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Animal Disease Surveillance and Control: Need Of an Integrated Approach Dr Barkha Sharma Assistant Animal Disease Surveillance and Control: Need Of an Integrated Approach Dr Barkha Sharma Assistant Professor Dept of Epidemiology and Preventive Medicine College Of Veterinary Sc. & A. H. UP Pt Deen Dayal Upadhyay Veterinary University DUVASU

 Animal Diseases cause major economic loss through mortality, reduced productivity, lower fertility, condemned Animal Diseases cause major economic loss through mortality, reduced productivity, lower fertility, condemned products and restricted access to potential markets Newly emerging animal diseases are known to cross over to human population and vice versa Approximately 60% of all known pathogens and 75% of emerging pathogens are zoonotic in nature Of all the newly emerging diseases encountered on daily basis , almost all are having their reservoirs in animals Impoverished settings mostly in tropical developing world act as hotspots for theses zoonoses. World has seen epidemics of diseases like Avian Influenza, Swine Influenza, FMD, RP, PPR, CBPP as well as RVF in the last two decades (Taylor et al. , 2001)

“Hot Spots” of the World Southeast Asia Cambodia China Indonesia Laos Malaysia Philippines Thailand “Hot Spots” of the World Southeast Asia Cambodia China Indonesia Laos Malaysia Philippines Thailand Vietnam Amazon Bolivia Brazil Colombia Ecuador Mexico Peru Congo region Angola Burundi Cameroon CAR Congo DR Congo Eq. Guinea Gabon Rwanda Tanzania Uganda South Asia Bangladesh India Nepal

Factors in Emergence Microbial adaptation and change Host susceptibility to infection Climate and weather Factors in Emergence Microbial adaptation and change Host susceptibility to infection Climate and weather Changing ecosystems Economic development and land use Human demographics and behavior Technology and industry

Factors in Emergence continued International travel and commerce Breakdown of public health measures Poverty Factors in Emergence continued International travel and commerce Breakdown of public health measures Poverty and social inequality War and famine Lack of political will Intent to harm

Animal-Human Connection People and animal interactions have a history of disease transmissions West Nile Animal-Human Connection People and animal interactions have a history of disease transmissions West Nile virus passes from birds to people via mosquitoes Lyme disease from mice to people via deer ticks SARS virus jumped to people from palm civets ? Avian flu in chickens transferred to humans © CDC © ebi bioinformatics

Economic Impact of Recent Zoonotic Epidemics (Burroughs et al. , 2002) Economic Impact of Recent Zoonotic Epidemics (Burroughs et al. , 2002)

What is Animal Disease Surveillance and why is it needed? Disease Monitoring is a What is Animal Disease Surveillance and why is it needed? Disease Monitoring is a continuous effort to assess the health and disease status of a given population. Disease surveillance is a more intense form of monitoring consisting of collection , collation and interpretaion of data along with targeted action (Thrusfield 2005) Disease surveillance has three components 1. a defined disease monitoring system 2. A predefined disease intervention strategy (directed action) 3. A defined threshold of disease frequency A disease Control programme (DCP) is the combined system of monitoring and surveillance, disease control strategies and intervention strategies that are employed over a prolonged period of time to reduce the frequency of a specific disease

Need of an effective surveillance system Recent global outbreaks of diseases Animal disease surveillance Need of an effective surveillance system Recent global outbreaks of diseases Animal disease surveillance can serve as sentinels for bioterrorist or natural infectious disease epidemics Surveillance systems can also contribute to the identification of disease priorities at international , national and sub national levels and lead to prompt recognition of emerging disease outbreaks To ensure effective global disease monitoring and surveillance, many national and international organizations are working round the clock , in consortium , to gain knowledge, and generate data regarding disease surveillance which can be shared by those who need it

Veterinary Information Systems (VIS) Collections of integrated disease related data to satisfy the informational Veterinary Information Systems (VIS) Collections of integrated disease related data to satisfy the informational requirements of its users Integral part of VIS is animal disease notification system designed according to international requirements, standards and recommendations and able to exchange relevant information between users An Information system plays an imp role in surveillance and provide information for economic assessment of diseases and fulfilling international reporting needs Various VIS operational through out the world

