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Global Alert and Response Against Emerging and Reemerging
Infectious Diseases –an Overview–
Tomimasa SUNAGAWA
Infectious Disease Surveillance Center, National Institute of Infectious Diseases
1-23-1 Toyama, Shinjuku-ku, Tokyo 162-8640, Japane-mail: sunatomi@nih.go.jp

Abstract
Emerging and re-emerging infectious diseases, in addition to accidental or deliberate release of biological agents, are a major threat to human health. In response to the Severe Acute Respiratory Syndrome(SARS) epidemic in 2003 in particular, international and bilateral (country-to-country) systems against
those threats were strengthened rapidly. The implementation of the International Health Regulations (IHR)
is one of the central concepts in mankind’s fight against those threats. Under the IHR, national core capacities including surveillance, response and issuance on port of entry are described as the major targets for thecountries to assess and develop in order to fulfill the goals of the IHR in a certain period of time. The Global
Outbreak Alert and Response Network (GOARN) is a coordinated mechanism for rapid assessment andresponse to the occurrence of outbreaks of international concern. The Field Epidemiology Training Program(FETP) is a newer program for many countries for building up their competency to investigate and containoutbreaks. In some countries, the program is also a part of GOARN. Harmonized rapid development of
those systems within each country and internationally is becoming more important and necessary for theworld’s citizens in the 21st century.
Key words: FETP, GOARN, international concern, outbreak, the IHR

1. Introduction
Infectious diseases have been a significant threat tohuman beings for ages. Throughout history, the humanpopulation has experienced major outbreaks of infectious diseases, often accompanied by large numbers ofdeaths, panic, disruption of trade and political instability.
When disease spreads rapidly in newly affected populations, higher morbidity and mortality are marked.
Modern scientists have successfully identified pieces ofgenomes from bacteria and viruses in the humangenome. It probably reflects an unseen history in whichmankind has been fighting against them to survive insevere circumstances on Earth with abundant biologicaldiversity.
After World War II, through the development and useof antibiotics including anti-viral drugs, it was once
believed that humans could overcome the threat of
infectious disease. However, the fact is that, in recent
years, we see the appearance of diseases caused by
newly emerging or even known infectious pathogens
once believed to be controlled. The WHO (World HealthOrganization) (2007a) defines emerging and re-emerging
infectious diseases as:– diseases that have newly appeared in a population;
Global Environmental Research
12: 63-67 (2008)
printed in Japan– diseases that have existed in the past, but are rapidly
increasing in incidence or geographical range.
Pathogens discovered after the middle of the 1970s are
historically called emerging infectious diseases (EID) or
re-emerging infectious diseases (REID). Following theoutbreaks of hemorrhagic fever in Africa in the middleof the 1990s, and especially with the appearance of
Severe Acute Respiratory Syndrome (SARS) between
2002 and 2004, international society has been strengthening its response against EID and REID. Recently strong
efforts have been made toward response and preparedness to avian influenza A (H5N1) as a threat of an
influenza pandemic. At the present time, the world also
faces the risk of outbreaks by accidental or deliberate
release of biological agents into human and or animal
populations, so-called bio-terrorism. EID, REID andbio-terrorism are three events which exhibit similarfeatures and require a special system for detection andintervention.

2. International Action to Contain Outbreaks
As the tools of transportation and communication aredeveloped, it becomes clearer that helping other countries deal with outbreaks reduces the threat of outbreaks©2008 AIRIES

