Description: APEC-EINet

The following document was submitted to the United States Centers for Disease Control and Prevention in support of the EINet project and required funding.

I. Problem and approach
II. Management Plan and Personnel
III. Budget justification

I. PROBLEM AND APPROACH

A. Problem Statement

The emergence of new infectious diseases coincident with the increase in speed and scope of travel and trade in the world has created a need for new and innovative surveillance strategies. The problem addressed in this proposal can be phrased as follows:

Given the new concern with emerging infections among APEC member economies do existing telecommunications-based networks which are linked to trade interests represent a feasible innovative strategy to enhance regional surveillance and control of emerging infections in the Asia Pacific region? How can such linkages serve to enhance collaboration between government and universities in the region?

The International Health Regulations epitomize the competing objectives of international disease control:

• to encourage timely and effective notification and control of disease
• to maintain global traffic of good and persons

To address this problem, innovative strategies in disease surveillance need to be put into place to facilitate the flow of information in pursuit of both of these objectives. This proposal describes a telecommunications based approach which draws an existing trade related telecommunications network into a dialogue about the emergence of new disease. This is accomplished through the identification and inclusion of Public Health authorities in the network. New content will then be put up on this network which will include:

• 1) exchange of reference material from existing library sources on the full range of emerging disease of interest to the region
• 2) exchange of disease specific surveillance information on a disease of universal importance within the trading group (m. tuberculosis)
• 3) inclusion of the CDC "self-assessment instrument" as a means of describing the capacity of participating partners and
• 4) the incorporation of existing didactic materials directed both the scientists and policy makers who access this network.

There has been a general recognition that:

• a ) The increasing economic interdependence of the Asia Pacific Economic Cooperation member economies has created new wealth. However, the increased traffic of goods and people in the region poses new public health challenges. The emergence or resurgence and epidemic dissemination of certain infectious diseases such as Dengue, Tuberculosis, Cholera, and others in the region is of particular concern. This concern with the emergence and reemergence of infectious diseases (EIDs) has thus appropriately become an issue on the Science and Technology agenda of APEC.
• b ) Existing national and international public health disease reporting structures are not tailored to the needs of the new economic cooperation of the region. They do not permit the speed and the high level of interaction and flexibility essential to react to EIDs in a timely way. EIDs pose a particular threat to an interconnectedeconomic cooperative. They threaten the health of societies, they may provoke non-tariff trade barriers as governments seek to protect vulnerable populations and they impose direct and indirect economic costs. For example, India estimates a loss exceeding $1.2 billion due to trade and travel restrictions imposed during the putative outbreak of plague in that country. Much of this economic damage could have been averted by timely diagnosis and proactive public health cooperation with trading partner nations.
• c) Emerging infections require rapid, responsive collaboration among the scientific communities, governmental bodies, and commercial interests of member economies for their effective prevention, surveillance and control. Universities, as centers of scientific training and research, have an important role to play. However, University/Government linkages will need to be strengthened to address this challenge.

The approach is broader than its technological base. We have developed a concept paper describing this activity which we have shared with our potential international collaborators. It is our intention that this work be responsive to the concerns of the community within APEC, and that our objectives accurately reflect the preoccupation's of the region. We have been in contact with the Emerging Infections program of WHO Geneva, and with the SEARO office in Delhi regarding this project, and will continue to involve these and other interested parties as well.

This cooperative agreement with CDC will cover the implementation of this first phase of project activity, but a broader vision of collaboration in the Asia Pacific region will eventually be realized. Through the linkages created with this project, CDC and the University of Washington will initiate collaboration with an expanding number of APEC institutions focused on the areas of epidemiologic and laboratory based surveillance of emerging infections. Eventually this collaboration will be institutionalized through ongoing long term research work and other cooperative public health activities to facilitate the prevention and control of infectious diseases.

B. Background/History
1. APEC and Emerging Infections

The Asia Pacific region has recently (1991) come together in a new economic cooperation: The Asia Pacific Economic Cooperation. This cooperation includes 19 economies and spans the Pacific. The agenda for the cooperation is primarily to assure free trade. The region, has not been spared from the global phenomenon of emerging infectious diseases. Dengue Fever has expanded its traditional epidemiologic range and now presents a major threat to Malaysia, Indonesia, Thailand and other southeast Asian countries. Cholera swept through Latin America in 1991 and 1992, including the APEC economies of Mexico and Chile in its wake. Tuberculosis is a major concern throughout the region, and the HIV/AIDS pandemic has exploded definitively in Asia in the past three years.

