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Other clues may also be available to help assess risk of a newly discovered pathogen, such as broad host range,or acquiring the ability to infect new host species. The concept of risk mapping, as in the ‘‘hotspots’’ maps discussed earlier, is a promising approach that continues to be refined.59 Effective global public health surveillance can also lead to better understanding of the ‘‘drivers’’ of emerging infections. Many disease problems are in areas undergoing major changes in land use or population patterns, including urbanization.2 The relative importance of such factors as which family a pathogen belongs to, origins from certain natural hosts or the hosts’ phylogenetic relatedness to humans (eg, nonhuman primates), and frequency or intensity of exposure remain open questions.53 An increasing amount of data also means an increasing need for interpretation. Effective surveillance therefore requires human capital. The power of the human mind to make sense of the data is too often taken for granted and overlooked. Whatever the technical advances, there is no substitute for the alert and informed mind, whether the ‘‘astute clinician’’ or an epidemiologist who notices a significant correlation. While true even today, with the more rapidly accumulating information we can expect in the future, it will become even more essential to distinguish signal from noise and be able to place potentially significant events in context. The workforce is therefore of crucial importance. Well-trained professionals, and the need to provide sustainable career paths, are critical now and will be critical in the future. In addition, surveillance is not enough. Although early warning is the necessary first step, it is not sufficient. For early warning to be useful, it must be backed up by a robust response system. This requires a strong national public health infrastructure in each country, both to foster and coordinate the local and national systems and to provide response capacity. Continued development of triggers and decision criteria, to ensure an appropriate response that is proportionate to the threat, also is essential. Public health surveillance remains a work in progress. It is clear that the capacity for public health surveillance has markedly improved in the past 2 decades, but many needs remain.18,61 For example, Feng and colleagues have noted that SARS and avian influenza H5N1 have greatly stimulated improved surveillance in China but that significant gaps remain in the ability to detect emerging infectious diseases.61 Concern is sometimes expressed whether surveillance systems for emerging or unusual infectious diseases, or for zoonotic infections, will be able to maintain capabilities while preparing for the next SARS outbreak or potential pandemic. But infectious disease outbreaks are occurring frequently all over the world, providing ample opportunities to maintain the capabilities of personnel and equipment. While some infectious diseases may become better controlled in the future, such as some of the vaccinepreventable diseases, it seems highly probable that infections will continue to emerge. The ecological conditions that drive emergence, allowing the introduction and potential dissemination of pathogens across the interface between humans and other animals, and increasing globalization are likely to continue resulting in emerging infections well intothe foreseeable future. The recent development of new and robust technologies for laboratory identification, and revolutionary advance in information technology and communications, enable more rapid reporting of potentially important health events, even from remote areas lacking communications or clinical infrastructure. For the first time, it may now actually be possible to develop global surveillance capabilities of a reasonably high order, even in resource-poor countries. The revised International Health Regulations also set a target for all members states to have the core capacities for surveillance by June 2012. While meeting this objective will probably require more time for most countries, it sets a good aspirational goal and specific plans toward which all countries can work. With these new and powerful tools, there is great promise for public health surveillance. The greatest concern may well be how to sustain capacity and maintain momentum and political will over the long term.
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