PREDICT AND PREVENT
An initiative to help prevent local outbreaks of emerging disease from becoming pandemics
Summary
Several new lethal infectious diseases crop up every year. Examples include the well-known
killers HIV/AIDS, avian influenza, and SARS, as well as drug-resistant strains of ancientscourges like malaria and tuberculosis. Three-quarters of new diseases are zoonoses, meaning
they've jumped from animals to humans. Urbanization and deforestation increase human-animalcontact, and with it, disease spread. Climate change is allowing insect populations to thrive innew areas, changing the face of mosquito-borne diseases. Through October 2008, Google.org's
Predict and Prevent initiative has committed over $30 million in grants to support partners to
identify hotspots where diseases may emerge, detect new pathogens and outbreaks earlier, andrespond quickly to prevent local threats from becoming global crises.
These grants will increase our understanding of emerging infectious diseases and generate vast
amounts of new data, samples, genetic sequences, and hopefully pathogen discoveries. One
promising way to put this new knowledge to work to save lives is to invest in robust, affordable
infectious disease diagnostics for use in Asia and Africa. There are also many ways in which
Google's data management, data sharing and collaboration platforms can improve data access andsharing, support online bioinformatics, and advance the genomics of infectious diseases. Finally,
as we get to know partners better, we expect that our grant making will shift to directly
supporting partners at the frontline in high-burden countries to build sustainable local capacity toidentify pathogens at their source.
Emerging Infectious Diseases
Despite advances in medical treatment and vaccine technology, emerging infectious diseases areon the rise worldwide. Over the last three decades, the World Health Organization (WHO) has
reported more than 30 brand-new infectious diseases, including killers like HIV/AIDS, Ebola andSARS.i
In addition, known diseases are expanding in geographic distribution, even shifting to entirely
new continents. For example, in the summer of 2007, health workers were shocked to diagnosechikungunya fever, a mosquito-borne disease normally confined to the tropics, in Ravenna, Italy.ii
In 1999, another mosquito-borne infection, West Nile Virus, jumped continents to appear in New
York, and became endemic throughout the United States within three years.iii
Other diseases have transformed into new threats as a result of drug resistance. For example,extensively drug-resistant tuberculosis (XDR-TB) is a new strain of an ancient disease that isresistant to a combination of standard and reserve treatment medications. iv,v
In the era of globalization, the risk of an isolated outbreak of disease becoming an epidemic oreven pandemic is greater than ever. Vastly expanded international travel and trade allow diseasecausing agents to move around the globe at accelerated speeds. Moreover, those areas of the14 October 20081

