Many of these efforts have been guided by the evolution of the goals of global health policy since the end of the Cold War, from those seeking to advance political and economic advantage, to seeking security and stability (Barnes and Brown, 2011). Driven by deliberative-based theories of inclusiveness for driving collective decisions (Brown, 2010), and practical awareness of effective methods to achieve development goals, the principle of establishing true partnerships with aid recipients was actively promoted in the mid-1990s (Barnes and Brown, 2011). The following decade brought the concepts of pursuing target country ownership of health programs, along with a more or less defined path toward capacity building: to assess, plan, monitor, and evaluate (Goldberg and Bryant, 2012). Along the way, many challenges and requirements have been documented to make these principles work, including jointly defining goals and metrics, the transference of operations to local control mechanisms, and the need to integrate the efforts of all aspects of public health infrastructure with disease detection (Garrett, 2007).

MRIGlobal, as a (not-for-profit/independent research) contractor, has been providing support for the Defense Threat Reduction Agency's Cooperative Bioengagement Program for the last 10 years, and also helped support global health security missions in the Middle East, South Asia, and Africa over the last 20 years. Executing these science-based programs has put us into direct continuing contact with local collaborators in infectious disease science, and consistently reinforced the absolute requirement to establish collegial relationships with our foreign partners to successfully execute programmatic objectives. Along the way, we have learned many lessons—some hard won—in communication and understanding across the cultural divide, and gained important insights from the many individuals engaged in these programs. We share here some of what we and others have discovered as an aid in the ongoing development of effective mechanisms for the near term, and to ultimately reduce the infectious disease burden globally.

Our experience is certainly not unique. Many other accomplished professionals have applied serious analysis and relayed formulations to successfully improve the capacity for detecting, responding and preventing infectious disease (or other risks, such as nuclear threats) throughout the developing world. These particular guidelines were chosen because they are fundamental, and so generally apply to human relationships across the board, in business, policy, or technology; but they seem especially essential for successfully changing views and behaviors across vastly different cultures. The reward of success in these programs, as Harold Varmus states, "is a connection made to the culture of science, in which decisions are based on evidence*. . .*and interactions among people of varied backgrounds are grounded in common goals" to improve global health security (Varmus, 2014). Investing in these relationships, in short, can help improve the health and well-being of countless lives, and bolster our collective security from disease risks.

### **Guides to Constructive Partnering**

(1) **Mutual respect is foundational.** While corporate and academic environments in the U.S. may lend themselves to productive adversarial or competitive approaches as key to success, these are counterproductive in establishing working relationships in most foreign cultures. Approaching potential partners with an appreciation and open respect of their knowledge and skills builds mutual understanding and trust. As has been noted, global health professionals need to value individual and organizational representative capacity, as well as technical competence (Kevany, 2014), and function as capable health diplomats to be successful (Novotny and Adams, 2007). A partners' willingness to cooperate, listen, and follow through with meaningful action is ultimately rooted in shared trust. No matter how profound the individual differences may seem, a personal connection is valuable when seeking mutual areas of interest and investment, to allow all parties to reach a position of shared purpose.

One indicator of achieving trust is a continued partnership, which can offer reward. A scientist who engaged a national Laboratory in West Africa and helped solve their cold-chain supply issues by facilitating installation of a nitrogen generator, was later called back to respond to the Ebola crisis and provided an "incredible amount of data" that wasn't accessible previously (Rozo, 2014). Trusting partnerships can provide low-key cooperative relationships even while government-togovernment negotiations are in flux, and offer reality checks on what truly constitutes a security risk (Franz and Lehman, 2009).

(2) **Ownership is essential.** "Country Ownership" is a capacity building strategy that shifts the leadership and responsibility for enacting systematic improvements onto the partner country and includes local involvement (Goldberg and Bryant, 2012). The most effective way to affect change is for a partner to adopt your goals and objectives as their own. They will ideally realize that outcomes will enable advances for individual and societal benefits—whether social, personal, political, economic, or strategic. Partners should take possession of the cause and advance it as their own. This "personalization of objectives" is a critical step toward sustainable programs. Without ownership, the associated programs and objectives will be abandoned once the foreign sponsor ceases involvement. Partner investment and ownership is essential to embed programs into national science and governance, and true partnerships are requisite to conduct systematic assessments, analyze challenges, define goals, prioritize action, and implement activities (Goldberg and Bryant, 2012).

In June, 2012 a group of U.S. science and engineering students and an experienced group of researchers from Yemen came together in Jordan under the auspices of the Federation of American Scientists' International Science Partnership. As they worked through issues to address Yemen's energy and water dilemmas it became clear that the Yemeni scientists were not only interested I furthering humanitarian concerns, but also "exploring new ideas, learning from peers, and gaining experience to further their own careers" (Jansson and Ferguson, 2012). While this is not surprising, it does demonstrate that ownership can be achieved from a number of directions.