Examples of VIS Pro. MED- mail (program for monitoring emerging disease): one of the Examples of VIS Pro. MED- mail (program for monitoring emerging disease): one of the first online disease reporting system in 1994 with main intent to assist local, national and international organizations by world wide dissemination of information in outbreaks of EIDs and toxins of humans, animals and plants and threat posed by bioterrorism. Has reported several first time outbreaks of Ebola in Zaire(1995), West Nile in US (1999), SARS in China (2002) and H 5 N 1 in Indonesia (2003) (Morse, 2006)

Main US agencies APHIS-VS- USDA Animal Plant Health Inspection Services-Veterinary services CEAH- Center of Main US agencies APHIS-VS- USDA Animal Plant Health Inspection Services-Veterinary services CEAH- Center of Epidemiology and Animal Health includes four Centers ADIS (Center for Animal Disease and Information Analysis) CAHM (Center for Animal Health Monitoring) CEI (Center for Emerging Issues) NAHMS (National Animal Health Monitoring System) NAHRS (National Animal Health Reporting System) VMDB (Veterinary Medical Database) Pulse- Net is a nation wide food borne disease surveillance system in USA

Europe VIDA II (Veterinary Investigation Diagnosis Analysis) – a mesoscale database in UK Epi. Europe VIDA II (Veterinary Investigation Diagnosis Analysis) – a mesoscale database in UK Epi. MAN- a decision support system in New Zealand for control of Exotic diseases GPHIN (Global Public Health Intelligence Network) along with Public Health Agency of Canada and Global Outbreak Alert and Response Network (GOARN) of WHO AVIS (Advanced Veterinary Information System) Conceived in 1992 in London with FAO and OIE GIDEON (Global Infectious Diseases Epidemiology Network) Middle East Regional Veterinary Information System Project It is a disease control project with Egypt, Israel, Palestinian Authority and Jordan as its members. There is a direct exchange of official disease notification to the OIE.

International Organizations Major Stakeholders in this field are FAO-WHO-OIE collectively known as International Technical International Organizations Major Stakeholders in this field are FAO-WHO-OIE collectively known as International Technical Agencies along with WTO, the World Trade Organization supported by smaller disease tracking initiatives as Pro. MEDmail, GIDEON, EMPRES, EHTF, AHEAD, Fsnet and Agnet etc FAO, WHO and OIE have developed various programs and initiatives to generate authentic and reliable information on animal health and productivity. They have long standing experience in direct collaboration regarding disease control and surveillance All these integrated efforts are based on increasing recognition and need to change Veterinarian’s traditional view through a holistic and transdisciplinary joint initiative called ‘One Health’

One Health A collaborative effort of multiple disciplines – working locally, nationally, and globally One Health A collaborative effort of multiple disciplines – working locally, nationally, and globally – to attain optimal health for people, animals, and our environment.

World Organisation For Animal Health An intergovernmental organisation preceding the United Nations In 2010 World Organisation For Animal Health An intergovernmental organisation preceding the United Nations In 2010 6 Sub-Regional Headquarters in 5 Regional Paris (France) Representations 20 Representations

178 Member Countries in 2010 Africa 52 – Americas 30 – Asia, the Far 178 Member Countries in 2010 Africa 52 – Americas 30 – Asia, the Far East and Oceania 36 Europe 53 – Middle-East 20 Some countries belong to more than one region 21

Governance structure of the OIE 5/13 The Director General The OIE is managed by Governance structure of the OIE 5/13 The Director General The OIE is managed by the OIE Headquarters in Paris, placed under the responsibility of a Director General elected by secret ballot by the World Assembly of Delegates. In 2010, Dr Bernard Vallat was elected Director General of the World Organisation for Animal Health for a third fiveyear term. 22

 • Animal health is a key component of animal welfare • The OIE • Animal health is a key component of animal welfare • The OIE is recognised worldwide as the leader in developing international standards on animal welfare • Improve animal health, veterinary public health, animal welfare, and consolidate the animal’s role worldwide Transparency of world animal disease situation (including zoonoses) Collect and publish veterinary scientific information, notably animal disease prevention and control methods Sanitary safety of international trade in animals and their products under the mandate given by the WTO

 A Geneva based UN specialized agency established on 7 th April, 1984 with A Geneva based UN specialized agency established on 7 th April, 1984 with a mission to attain highest level of health for all people Has 192 member states Supports the building of stronger and more resilient national health systems Shares resources with FAO and OIE to develop common disease information system and keep international community constantly alert to the threat of outbreaks of infectious disease

