The Human-Animal Interface and Zoonotic Threats:

The Russian Federation Approach

Tracey McNamara, Alexander Platonov, Tatyana Elleman, and Louise Gresham

Zoonotic pathogens have caused the majority of emerging infectious disease events in the past 6 decades. With most

emerging infectious diseases arising from animal origins, including many of the select agents identified as most likely

candidates for bioterrorism, linking human and animal surveillance systems will be critical to effective disease identifi-

cation and control in the future. Lack of this linkage has been the focus of a number of important policy papers in recent

years. These have expressed concern over the continued lack of preparedness for addressing zoonotic threats and have

called for a new approach to integrating biosurveillance. However, these studies have been mainly Western-centric in

viewpoint and have overlooked the example of the Russian Federation (RF) Anti-Plague System (AP system). In this

article we submit that the RF AP system has select components that effectively address recent concerns and inform the US

and UK intersectoral efforts on human-animal health surveillance, forming a basis for US, UK, and RF collaboration.

Recent disease outbreaks such as SARS, Nipah vi-rus, Hendra virus, and highly pathogenic avian in-

fluenza (HPAI) have forced governments to reevaluate theirapproaches to detection of and response to diseases at thehuman-animal interface. In 2004, a study recognized thatemerging zoonoses ‘‘have taken us by surprise and thecomplexity of the interactions between agents, animal hostsspecies and the environment represent a challenge for ef-fective forecasting, surveillance, prevention and control ofzoonotic diseases.’’1(p23) Recommendations included stud-ies to understand ‘‘the underlying causes for disease emer-gence and the ecology of pathogens and their hosts.’’1(p49)

Other policy papers have also come out in favor of a moreholistic approach to zoonoses that would require betterintegration of the interfaces among human, animal, andecosystem health domains.2-4 Integration can refer broadlyto use of routine surveillance information with veterinarycare, meteorological, agricultural, and even intelligencedata.5 As many existing surveillance systems are passive,

disease specific, and independent, there exists great poten-tial for missed opportunities to share information and de-tect previously unknown diseases.6

Inability to detect and respond quickly to emergingzoonoses can be costly both from a fiscal and a human-animal health perspective. A 2009 IOM committee foundthat a needed investment of $800 million pales in contrastto the economic losses from emerging, highly contagiouszoonotic diseases that have exceeded $200 billion over thepast decade.7

Recognition of current limitations has prompted in-vestment into novel surveillance systems. Google.org’sPredict and Prevent Initiative has provided millions ofdollars in support of efforts to identify hot spots wherediseases may emerge, detect new pathogens circulating inanimal and human populations, and respond to outbreaksbefore they become global crises.8

What few realize is that what is viewed as new and in-novative by the West has been practiced in the Russian

Tracey McNamara, DVM, is Professor of Pathology, College of Veterinary Medicine, Western University of Health Sciences, Pomona,California. Alexander Platonov is with the Laboratory for Zoonoses, Central Research Institute of Epidemiology, Moscow, RussianFederation. Tatyana Elleman is with the International Council for the Life Sciences, Arlington, Virginia. Louise Gresham, PhD, MPH,is President and CEO, Fondation Merieux, Washington, DC.

Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and ScienceVolume 11, Number 3, 2013 ª Mary Ann Liebert, Inc.DOI: 10.1089/bsp.2013.0054

185

Federation (RF) for more than 100 years. Faced with se-rious zoonotic threats at the turn of the century, the Rus-sians created a unique, integrated, ecologically basedzoonotic disease surveillance system known as the Anti-Plague System (AP system). While this system has beenevaluated from a proliferation threat perspective,9 its epi-demiologic power has not been fully appreciated by thepublic health community. As the world struggles to meetthe challenge of emerging zoonoses, it is worth looking at asystem that has served the RF for many years. Rec-ommendations found in recent policy papers are already inplace in the RF.

In this article we address several questions:

� Why was the AP system originally created as an inte-grated human-animal surveillance system for zoonoticthreats?

� How did this innovative approach sustain itself during100 years of tremendous technological, scientific, polit-ical, economic, and social change?

� How did the AP system operate historically, and howdoes it operate now?

� What lessons can be learned from the RF by those nowattempting to create integrated surveillance systems inthe Western world and in developing countries?