Although health is not the focus of the APEC process, the issue of Emerging Infections was introduced by the United States government onto the Science and Technology ministerial agenda in September of 1995, and this initiative was the subject of a follow up working group in Indonesia more recently. The introduction of this issue: "officially" into the proceedings of APEC, positions it as an appropriate issue for work by the APEC educational consortium. This consortium of institutions from APEC member economies seeks to study collaboratively questions of importance to the overall agenda of the organization. Our proposal describes a project which would be carried out collaboratively by the School of Public Health, the APEC Study Center and five APEC member institutions to enhance the prevention and control of emerging infections in the region.

Emerging Diseases was introduced into the APEC agenda through an initiative from the United States. The initiative was introduced at the APEC Ministers' Conference on Regional Science and Technology Cooperation meeting held October 5-6, 1995, at the China Hotel, Beijing. As pointed out in the proposal "Effectively addressing these infectious disease threats requires effective surveillance, response and prevention," the proposal goes on to emphasize the need for systems of surveillance and control based in a strong and stable research infrastructure. Such an infrastructure can be built through the APEC consortium over time.

The recently described phenomenon of emerging and reemerging infections has renewed concern about epidemic infectious disease around the world. The 1992 Institute of Medicine Report "Emerging Infections" highlighted two important aspects to this phenomenon: the changing ecological conditions through activities of economic development in areas such as travel, technology, population and land use; and the coincident decline in infrastructure globally for prevention and control. The public sector, through the United Nations system and its technical agency, the World Health Organization has historically orchestrated epidemic response internationally. However, public sector spending generally is being curtailed, and it is unclear that traditional international public health structures alone will be adequate to cope with the renewed challenges of emerging infections in the modern world. Thus the vision presented above of a collaborative project which brings together university centers, technical government resources and trade interests is particularly timely and potentially important.

In summer of 1995 an interagency group chaired by the White House Office of Science and Technology outlined the issues and programmatic plans for a national response to the challenge of new infections. New strategies for international collaboration to prevent and control emerging infections are needed, and there is a US Government commitment to the issue, as put forward in the APEC discussions, and detailed in the CISET report.

2. University of Washington and Emerging Infections
A significant literature has subsequently described the phenomenon of infectious disease emergence more closely. The University of Washington began a course in Public Health on Emerging Infections of Public Health Importance in 1993, and this course has been extremely well received. In addition, we have developed a interdisciplinary working group on Emerging Infections which links 150 faculty and graduate students in an electronic list serve. The working group sponsors speakers, and promotes information exchange about research and curricular developments on the campus and elsewhere related to emerging infections. Washington State through a long history of University/Government collaboration epitomizes the kind of town-gown collaboration which will be most successful in this effort. In fact "outbreak investigation" has become an accepted mode of teaching within the University, and simultaneously serves the need to the surrounding communities. In a number of APEC member economies similar cooperation is within reach. Such cooperation and information sharing will be an asset in the effort to limit the spread of EIDs. Field Epidemiology Training Programs already exist in Thailand, Indonesia, Philippines (with a similar program ongoing in Canada) and provide another source of expertise which can contribute to this effort.

Increased interdependence creates not only public health challenges, but also opportunities. New technologies such as the APEC Telecommunications Network (see below) and personal and institutional networks can facilitate the open exchange of information and ideas. Over time, such collaborations will assure the effectiveness of efforts to counter the spread of EIDs throughout the Asia-Pacific region.

3. The University of Washington and APEC
In response to the APEC Leaders Education Initiative of November 22, 1993 , calling for "an investment in our future generations by establishing an APEC Education Program to develop regional cooperation in higher education, study key regional economic issues, improve workers skills, facilitate cultural and intellectual exchanges, enhance labor mobility and foster understanding for the diversity of the region" APEC member representatives met in Seattle in May of 1994 and defined a three component APEC Leaders Education Initiative. The first component entailed the founding of APEC Study Centers through the Asia Pacific region to focus on policy issues of regional importance and encourage education networking among the centers. The United States inaugurated an "APEC Study Center Consortium" comprised of twelve U.S. Universities and Institutions. Dr. Donald Hellmann, University of Washington, is Chair of the executive board of this consortium, with Michael Oksenberg of the East West Center/University of Hawaii acting as secretariat. In 1995, Secretary of State Warren Christopher called for a telecommunications network initiative to link all APEC Study Centers to facilitate the exchange of information and enhance collaboration. The lead on this networking activity was taken by the University of Washington and the product, the APEC telecommunications network(APEC EduNet) is in place. The network carries the endorsement of the U.S. Government as evidenced by the letter appended by Vice President Al Gore. It is this network which will serve as the vehicle for the proposed project. Dr. Ann Marie Kimball served on the planning and advisory group for the establishment of the current APEC Study Center at the University of Washington.