Food and Agriculture Organization Rome based UN agency established on October 16 th, 1945, Food and Agriculture Organization Rome based UN agency established on October 16 th, 1945, responsible for agriculture development and food production. mandate to fight hunger, malnutrition and extreme poverty. In September 2012, the priorities expanded to include joint action on progressive control of TADs like FMD, PPR, and RVF, establishment of regional animal health centers, joint work on food safety and wildlife diseases and aquatic diseases and aquaculture. includes Animal Health Services (AGAH) to assist member countries in the controlling animal diseases , improving livestock production , to reinforce network of reference labs for specific diseases and to promote the application of biotechnology for disease diagnosis and vaccine production. AGAH has played a major role in prevention, diagnosis and control of diseases as FMD, Trypanosomiasis, ASF, RVF and Screw worm FAO along with OIE aim to provide a system that would greatly improve exchange of disease information, enabling each national veterinary service to be readily aware of the disease status of every member country of OIE and/or FAO.

Emergency Prevention System (EMPRES) Established in 1994 , works to control and eliminate progressively Emergency Prevention System (EMPRES) Established in 1994 , works to control and eliminate progressively epidemic livestock diseases. EMPRES has four major precepts: early warning, early reaction, coordination, and enabling research EMPRES Global Animal Disease Information System (EMPRES-i) is a web-based application to support veterinary services by facilitating regional and global disease information. It contributes to the joint FAO/OIE/WHO Global Early Warning and Response System for major transboundary animal diseases, including zoonoses (GLEWS).

GLEWS Global Early Warning System a joint FAO, OIE and WHO initiative aims at GLEWS Global Early Warning System a joint FAO, OIE and WHO initiative aims at improving global early warning as well as transparency among countries through sharing of information on animal disease outbreaks and epidemiological analysis (WHO 2010). FAO/OIE GLOBAL FRAMEWORK FOR THE PROGRESSIVE CONTROL OF TRANSBOUNDARY ANIMAL DISEASES (GF-TADs) a joint FAO/OIE initiative started in 2004 to empower countries and regional alliances in the fight against TADs based on their regional priorities, to provide capacity building, to improve food security and economic growth of developing countries through the reduction of the damaging effects of epidemic animal disease and to promote safe trade in livestock and animal products at all levels.

In 2005, the 58 th World Health Assembly adopts the revised International Health Regulations, In 2005, the 58 th World Health Assembly adopts the revised International Health Regulations, “IHR”

International Health Regulations (2005) Legally binding framework adopted by World Health Assembly in 2005 International Health Regulations (2005) Legally binding framework adopted by World Health Assembly in 2005 in response to recognized link between globalization and disease spread Entered into force on 15 June 2007 Main objective: prevent and respond to the international spread of disease while avoiding unnecessary interference with international traffic and trade

Permanent institutional cooperation with public global partner organisations In 2010 WHO - World Health Permanent institutional cooperation with public global partner organisations In 2010 WHO - World Health Organization FAO - Food and Agriculture Organization WTO - World Trade Organization IPPC - International Plant Protection Convention World Bank CABI - CAB International ILRI - International Livestock Research Institute 31

Organizations and networks at regional and sub regional level bottom up approach as they Organizations and networks at regional and sub regional level bottom up approach as they connect local, national and transnational surveillance along with top down global and larger regional systems through horizontal cooperation across the borders and sectors (Moore et al. , 2013). two main actions Development of veterinary capabilities based on quarantine, rapid lab diagnosis, epidemiosurveillance and information system Designing of control programmes targeting diseases important at regional levels FAO probably the first international organization to realize the need of a regional approach to combat different animal diseases as different situations prevail in different regions which can be efficiently dealt only by local or regional participation and guidance.