Background

The Nuclear Threat Initiative (NTI) previously fundedresearch on the AP system in Central Asia. Recognizing thatthe Soviet Union historically had a unique approach tozoonotic threats that might inform current Western efforts,NTI engaged with experts from the animal and humanhealth systems in Russia, Kazakhstan, the UK, and the USto determine the status of current national infectious dis-ease surveillance systems and provide recommendations forhigh-level engagement of Russian and US experts aimed atimproving integration between human and animal health.This project was implemented in cooperation with expertsfrom the international disease control and related com-munities. NTI hosted an experts workshop in Moscow inJune 2009 to discuss their respective approaches to thehuman-animal interface. The following is an analysis of theRF approach to zoonotic threat detection and response.

Russian Federation System

for Epidemiologic Surveillance

The RF has a 3-level system of epidemiologic surveillanceand control for especially dangerous infectious disease atthe federal, subfederal, and regional levels (Figure 1). Twomain entities control and supervise veterinary and publichealth: (1) Rosselkhoznadzor, which reports to the Ministryof Agriculture (MoA), and (2) the Federal Service for

Surveillance in Consumer Rights Protection and Welfare(FSSCRPW), or Rospotrebnadzor (also formerly known asSanitary and Epidemiologic Service [SES]), which reportedto the Ministry of Health (MoH) until 2012 and directly tothe government of the Russian Federation since 2012.10-17

FSSCRPW (Rospotrebnadzor) consists of a network offormer SES facilities, with centers in cities or regions, andspecial federal entities including 1 Anti-Plague Center, 5scientific and research Anti-Plague Institutes, and severalAnti-Plague stations (APS) located throughout the country.In general, the SES system deals with many traditional publichealth functions, while the specialized Anti-Plague system’smain responsibilities have to do with preventing outbreakscaused by especially dangerous pathogens (EDP), includingoutbreaks of zoonotic infections18 (Figure 2). What is uniqueabout the RF AP system is that a single agency has jurisdictionover humans and animals in regards to zoonotic threats.

The AP system evolved as a result of the considerablehistorical threat posed to public health by plague (Yersiniapestis). In the beginning, the main focus of the AP systemwas on plague, but today it covers many viral and bacterialagents such as tularemia, brucellosis, and cholera.

Unlike the West, where human, animal, and environ-mental health activities are the responsibility of separateagencies, the investigation and control of diseases in all 3domains have been mandatory for the AP system since itscreation. Russian federal law mandates that the AP systemhave authority over any activity ‘‘related to shedding ofpathogenic microorganisms by humans, animals or by theenvironment, detection and treatment of people displayingsymptoms of infectious diseases, as well as scientific, edu-cational and productive activities involving use of agents ofinfection.’’19(p2)

The AP system has always had an environmental focuson the study of zoonoses, and its work has involved ob-taining samples from the environment, wild rodents, andbirds. On an annual basis, the AP system collects approx-imately 50,000 animal samples (mainly rodents), 100,000ticks and mosquitoes, and 10,000 water samples. Roughly10,000 to 20,000 virological investigations and up to100,000 microbiological investigations are performed. TheAP system represents a rare example of systematic, sus-tained, well-supported, integrated biosurveillance for zoo-notic threats. No parallel exists in the West.

History of the Anti-Plague System

The AP system was created by Czar Nicholas II in the1890s to respond to numerous outbreaks of plague. CzaristRussia and the former USSR had 43 ‘‘natural foci’’ ofplague covering 550 million acres of land.9,20,21 From theturn of the century to 1925, more than 177 outbreaksoccurred affecting 2,105 people.

In response, anti-plague institutions were organized inRussia from 1898 to 1915. These included the State

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Commission for Prevention and Control of Plague Infec-tion, 2 research laboratories in St. Petersburg and KronstadtCity, 10 regional anti-plague laboratories, and 45 regionalanti-plague stations in areas of plague activity.