C. Purpose and Approach

This project will reinforce the existing international efforts at disease prevention, surveillance and control through enhancing communications and exchange among scientific and technical resource institutions in the APEC educational consortium. Using a recently created APEC telecommunications network we will:

• Establish a program of structured communications and interchange about the technical issues pertinent to emerging infections
• Closely monitor and evaluate the effectiveness of the communications network using a defined set of evaluation criteria.
• Extend the range of disease topics in our communications over time, and the sophistication of that communication
• Extend the network from a pilot group of institutions more generally to other APEC member economies.

In sum, we are capitalizing on a newly available technology to bring traditional partners in public health (universities and ministries of Public Health) together in a non-traditional forum (APEC) to address an issue of strong regional concern.

The use of telecommunications in health is a rapidly developing field of study. In reviewing the literature we find that applications in education, and disaster relief point up the utility of this technology. Specifically, the capacity for flexible, interactive communication has been used to train physicians. The University of Washington houses one of the few national projects on telemedicine to allow medical consultation through such technology with remote sites. In disaster relief, the immediacy of communication by linking practitioners with appropriate equipment at each level of response has been a promising innovation.

There are several networks for Public Health in development currently: The "Satellife" project (funded by Rockefeller Foundation) uses low technology links to bring health information to Africa and other parts of the developing world without access to Internet linkage; the European Economic Union envisions a global public health network with eventual worldwide disease surveillance. Most of the sub-projects are now in the planning stages with a variety of partner governments, largely from the OECD countries. Finally, Rockefeller University has launched "PROMED" which boasts thousands of subscribers and hundreds of countries linked to a loosely moderated listserv on emerging infections. The key difference between these efforts and the current effort is the identification through APEC of a community of interest—countries which have, because of their economic and trading relationships, a self interest in learning about health problems in other economies.

Disease surveillance is increasingly being carried out electronically both domestically and internationally. This work has progressed to the point that using Internet based technology we can now;

• transfer large amounts of data from remote point to point using affordable high speed modem technology
• create dialoging capacity to link professionals and discuss aspects of information and other concerns
• access extensive literature on diagnosis, epidemiology and control innovations.

This latter capacity has been a central concern of the IAMS project here at the Library of the Health Sciences. These new technological capacities will be the basis for the proposed project. Washington state is one of the leaders in electronic connectivity in Public Health. The University of Washington and the Department of Health of Washington State have been working with CDC on the INPHO project to link local health departments to facilitate electronic disease reporting, and this initial project will be followed by a more extensive effort being funded by the Woodruff Foundation. This experience, although primarily domestic, has enhanced our capacity to meaningfully apply telecommunications solutions to health problems.

Tuberculosis has been chosen as an initial "pilot" disease to use in defining this new capability of looking at surveillance and control information within the APEC community. Tuberculosis is certainly a regional priority, but is certainly not the sole disease of concern. New strains of N. Meningitis, fluoroquinolone resistant gonorrhea, influenza, Dengue, cholera and most recently ebola in primates have all been new disease threats which are of concern to Public Health. Any of these would be eventual candidates for this communications technology to promote diagnosis, surveillance, prevention and treatment. Our vision is to include additional entities after assuring the initial feasibility and utility of this strategy.

Southeast Asia joins sub-Saharan Africa in having the highest global prevalence of tuberculosis in human. WHO counted 1,874,950 cases annually on average between 1989 and 1991 in Southeast Asia (see table 1). This represents a rate of 146.2 per 100,000 people. With the relatively recent incursion of HIV into the region WHO has estimated that the number of individuals co-infected in Asia will multiply seven fold in the decade (table 2). It should be noted that these data are diverse: the case count is for the SEARO region of WHO whereas the projection is for the SEARO and WPRO regions of WHO combined. Each of the initial partner countries has active Tuberculosis control programs. Thailand has decentralized its control efforts to include an integrated provincial level approach. Downward trends have been reported from Thailand (see annex for data tables) despite the major HIV epidemic underway in that country. Thailand continues to rely on short course therapy. One indicator reported and tracked by Thailand which may of use for the proposed electronic network information is the infection rate for children ages 0-14. Drug resistance appears to be essentially stable in the country since 1966. Fewer recent published data are available for Philippines and Indonesia. One report suggests there are 500,000 smear positive cases of tuberculosis in Indonesia and 400,000 smear positive cases in Philippines which serve as a regional reservoir of infection. Current data on drug resistance is not available but on note, on the Tuberculosis National Prevalence Survey in 1983 suggested that of 65% of symptomatic persons under treatment, 39% were self medicating.