world most vulnerable to disease outbreaks are typically also those with the weakest systems for
public health surveillance – putting all nations at risk.
One Health
A comprehensive understanding of emerging infectious diseases requires a ‘One Health’
approach, which recognizes the interdependence of humans, animals and the environment.
For example, environmental changes such as deforestation, global warming, pollution, andurbanization all disturb healthy ecosystems, which are regarded as an important safeguard against
the emergence of disease.vi As humans increasingly infringe upon natural habitats with highbiodiversity, they are exposed to larger numbers of potential pathogens. These biophysicalstresses are compounded by the impact of rapidly changing social contexts – poverty, inequality
and social unrest all contribute to the risk of epidemic outbreaks.vii
In addition, more than 70 percent of newly identified infectious threats are zoonoses, meaning
they have jumped the species barrier from animals to humans.viii Animals such as non-humanprimates, bats and rodents have been recognized as important reservoirs and vectors of disease.
Livestock can also be a key source of infection, as evidenced by the recent outbreaks of avian
influenza in poultry. Wildlife and livestock often serve as sentinels of human disease.
The impact of disease is also mediated by the relationships between humans and animals. The
lives and livelihoods of the rural poor are often tied to their animals, with more than 70 percent
dependent on livestock for income.ix They are not only vulnerable to severe or fatal infection due
to close contact with infected animals and animal products, but also bear the economic brunt of
livestock losses due to animal disease or disease control programs.
Identifying and responding to emerging infectious diseases requires integration of livestock,wildlife, agricultural, environmental and human data. Despite these overlaps, government
departments, academic institutions, and international agencies typically specialize in human,
animal or environmental health and true interdisciplinary collaboration remains rare. An
integrated approach necessitates breaking down historical divisions to allow sharing of
knowledge and experience across and beyond disciplines.
From Reactive to Proactive Approaches – the Lessons of HIV
In practice, fragmented and crisis-driven disease management strategies have resulted in marked
human and animal suffering and death, as well as extreme financial costs. Billions of dollars
have gone into the emergency response to emerging diseases in general, and to one disease inparticular – HIV/AIDS.
Recent estimates state that just over 33 million people are now living with HIV/AIDS.x As thestandard HIV/AIDS epicurve shows (depicted in orange in Figure 1), this emerging disease firstgained global attention when it was detected in California in 1981. However, retrospective
studies of stored samples have found a case that dates back to as early as 1959 in Kinshasa,
Democratic Republic of Congo. Accounting for this new information dramatically changes thegraphic depiction of the HIV/AIDS epidemic (the grey dashed line in Figure 1). In fact, it islikely that the virus was circulating for 60-80 years before the first reported case, but because thedisease was not detected, any opportunity for early containment was missed. xi
In addition, research has revealed that HIV began as a primate disease that later crossed thespecies barrier to infect humans. We can only speculate about the period when HIV wascirculating in animals and evolving into a human pathogen. If we had had a better understanding

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of the complex factors that cause diseases to emerge, could we have been watching and waiting
when HIV made its earliest jump to humans?

Estimated number of people newly
infected with HIV/AIDS (millions)

If we reflect back on the existing HIV/AIDS pandemic and begin to imagine how we might havepredicted and prevented the global spread of this devastating disease, three important areas ofaction become apparent. First, we have the period after 1981 (on the far right of the HIV/AIDSepicurve) when the disease had been recognized as a threat that was circulating in the humanpopulation. At this stage, responding quickly to find new cases and prevent disease transmission
is key. This relies on a robust system of public health surveillance.

43.5
32.5

Earliest caseidentifiedin 1959

21.5
10.5
01920?
1940

1960

1980

2000

Figure 1: HIV/AIDS epidemiological curve
Source: based on data of UNAIDS/WHO (2007)

However, we know that millions of lives could have been saved if we had found cases of HIV in
the 1950s or before. Instead of beginning our response once the number of human cases wasalready climbing (on the far right of the epicurve), we could have intervened several decades
earlier – shifting the point of response one step to the left of the standard HIV epicurve. To dothis, we would have needed fast and accurate methods to find threats earlier.
However, to have contained the HIV epidemic altogether, we would have needed to shift ourresponse a second step to the left of the standard HIV epicurve by catching the virus right at its
origin - at the point when it made the very first jump from chimpanzees into the humanpopulation. This may seem like an impossible feat, but if we really understood why and how
diseases emerge when they do, we would have a much better idea of where and when to expect