In 1921 another outbreak in the Russian Far Eastprompted the creation of special anti-plague trains. Thesetrains consisted of 8 to 11 cars with a kitchen, a storeroom,a pharmacy, a laboratory, an isolation ward, an observationward, a disinfection chamber, and cars for staff, quarantineguards, and the deceased. The staff of the train included 2doctors, 4 medical assistants, a disinfection specialist, 10nurses, 6 quarantine guards, and a conductor. The trainsexamined the populace in high-risk areas, removed sus-pected cases of plague and placed them in an isolation ward,and later moved them to a secured quarantine site.22 Thiswork is an extraordinary example of field epidemiology atits best. The anti-plague train-laboratory was a historicalprototype of modern day mobile response teams known asSAETs (sanitary and anti-epidemic teams).

After the revolution, the Regional Institute of Micro-biology and Epidemiology was organized in Saratov City

(in the Volga region). The main tasks of the institute in-cluded plague surveillance and prevention, field studies ofzoonotic cases, and development and manufacturing of lab-oratory tests and therapeutic and prophylactic vaccines andsera. This institute is now known as ‘‘Microbe’’ and is thecore of the Russian anti-plague system. It serves as a referencecenter for plague and other dangerous zoonotic infections.

In 1924, AP specialists shifted from response to pre-vention of zoonotic outbreaks. Fourteen field epidemiologyteams were created to inspect the steppes and deserts todetect epizootic outbreaks.8 From 1926 to 1940, the ma-jority of plague epidemics and epizootics were in the Eu-ropean part of the USSR, particularly in the Caspiansteppe, where 151 outbreaks affecting 592 people wererecorded. The Soviet AP system was established from 1929to 1935 to address the situation. Structural and legislativework was finished in 1939, when the statutes and instruc-tions for anti-plague institutions governed by the Sovietministry of health were issued.

The total eradication of rodent reservoir hosts and vec-tors of plague, the tarbagan (Marmota sibirica) and the little

Figure 1. Structure of Russian Federal Service for Customers’ Rights Protection and Human Well-being Surveillance Including Anti-Plague System. Russian government consists of 21 ministries and 20 federal services and agencies including at the ‘‘government level’’Federal Service for Customers’ Rights Protection and Human Well-being Surveillance (FSCRPHWS). Its institutions serve the wholecountry and constitute the federal level of management, whereas at the subfederal level there are the institutions that serve large parts ofRussia. The regional level means the level of so-called subjects of the Russian Federation, called Republic, Krai, Oblast, or AutonomousOkrug. Currently there are 83 subjects of the Russian Federation.

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Figure 2. Functions of Federal Service for Customers’ Rights Protection and Human Well-being Surveillance. Among the 3 majorbranches, 1 deals mainly with routine sanitary and epidemiologic surveillance and control (left); the research institutes are chargedmainly with academic science (right), whereas the AP system involves both in practical investigation and control of extremelydangerous diseases and the fundamental studies of these infections.

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souslik (Citellus pygmaeus), was started in the mid-1930s.Anti-plague stations in endemic areas investigated rodentpopulations every year. If the infection rate increased, theeradication measures were intensified. Teams were sent intothe field twice a year to monitor and obtain baseline in-formation on rodent and flea populations and to system-atically map natural foci of plague, a formidableaccomplishment of the AP system (see Figure S1, supple-mentary material, at www.liebertonline.com/bsp).11,23

Both in czarist Russia and in the early years of the USSR,the integrated approach to zoonoses was to some extentforced by the limited number of trained specialists in a largecountry. By necessity, the small workforce needed to workwith both human and animal threats. However, there wasalso a firm scientific basis for such an approach. In 1939,Evgeny Pavlovsky, the father of Russian epidemiology,introduced his concept of ‘‘natural nidality of disease.’’24-27

‘‘According to Pavlovsky, ‘nidus’ is a translation of the rootword ‘ochag,’ meaning a hearth. Thus a nidus of disease isits nest, home, or habitat (equivalent to the Latin ‘fo-cus’).’’28(p913) He pointed out that certain diseases occurnaturally in wildlife and are transmitted from wildlife tohumans by insect, tick, or mite vectors when humans in-trude on their territory. Later, he showed that the type ofdisease present could often be predicted from the type oflandscape. His nidality concept, which is just being redis-covered by the West, ‘‘led to the emergence of the con-temporary science of landscape epidemiology.’’27(p462) Thetheory behind landscape epidemiology is that

knowing the vegetation and geologic conditions necessaryfor the maintenance of specific pathogens in nature, onecan use the landscape to identify the spatial and temporaldistribution of disease risk. Key environmental elements,including elevation, temperature, rainfall and humidity,influence the presence, development, activity, and longev-ity of pathogens, vectors, zoonotic reservoirs of infection,and their interactions with humans.29

