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Prevention and Control of Emerging Infectious Diseases in the Arctic: Establishing an International Circumpolar Surveillance System

 Rediger
 1 Published: 18.11.04 Updated: 18.11.2004 15:15:13
A. J. Parkinson, J. C. Butler
Arctic Investigations Program, U.S Center for Disease Control and Prevention, Anchorage, Alaska, USA
With the formation of international economic alliances (European Union, Asia Pacific Economic Cooperative) comes the opportunity for increased global communications and collaboration between countries to address human health issues of common concern and the opportunity to promote the formation of international emerging infectious disease surveillance and response networks. The Arctic council was established in 1996 to promote co-operation and interaction between Arctic Nations (US, Canada, Greenland/Denmark, Iceland, Norway, Sweden, Finland and the Russian Federation). It includes prevention and control of infectious diseases as part of the Arctic council’s Sustainable Development program. The objectives of the program are to establish an International Circumpolar Surveillance System by linking clinical and reference laboratories and public health facilities in Arctic countries to monitor emerging or re-emerging infectious disease problems with Arctic populations.

Background

Arctic populations have long endured the debilitating effects of both endemic and epidemic infectious diseases, the effects of which have impacted social and economic development in circumpolar regions of the globe. With the advent of antibiotics, tuberculosis and other life threatening infections seemed conquerable. The incidence of diseases of childhood such as diphtheria, whooping cough, and meningitis were reduced dramatically through the use of vaccines. These advances, together with improvements in sanitation and water quality, dramatically lowered the incidence of infectious diseases in many peoples throughout the developing world including those of the Arctic (1). However, as we enter the 21st Century, the specter of new virulent and antibiotic- resistant forms of old diseases such as tuberculosis, measles, diphtheria, and meningitis once again is threatening circumpolar communities. Our communities are now faced by a number of newly emerging diseases, such as HIV, hepatitis C, and a host of food and waterborne illnesses. This increase in emerging and re-emerging infectious disease problems in Arctic populations can be attributed to a number of interrelated factors including: rapid population growth; depopulation of small Arctic communities; urbanization of Arctic peoples and ensuant social and economic difficulties; changes in governments, fiscal and public health policies; increased regional and global travel; changes in  the food supply; changes in human behaviors such as increased substance abuse, intravenous drug use and risky sexual behavior; the use of more antibiotics in remote Arctic communities, hastening the development of antimicrobial resistance; and contamination of the subsistence food supply with heavy metals and pesticide residues with potential deleterious effects on the developing human immune system.

In the US Arctic (Alaska), the US Centers for Disease Control and Prevention’s Arctic Investigations Program, together with other federal, state, and Alaska Native Health organizations maintain infectious disease surveillance and prevention and control activities among both Native and non-Native residents (2). Similar surveillance and disease prevention and control activities are maintained in the Canadian Arctic by provincial and territorial health departments and by Health Canada’s Laboratories Centres for Disease Control, and in Greenland by the Director General of Health. The Nordic countries (Denmark, Iceland, Norway, Sweden and Finland), also have established surveillance systems in place and have a long-standing tradition in the field of international infectious disease prevention and control initiatives, and with the support from the Nordic Council of Ministers, are currently conducting a collaborative project to strengthen infectious disease control in the adjacent Baltic and Barents Sea regions of the Russian Federation (3). With the formation of a number of international economic alliances (European Union, Asia Pacific Economic Cooperative), comes the opportunity for increased global communication and collaboration between countries to address human health issues of common concern and the opportunity to promote the formation of international emerging infectious disease surveillance and response networks (4). The Arctic Council is a high level ministerial forum established in 1996 to promote co-operation, co-ordination, and interaction between Arctic Nations (US, Canada, Greenland/Denmark, Iceland, Norway, Sweden, Finland and the Russian Federation) on matters of environmental protection and economic sustainable development. Since many of the factors responsible for the emergence, and re-emergence of infectious diseases in Arctic communities are also important factors in establishing sustainable development, it is important to include prevention and control of infectious diseases as part of the Arctic Council’s Sustainable Development program. 
International Circumpolar Surveillance

The objectives of this project are to establish an International Circumpolar Surveillance (ICS) system by linking clinical laboratories, reference laboratories and public health facilities in Arctic countries to monitor emerging or re-emerging infectious disease problems (4). The project has initially focused on establishing a international surveillance system for diseases caused by Streptococcus pneumoniae. This bacterium is a leading cause of pneumonia, meningitis and bacteremia in both the very young and the elderly. Once easily treatable with antibiotics, this bacterium is now becoming resistant to commonly used antibiotics. This is of great concern to the public health community and  is increasingly a target for surveillance by many countries world wide.  Vaccines are available for the prevention of pneumococcal infections. In the US Arctic the 23 valent pneumococcal polysaccaride  vaccine is recommended for all those over 55 years of age. A new vaccine for infants has been licenced in the US and the European Union, and licensure in Canada is anticipated in 2001.  The fact that  diseases caused by Streptococcus pneumoniae are already being monitored by many public health organizations within the Arctic Council countries makes establishing a circumpolar surveillance system for this infection feasible.  In addition the availability of a vaccine for adults and the advent of a vaccine for infants makes preventable much of the illness caused by Streptococcus pneumoniae.

