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U.S. Department of Health and Human Services

Animal & Veterinary

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WHO Activities to Build Laboratory Surveillance Around the World by Danilo Lo Fo Wong, M.Sc., Ph.D.

DR. WONG: Thank you, Madam Chair. And now I’ll move on to something I’m much more familiar with and comfortable to talk about. But before I go there, I would like to thank the organizers for giving me the opportunity to bore you with something that I usually like to talk about, and usually it’s a challenge for me to keep that within 10 or 15 minutes, but I’ll do my best.

So, I was asked to talk to you about the Global Foodborne Infections Network. And I realize that for those of you who are involved, actually quite a few -- all of you have been involved at one point in time and have still are involved, which is great. But some of you may not know this network. It’s not new. I used to be called WHO Global Sound Surf, and for those of you who don’t know that, WHO Capacity Building Network that tries to help countries detect, control and prevent foodborne and other enteric infections from the farm to the table.

(Slide)

So, GFN is a network of professionals like yourself and myself that come from various disciplines, background, all these disciplines that are inherently involved when you work with food safety and zoonoses. So there are veterinarians, food specialists, and public health, epidemiolgists and microbiologists, that are helping us to build the capacity in countries to do this kind of surveillance.

(Slide)

Now, our mission is exactly to do that, to build this capacity because we do know there is a great need for it. And one of the things that we really target is intersectoral and multi-disciplinary collaboration. That’s something that has been said many, many times, and many places, we have been doing this since 2000 with I think with good success. Because as you know if you work in this area you go from the farm to the table, you cross several jurisdictions and you have -- you need various disciplines to come together to not only to collect the data but to turn that into information and share it to the people that can actually do something about it.

And finally working in the area of food safety foodbore pathogens. We are trying to promote laboratory-based surveillance. Trying to go away from syndromic surveillance into being able to identify the pathogen and on occasion on top of that able to identify whether or not it’s susceptible for certain antimicrobials.

(Slide)

So, the governance of the WHO is WHO program, even though we do encourage a lot of collaboration also with international organizations. It has a Steering Committee which I will introduce you to in a minute. Under that there are several subcommittees. We have designated regional centers of excellence which are excellent institutions that help us not only train but also do reference testing of the services in the region and under that we have training sites, also.

But as I showed you earlier, we have the same kind of structure in terms of governance which is not a coincidence, because both the work our, AGISAR and in GFN are very closely related. So we have lots of organizations and networks, institutes, universities and individuals with certain skills that are putting in their own time and taking the fights with their bosses to come to these training courses and provide a lot of support in kind, which is what we are very, very grateful for.

(Slide)

This is the Steering Committee today. I will not go through it in great detail but you will recognize some of these logos. Some of them have organized this meeting.

The other thing that I would like to point out, if you look at the Steering Committee, we actually have organizations that represent both veterinary, food and public health. Which is I think already at that level we are signaling that we need to work together and we can work together.

Then the subcommittees, some of them come and go as there is a need for it, but the most long-standing subcommittees are the lab-subcommittee that is working on protocols and lab curriculum development and the Epi-subcommittee that is helping us do case studies, adapt the case studies that are existing or developing new ones and also work on the Epi-curriculum for our training.

(Slide)

So, we started in 2000 as a pure bench top training program. This was based on a perceived need from a survey that was done, a global survey that found out that yes, a lot of countries can do Salmonella serotyping but a lot of those that cannot, are developing countries, so there was a need to work on Salmonella. This is what we started on.

A year later, we already introduced Campylobacter, and in 2002 we came to the realization that we not only need to teach people how to generate data but we also need to teach them that that data needs to be shared, and quite often they would not know the people who to share it with. So we brought them to the training course and from that moment on we started doing joint training courses with microbiologists and epidemiologists to get to know each other and to build informal networks in times of peace so they would be able to find each other when enteric outbreaks and such.

In 2003 we introduced E. coli into our curriculum, V. cholera and Brucella were introduced first time in 2004. In 2005 we were five years old. And we did our -- we finished the first five year program and we devised another strategic program along the same lines. So we kept continuing doing the training and other activities.

2006, Shigella and our first S. typhi demonstration. We would not play around with the life of S. typhi in the labs. 2007, in terms of the program nothing much happened other than the fact that I had the distinct privilege to take over as the Coordinator for the network. 2008 we introduced MRSA.