This is the type of environmental information that wasand is routinely collected by the AP system. The science-based, integrated approach of the AP system to diseasesat the human-animal-ecosystem interface is one onlynow being explored by the West, which is attempting topredict emerging zoonoses in hot spots of disease activ-ity. Pavlovsky’s nidality of disease concept, which lookedat wildlife vectors and the ecosystem as a means ofpredicting infectious disease outbreaks, was written 74 yearsago, but the approach is as fresh and applicable today asit was then.

When the Communist party came into power, it decidedto keep and enhance the AP system. In the 1940s, newendemic areas were found as anti-plague institutes andstations grew and expanded their surveillance of hosts andadded serology to classic bacteriologic methods. In the late1950s, special commissions on plague were established.

These studied ‘‘known natural plague foci and investigatedwhether other unknown foci existed in the USSR.’’30(p52)

The research agenda of these commissions included ‘‘studiesof hosts and vectors that carried and transmitted plaguebacteria, diseases that afflicted the plague hosts, and decon-tamination methods. To accomplish this ambitious researchagenda, numerous regional and field AP stations were set upin regions in which natural plague foci existed.’’30(p52)

In 1966 the plague enzootics appeared again in the trans-Baikal region and later in the Caspian steppe (in 1972). Atthat time the system was primarily engaged in defendingthe country against endemic and exotic diseases.

By the late 1970s, the system was enlisted in a biologicalwarfare program and was composed of 87 facilities engagedin disease surveillance, research, production and testing ofvaccines and laboratory equipment, and training of civilianand military personnel. Most important, the AP systemstretched beyond Russian borders into Central Asia, theCaucasus, Ukraine, and Moldova, with facilities strategi-cally located in 11 republics.31

In its heyday, before the collapse of the Soviet Union, theAP System employed 14,000 people including 7,000 sci-entists whose expertise broadened beyond plague to otherendemic zoonotic diseases, such as anthrax, brucellosis,tularemia and Crimean-Congo hemorrhagic fever. Theyhad a formidable workforce capable of both surveillanceand response to zoonotic threats.18

From 1990 to 2009, most changes related to the newtechniques for EDP diagnostics and investigation of theevolution of the organisms, but the ruling principles andorganizational structure of the AP system were kept in thepost-Soviet Russian Federation.

Today, there are 12 anti-plague stations in the RussianFederation, as well as 5 anti-plague research institutes,most of which are found in plague-endemic areas or re-gions connected with plague-endemic areas. The AP sys-tem is governed by the Federal AP Center in Moscow.Institutes are designated as reference centers, meaning thatthey handle the state collection of strains, do their finalidentification, and develop and supervise procedures. Al-though they can work with any EDP, institutes will usu-ally specialize in a pathogen—for example, Saratov forplague and Stavropol for Crimean-Congo hemorrhagicfever. Sanitary regulations stipulate safety procedures forhandling EDP and procedures for record keeping andstorage, transfer, and transportation of microorganisms.19

There are also roughly 60 anti-plague facilities in CentralAsia and the Caucasus, where the largest and most activenatural disease foci are concentrated. Because of post-Soviet difficulties, there were human cases in neighboringcountries (Kazakhstan, Uzbekistan) and an increase inepizootics in these countries. The danger of importationof plague from Central Asia, Mongolia, and China stillexists.

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Strengths of the Anti-Plague System

Education and TrainingThe AP system has addressed some of the concerns of theIOM report on implementation of joint human and animalhealth field epidemiology training programs and multi-sectoral coordination and communication in producing aworkforce capable of carrying out zoonotic surveillance.7,9

The AP system has a long tradition of training medical andparaprofessional staff (biologists) in the recognition, han-dling, and response to zoonotic pathogens.32 Beginning inthe 1940s, all AP employees received training in a 6-monthspecialization course at the Microbe Institute.9,18

The head of FSSCRPW approves the programs fortraining specialists in IHR (2005) and sanitary protectionof the Russian Federation territory. The mandatory sanitaryand anti-epidemic team personnel training includes base-line specialization and regular advanced training at theMicrobe and Stavropol AP Institutes, as well as annualseminars and workshops at their institutes.32 Annually 500to 1,000 people receive formal training and are certified.Another 1,000 to 1,500 specialists attend lectures. Astrength of this training is that it includes not only theepidemiologic investigation and diagnostics of humandisease outbreaks but also the investigation of emergentsituations in domestic animals and wildlife if these zoonosespose a threat to public health.