Technical and scientific cooperation with regional public organisations European Commission CEBEVIRHA Andean Community PVC Technical and scientific cooperation with regional public organisations European Commission CEBEVIRHA Andean Community PVC AOAD SPC IICA AU-IBAR OIRSA IDB 34 PAHO ECOWAS SADC

Regional public organisations ASEAN - Association of the South East Asian Nations SAARC - Regional public organisations ASEAN - Association of the South East Asian Nations SAARC - South Asian Association for Regional Cooperation WAEMU - West African Economic and Monetary Union SEAFDC - Southeast Asian Fisheries Development Center 35

Americas, Europe, Canada South Eastern Europe Health Network (SEEHN) I a political and institutional Americas, Europe, Canada South Eastern Europe Health Network (SEEHN) I a political and institutional forum set up in 2001 by governments of Albania, Bosnia and Herzegovina , Bulgaria, Croatia, Montenegro, Rep of Moldova, Romania, Serbia and former Yugoslav republic of Macedonia to promote health in the region. Israel joined the network in 2011 as 10 th member. Technical support to SEEHN’s various health projects is provided by Europe Pan American Health Organization (PAHO) Born in 1902. , works to promote and coordinate efforts of American countries to combat diseases, supports veterinary public health services concerning zoonoses and sanitary inspection of livestock and fishery products (Alleyene, 1998). Inter American Institute for Cooperation on Agriculture (IICA) provides technical assistance to veterinary services through regional mechanisms such as Inter American laboratories network, Animal and Plant Health Information and Monitoring Network, Caribbean Animal and Plant Health Information Network. Regional International Organization for Plant Protection and Animal health (OIRSA) Works for improving plant and animal health and quarantine services to develop and coordinate programmes for prevention, control and eradication of diseases in its member countries- Belize, Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, Nicaragua and Panama (OIE, 2014) Inter American Cooperation Group on Animal Health (GICSA) a platform to exchange information, avoid duplication and promote complimentary support of specific activities and comprise the PAHO, Pan American Zoonoses Center, the Pan American FMD center, OIE and the regional Organization for Animal and Plant Health. Canadian Animal Health Emergency Management (CAHEM) strategy Founded in 1962, this association has currently 52 member countries divided under six regions representing East, Central and Southern Africa, West Africa, Australasia/Oceania, Canada/Caribbean and UK/Mediterranean.

African Continent Organisation for African Unity / Interafrican Bureau for Animal Resources (OUA/IBAR) Southern African Continent Organisation for African Unity / Interafrican Bureau for Animal Resources (OUA/IBAR) Southern African Development Coordination Conference (SADCC) Southern African Regional Commission for the Conservation and Utilisation of the Soil (SARCUSS). FAO has initiated Middle and Near East Regional Animal Production and Health Project MINEADEP, the PARC, the West Asian RP eradication Campaign WAREC, the SECNA and the RADISCON. Caribbean Animal Health Network (Carib. VET) est 2006 Southern African Centre for Disease Surveillance (SACIDS) The East African Integrated Disease Surveillance Network (EAIDSNet): a joint FAO/IFAD endeavour started in April 1994 targeted at 29 countries of Africa, Middle East and Gulf to promote animal disease surveillance within and among them by assisting each country to establish its own National Animal Disease Surveillance System (NADSS)

 Inter-African Bureau of Animal Resources (IBAR) most important organization dealing with livestock in Inter-African Bureau of Animal Resources (IBAR) most important organization dealing with livestock in Africa. Based at Nairobi, Kenya, IBAR is a technical branch of the organization of African unity (OAU). It periodically issues Bulletin of Animal Health and Animal Production, which contains technical and scientific articles concerning disease control, research and animal production. It also issues monthly animal health statistics giving the status of the major contagious diseases in Africa.

ASIA South Asian Association for Regional Cooperation SAARC Mekong Basin Disease Surveillance Network (MBDS)- ASIA South Asian Association for Regional Cooperation SAARC Mekong Basin Disease Surveillance Network (MBDS)- one of the oldest successful self organized infectious disease surveillance network comprising of six countries (Cambodia, China, Lao PDR, Myanmar, Thailand Vietnam) of Mekong Basin Area in Asia which is considered to be a hot spot for the emergence of new emerging diseases Middle East Consortium on Infectious Disease Surveillance (MECIDS) initiated in 2003, comprises Israel, The Palestenian authority and Jordan In 2009, it coordinated efforts against the dreaded H 1 N 1 influenza outbreak in these countries Animal Production and Health Commission for Asia and Pacific (APHCA) Established by FAO at 60 th session of the FAO Council with headquarters at Bangkok, based on the concept of Technical Cooperation among developing Countries (TCDC), it aims at developing strategies to solve important problems of livestock agriculture, . The APHCA also maintains semen and vaccine banks. Its publication includes a monthly magazine known as ‘Asian Livestock. ’ Association of Southeast Asian Nations (ASEAN) an association of 10 Southeast Asian nations. Under ASEAN-COFAF, it has the mechanism to endorse the disease free status of a member country or a part of it. In past, some parts of territories of Malaysia and the Philippines have been endorsed as FMD free by the ASEAN.