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them. Knowing where to look for disease emergence allows us to target our surveillanceaccordingly.
Initiative Goals
Predict and Prevent aims to work in three areas: responding quickly to improve where we aretoday, finding threats earlier to take us one step to the left, and knowing where to look to take us
two steps to the left. We will work in partnership with others to strengthen traditional disease
surveillance and response, and establish better systems for early warning. We will also strive tofind threats faster by improving technologies for better detection and validation. At the sametime, we will support efforts to build the science, technology and capacity in the developingworld to map regions vulnerable to future outbreaks. The result of this will be to change thenature of disease response from reactive to proactive, moving us two steps ahead of where we aretoday.
Initiative Strategy
Responding quickly
Currently a lack of accurate and timely information exchange between local, provincial, nationaland regional levels hampers surveillance systems in the developing world. Human and animalhealth services are typically strictly segregated, precluding opportunities to detect disease insentinel animal populations. There is inadequate human resource and laboratory capacity for datacollection and analysis, and accurate diagnosis.
We will work with key partners to develop mechanisms for community-based and cross-sector
reporting, building on the success of mobile phone technologies in the developing world. Support
to our partners may extend beyond funding where there are opportunities to leverage existing
Google tools and resources.
Successful early warning and response will depend on having basic epidemiology and laboratory
capacity throughout the world and the willingness to openly share important data for disease
control and prevention. We will support improved field investigation by partnering to build
laboratory capacity and epidemiology training programs that take an integrated ‘One Health’approach.
As diseases do not respect national boundaries, these activities are best situated within regional
disease surveillance networks, which provide a mechanism for cross-border sharing of data,expertise and best practices.
In short, Predict and Prevent will focus on:•••

Using innovative methods to enable timely information transfer to and from the field
Strengthening regional networks that are using integrated ‘One Health’ approaches todisease surveillance and response
Engaging key stakeholders, from villagers to global health authorities

Finding threats earlier

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To prevent pandemics, we need to identify emerging infections wherever they occur. Our work
to support better detection of disease threats includes activities in digital detection and geneticdetection.
We can capitalize on faster, stronger and more ubiquitous Internet and mobile technology toenhance our traditional surveillance activities. This can be done by building upon data-mining
efforts that monitor news feeds and other online resources to identify early signals of potential
disease threats, and improving the speed of reporting to the appropriate responders. Automatedalerts require validation by on-the-ground personnel. We will strengthen a global network of‘threat detectives’ by enhancing collaboration between outbreak investigators around the world.
We can also take advantage of new molecular technologies to advance understanding of thegenomics of infectious diseases. This includes work to map out the range of pathogen diversity
and study how viruses circulate and evolve before they jump species. We will support targeted
sample collection at the human-animal interface in hotspot countries. Key activities can range
from monitoring cohorts of vulnerable populations, to ‘One Health’ surveillance of key emerging
infections through screening of arthropods, wildlife, livestock and humans to identify vectors,
hosts and reservoirs of disease. We will also invest in robust and affordable infectious diseasediagnostic technologies, ranging from point-of-care tools right up to more sophisticated systems
for pathogen discovery.
Google.org also will strive to leverage Google’s knowledge, technology and products to enhance
open access, open source bioinformatics data platforms and tools that will support virtual
communities and enhance innovation and discovery.
Predict and Prevent will support projects that:•••

Enhance the use of automated systems for effective disease surveillance
Improve pathogen discovery and understanding of which classes of viruses pose thegreatest threatStrengthen efforts to bring molecular sequencing capacity closer to hotspots countries

Knowing where to look
One of the keys to finding a new disease at its source is knowing where to look. Although nomodel can predict precisely when or where a new infectious disease will emerge or how it will
spread, an understanding of the complex drivers – such as climate change or deforestation – thatlead to disease emergence and transmission can help communities to anticipate potential
outbreaks and target scarce resources.
By integrating high quality, local level data on land use, ecosystem dynamics, climate, anddemographics we might be able to identify areas of the world at greatest risk, allowing for
focused surveillance and preparation. Predicting hotspots of disease emergence requires anintegrated understanding of the multiple factors that create vulnerabilities. Building thisunderstanding necessitates sharing knowledge and experience across and beyond disciplines.
Predict and Prevent is focused on:•Sharing knowledge of key drivers of disease emergence, such as climate change anddeforestation, across human, animal, and environmental health sectors

14 October 20085••

Improving data collection, sharing, visualization and analysis for enhanced vulnerability
mapping and predictive modeling of, for example, long-term weather and climate
patterns that affect disease emergence and could provide early warning of disease
outbreaks
Applying risk-based approaches to target surveillance and management programs