And the last year we finally managed to shift name. We had been talking about this for five years and we told between -- we have some name recognition but the name that we had doesn’t really reflect what we’re doing. So finally we found some letters and put them together and we all could agree on. So hence the birth of the Global Foodborne Infections Network.

You also can see that we went from a single pathogen program that was very much focused on Salmonella in all our program elements to an issue that -- a platform that can basically address lots of different issues, depending on the regional needs.

This year we just celebrated our 10th birthday at the Conference a few days back and we will go and devise our third five year strategic plan and of course I cannot say what’s going to happen because we need a lot of input from a lot of people. But what I personally hope for is that we’ll be not only building capacity but we’ll be a network that starts using the capacity that we’ve been building and challenging other people that we’ve been training to contribute to the global picture and thereby building more capacity.

(Slide)

So, our main activity by far shows where our biggest part of our budget goes to is the international or national training activities. Then we have an external quality assurance program, once a year that tests labs and their ability to serotype Salmonella or Campylobacter or Shigella, but also antimicrobial susceptibility testing.

We have a country data bank, where we collect Salmonella serotype data which unfortunately has been misperceived as being a surveillance system, it is not. It is annual data. But for us it was another way of training, another way of getting information from countries that previously were not getting data. So on the one hand it was an idea, to get an idea of the impact of our training and also to show that it’s not necessarily scary to share data.

We perform reference services, both technical and practical. Then we have focused regional and national projects that are usually coming out of the training because during these training sessions we have a lot of interactions between the participants and the trainers and every now and then we stumble upon something which is really interesting. So we get together, we do a low or no budget project that usually ends up being published. Which is really good. And then various forms of communication.

So, this is where we are today. I realize it’s a bit small, but on your left corner there is the world as we know it. We have 17 active training sites around the world. And with the exception of China and Moscow, Russia and Brazil, all international training courses. But those three sites are national training courses due to the sheer size of the country, of course.

A couple of sites that we’re working on like in India and Mozambique and South Africa to set those up for training.

And currently we have a little over 1,600 individual members that represent 700 institutions, from 179 Member States and territories. So we’ve come a long way.

(Slide)

So, our training courses traditionally we have microbiology components, where we started off with Salmonella but now basically do a whole range of pathogens based upon the needs of the training site in that region. Those generic laboratory stuff on quality assurance, quality management, biosafety, but also antimicrobial susceptibility testing, which has been a component since the very start of our program.

On the epidemiologic side we do quite some classic epidemiology outbreak investigations, evaluation surveillance systems, study design, but also some of the more newer harder trends, such as source attribution and burden of disease.

One thing I didn’t tell you is that a training course only lasts for a week, so we have them for a week, so that means we’re not creating microbiologists and we’re not creating epidemiolgists because you cannot do it in a week. So we taking people that are in a position that are doing their job, but we’re sensitizing them to our area and the special features of our area, which means that they need to work together.

And that’s also my favorite part of our training, when we bring them together and we put them through some exercises and group work that is inherently multi-disciplinary such as integrated surveillance, risk assessment, country plans of action. So we stimulate them to think integration, to think on how to good integrate, where are they now, where do they want to go, and how do they get there. And those are usually very good exercises, also for people who don’t usually know each other.

Advocacy and communication, very important because in many countries unfortunately food safety and zoonoses are not very high on the agenda. But I see a changing trend in that which is very lucky. And also being part of WHO there is a lot of information networks that we want them to contribute to. So we want them to be able -- want them to see their roles and influence their role in IHR, so you’re not just isolating a pathogen for a year report, but actually sending some information that in some cases may be of international concerns. So you need to know that this information needs to be shared nationally, sometimes internationally.

(Slide)

As I said we started in 2000 and we went once around the world, twice around the world, three times around the world. And recently we have our 70th training course in Argentina. Which I personally think is quite impressive if you realize how we are funded. It’s very ad hoc. People put in their own time and money. There are some regional foundations that put in money for a training course here and there. But through a lot of enthusiasm, a lot of dedication, we get this done.

(Slide)

So, in terms of laboratory manuals there has been a lot developed for our training. But then also made available not only through CDs after training, but also on the web so people can download them and use them as they see fit. And right now we’re in a large exercise of getting all our protocols updated and then we’ll do the next effort in trying to translate them into as many languages as possible.