 Asian Partnership on Emerging Infectious Disease Research (APEIR) also known as emerging infectious Asian Partnership on Emerging Infectious Disease Research (APEIR) also known as emerging infectious disease research (Cambodia, China, Indonesia, Laos Thailand Vietnam) a multi-country, multi-sectoral, multi-disciplinary research partnership launched in 2006 for regional collaboration in influenza research, later expanded its scope to include all emerging infectious diseases.

 launched In 2009 by the Nuclear Threat Initiative NTI , a global non launched In 2009 by the Nuclear Threat Initiative NTI , a global non governmental alliance to link regional and sub regional infectious disease networks. Consisting of EAIDS Net, SACIDS, SEEHN, APEIR, MECIDS and MBDS main purpose to speed up the capabilities of all CORDS network members by combining the strengths of all networks of the area in order to boost up the global surveillance against various infectious diseases of humans and animals. It further supports the mandate of FAO, WHO and the OIE to improve global health security vision. Its vision is a world united against infectious diseases

Asia Pacific Strategy for Emerging Diseases (APSED) 5 major components Surveillance warning, and rapid Asia Pacific Strategy for Emerging Diseases (APSED) 5 major components Surveillance warning, and rapid response Laboratory diagnosis Risk communication Infection control/biosafety Zoonoses Regional Strategic Framework for Prevention and Control of Zoonoses in the South-East Asia Region

Disease Surveillance: Indian Scenario Disease Surveillance: Indian Scenario

 Since India categorized as a “hot spot” for emerging infectious diseases (EID) the Since India categorized as a “hot spot” for emerging infectious diseases (EID) the concern for animal health increased manifold. (Krishnan, V. 2014) Disease surveillance in India has always been practiced by the states (health being a state subject) The function of surveillance and control of exotic as well as indigenous animal disease is under the Deptt. of Animal Husbandry , Ministry of Agriculture (GOI) Central Council of Health and Family Welfare CCHFW is the apex political and policy formulating body for zoonotic diseases

Constraints The animal disease and surveillance programmes in India wholly inadequate and obsolete. among Constraints The animal disease and surveillance programmes in India wholly inadequate and obsolete. among major zoonoses, there exist only a few national programmes among human population covering TB, JE and Leptospirosis, fewer progammes among animal population, mainly covering rabies that too in select cities. (Asokan et al. , 2011).

Disease surveillance in India The establishment of the National Surveillance Programme on Communicable Diseases Disease surveillance in India The establishment of the National Surveillance Programme on Communicable Diseases (NSPCD) in 1997 and the Integrated Disease Surveillance Project (IDSPwith assistance of World Bank in 101 districts (idsp website). NCDC is the focal point of IHR (international Health regulations 2005) in India (Dikid et al. , 2013).

IDSP decentralized, State based Surveillance Program in the country established 2004 , with the IDSP decentralized, State based Surveillance Program in the country established 2004 , with the assistance of World Bank detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner. Major components of the project are: (1) Integrating and decentralization of surveillance activities (2) Strengthening of public health laboratories (3) Human Resource Development – Training of State Surveillance Officers, District Surveillance Officers, Rapid Response Team, other medical and paramedical staff (4) Use of Information Technology for collection, collation, compilation, analysis and dissemination of data.

National Surveillance Programme for Communicable Diseases (NSPCD) launched by the Centre in 1997 -98 National Surveillance Programme for Communicable Diseases (NSPCD) launched by the Centre in 1997 -98 in five pilot districts of the country (centrally sponsored scheme) and over the years extended to cover 101 Districts in the country in all 35 states and UTs in the country. the states are the implementing agencies NCDC Delhi is the Nodal agency for coordinating the activities. This programme is based on outbreak reporting (as and when outbreaks occur) with weekly reporting of epidemic prone diseases directly from Districts (including nil reporting) to the Centre.