Table 1. Tuberculosis Case Notifications and Average Notification Rates by World Health Organization (WHO) Region*

	1984 Through 1986, Average Total			1989 Through 1991, Average Total			% change from 1984-86 to 1989-91
WHO Region	Cases	%	Rate **	Cases	%	Rate **	Cases	Rate **
African	264,037	9	66.8	365,465	10	79.6	38.4	19.0
American	227,277	8	34.2	207,790	5	32.7	-8.6	-4.5
E. Mediterranean	212,872	7	64.9	281,182	8	74.7	32.1	15.1
European	307,617	10	37.4	242,643	6	29.6	-21.1	-20.8
Southeast Asia	1,338,896	45	115.5	1,874,950	49	146.2	39.9	26.6
Western Pacific	600,185	20	42.6	826,507	22	54.5	37.7	27.9
Global	2,950,884	100	61.8	3,798,537	100	74.6	28.8	20.8

* Data from Tuberculosis Programme, World Health Organization
% Percentages may not total 100 due to rounding
** Rate per 100,000 population

table 2. The HIV-TB outlook in Asia* compared with the rest of the world

	1990		1995		2000
Morbidity-mortality	Asia	World	Asia	World	Asia	World
Annual illnesses:
TB cases (million)	4,945	7,537	5,544	8,768	6,207	10,222
TB cases among HIV positive people (thousands)	85	317	282	738	639	1,410
Percent of all TB cases attributable to HIV	1.7	4.2	5.1	8.4	10.3	13.8
Annual deaths:
TB deaths (millions)	1,731	2,530	1,940	2,977	2,172	3,509
TB deaths among HIV positive people (thousands)	30	116	99	266	224	500
Percent of all TB deaths attributable to HIV	1.7	4.6	5.1	8.9	10.3	14.2

* Includes Southeast Asia and Western Pacific

II. MANAGEMENT PLAN AND PERSONNEL

A. Strategic Outcome and Process Objectives

1 ) To enhance existing communication links between an initial group of APEC member economies to include information exchange pertinent to infectious disease control.

• to upgrade access in other member economies to existing on line resource materials available through the University of Washington and its work with the Library of Medicine and other national libraries.
• to share didactic materials developed at the University about the general issue of emerging infections and to identify and share other pertinent materials on diagnosis, epidemic investigation and prevention and control which can benefit the collaboration of APEC economies in this area.
• c) initiate and test a responsive surveillance network which provides an accurate description of the re-emergence of tuberculosis infection as a model of EIDS in the APEC economies.

2) Assist participating economies in the completion of the CDC developed "self assessment instrument" for APEC member economies. This instrument will inventory existing capacity in the region with regards to the prevention and control of emerging infectious diseases.

3 ) To increase and strengthen collaboration between academicians, policy-makers and commercial interests concerned with EIDS and their impact on interactions between APEC member states. This will be accomplished by

• working onset in country to identify and promote contact and collaboration between government (MOH) and university partners in participating economies,
• eventually (and through a collaborative process) identifying and including on line materials tailored to policy makers including cost and economic impact information on Emerging Infections from existing studies.

4 ) To establish and promote the multivalency of the evolving APEC Education Telecommunications Network. The addition of health and medical information would enhance the depth of the network and create an environment conducive to even more diverse information sharing

B. Time Frame—Year One of Three

Quarter 1	Finalize contacts with network participants, convene first planning meeting. Begin to onload information. Finish web site construction. Form technical advisory group (TAG)	University of Washington Centers for Disease Control, ASPH. Planned for Seattle first week of August, 1996*
Quarter 2	Visits to sites to facilitate participation, outline equipment needs, and provide technical collaboration	University of Washington (Possibly direct CDC participation in site visits)
Quarter 3	Evaluate early transmission of data, collaboratively develop Internet based learning materials. Draft report for APEC Secretariat defining next steps, support needed	University of Washington Centers for Disease Control
Quarter 4	Refine platforms for data transmission, follow up technical assistance to target countries, Begin to bring on new sites, new infections per advice of TAG.	CDC, University of Washington and TAG members.

*pending final commitment from APEC Center for travel funding.

C. Methodology

1. Use Existing Telecommunications Linkages

We will make use of existing Internet linkage among member economics to assist in the rapid and timely identification of information regarding EIDS and related health concerns. The Internet presently lacks a structure to allow users to browse and extract pertinent health information in a systematic manner. The pooling together and organizing of these resources will greatly enhance the effort to disseminate and produce information. The University of Washington has a unique contribution to make in this area because of extensive prior activity domestically working with the National Library of Medicine and other national library resources through the IAMS Project (see appendix). In this effort we will look at the application of newly developed technologies such as WONDER and assess the utility of such platforms in our work.