(Slide)

In terms of external quality assurance system, I guess the main aim for those labs that sign up is to evaluate their own performance, how are they doing in terms of serotyping and susceptibility testing. And by improving their performance they improve the quality of their surveillance data.

Now, what’s in it for us is that we get a good overview of the performance globally in these lab techniques and also evaluate the effectiveness of the training courses. And finally to identify what other barriers for not doing this or not doing this properly. And hopefully we can address those.

(Slide)

So, as of today, we have little over 1,100 data sets in our country data bank from 80 countries representing 1.5 million human isolates and as well as 400,000 non-human isolates.

And so I should tell you a little bit more about the data bank. What we tried to get is countries top 15 serotypes in human and non-human sources. So, that’s maybe of limited use but it’s also of limited threats.

So, countries are actually willing to provide this data to us, we can still see that there are some serotypes that are region specific and we can still see the trends from one region to the other. So, it does provide us with some information but again I think the biggest worth of the database is that it’s something that people are willing to put data in and they can see some results.

It also holds the addresses of all our members. There is a little over 1,600 addresses in there, if you want to contact people in countries. And that’s a direct link to it.

(Slide)

So, what we’ve been doing so far if we get this data, at conferences like this we always give an update. In this case we divided the world I think into 13 Epi-regions. And for those regions we have a top five human serotype, top five non-human serotypes, and just -- well, descriptively see if there’s any link.

But if you go to the raw data which is publically available on the web, you can get different kinds of reports, but they’ll show you table after table after table. Just not very intuitive and it doesn’t really give you a good overview.

(Slide)

So, quite recently with our collaborating center in Denmark we started -- but we’re doing a new interface for the country data bank and showing the data in different ways. You can see trends over time, for the various sources, for countries and serotypes. It’s still in development but I think it’s a lot more attractive then it has been before. And again it’s a database that we can build upon and get more data in which is the idea to get as antimicrobial resistance profiles, data from other pathogens and this is also a learning process for us on how to show this data and give people a pretty good idea of what’s going on.

And the other thing we’re doing is we’re combining with in this case production and consumption data as freely available for the FAO. And also if you can -- if you can see any linkages there.

(Slide)

So, in terms of projects, we have several projects that come out of the training as I said before. The first one we ever did was S. Weltevreden, which is a very region serotype which we don’t usually see other places in the world other than related to an outbreak for example shrimps, of Southeast Asia. So that was one thing that participants kept mentioning during the training course, that was one of their top three, four, five serotypes and we were intrigued by that. We did a project and got that published.

And since then we have done many different pathogen specific projects, burden of illness projects, which basically tries to estimate the under reporting of pathogens. We’ve done enhanced surveillance studies such as the one that Professor Danilo just presented to you earlier. And so far we’ve done a little over 30 projects and more than 25 of those actually ended up in the peer-reviewed for teacher.

So, to me this is another way of building capacity because some of these co-authors are main authors would never published international literature if they had not got engaged in these projects. So that’s another way of getting involved and getting data from regions that we usually don’t get information from.

(Slide)

Reference services, there is a service that we provide for free that countries can send isolates that they’re struggling with and we’ll do the verification for them for free. We will not pay shipment. And that’s of course the main barrier not to overload our system but it also, it’s shown to be a good screening tool, so the samples that we do get and we do get lots of samples, they are the samples that they really want to have investigated.

Most of it is replying to technical questions because of course during the training course you get a lot of personal interaction with participants, the participants always have a favorite trainer that they can e-mail with questions and questions and questions and of course we answer those as much as we can, as good as we can.

On top of that there is a good increasing trend of participants in developing countries of finding or locating funding to either come to our labs at FDA or in Denmark or other places, to do individual lab courses, hands on training, which is of course a very intensive way of building capacity. And suddenly we find money to go and do site visits and do training in their lab addressing the needs that they have in the lab. But hopefully they’ll have more funds to do that because I think it’s of course useful to bring somebody to a super-lab and show them how it needs to be done, but it might be more useful to go to a lab and see what the restrictions are that they’re working with and trying to address those on the spot.

And of course participation in the regional projects that I mentioned earlier. And of course so far we have done little over 20 laboratory manuals that are all freely available on the web.