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T. SUNAGAWA

Fig. 1 Field operations and functions in outbreaks. (Source: WHO)

spreading internationally (WHO, 2000). Many countries
offer bilateral assistance to countries affected by outbreaks. It is sometimes very effective when the support
is comprehensive and continuous to the affected country.
Sometimes in countries facing problems of conflicts or
natural disasters including disease outbreaks, nongovernmental organizations (NGOs) work on thefrontlines to assist countries through medical care,vaccination, provision of water sanitation and social
mobilization. The support by NGOs is mostly ahumanitarian approach capable of covering part of theintervention. International bodies have also been involved in fighting against outbreaks for a long time. The
function of outbreak response is getting complicated andfragmented. A number of international networks for
specific disease threats have been established. The roleof international organizations such as the WHO is now
more focused on coordination to help diverse partners
collaborate effectively, rather than in direct intervention(Fig. 1). The IHR is a concept for timely sharing of
information and rapidly responding to threats internationally. GOARN is a coordinated mechanism forproviding professional tools and human resources tocontain outbreaks.
2.1 IHR2005
The International Health Regulations (IHR) (Fig. 2)
entered into force on 15 June 2007. According to theWHO, the IHR are an international “legal” instrument(Baker & Fidler, 2006) that is binding in 194 countries(as of end of March 2008) across the globe, including all
the Member States of the WHO. Their aim is to help
international society prevent and respond to acute publichealth risks that have the potential to go across national
borders and threaten people around the world. In fact,
outbreak threats are chiefly seen as coming from outside,

Fig. 2 The cover of “International HealthRegulations (2005)” book.
(Source: WHO)beyond city or national borders. The IHR target not only
infectious diseases but also chemical events (e.g.,chemical leakage), nuclear melt-downs or whatever isrecognizable as a Public Health Emergency of International Concern (PHEIC). In Annex 2 of the IHR, a decision instrument on infectious diseases is describedprimarily for the assessment and notification of events
that may constitute a PHEIC. The summary is shown in
Fig.3. There are four criteria to consider in deciding
whether or not the event might constitute a PHEIC; 1) Is
the public health impact of the event serious? 2) Is theevent unusual or unexpected? 3) Is there a significant
risk for international spread? 4) Is there a significant
risk for restriction of international travel or trade? Basedon the assessment on their own, countries are required toGlobal Alert and Response Against Emerging and Reemerging Infectious Diseases

report certain disease outbreaks and public health eventsto the WHO under the IHR. The WHO indicates that the
IHR defines the rights and obligations of countries toreport public health events.
Another aspect of the IHR is related to national corecapacity building, especially regarding surveillance andoutbreak response. Minimum core capacity at points ofentry is included, too. Countries have to assess theirnational systems and resources and to develop plans ofaction to ensure that core capacities are present andfunctioning. However, the level of existing capacity andthe need for further actions vary from country to country.
Prioritization of core capacity-building and the WHO’s
support/advice are mandatory. In Japan, some researchis ongoing regarding IHR implementation and preparedness.
2.2 Epidemic Alerts and Verification
The process of global disease surveillance, which
was initiated in 1997 by the WHO, involves the systematic collection and collation of information, including65

both official information and rumors, from many different sources, such as countries’ ministries of health, other
United Nations organizations, mass media and personalcommunications (WHO, 2006). As a source of information, outbreak verification relies on a broad range of
information sources including the Global Public Health
Information Network (GPHIN) which is a web-based
electronic system developed by Health Canada incollaboration with the WHO which scans the web invarieties of languages to identify suspected outbreaks.
The four above criteria nominated as decision instruments in Annex 2 of the IHR, have been established to
identify events that may constitute an international public health risk. If the event is assessed as being a potential public health risk of international concern, thenverification and further information are sought from theaffected country. Verified events undergo continuous
risk assessment and monitoring to assess the need forfurther information and response. The aim of this process, “epidemic alert and verification,” is to improve
epidemic disease control by actively collecting and

Fig. 3 Decision instrument. (simplified from Annex 2 of the International HealthRegulations (2005)) (Baker & Fidler, 2006)