2.Share Resource information

Through our work on the IAMS project we have learned a great deal about organizing and accessing information in a useful fashion for researchers, and policy makers. Early in the project we will make available on line resources in areas pertinent to Emerging Infections in the Asia Pacific region such as Medlars search capacity and abstracts of new publications, etc.

3. Develop a Pilot Activity

A pilot effort to exchange published surveillance information will be developed based on tuberculosis (TB), a re-emerging disease that represents a serious public health problem in all APEC member states. The exchange of pertinent data from five participating nations* will be a "first step". Initial activity to develop this exchange is already underway and the following have been accomplished: identification of appropriate collaborators in five target APEC countries, solicitation of comment from international collaborators on draft concept paper, establishment of collaboration with Washington Department of Health and Seattle King County Department of Health for the provision of recent TB data. Initial entry of data onto Web site is proceeding.( see appendix for current Washington state TB data)

The focus of this pilot activity will be on aspects critical to TB control:

• TB's re-emergence and wide spread prevalence—The characterization of the epidemiology of this new resurgence is of key importance to an eventual coordinated public health response. Accent will be on population based rates of disease, description of age-specific case rates, rate of infection in young children and mortality rates. In essence to describe the new epidemic in person place and time in each of the five economies initially participating.
• The development of multi-drug resistance—a surveillance network can incorporate efforts to monitor resistance and aid in "early warning" about increasing resistance. WHO already has a network for the detection of antimicrobial resistance, and we would also exchange information with this ongoing effort to avoid duplication of effort. Reporting could take a form similar to that carried out in the GISP project which tracks resistance of gonorrhea to penicillina, fluoroquinolones and other antibiotics.(see annex for sample table for UW collaboration in GISP)
• TB's relationship to HIV infection—TB is synergistic with HIV. With the ongoing HIV worldwide pandemic, TB will become a more significant contributor to morbidity and mortality in the Asia Pacific region. Most countries will not have coordinated TB/AIDS reporting—in fact this is problematic in many states in the United States. However, recent published information on seroprevalence of HIV will be included for the participating countries to begin to look at this issue.

After this initial model of our network is established, the participating economics then will collectively define, through a TAG process continuing efforts to broaden the geographic scope as well as the breadth of infections under study.

4. Initiate collaboration on didactic, training activity in the area of emerging infections

Instructional modules will be developed to allow participants to stay current with the evolving nature of disease control. These modules will be developed both at the technical level tailored to scientists and academicians as well as at the lay level to provide background for business interests and policy-makers. Much curricular development has already occurred at the University in a broad variety of course offerings. These syllabi are already being entered in the Web site. However, our vision is to collaboratively develop modules more tailored to the needs of the international partners in this project. This tailoring will depend on the operationalization of the free communication flow envisioned in the first two activities of the project. It would be our intent to involve ASPH and its network of Schools of Public Health in this activity. For example, we are aware that Yale has developed an on line seminar on emerging infections which may offer some additional materials for modular development.

5. Assure the completion of the CDC Self-Assessment Instrument by the five participating economies.

CDC has taken a lead in assessing existing capacity of the APEC community to address the challenge of emerging infections. In the meeting of the Science and Technology working group in Indonesia, a self assessment instrument was introduced which has been developed by the International Health Program office of CDC. The instrument is being put on the web site of the APEC network at this time. It is a comprehensive questionnaire which will serve as a valuable learning exercise for economies which complete it. It is particularly pertinent as a teaching tool, an assessment tool and an evaluation tool to this network effort (see evaluation below). Our intention will be to collaborate with CDC in offering technical assistance to economies to assure their completion of the instrument.

Responsibilities of ASPH, CDC, in the Project

The primary scientific role in the APEC deliberations described above has been taken by the Centers for Disease Control. CDC will have the primary responsibility for technical consultation for the self assessment instrument, will serve as a source of advice on WONDER applications, and will serve as a technical resource for data interpretation. We see CDC as a true partner in this venture with a jointly elaborated formal work plan and frequent communications between the University of Washington and CDC during the course of the activity.

As activities progress, the Association of Schools of Public Health will serve as a network for tapping additional pertinent expertise both in Asian area studies and in Infectious Diseases. The initial project will provide a framework which can be broadened to include additional collaborators on this side of the Pacific and ASPH can facilitate the identification of these partners in later phases of the project.