(Slide)

I guess the main challenge that we have such as --- and sustainable funding, we have to admit we’re doing pretty good without it. But it could be better.

The other thing that we’re facing is the national priorities, which is nothing new. It’s something that we have a direct effect on but it’s something that we can try to address. The food safety is usually not on the top of people’s lists. And arguably so there are other diseases that have both the higher profile, but not necessarily higher impact.

The other thing that we sometimes struggle with and sometimes it’s cultural, sometimes it’s practical, is to get the right participants. Because we go to great lengths to get them there, it’s quite an investment to get people to training courses. We don’t always get the right participants. We want people that are able to bring their expertise to the table, try to make it fit, and also do something with the information that we provide them.

The other thing of course is followup, even though we’re going, a number of people are still, a few people that have to do a followup, but a lot of participants that have made big plans but they need to be asked how it’s going, what are the barriers, how can we help you.

(Slide)

And or course these are the number of barriers, between public and private. In the various sectors and the various disciplines, which is basically the core of what we try to tackle.

(Slide)

So, what we’re promoting is for example, agriculture and health, industry and consumers to work together but somehow find a forum where they’re all glued together in a coordinating body or steering committee so they can start forming an integrated surveillance system.

(Slide)

And finally, like any other program we have to document our impact. And we know we make an impact and we have -- anecdotal evidence for it but it’s really difficult to really show and take credit for some of the changes that we’ve seen in countries after we have been training.

To the perspective, of course we want to assure sustainability. There are a lot of activities going on within WHO. There is a lot of expertise data that we could tap into and we’re trying to especially in relation to the international health regulations group, but also others that are doing outbreak response out there in the world.

(Slide)

But also since we’re preaching from the table, I think we should reflect that on the organizational level as well, so we are increasingly engaging with FAO and OIE in our training activities, but also other regional institutions such as --- and CDC.

Of course for our own program we want to increase the data that goes into the country data bank in terms of maybe other pathogens and antimicrobial resistance profiles. Also to strengthen the non-human side of things. It’s been difficult to get data from the non-human side. And increase our geographical coverage.

And also we want to make sure that while we do what we do we increase our impact. One end by getting more political support. By making sure that what we do is involved for the region and that not a one size fits all program. By increasing the number of targeted studies because we’ve seen that that’s a very good way of not only engaging participants from developing countries, but also getting results and motivating them and others in their neighborhood. And getting the right participants, that they are, they are able to take on material and to really set up their own national or regional training course.

And finally I strongly believe that if you’re part of a network you should get something out of it. Of course we have our training manuals, an other idea we’re playing with is to make this material more centrally available. Maybe password protected so that people can contact us when they have the intention of doing training course which also allows us to followup and say, well, you’ve requested this material, how did it go and can we help you.

Putting out new information through articles, newsletters, website, and finally also a new country data bank interface should help us.

(Slide)

So, the immediate way forward is for course we would like to make a lasting impact on the world, so as many other people. For that we need to seriously plan because we’re not the only offer in town and I do think there is a lot to be gained from working together and a lot to be gained from thinking outside the box.

(Slide)

It is also important in that sense that we’re putting it to a big picture, maybe include other disciplines or other areas that are directly or indirectly related to our work.

(Slide)

And finally just be smart about it. So knowing where we are, knowing where we want to go and how to get there.

And some of those discussions will take a month from now at our Strategic Planning Meeting which will be preceded by a Stakeholder Meeting where we hope we get a lot of input from different agencies, foundations and organizations on what they feel are the training needs for the next five years and see how we can fit in there.

So, with that, thank you for your attention.

(Applause)

DR. CARATTOLI: Thank you so much for this overview of your work. There is no time I guess for more than one question. Do you want to break now? Okay.

So, the last talk after the break project is proposing okay. See you in 15 minutes. Okay. Good.
(Whereupon, a short break was taken.)

DR. CARATTOLI: Okay. We can start now. Thank you. So, the last presentation for today is our speaker is Peter Silley.

And Peter was responsible for Science Communication of the National of Excellence of MED-VET-NET. And I am fortunate to say that it was just concluded this year and since we were all financed by MED-VET-NET, and so it’s his program was excellent and just finished.

And now he talks about the surveillance in Europe, challenges and pitfalls. Thank you.