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U.S. Department of Health and Human Services

Animal & Veterinary

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NARMS International Activities - Comments

by Pat McDermott, Ph.D.

DR. MCDERMOTT: Thank you, Linda. What we will do first is I will talk a little bit about international surveillance supported by NARMS, Tom is going to make a few points about other national surveillance programs that interact with NARMS, and then Shaohua will talk about PulseNet International. So there is really three of us that are going to contribute to this topic today. It probably would be best if you have questions, to wait until we have all presented. That might make it go more smoothly.

NARMS programs supports the work of international organizations involved in foodborne disease surveillance and monitoring. We do it in a number of different ways; we are really going to focus on three points: The WHO Global Salm-Surv; Tom will talk about interactions between NARMS and other national surveillance networks; and then Shaohua on PulseNet International. I mentioned the training of scientists in this slide, only because I know that all three laboratories (CDC, USC, FDA) have been involved in the past, or are currently involved, in training scientists from around the world who are interested in the same sort of programs that we put together in NARMS. So, Paula mentioned interacting with CIPARS and also supporting the Mexican Resistvet Project by training their scientists. We currently have two visiting scientists from the People’s Republic of China who are trying to do what we are doing in NARMS; that is, to include in their surveillance animal isolates and food isolates. So they are in our labs for most of the summer, working with our scientists. So I consider that part of our international activities because we at least have the reputation that inspires people to come and seek our expertise, whether at USC, CDC, or at FDA.

(Slide)

I am going to address one important way in which we are involved with international activities. And Dr. Walker had this mentioned in his slides on the budget that FDA-CVM contributes financial and technical support to this program, the WHO Global Salm-Surv.

The WHO Global Salm-Surv mission is to build capacity in foodborne disease surveillance and response.

(Slide)

What I want to emphasize, at the outset, is it is not a program which WHO intends to run indefinitely. The goal is to help countries build that capacity for themselves to take over, ultimately, the financial responsibility, garner the political support, train scientists in the area in lab-based surveillance and in outbreak response.

(Slide)

The steering committee, in addition to FDA-CVM, Centers for Disease Control and Prevention -- and I would be remiss if I didn’t applaud Dr. Angulo who has really spearheaded much of the work this program has done, and has seen it grow from one training course in Thailand to now really a global organization.

Institut Pasteur is on the steering committee; the Danish Institute for Food and Veterinary Research. You can see Public Health Agency Canada in the Netherlands; and Lelystad, the Animal Sciences Group; the Australian Surveillance Group; and then Enter-Net, which Tom may talk about, which is a European surveillance network.

(Slide)

The goals are: to strengthen capacities of national public health institutions; establish regional centers for specialized training; and to expand to new areas of need -- so this is a level at which, through the regional centers, we hope to turn over responsibility for building on the initial training and coordination provided by WHO to regional centers. I will say a little bit more about that. Another goal is to foster collaboration among microbiologists and epidemiologists. We all struggle to do that more effectively. It is considered, in some cases, a major barrier to really fully integrate a mature system, that is to keep those channels of communication open.

(Slide)

The other goals -- of course, these all look familiar to us in NARMS – are to advocate for financial and national support, to foster global communication; and to improve quality and reporting of national data.

(Slide)

This shows members, or member institutions, around the world. There is now more than 800 such members around the world. It has really become a worldwide organization.

(Slide)

And the activities, the way WHO-GSS seeks to meet its mission statement and the goals of the program, one of the main ways, and one of the ones which requires a lot of the financial support, is to conduct international training courses. Courses are setup in regions, and multiple countries send representatives to participate and to learn the laboratory methods and the epidemiology methods.

Another major activity is to develop the regional center so they can pick up the responsibility for promoting the program and maintaining, sustaining, if you will, the program. We do have an external quality assurance system which also some of the NARM sites participate in, in which Salmonella are sent out to the participating institutions for serotyping and susceptibility testing.

We also send campylobacter isolates out for speciation. Susceptibility testing of Campylobacter may be forthcoming.

There is a list-serv and electronic discussion group. A country data-bank in which the countries who have received training are required as part of that training to provide information on the top Salmonella serotypes in their regions or countries.

Because there are region-specific foodborne illness issues, focused regional and national projects often come out of this training and are encouraged; and, coordinated in some cases by the regional centers. These centers are also required to provide reference testing.

(Slide)

International training courses are done in multiple cycles and there are different levels of training. Some members, some laboratories, some institutions have some experience but are interested in learning more and expanding their surveillance capacity. Other places have no experience, essentially. And so, depending on the needs of the nation, and the experience of the members, and the participating laboratories, we will try to adjust and customize the training to best suit their needs.