6. Evaluate the success of the network

Evaluation of this activity will be carried out collaboratively with the APEC center here and with the Centers for Disease Control. The self assessment instrument described above contains a number of sections regarding communications and information access which could be adapted to use in our effort. Specifically, we would work with CDC to design a complimentary effort to assess capacity systematically in the five economies which will be the pilot participants both at the outset of our networking activity and in the last quarter of the project. This before and after look will give and indication of the extent to which we have succeeded in our objectives.

We anticipate the initial transmissions from the countries to the US partners will occur by the second quarter of the project. Depending on the platforms and indices we have chosen, we will be able to evaluate the success of data transference at that time. While we are confident that all target countries have national TB programs, and transmit data on prevalence and incidence internationally, the capacity to retrieve, format and transmit up to date information is less clear. In essence, we will be "trouble shooting" in this process. Ideally WONDER technology would allow the generation of reports, charts and data from large deidentified datasets on site. The technology is flexible but we will need to determine the structure of data files and capacity to access them on site to be able to use WONDER to its full capacity. It may be that at this early phase we will be confined to published reports which are entered by hand with very little ability to create new informational formats.

In addition, we will design a survey instrument which will be used annually to assess user satisfaction and suggestions for the network. This will allow us to systematically capture innovations which occur to network users in the course of their work, and to improve the performance and utility of the network. The email function which we are building in will also solicit comments from all users of the web site.

"First Round" Participating Economies in APEC

Current candidate economies are: US, Canada, Philippines, Thailand and Indonesia. These are economies in which the University of Washington has previous research linkages through activities in HIV/AIDS, the Primate Research program and our own training programs. They are also economies heavily affected by Tuberculosis or with a predominance of tuberculosis among foreign born populations from Asia (U.S., Canada). We have initiated communication with the prospective partners and have received a strong endorsement of this concept by Philippines, Thailand and Canada. Indonesia is still considering a response. While we are encouraged by this initial enthusiasm, it is our intent to bring the prospective participants to Seattle in early August to more fully involve them in the onward planning, to assure project activities meet their needs. CDC will also be invited to attend this meeting.

7. Qualifications of Professional and support staff

Principal Investigator: Ann Marie Kimball, MD, MPH- Dr. Kimball is an epidemiologist, and infectious disease-trained physician who serves as the Director of Community Medicine for the School of Public Health and Community Medicine. Dr. Kimball has been working in the area of communicable disease surveillance both domestically and internationally for over fifteen years: first in vaccine preventable diseases in Africa, then in HIV/AIDS surveillance in Latin America and the Caribbean and more recently the surveillance of emerging infections. Currently she co-chairs the working group on Emerging Infections at the University of Washington, and teaches the main survey course in this area in public health. She has recently consulted with the new WHO division on "Emerging and Other Communicable Diseases Surveillance and Control" Dr. Kimball has worked with APEC member economies on the issues of public/private partnerships in the prevention of HIV/AIDS in the Pacific. She founded the Asia Pacific Alliance against AIDS in the Asia Pacific region in 1994 which was initially funded by US AID, CDC and with Royalty funds from the University of Washington, subsequent sustained support has come from the corporate sector. Through this experience she has developed working relationships in the region which will be brought to bear on the current activity. Her other research interests include the impact of resource allocation on local public health prevention and surveillance activities, and developing non-traditional partnerships in support of Public Health. Dr. Kimball was an EIS officer at CDC from 1977-1979 and currently is finishing her term as President of the EIS Alumni Association. She has worked in over twenty countries.

Dr. Kimball will be responsible for the overall execution of the project, and will supervise the collection, technical review and implementation of materials at the University of Washington hub. She will also have responsibility for liaison with the international partners, facilitating technical cooperation with them to assure their successful participation in this project. She will assure communications and consultation with CDC and other partners.

Co-Investigator: Dr. Patrick O'Carroll, MD, MPH (10% donated) - Dr. O'Carroll is a medical epidemiologist with the Public Health Practice Program Office at CDC. He is currently assigned by CDC to the State of Washington Department of Health and the University of Washington School of Public Health and Community Medicine, as part of the CDC INPHO (Information Network for Public Health Officials) initiative. At UW, he holds appointments as Clinical Associate Professor in the departments of Epidemiology and Health Services. Dr. O'Carroll was trained as an EIS Officer at CDC, working in injury control epidemiology for seven years. In the last three years, Dr. O'Carroll co-managed the CDC WONDER information systems project, including the development of the Distributed WONDER technology which may be employed in this project. He was also involved in the development of several innovative computer-based training exercises for incoming EIS Officers at CDC and MPH students at Emory University School of Public Health. As part of the INPHO team at CDC, Dr. O'Carroll worked extensively with colleagues in state and local public health departments prior to his current assignment. He continues that work here in Washington, and is collaborating on this project as part of his officials duties, with endorsement from PHPPO/CDC.