Structured Reporting FrameworkThe RF health system has a very well-defined and timelyreporting hierarchy for suspect zoonotic threat cases. This issupported by the federal legislation that regulates the re-porting timeline in case of an epidemiologic emergency.33

According to the legislation, any medical facility that sees asuspect case of an EDP must send an emergency special

report to the local Sanitary and Epidemiologic Servicesoffice within 2 hours (Figure 3). The regional Rospo-trebnadzor authority must report the emergency to the fed-eral Rospotrebnadzor office within 24 hours. Decisions forresponse beyond the regional level, such as deployment ofmobile sanitary and anti-epidemic teams, are made at thefederal level by Rospotrebnadzor.34 Detection of unknowninfectious diseases is viewed as an emergency and requiresurgent transfer of information to the federal level in the formof 2 consecutive messages: a preliminary one, provided ur-gently within 24 hours, and a final report within 15 daysafter an emergency situation is restored to normal.19,33,35,36

There is a single reportable disease list. Different diseaseshave different triggers for reporting. For example, every caseof plague, SARS, West Nile fever, Crimean-Congo hem-orrhagic fever, rabies, anthrax, typhus, and legionellosismust be reported, whereas every 3 cases of brucellosis arereportable.33

Biological agents of greatest pathogenicity are classifiedas Groups I or II. Other microorganisms are in Groups IIIand IV.19 Samples taken by physicians from suspect re-portable disease cases are sent by courier from the localhospital to the nearest Center of Hygiene and Epidemiol-ogy or an AP affiliate, where serologic studies, PCR, andbacteriologic and virus isolation may be performed. Sub-sequent vertical flow of highly pathogenic pathogens in theFSSCRPW is depicted in Figure 4.

Intersectoral CooperationThe WHO report called for the creation of ‘‘intersectoralcommittees for zoonoses preparedness and control in eachcountry.’’1(p46) Another strength of the RF system is that italready has effective interdisciplinary bodies at the regionaland sometimes federal levels known as emergency com-mittees. Special anti-epidemic and anti-epizootic commis-sions may be organized by the Russian government or

Figure 3. The Timing and Flow of Clinical Case Reporting in the Russian Federation. This scheme and timing is mandatory for allmedical and epidemiologic facilities according to Russian legislation.

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by regional governments of provinces (Oblasts andRepublics).37

Most regional governments have permanent sanitaryanti-epidemic and anti-epizootic commissions that includerepresentatives of the local offices of the ministry of health(clinical treatment); Rospotrebnadzor (epidemic control);Rosselkhoznadzor; the ministry of internal affairs (police);the federal security service; the ministry of extraordinarysituations; the office of public prosecutor; housing andcommunal services (waterborne outbreaks); air and railwaytransport (distant spread of infection); and the ministry ofeducation (outbreaks in schools and universities). Com-missions are chaired by a governor of the region or his orher deputy. Such intersectoral committees make immediateand widespread implementation of the epidemiologists’recommendations possible. For example, if the governorimposes quarantine in the region, it will be supported by allof the abovementioned ministries and services. In additionto emergency situations, these commissions meet regularlyto coordinate preventive measures.

Defined ResponsibilitiesUnlike many countries in which jurisdictional issues in azoonotic outbreak remain unclear, the responsibilities ofthe Russian authorities are well defined. The course of ac-tion is determined by the type of infection and is sanctionedby the province governor. The AP system (as a subordinateof Rospotrebnadzor) can impose a quarantine, order live-stock expropriation, introduce other special restrictions inthe affected area on a regional level, and promote the

organization of anti-epizootic and anti-epidemic emer-gency committees.