In general, about 10 countries attend each training course, although it varies somewhat. We try to go back to that same training center within a reasonable amount of time, 12-18 months. Because in that process, what is done in the previous training course is sort of reinforced and repeated, and then other more advanced courses are introduced at that time.

And again, the goal is to bring together microbiologists from the human, veterinary and food disciplines. So, just like we are doing in NARMS, we are trying to encourage the same sort of WHO recommended three-part approach to surveillance.

So we bring together microbiologists and epidemiologists in this course work. It is to develop -- as it notes in the final bullet -- practical skills; the importance of communication and interaction between the disciplines; platforms for communication, a critical element; and we ask them to participate in providing future plans for their countries. So now that you have this training, what can you do with it. Show us, give us some evidence, give us a plan on how you are going to implement it. What you can do in terms of communication and training others within your area in gaining political support, and so on.

(Slide)

So the courses are both microbiology, largely bacteriology, and then an integration of that with the epidemiologists. So it is hands-on teaching, lectures, and exercises. Usually, in the basic course, it begins in focusing on one pathogen, Salmonella. And then in subsequent advanced courses, more sophisticated methods, and additional pathogens are added to the surveillance, and so on.

We spend a lot of effort teaching them proper methods for susceptibility testing. And then when we bring the micro. and epi. groups together, we review the micro-course so the epidemiologists can get an understanding of what goes on in the laboratory-based side of it. And the laboratory people meet the epidemiologists, so they can basically understand each other and use the information from both disciplines to do their capacity building.

In these integrated courses, we have small group discussions with lectures and exercises where they do simulated outbreak investigations and things of that nature. And then also at these meetings, we request a joint country plan of action by the microbiologists and epidemiologists. So there is always this push to show that the training has benefitted you and that the support WHO and the program has provided, you are actually going to implement. Because we don’t want to go back to a country where, either through lack of political support, or just an inability to generate interest, that the training isn’t really put into use.

(Slide)

This shows places around the globe where the training sites are and also the regional centers. You can see there are four regional centers. And at the time of this slide, anyway, I think it has changed a little bit, over 90 countries have participated. There are new proposed training sites in different parts of the world. We are trying to do our best to provide training in areas where we can get the most attendance and the best bang for the buck, if you will.

(Slide)

We don’t just give them the information then and cut them loose, so-to-speak. So we do ask for them also to tell us how we can do the job better on a regional basis. Because as I mentioned, some areas have different needs and different experiences than others. So we ask them to evaluate the training course, and CDC’s developed this type of evaluation form; which is a fairly recent addition. I mentioned the external quality assurance system to help also measure the impact of the training. And also, the regional and national projects, which can come out of the training.

(Slide)

Some of this I mentioned, I really have this slide up here so that you can see the website. There is an English and Spanish version on the website if you want to learn more details. It wasn’t my intention to do more than just give a general overview today, but it is an excellent program that, I think, has done a lot on a shoestring often. So it is something that FDA-CVM has seen as valuable in its public health protection function of GSS.

(Slide)

I want to say just a few things about another project that CVM has supported in the international arena, and I should say USDA also. And that is the Resistvet Project in Mexico.

Again, Mexico expressed an interest in trying to set up an national surveillance system modeled on NARMS. So we provided expertise again and financial support to help them develop this. Paula was instrumental in getting this off the ground, along with Dr. Tollefson and Marsha Headrick.

We have participated as advisors, generally, in training and in some collaborative research projects.

(Slide)

This shows the states that are participating in the Mexican surveillance system. There are four states that have been included in, really, what is a pilot attempt to get this off the ground.

(Slide)

They are looking at healthy and ill humans. They look at all intestinal and extra intestinal isolates from one hospital and two primary care centers within each of the regions --states, if you will. They also look at healthy, asymptomatic children in kindergartens and also food-animal products. And it shows you here that they go out and collect poultry and pork at the supermarkets in the same area where the asymptomatic children are sampled.

(Slide)

As far as moving to slaughter houses, that has been a major challenge in this project. Getting the political support, getting the producers and local authorities to grant that access. Dr. Zadi, who runs a program in Mexico, has had some success in this arena. So there is more support, I think, to have access to the slaughter houses. And, of course, some you don’t know where they are. I thought to bring some pictures of Mexican slaughter houses, it is quite a bit different than the U.S. system.

(Slide)

And then we can all be familiar with these points. They have met major obstacles trying to get this off the ground. Recruiting, training, and retaining personnel in the laboratories. They had some problem early on with campylobacter isolation, which they resolved; and campylobacter susceptibility testing which, hopefully, will be resolved by the availability of the broth method.

So that is all I wanted to say. I just wanted to give that information to you to just, basically, tabulate it for you without showing you the data -- which there is a lot from WHO Global Salm-Surv. And you can get an idea of that from the website.

I am going to let Tom take the podium now and talk about other collaborations between NARMS and other national surveillances.