Goals

1. To promote human health as an priority  issue of community concern  within the Arctic Council sustainable development working group. The Arctic Council provides access to government, non government and indigenous peoples organizations important for improving health in Arctic regions as well as access to other multinational economic cooperatives with interests in infectious disease prevention and control (Council of Nordic Ministers, European Union’s Northern Dimension, Council of Baltic State Ministers). 
2. To identify key public health contacts within Arctic Council countries. These persons should be familiar with infectious disease surveillance systems in place within the member country. Through correspondence, individual or working group meetings, the scope and gaps of individual surveillance systems will be determined. 
3. To determine the comparability of laboratory and data collection methods, and negotiating standard protocols, quality control programs (which will define  comparable laboratory and data collection methods).
4. To facilitate sharing of data in agreed formats, and publication and dissemination of  reports.
5. To establish a diseases specific (ie invasive bacterial disease) working group of key laboratory and public health contacts to coordinate surveillance within their respective jurisdictions to review problems, progress, compliance,  report generation, and future plans.
6. To establish a steering committee of national public health, and indigenous peoples  representatives to determine and coordinate new infectious disease priorities  or human health objectives and initiatives within ICS.

Progress to date

In 1999 the US CDC’s Arctic Investigations Program, together with Health Canada’s Laboratory Centre for Disease Control, Bureau of Infectious Diseases,  initiated a pilot program linking public health laboratories in Alaska, the new territory of Nunavut,  Yukon Territory, Northwest Territories, northern Quebec, and Labrador to monitor invasive diseases caused by Streptococcus pneumoniae.  This surveillance system, which now spans the entire arctic region of North America and has allowed the standardization of laboratory and data collection methods, the assessment of disease rates in Arctic communities, and allows the evaluation of effectiveness of vaccination programs on disease rates and serotype distribution, the monitoring of emergence of antimicrobial resistance treatment failures associated with these infections, and design of collaborative applied research on risk factors for infection and prevention strategies.  In 2000 surveillance of invasive diseases caused by Haemophilus influenzae, Neisseria meningitidis, Group A and Group B Streptococcus was added to this surveillance system.   In 2000 Greenland joined ICS utilizing  17 regional laboratories and a reference laboratory in Copenhagen, Denmark to provide information on invasive diseases caused by Streptococcus pneumoniae identified from patients seeking medical care in Greenland.   At the October 2000 ministerial meeting of the Arctic Council in Barrow, Alaska, the Arctic Council endorsed and approved the proposal to develop an International Circumpolar Surveillance for infectious diseases, providing both  political and international visibility for this infectious disease prevention and control initiative.  The move of the Arctic Council chairmanship to Finland for 2001-2002,  presents the opportunity to further advance the ICS by linking clinical laboratories, reference laboratories and public health facilities in northern Europe to complete the ICS for invasive bacterial diseases, and consider surveillance of other infectious diseases of community concern.  Using established population based surveillance systems, Finland, Norway and Iceland joined the ICS beginning in 2000 providing data on rates of invasive diseases caused by Streptococcus pneumoniae.  Also in 2000, an ICS steering committee of public health experts was formed to consider and  recommend the inclusion of other infectious disease priorities and other Arctic health concerns, as part of the ICS.

Plans for 2001-2002 include

1. The continued development of collaborative relationships already formed between clinical, reference laboratories, and public health authorities within participating Arctic Council countries (US, Canada, Greenland, Iceland, Norway, Finland and Sweden) to fully establish the ICS for invasive pneumococcal disease as well as diseases caused by  Haemophilus influenzae, Neisseria meningitidis, Group A and Group B Streptococcus.
2. To explore opportunities to expand ICS to include public health authorities, epidemiologists, and clinical laboratories the Barents Sea regions of the Russian Federation.
3. To expand membership of the ICS steering committee to include public health expert representation from Iceland, Norway, Sweden, Finland, the Barents Sea regions of the Russian Federation and representation from indigenous peoples organizations.
4. To establish a working group to discuss, design and implement an International Circumpolar Surveillance system for tuberculosis.
5. To explore opportunities to utilize ICS to address other important non infectious health problems common to Arctic countries.
6. To continue to build political support for ICS and Arctic Health issues in general within the Arctic Council and other multi-national economic cooperatives.
Significant outcomes of this project
The linkage of public health facilities within the Arctic states will  allow the collection and comparison of standardized laboratory and epidemiological data which will describe the prevalence, risk factors, and patterns of occurrence of  infectious diseases of concern within Arctic populations. ICS will allow the monitoring of drug resistant infections, and facilitate efficient targeted use of prevention and control tools such as vaccines, risk factor reduction, and educational programs aimed at controlling the spread of drug resistant infections.  When fully established, the ICS will provide a model for strengthening the circumpolar public health  capacity to detect, investigate, monitor, and respond to disease and injury.   

References

 1. CDC. Preventing emerging infectious diseases: A strategy for the 21st century. Atlanta GA; US Department of Health and Human Services, Public Health Service 1999. (Copies can be obtained from the Office of Health Communication, National Centers for Infectious Diseases, CDC Mailstop C-14, 1600Clifton Road, Atlanta GA 30333, fax (404) 639 4194).
2. Butler JC, Parkinson AJ, Funk E, Beller M, Hayes G, Hughes, JM. Emerging infectious diseases in Alaska and the Arctic: A review and a strategy for the 21st Century. Alaska Med, 1999; 41: 35-43.
3. Bulletin of the Network for Communicable Diseases. Project: Infectious disease control in the Barents and Baltic Sea regions, 1998-2000. EpiNorth, 2000; 1: 2-3.
4. Parkinson AJ, Bell AA, Butler JC. International Circumpolar Surveillance of infectious diseases: Monitoring community health in the Arctic. International Journal of Circumpolar Health, 1999; 58: 222-225.


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