In cases of plague, the AP system, not the ministry ofagriculture, is responsible for monitoring the disease inrodents and arthropods. If a case of plague were diagnosedin a camel by the ministry of agriculture, they would reportit to the anti-plague station, which would then carry out allfield studies, evaluate clinical and pathological materials ofsuspect cases, and implement anti-epidemic measures. Pa-tients with suspected or confirmed infection are tested,vaccinated, and quarantined.

The responsibilities are distributed similarly if a humancase of anthrax is diagnosed. The state sanitary and epide-miologic service conducts a full outbreak investigation withlimited assistance from the veterinary service.36 The mostrecent equine anthrax outbreak started in the Omsk regionin June 2010 and resulted in 6 human cases with 1 fatality.Anthrax strains were isolated from sick horses by veteri-narians (Rosselhoznadzor, ministry of agriculture) and theblood of a patient by the Regional Center of Hygiene andEpidemiology, Rospotrebnadzor. The strains were studiedby Stavropol API (Russian Reference Center) and werefound to be genetically the same.38

In cases of brucellosis, the ministry of agriculture informsstate sanitary and epidemiologic control authorities oflivestock cases. The ministry of agriculture undertakes anti-epizootic control measures, but Rospotrebnadzor will, to-gether with specialists from the veterinary service, conduct afield investigation, vaccinate personnel on the farm, per-form medical evaluations of people who came into contactwith a source of infection, and enforce other anti-epidemic

Figure 4. The Flow of Highly Pathogenic Strains in Federal Service for Customers’ Rights Protection and Human Well-beingSurveillance. (1) Mobile Special Anti-Epidemic Teams operate only in a case of emergency and/or in the regions with scarce diagnosticfacilities. (2) Only AP institutions, but not Centers of Hygiene and Epidemiology, are involved in handling and investigation of plaguestrains. (3) Strains of less pathogenic species may be sent by Centers of Hygiene and Epidemiology directly to Federal ReferenceCenters for specific pathogens usually operated by the Research Institutes.

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measures. If a human case is detected, Rospotrebnadzor isnotified of the emergency within 12 hours. Evaluation ofthe workplace where the infection occurred is conductedjointly by veterinary and public health personnel.35

Defined Response TeamsThe 2008 WHO/FAO/OIE Joint Consultation onemerging zoonotic diseases recommended that when a newzoonotic agent emerges,

two multidisciplinary teams should be dispatched wherevernecessary: one to investigate and contain the human healththreat, and the second to investigate the ecology of theagent. Longer-term research should be undertaken toidentify all factors contributing to the emergence of thenew agent and the scope of the agent’s host range, so thatappropriate control and prevention strategies can be de-veloped.1(p9)

This recommendation describes the combined efforts of theRF anti-plague stations, anti-plague institutes, and mobilesanitary and anti-epidemic teams. Russian authoritiesconsider the teams to be mobile, autonomous, multifunc-tional, highly technological, modular, safe and are intendedfor prophylactic, anti-epidemic and sanitary measures incases of natural or man-made disasters, including epidemicsand bioterrorism.14,34,39

The teams are trained to rapidly deploy to an outbreaklocation. They work at the national, regional, and locallevels and, most important, work across the human-animalinterface. Sanitary and anti-epidemic teams were foundedin 1965 and have been deployed more than 100 times sincethen.40

They are multidisciplinary and are composed of epide-miologists, microbiologists, zoologists, entomologists, andother specialists and support staff (Figure S2, supplemen-tary material at www.liebertonline.com/bsp). Each teamhas a reserve crew waiting at an anti-plague institute if staffneed to be replaced. Crews work 24/7 when deployed.14

The head of a sanitary and anti-epidemic team is alwaysan epidemiologist appointed by the director of the corre-sponding anti-plague institute. Upon receiving an urgentreport, the teams are put on high alert, deployed as full orpartial teams, relocated, replaced with a new team, or re-turned to the permanent base by order of the head ofRospotrebnadzor. Sanitary and anti-epidemic teams arestaffed with personnel from the AP system (institutes andstations) and other health professionals that pass thetraining, which includes 6 months of baseline specializationand regular advanced training at Microbe and StavropolAP Institutes as well as annual seminars and workshops attheir institutes.19,32

Sanitary and anti-epidemic teams coordinate with localauthorities and involved agencies; perform epidemiologicreconnaissance, surveillance, analysis, and forecasting of the

epidemiologic situation in the area of emergency; organizedelivery of samples from people and the environment forresearch; perform laboratory diagnostics; detect pathogensin the environment; perform laboratory control of food andwater for contamination; participate in the developmentand implementation of anti-epidemic measures includingdisinfection and rodent and pest control activities; ensurebiosafety requirements when conducting diagnostic studies;provide daily reporting; and participate in emergencycommissions32,33 (see Figure S3, supplementary material atwww.liebertonline.com/bsp).