As co-investigator, Dr. O'Carroll will review data input, and be responsible for assuring format compatibility of platforms identified within the system. He will work closely with Dr. Kimball on international liaison bringing his skills in informatics to issues of technical cooperation among the partners.

Co-Investigator: Dr. John Kobayashi (5% donated) - Dr. Kobayashi has served as the Head of Communicable Disease Epidemiology for Washington State since 1982. He served as an EIS Officer with CDC from 1979-1980. Prior to that he received his MD from Stanford and his MPH degree from Harvard and trained and is board certified in Family Medicine. Dr. Kobayashi lectures frequently at the University and has worked with our students on numerous outbreak investigations. He is known as an excellent mentor for EIS officers and a talented, creative field epidemiologist. He has extensive insight and experience with infectious diseases pertinent to the Northwest which he brings to the project. In addition, Dr. Kobayashi has been actively testing disease reporting formats in Washington state for IHPHO and other projects. He will work with the project team on design of platforms, and in assuring access to pertinent data sets available through the DOH. In addition, as our activities move into the area of working to use our network to reinforce teaching of disease control and prevention in the region, we will call upon Dr. Kobayashi as a teacher with great practical experience.

Project Librarian, "Web Master" (10% donated) : Laura Larsson - Ms. Larsson has been providing information to public health practitioners (at the state and local levels and to researchers in the School) and to health services researchers since late 1980. In the past two years she has developed several Web pages for the School of Public Health and Community Medicine (SPHCM), for Washington State Public Health Nutritionists, for the Department of Health Services, and has developed several ProjectWebs (US AID/IREX/AUPHA Partnership, and others). Laura is on the School's Distance Learning Committee and is involved with several projects top turn paper-based course materials into electronic coursepacks for dissemination on the World Wide Web. She teaches several introductory classes on the Internet and on Creating Web Sites for University of Washington Extension and was responsible for developing two syllabi for the Medical Library Association (Health Services Research, Health Care Administration).

Research Assistant - The Research assistant will be recruited from among graduate students at the School of Public Health and Community Medicine. We will recruit a student with particular interest (and possibly language capability) in the Asia Pacific Region. Under the direct supervision of the Principal investigator the research assistant will work to carry out systematic survey work during the life of the project to assess the feasibility and success of the project and to propose additional studies where appropriate. The responsibility of the Research Assistant will be to work with the project team to assure day to day communications with partners, assemble existent surveillance data from the partners on Tuberculosis and other relevant condition, do pertinent library research, assist with logistical planning, draft correspondence and quarterly reports.

Computer Scientist - The person for this slot will be hired in year two. This person will provide advanced application development to our World Wide Web infrastructure, including back-end database management; development of ad hoc, Web browser-based database query capabilities (including coordination with computer scientists and developers at CDC engaged in Distributed WONDER development); implementation of security and confidentiality measures at the technical level; and development of on-line Web-based distance learning programs. The person hired would have skills commensurate with this task, including experience in relevant programming languages (e.g., C, C++, PERL), World Wide Web protocols and interfaces (e.g., HTTP, CGI), and UNIX-based database management and application programming.

Secretary - Secretarial support will be provided by the Community Medicine secretary, in line with the commitment of the University to this project .

Technical Advisory Group - We propose a technical advisory group to assist in the direction of this project. From the University we would propose three members, to be complemented by membership from CDC and each participating economy. This group would meet annually to consider progress and plan new directions for the project. The University members would include:

Dr. Walter Stamm - Dr. Stamm is Chair, Department of Infectious Diseases at the University of Washington School of Medicine in Seattle. He brings a seasoned national and regional perspective on communicable diseases. Dr. Stamm His has carried out extensive research on the epidemiology of chlamydia and urinary tract infections in women He served as Chief, Hospital Infections Branch, Bacterial Disease Division of CDC and sits on many national advisory groups.

Dr. Charles Nolan - Dr. Nolan is Director of the Tuberculosis Control Program of Seattle, King County and has also participated in the National Advisory Council on Tuberculosis and has served as an advisor to CDC. He will assure that the TAG is fully cognizant of technical issues and advances in Tuberculosis surveillance from the local and regional perspective.