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T. SUNAGAWA

verifying information on reported outbreaks and informing key public health professionals in the world aboutoutbreaks (WHO, 2006). Since the implementation of
the IHR in June 2007, the WHO has shared all information regarding the current public health risks of international concern with its Member States through their
National Focal Points (NFPs) designated by the IHR.
The results of a recent Epidemic Alert and Verification situation, which occurred in around 2006, aresummarized by the WHO (WHO, 2007b). In 2006,
WHO identified 279 events primarily associated withepidemic-prone diseases. Investigations were successfully completed in 246 (88%) of these events; 71% (197
events) of them were verified as being a potential risk tointernational health security and 18% were determined
to be of no international concern. Twelve percent remained unverified. Of the 197 verified events, 37 (19%)
were attributed to cholera or acute watery diarrhoeal
syndrome, 30 (15%) to influenza (non-H5N1) or acuterespiratory syndrome, 23 (12%) to Meningococcal diseases and 7 (4%) to influenza A (H5N1). Other common
syndromes or diseases include acute diarrhoeal syndrome, measles, acute haemorrhagic fever syndrome,malaria, poliomyelitis, chikungunya, dengue fever andyellow fever.
Some countries are also conducting Epidemic Alert
and Verification activity (personal communication).
Applications using other languages to scan web-based
information including those in Asia are now being
developed.
2.3 GOARN
GOARN, the Global Outbreak Alert and Response
Network, is a coordinated mechanism for rapid identification, confirmation and response to outbreaks ofinternational concern through technical collaboration
among existing institutions and networks. According to
GOARN’s website (WHO, 2008), its objectives are described as:– combating the international spread of outbreaks,– ensuring that appropriate technical assistance reaches
affected states rapidly and– contributing to long-term epidemic preparedness andcapacity building.
It started officially in 2000 through a coordination of
the WHO in an outbreak response. One of the earliest
examples of dispatch by GOARN to the field was during an outbreak of Ebola hemorrhagic fever in Uganda
in 2000 (WHO, 2001). The outbreak was contained bygetting technical support from 104 specialists (23 partner institutes) and financial support from many countries and organizations. GOARN’s partners include
scientific institutions in Member States, medical andsurveillance initiatives, regional technical networks,
networks of laboratories, United Nations organizations(e.g., UNICEF, UNHCR), the Red Cross and international humanitarian NGOs (e.g., Médecins sans
Frontières, International Rescue Committee, Merlin andEpicentre). In Japan, the National Institute of Infectious

Diseases (NIID) is one of the partners of GOARN.
GOARN has been discussing and bringing agreed standards to international epidemic response through thedevelopment of the Guiding Principles for International
Outbreak Alert and Response and operational protocols.
They will include laboratory, clinical management,
research, communications, logistic support, security,
evacuation and communications systems. In an article
published by the WHO in 2000, an outline of the function of these networks was briefly illustrated (Fig. 4).
When SARS outbreaks occurred in Asia in 2003,
GOARN requested partner institutions to dispatch field
epidemiologists to the fields. For example in Hong
Kong, epidemiologists were gathered from multiple
countries such as the United States, Australia and Japan.
Two were sent from Field Epidemiology Training
Program (FETP) in Japan. One of the important activities for them was to summarize a descriptive epidemiology at an early stage of the outbreak. The investigation
included interviews with patients, analysis of epidemiological information and observational studies where outbreaks occurred (Fig. 5).
Global Alert and Response
Network Functions

Alert

Response

Preparedness

Fig. 4 Possible functions of Global Outbreak Alert andResponse Network. (WHO, 2000)

Fig. 5 A view from the corrider of “Apartment A” on the
16th floor, where many SARS cases were reported in
Hong Kong. (April 2003, photo by T. Sunagawa)Global Alert and Response Against Emerging and Reemerging Infectious Diseases

Fig. 6 TEPHINET member programs of the world.
(TEPHINET, 2008)