Regions of Focus
Predict and Prevent will initially focus on Southeast Asia and sub-Saharan Africa as these tworegions have been recent hot spots of emerging disease and together bear the biggest infectious
disease burden.xii In Southeast Asia, which has been the center of the emergence of both avian flu(H5N1) and SARS, infectious diseases cause about 40 percent of annual deaths.xiii The disease
threat is heightened in this region as it has the most intense animal-human coexistence in theworld, which hastens the exchange and spread of new and re-emerging infections.xiv Sub-SaharanAfrica bears the greatest infectious disease burden and has the weakest public healthinfrastructure in the world.xv More than half of the African population lacks access to healthfacilities and 40 percent lacks access to safe drinking water and sanitation, leaving them evenmore vulnerable to the emergence and outbreaks of new and re-emerging infectious diseases.xvi
Poverty and poor infrastructure in both regions heighten vulnerability.
Conclusion
Current disease surveillance and response approaches often lead to action after the peak of theoutbreak has passed – or worse, after outbreaks have developed into epidemics or evenpandemics. The Predict and Prevent initiative aims to save lives by contributing to changing thisreactive approach towards a proactive, one-health approach. Our vision is a future in which
proactive surveillance systems are targeted to known disease hotspots, where outbreaks arereported within days not weeks, where known diseases are routinely diagnosed at the point ofcare, and where the response to outbreaks is rapid and effective.
iWorld Health Organization
http://www.searo.who.int/EN/Section980/Section1162/Section1167/Section1171_4750.htm andNational Institutes of Health
http://www.niaid.nih.gov/publications/dateline/0997/introsto.htm
iiWorld Health Organization Regional Office for Europe (2007) Chikungunya in Emilia Romagna Region,Italy. Communicable Disease Surveillance and Response Update: 16 September
http://www.euro.who.int/surveillance/outbreaks/20070904_1
iii
Nash, D, Mostashari, F, Fine, A et al (2001) The Outbreak of West Nile Virus Infection in the New York
City Area in 1999. New England Journal of Medicine 344 (24): 1807-1814.
iv
Brownlie, J, Peckham, C, Waage, J, Woolhouse, M, Lyall, C, Meagher, L, Tait, J, Baylis, M and Nicoll,A (2006) Foresight Infectious Diseases: Preparing for the Future. Office of Science and Innovation:London.
v
Centers for Disease Control and Prevention (2006) Revised definition of extensively drug-resistanttuberculosis. MMWR 55: 1176.
vi
http://www.milleniumassessment.org
vii
Smolinski, M, Hamburg, MA, Lederberg, J (2001) Microbial Threats to Health; Emergence, Detection,and Response. Institute of Medicine of the National Academies: Washington DC.
viii
Chomel BB, Belotto A, Meslin F-X (2007) Wildlife, Exotic Pets, and Emerging Zoonoses. Emerging
Infectious Diseases [serial on the Internet]. Jan. http://www.cdc.gov/ncidod/EID/13/1/6.htm
ix
Livestock in Development (1999) Livestock in Poverty-Focused Development. Crewkerne: Livestock In
Development. http://www.theidlgroup.com/downloads/livestock.pdf
x2007 AIDS Epidemic Update, UNAIDS and World Health Organization
http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/
xi
Sharp, PM and Hahn, BH (2008) Pre-history of HIV-1. Nature vol. 455, 2 Oct.

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xii

Global Health Council, Infectious Diseases http://www.globalhealth.org/view_top.php3?id=228
World Health Organization (2005) Combating Emerging Infectious Diseases in the South-East Asia
Region, WHO Regional Office for Southeast Asia: New Delhi,xiv
Ibidxv
Davis, JR and Lederberg, J (eds) (2001) 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, DC
xvi
Kaseje, D (2006) Health Care in Africa: Challenges, Opportunities and an Emerging Model forImprovement. Presented at the Woodrow Wilson International Center for Scholars
www.wilsoncenter.org/topics/docs/Kaseje2.pdf
xiii

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