http://www.searo.who.int/EN/Section1430/Section1439/Section1638/Section1
889/Section1940_10359.htm

9 WHO-Review of Regional Work of WHO on Health Research 2004-2005.

http://www.searo.who.int/LinkFiles/RPC_Work__WHO_Health_Research-2004-
2005.pdf

10 Davis, Jonathan and Joshua Lederberg. EMERGING INFECTIOUS DISEASES

FROM THE GLOBAL TO THE LOCAL PERSPECTIVE. A Summary of a Workshop
of the Forum on Emerging Infections. INSTITUTE OF MEDICINE. NATIONAL
ACADEMY PRESS
Washington, D.C. 2001.
http://www.nap.edu/openbook.php?record_id=10084&page=52
11
http://www.coordinationsud.org/spip.php?article14484
12
http://www.thefreelibrary.com/EMAC+and+environmental+health+in+eme
rgency+response- a0165359521
13
http://www.citizencorps.gov/cert/start-0-1.shtm
14

http://www.uwhealth.org/emergencyroom/emergencyresponseteamscheta/1
0773
15

http://www.mir3.com/Solutions/Solutions_by_Industry/Government_and_Emer
gency_Response.php