2.4 Field Epidemiology Training Program
The Field Epidemiology Training Programs in eachcountry formulate a global network which is called theTraining Programs in Epidemiology and Public HealthInterventions Network (TEPHINET, 2008). It wasincorporated in 1999 as a non-profit organization withthe aim of strengthening international public healthcapacity through the support and networking offield-based training programs. This network comprises
32 countries as of end of March 2008 and is expanding
year by year (Fig. 6). In particular under the IHR, every
country needs at least a minimum core capacity inepidemiology for evaluating their health promotion anddisease control programs and monitoring progress
towards achieving program goals, which will contributeto global alerts and responses to emerging and reemerging infectious diseases. Many programs are locatedamong the institutions of the GOARN partners. The primary goal of these training programs is to foster thedevelopment of field-trained epidemiologists who arecompetent in the practical application of epidemiological methods to a wide range of public health problems intheir respective areas. There are various models offield-based training programs in the world. All of themare programs based on training through service and areadapted to meet the health needs of the country or area
in which they function.

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industrialized countries including Japan, the capacity for
response to EID and REID is not always sufficient andparticipation in global networks is crucial. GOARN is
an international coordinated mechanism for response to
EID and REID. Standardized competency of the partner
institutions in each field will be important. FETP isa possible mechanism for most of the countries tocollaborate easily with other programs with a similarlevel of capacity because of its standardized training
world over. For some countries such as Japan where
there already exists a strong laboratory capacity, there isalso a need to strengthen field epidemiology programs.
In order to respond effectively and efficiently against
EID and REID at a global level, international collaboration based on harmonized development of the necessaryfunctions under the IHR in each country will be necessary.
References
Baker, M.G. and D.P. Fidler (2006) Global Public Health Surveillance under New International Health Regulations. Emerging
InfectiousDiseases, 12(7): 1058-1065. Available at http://www.
cdc.gov/ncidod/Eid/vol12no07/05-1497.htm
TEPHINET (2008) Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET). Available at
http://www.tephinet.org/
WHO (2000) A Framework for Global Outbreak Alert andResponse. Available at WHO/CDS/CSR/ISR/2000.2
WHO (2001) Outbreak of Ebola Hemorrhagic fever in Uganda,
August 2000-January 2001. Weekly Epidemiological Record
2001, 76: 41-46
WHO (2006) Epidemic alert and verification: summary report2005. Weekly Epidemiological Record, 81: 357-364. Available
at http://www.who.int/wer/2006/wer8138/en/index.html
WHO (2007a) International travel and health Situation as on 1
January 2007
WHO (2007b) Epidemic alert and verification: summary report
2006. Weekly Epidemiological Record, 82: 105-116. Available
at http://www.who.int/wer/2007/wer8213/en/index.html
WHO (2008) Global Outbreak Alert & Response Network. Available at http://www.who.int/csr/outbreaknetwork/en/

Tomimasa SUNAGAWA

3. Conclusion and Discussion
Response to infectious diseases is often like that todisasters. Preparation is most important. Many countries
have started preparing for effective implementation of
the IHR. A few countries have developed and implemented work plans for strengthening their core capacity
for EID and REID. For many countries, it seems thatawareness of the importance of the IHR is still important and needed. Multisectoral workshops for advocacy
and administrative arrangements have to be planned andconducted. In order to achieve effective implementationof the IHR, assessment of national core (minimum)
capacity is an essential first step and should now be
ongoing in countries. The level of existing capacity andthe need for future actions vary by country. Even for

Tomimasa SUNAGAWA graduated from the
University of the Ryukyus School of
Medicine in 1991 and served at the US
Naval Hospital in Okinawa. In 1993, hejoined the Pediatric Department at the
Osaka Graduate School of Medicine
where he earned his doctorate in 1998.
In September 1999, he joined the Field
Epidemiologist Training Program (FETP)
in National Institute of Infectious Diseases (NIID). He became a seniorresearcher at Infectious Disease Surveillance Center in NIID from
November 2002, where he investigated Severe Acute Respiratory
Syndrome (SARS) in 2003 and Avian Influenza in 2004. From August
2004, he was given a short to long-term appointment to the WHO/EPR
Division, returning to NIID in June 2007. Since then, he has been working
mainly for FETP program, national measles elimination plan, andpandemic influenza preparedness in Japan.

(Received 3 May 2008, Accepted 16 July 2008)