Dr. James Quitslund - Dr. Quitslund has worked as Associate Director of the APEC Study Center at University of Washington since its inception and has been an active proponent and collaborator in the design of this project. As a TAG member he brings his extensive knowledge of the political realities of APEC in the region into the discussion of the desirable directions to be taken by this project.

Mr. Ron Johnson - Mr. Johnson is the Vice President for Computing and Communications of the University of Washington and has been the driving force behind the University preeminence in this field. Despite his administrative responsibilities, Mr. Johnson continues to pioneer new technology both on the Internet and in even more advanced computer applications of communications. A chief supporter of the APEC Telecommunications Network, he will bring an invaluable insight into the issues in application of computer technology posed by this project.

III. BUDGET REQUIREMENT—JUSTIFICATION

Application for additional funds to support this work has been made to the University of Washington (Royalty Research Fund) and will be made to the APEC Educational Foundation. We have met with the TB control program of Seattle King County and the Communicable Disease Division of the Department of Health, Washington State who are enthusiastic about participation in this effort. Finally, we have discussed the project with our colleagues in Canada, at the Centers for Disease Control there and at the Thai Ministry of Health, Philippine Ministry of Health and Indonesian Ministry of Health and they are also enthusiastic about this work as indicated by the included letters of support. It is our anticipation that if this early work proves valuable to the participating economies, there will funding opportunities through APEC (or through the APEC Educational Foundation) and through the participating economies themselves. Telecommunications development is an APEC priority so this project would figure within that.

The budget included in this proposal is an estimate of costs which cannot be met with other sources at this time. Each dollar spent by CDC will be highly leveraged by other University of Washington and State of Washington activity in this area. In particular, the APEC Study Center staff are supported by central funds from the University and by funds from the Jackson Foundation and this project fits within their terms of reference for their activities. In addition, support to this project falls within the mission of the library resource budget, allowing Ms. Larsson to donate her time. Thus the budget submission should be assessed in this optic--donations represent firm commitments as reflected in appended letters of support.

Specific activities include the assembly of existing didactic information and its entry onto the established UW web site. This activity is underway, and the funds requested for data entry represent the keying costs of entering the additional data only--that of the TB pilot project. Costs of data assembly for the latter are included within the responsibilities of the research assistant. Equipment needs are not budgeted because any equipment identified as necessary by the international partners will be purchased through their own funds or efforts will be made to identify APEC related monies for these purchases. Such grant making is already underway in Thailand.

Travel is budgeted based on a single trip during each year to all sites. This trip will allow the identification of technical cooperation needs, but support to address these needs on site will be identified from other sources such as APEC, CDC or other national monies in country if travel is required. Resources included in the budget will assure that consultation will also be available on line to these partners. The primary focus of trips in year one will be to establish the human linkages between academia and government to assure access to the APEC network and collaboration in its use for the issue of Emerging Infections. Round trip airfare between Indonesia, Thailand, and the Philippines will cost approximately $2,000. The remained balance requested for travel will be used for transportation within the cities, lodging, and food. The yearly trip will be done over a two-week period.

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Sources:

IOM Report "Emerging Infections: Microbial Threat to Health in the United States" Lederberg, Shope, and Oaks, eds. National Academy Press. Washington DC 1992.

"Infectious Diseases—A Global Threat" Report of the National Science and Technology Council, Committee on International Science, Engineering and Technology Working group on Emerging and Reemerging Infectious Diseases, September 1995.

Oberle MW, Foy HM, Alexander R, Kobayashi J, Helgerson SD. Enhancing student practicum opportunities: the outbreak investigation option. J Public Health Management Practice. 1995, 1(2), 69-73.

Cohen, JJ, "Educating Physicians in Cypberspace" Academic Medicine Vol 70, August 1995. p.698.

Llewellyn C.N. "The Role of Telemedicine in Disaster Medicine" Journal of Medical Systems. 1995, February 19(1) p 29-34

Hannoun-C "Role of International Networks for the Surveillance of Influenza" Eur. J. Epidemiol. 1994 August 10 (4) p. 459-61

Raviglione, M-C, Snider, DE, Kochi, -A. "Global Epidemiology of Tuberculosis. Morbidity and Mortality of a worldwide epidemic" JAMA, 1995. Jan 18, 273(3) p220-6

Sriyabbaya,N, Payandandana V, Bamruntrakul-T, Konjanart-S "Status of Tuberculosis Control in Thailand" Southeast Asian Journal of Tropical Medicine and Public Health. 1993 September 24(3) 410-9.

Aditama, TY, "Prevalence of Tuberculosis in Indonesia, Singapore, Brunei Darussalam and the Philippines" Tubercle. 1991 December 72(4) p 255-60.