 Animal Disease Surveillance, information is collected on the incidence of various livestock and Animal Disease Surveillance, information is collected on the incidence of various livestock and poultry diseases and disseminated in the form of a monthly ‘Animal Disease Surveillance Bulletin’ to all the states and also to organizations like the OIE, APHCA etc proposal to integrate human and animal disease surveillance programmes, following regular outbreaks of Japanese encephalitis, leptospirosis and H 1 N 1 influenza— all of which have jumped the species barrier and are now endemic in India. The National Institute of Communicable Diseases (NICD) has been upgraded to National Centre for Disease Control (NCDC) as a centre of excellence with responsibility for enhanced capabilities for rapid response and laboratory based surveillance of communicable diseases(GOI< 2010 The government plans Rs 3, 049. 35 crore for NCDC in the 12 th Plan, out of which Rs 52 crore will be directed at strengthening laboratories, manpower and IEC (information, education and communication) activities for zoonotic diseases

National Level Facilities By the Indian Government High Security Animal Disease Laboratory (HSADL), Bhopal National Level Facilities By the Indian Government High Security Animal Disease Laboratory (HSADL), Bhopal a containment laboratory of Biosafety level 4 (BSL-4) High Security Animal Disease Laboratory (HSADL) established in 1998 at Bhopal, generates base line data regarding each disease prevalent in the country. Project Directorate Animal Disease Monitoring And Surveillance (PD- ADMAS) established in 1987 by ICAR to develop a system of diseases monitoring and surveillance of economically important livestock diseases in the country, with a view to evolve strategic control measures. developed weather based forecasting models for endemic diseases Played a crucial role in RP eradication envisaged“Vision 2030” to attain freedom from diseases, food safety and income security through sustainable livestock health and economics by using tools of epidemiological surveillance (PD ADMAS Vision 2030). developed an innovative india. admas Epitrak epidemiology software , a dynamic and interactive livestock disease relational database supported by Geographic Information System (GIS).

National Animal Disease Referral Expert System (NADRES) An interactive web- based software developed by National Animal Disease Referral Expert System (NADRES) An interactive web- based software developed by the PD- ADMAS as a component of National Agriculture Technology Program Funded Mission Mode Sub Project on “Weather Based Animal Disease Forecasting” and “Animal Health Information System through Disease Monitoring and Surveillance” especially to forecast 15 major livestock diseases in Xth plan

The National Animal Disease Reporting System (NADRS) implemented by the Department of Animal Husbandry, The National Animal Disease Reporting System (NADRS) implemented by the Department of Animal Husbandry, Dairying and Fisheries (DADF) during 2010 -11 through the National Informatics Centre (NIC). funded by the Union government with a grant of Rs 104. 05 crore. Around 143 animal diseases scheduled in the Prevention and Control of Infectious and Contagious Diseases in Animals Act, 2009 included in this reporting system. going on successfully in the states of Rajasthan, Delhi, Gujarat, Kerala and Andhra Pradesh.

Network of Reference Laboratories for Surveillance in India Kasauli Delhi New Delhi Lucknow Dibrugarh Network of Reference Laboratories for Surveillance in India Kasauli Delhi New Delhi Lucknow Dibrugarh Ahmedabad Kolkata Mumbai Pune Bangalore L 5 labs Proposed BSL-3 under ICMR Chennai Pondicherry World Health Organization Country Office -

Conclusion Control and eradication of major epidemic diseases of livestock in any area of Conclusion Control and eradication of major epidemic diseases of livestock in any area of the world is the ultimate necessity and requires a coordinated regional approach need of close collaboration of among all the countries especially the developing and underdeveloped countries HOTSPOTS groping with the problems of disease epidemics and livestock mortality to draw baseline disease prevention and control strategies and exchange of disease information. although WHO, FAO and the OIE are exceptionally involved as a part of their global initiative support system , the onus lies on the governments, trained technical staff and the people involved in decision making to realise the goal Geographic information system (GIS) and remote sensing could be utilized as early warning systems and in the surveillance and control of infectious diseases cost of disease prevention must not exceed the benefits it can provide to the masses The detection and fight against animal diseases and zoonoses need to be done in a coordinated way.

Multiple expertise needed ! Public Health Infectious diseases Epidemiology Telecom. & Informatics International field Multiple expertise needed ! Public Health Infectious diseases Epidemiology Telecom. & Informatics International field experience Laboratory Information management

Widespread existence of preventable diseases and deaths is a disgrace to the society which Widespread existence of preventable diseases and deaths is a disgrace to the society which tolerates it. Thank You