From 2005 to 2009, automated pathogen identificationsystems and modern means of securing biosafety were in-troduced to sanitary and anti-epidemic teams.14 They nowhave technical facilities that enable them to function in-dependently of local facilities (Figure S4, supplementarymaterial at www.liebertonline.com/bsp). Five special pur-pose anti-epidemic teams have been upgraded with new labequipment. In addition to classic low-tech microbiologicaland animal-based virological techniques traditionally usedby the AP system, they now use ELISA and real-time PCRmachines.40

Today, there are 10 sanitary and anti-epidemic teams.Training of the reserve crews is still in progress but there areapproximately 500 to 600 certified sanitary and anti-epidemic team specialists.14,32,41

An example of a sanitary and anti-epidemic team inaction is when they were deployed to the republic of NorthOssetia on August 9, 2008, immediately after war brokeout. On August 10, 6 sanitary and anti-epidemic teamvehicles with 24 people arrived at Vladikavkaz and Alahirand on August 11 at Tzkhinval. Team personnel includedthe director of the institute heading the operations; anepidemiologist (the team head); the deputy head, respon-sible for logistics; an epidemiologic unit with 2 epidemi-ologists, 1 zoologist, and 1 sanitary doctor; a bacteriologicunit with 6 doctors, 2 laboratory technicians (also workingin the food unit), and 1 disinfection specialist; technicalsupport with 2 engineers (electrician and a diesel operator)and 6 drivers-disinfectors.32,40-43 The situation was fraughtwith a high risk of zoonotic disease outbreaks, as 100% ofhouseholds were infested with rodents. Waterborne infec-tions were also a great concern, as only 2 wells were oper-ational. Interruption of waste collection resulted in largegroups of scavenging dogs and rodents.

The task of the sanitary and anti-epidemic teams was toprevent an epidemic of enteric and other infections. Thefirst thing the teams did was conduct door-to-door visitsto identify infected people. The teams launched PCR,sanitary-hygienic, and bacteriological studies. They alsodisinfected and monitored the water supply and offered anumber of technical solutions to optimize the supply ofchlorinated water. Total eradication of rats in Tskhinvalwas performed, and rabies prophylaxis was administered tothe population as needed. Between August 11 and Sep-tember 3, the team surveyed 78 sites and completed 780

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laboratory tests. Through their efforts, spread of entericinfections was stopped and those foci that existed wereisolated and eliminated.43

Weaknesses of the Anti-Plague System

While the Russian AP system has features that are worthemulating, including its integrated approach to zoonoses,well-defined reporting structure, rapid response teams,multidisciplinary training, and fusion centers, it also hasweaknesses, partly linked with its advantages. As a bu-reaucracy, it responds best to known threats but is strug-gling to impart necessary flexibility to respond to emergingthreats. Also, as a vertically organized structure, with ver-tical transmission of data, information is not always re-leased to the general public in a timely manner. There is nopublic input into the priorities set by the AP system. Inaddition, as a ‘‘do what you are ordered’’ system, it requirescomplete, up-to-date, and consistent legislation for effectiveperformance. For example, current communication be-tween public health entities and the ministry of agricultureis admittedly poor. A key reason for this is that regulationsgoverning the organizations became obsolete because ofstructural changes as a consequence of administrative re-forms. This has yet to be addressed.

Discussion

The Russian public health system has demonstrated theability to diminish the threat of dangerous zoonoses. Therehave been no plague cases and only sporadic cases of an-thrax and rabies in the past few decades. The incidence ratesof brucellosis, Q fever, leptospirosis, and tularemia arestable at fewer than 4 cases per 1,000,000 of population andusually fewer than 2 cases per 1,000,000. This is a realachievement for an economy ‘‘in transition’’ and in acountry where practically all rural areas are endemic for anumber of zoonotic diseases. The Russian AP systemcontributed greatly to this achievement and confirmed itsusability and sustainability during the century, full of socialand epidemiologic challenges. In contrast to most Sovietinstitutions, it still operates in the modern Russian state.

