Partnerships for detecting emerging infectious diseases: Nepal and global influenza surveillance.

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Partnerships for Detecting Emerging Infectious Diseases: Nepal and Global Influenza Surveillance
To the Editor: With new influenza strains emerging each year, identification of circulating strains by coordinated global surveillance is crucial to vaccine development for the coming year (1)(2)(3). Approximately 110 laboratories in 80 countries voluntarily participate in the World Health Organization (WHO) influenza surveillance network (4). Comprehensive surveillance is especially important in Asia, since new influenza strains often originate there. To participate in influenza global surveillance, countries need not rely on their own laboratory capability. Clinical specimens from patients thought to have influenza can be sent to designated laboratories around the world for analysis. A unique partnership has led to the expansion of the WHO global influenza surveillance network to Nepal.
The U.S. Army Medical Component -Armed Forces Research Institute for Medical Sciences (AFRIMS) (5) in Bangkok, Thailand, is well situated to assist with surveillance in Asia. Scientists at AFRIMS have conducted medical research in collaboration with Nepali colleagues for more than 20 years. Several studies have been conducted in collaboration with the CIWEC Clinic Travel Medicine Center (a travel medicine clinic that serves the diplomatic, aid, and tourist communities in Nepal). The clinic has approximately 5,000 patient visits per year, of which half are drawn from the 2,500 expatriates in Nepal and half from the 200,000 non-Indian tourists who visit Nepal annually.
A protocol was developed for a pilot influenza surveillance program. The staff of the CIWEC Clinic was responsible for volunteer recruitment, clinical evaluation, and specimen collection. Febrile upper respiratory infections were defined as temperature ≥ 100°F (37.8°C, oral or equivalent) and cough or sore throat of ≤ 72 hours duration. Other symptoms, such as streptococcal pharyngitis, were excluded. No age or gender restrictions were included. Volunteers had to have been in Nepal for the 5 days preceding illness. Only the first patient in any single household with similar symptoms within days of other household members was asked to participate.
The AFRIMS field station in Kathmandu (locally known as the Walter Reed/AFRIMS Research Unit -Nepal or WARUN) was responsible for shipping specimens collected by the CIWEC Clinic to AFRIMS, Thailand. Since dry ice was not available in Kathmandu, dry ice and shipping containers were sent by AFRIMS, Thailand for use by WARUN. Shipments from WARUN were then sent back to AFRIMS, where specimens were repacked in dry ice and sent for testing at the central laboratory of the U.S. Air Force's Project Gargle (6) in San Antonio, Texas. Project Gargle has been testing viral respiratory Letters specimens from distant Air Force installations for more than 20 years. Each specimen was tested for influenza A and B; parainfluenza virus 1, 2, and 3; adenovirus; enterovirus; and herpesvirus. Characterization of selected influenza A and B isolates by hemagglutination-inhibition testing was performed by the Centers for Disease Control and Prevention (CDC).
Between December 1996 and February 1997, the CIWEC staff collected specimens from 18 patients. Samples were collected from 11 (61%) residents and seven (39%) tourists, who were evenly distributed by gender and had a median age of 35 years. Influenza B/Beijing/184/93-like viruses were isolated from five (28%) of the 18 specimens. All patients from whom influenza viruses were obtained had mild illnesses with fever and upper respiratory syndromes. Herpes virus type 1 and adenovirus type 6 were each identified in one other specimen. No respiratory viruses were identified in the remaining 11 specimens.
Because of the importance of China in the emergence of new strains of influenza, CDC's WHO Collaborating Center for Surveillance, Epidemiology, and Control of Influenza has worked with colleagues in China to establish a national Chinese network of influenza surveillance sites. Analysis of viruses isolated in China between 1988 and 1997 in comparison with other viruses obtained through WHO's global influenza surveillance network has shown that influenza variants are frequently identified in China before becoming prevalent in other regions of the world. Nepal is another especially valuable surveillance site, given its location between China and India (at the crossroads between northern and southern Asia) and its historic importance as a trans-Himalayan trade route.
Especially relevant are data from China demonstrating that the two antigenically and genetically distinct lineages of influenza B viruses represented by B/Victoria/02/87 and B/Yamagata/ 16/88 (7)  Our unique international partnership between several civilian and military organizations (e.g., CIWEC Clinic, CDC, U.S. Air Force, and U.S. Army) demonstrates the feasibility of such partnerships as well as the usefulness of influenza surveillance data at both the local and global levels. Despite the small number of isolates obtained during this study, we were able to determine that the influenza B component of the trivalent vaccine prepared for the 1996-1997 influenza season would likely have offered protection for travelers and the local population against the influenza B strains isolated in Kathmandu. Ongoing surveillance data will establish geographic and temporal patterns of circulation of influenza viruses and thus provide valuable information for guiding public health policies for influenza vaccination. On a global level, these data are useful for annual vaccine strain selection.
Advances in communication, laboratory, and specimen transport technologies contributed greatly to the identification of viral pathogens from a new sentinel surveillance site in Nepal. In evaluating future collaborative sites, prior surveillance experience and reliable specimen shipping should be prime considerations. Approaches that use existing resources might foster greater international cooperation toward improved global detection and reporting of infectious diseases.