The Russian AP system was created in a country withmany natural foci of zoonotic diseases and therefore may bemost applicable to less developed nations in Asia, Africa,and the Middle East, which are similarly challenged andhave been the focus of recent zoonotic disease outbreaks.These resource-limited countries often have inadequate orno healthcare facilities. Consequently, these countries donot have adequate domestic disease detection or responsecapabilities.44

The Russian experience in emergency response is ex-tremely useful. Rapid response teams have recently beenformed in Africa45 and Asia46 to address cross-border dis-

ease surveillance. In Asia, the Mekong Basin Disease Sur-veillance (MBDS) network was formed because the lower-income countries in the region had weak health systems,46

and those weaknesses threatened the entire region. MBDSincludes Cambodia, China (Yunnan and Guangxi), LaoPDR, Myanmar, Thailand, and Vietnam. Lao PDR hasdeveloped Rapid Response Teams (RRTs), and Thailandhas Surveillance and Rapid Response Teams (SRRTs). In2008, Thailand MBDS responded to a devastating cyclonein Myanmar by forming multidisciplinary rapid responseteams that included physicians, psychologists, and envi-ronmentalists. While this is progress, many countries inSoutheast Asia continue to be resource-poor and havelimited infrastructure.47

In Africa, the East African Integrated Disease Surveil-lance Network (EAIDSNet) was formed in recognition ofthe difficulty of responding to disease outbreaks due tofragmented disease interventions and poor lab capacity.EAIDSNet has pulled together cross-border surveillanceand response committees that are now in place betweenKenya and Tanzania, Kenya and Uganda, and Rwanda andUganda. There are plans to develop similar response teamsbetween Tanzania and Rwanda, Tanzania and Burundi,and Rwanda and Burundi.45 However, a field exercise re-vealed continued weaknesses in coordination of responseactivities, poor communication, and inadequate biosecuritymeasures.45

The RU AP system has extensive and time-proven ex-perience in developing zoonotic disease response systemsthat is applicable to these regions. Its tradition of education,training, and monitoring are valuable for Africa, Asia, andother epidemiologically active regions. Governments inthese parts of the world do not necessarily have well-developed veterinary or public health systems that would beresistant to change. The RF AP system is unique in itsmultidisciplinary approach, which includes ecologists andbiologists with extensive knowledge of animal behavior,biology, and landscape ecology. Could this not serve as anopportunity to take an integrated and multidisciplinaryapproach to zoonotic threats when building health systems?

It should also be noted that until relatively recently, theAP system functioned with basic, low-tech classic micro-biological methods and well-trained personnel, whichmight suit the fiscal challenges of these areas.18 Additionalstrengths of the AP system are a clear and orderly (albeitbureaucratic) system for sample collection, handling, bio-safety, reporting of zoonoses, decision making, and distri-bution of responsibilities; well-defined response protocolsthat apply to both humans and animals; and speciallytrained medical and paraprofessional personnel. Thesemight serve as a template for other countries as they try todevelop integrated biosurveillance systems.

In conclusion, in times when the world is constantlychallenged by a full spectrum of biological threats, it wouldbe improvident to dismiss the rich experience and century-old history of the Russian AP system.

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Acknowledgments

This work was undertaken as part of the biological programat NTI, a Washington, DC–based NGO, and we aregrateful to the Russian Federation, Central Research In-stitute of Epidemiology, for hosting the global scholars whocontributed to this comparative analysis. For AEP, thiswork was supported in part by the contract with theMinistry of Education and Science of the Russian Federa-tion No. 14.515.11.0011. We would also like to thankMatthew Finn, NTI intern, for his research and dedicatedrefinement of the manuscript.

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Manuscript received January 23, 2013;accepted for publication July 17, 2013.

Address correspondence to:Tracey McNamara, DVM

Western University of Health SciencesCollege of Veterinary Medicine

309 E. 2nd StreetPomona, CA 91766

E-mail: tmcNamara@westernu.edu

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