(3) **Remain perceptive.** While the term "cultural sensitivity" has become a cliché, it is vital to appreciate why people speak or act as they do. Listen actively and cultivate an awareness of nonverbal cues such as body language; and consult with sympathetic local nationals to get an idea of whether cultural customs may be playing a part in your interactions (Katz et al., 2014). By a common example, it is considered polite to exchange pleasantries and inter-personal banter prior to starting a meeting. Despite our Western urges to get on with the agenda and limit our introductions to 30-s elevator speeches, this approach is widely considered rude by others. Regarding hierarchical systems, an individual's professional background determines the credence given to all later statements in a meeting. Also, due respect must be paid to senior members of any delegation. Partners can be protégés of their respective patrons throughout their careers—they may have little individual power to make decisions without the full agreements of their boss. Overall, developing a knowledge of foreign cultures, values, and norms is key to success (Katz et al., 2014) and adaptation to local needs and customs is often essential (Kevany et al., 2012).

to resolution. For example, management or policy forces your partner to react, local law prevents action, or traditional corruption or patronage pathways are obstructive. Often, approaching the immediate partner face-to-face and asking what might be acceptable to their management, along with offering alternatives, is a successful path to conflict resolution. For example, we were once confronted with refusal to export microbial strains from a country we engaged with, preventing any progress on an entire joint research program. We worked out alternatives—raw sample transfer, DNA transfer, data transfer—and asked our local project collaborators what they thought their ministries would accept. Our sponsors took that information to the ministries, and we were able to negotiate a compromise. In summary: Stay flexible and develop alternate plans for reaching your goals.

As a corollary, be careful if you are considering citing someone's support for a concept directly to their management. In other words, do not argue to upper levels of management that they should buy into an idea because their underlings agree. This approach may fly I the face of hierarchal decision-making and backfire, as well as put allies at risk.

In a time when pathogen discovery and disease disclosure can have serious political, diplomatic, economic, or military implications, extreme caution needs to be exercised in approaching the right authorities with the correct information, and offer constructive, accurate, and actionable solutions. The emergence of influenza strain H5N1 in Indonesia, for example, caused the sequestration of critical viral samples ("viral sovereignty," among other downstream events, Elbe, 2010; Smith, 2014); such reactions can potentially have disastrous consequences.

At the end of the day, health diplomats whether clinical, scientific or policy-makers, need an understanding of the structures, programs, approaches, and pitfalls of their relationships (Novotny and Adams, 2007). As one illustration, the International Science and Technology Center (ISTC), an multi-country consortium that seeks to counter proliferation, has had their projects curtailed in Russia due to political mistrust. This situation may be compounded by the demise of influence of scientists and their influence on policy (Bergstrom, 2011).

(7) **Don't rely on individuals.** Political and management structures can rapidly change, and while you take time to build and cultivate good interpersonal relationships, trust is not necessarily a transferable commodity (Smith, 2014). Expect to educate new players as they come onboard; this may also translate to educating their entire staff. Patronage systems often involve wholesale change: When one chief is dismissed, all the other subordinates can fall, too. It has also been pointed out that whatever legitimacy is forged among scientists must be transferred to policy setters to have a larger effect, and that transmission requires connectivity; trust can be difficult to transfer (Smith, 2014). Harold Varmus has in fact proposed that while admirable efforts to build capacity in Uganda and Mali, these have been overtaken at times by larger political forces (Varmus, 2014).

#### **References**

such as improving prioritization of risk, these are critical to assess (Franz and Lehman, 2009).

(10) **Outliers can be central.** Institutions or individuals who are not primary programmatic or contractual targets may end up being fundamental to achieving sustainability. If you approach these players, there can be big payoffs. Never turn away a potential participant without carefully considering what they can bring to bear. If you approach them independently, they may well be honored—and there may be benefits to them and their institutions. Such is often the case, for example, with universities educating the pipeline of new leaders. Makerere University's Ugandan Cancer Institute survived through the Amin dictatorship largely due to the heroic efforts of Charles Olweny, who was mentored early in his career by colleagues at the U.S. National Cancer Institute and Sweden's Karolinska Institute (Varmus, 2014). Strive for a broad but effective reach within the limitations of schedule and budget, and with sponsor approval.

Engaging with foreign cultures to generate cultural scientific change and promote genuine improvements in human and animal health can be both frustrating and rewarding. Continuous recycling back to the same issues, dealing with a revolving door of officials, stonewalling, and sometimes plain abject rejection are all challenging. However, accept that change will be incremental and that good ideas often take years to have an impact, even in our own systems. Some estimate that it will take at least a full generation or more to substantially improve public health in some of the developing world (Garrett, 2007). Maintain patience; keep educating as new players enter the scene. Stay positive; soured relationships rarely turn around once mistrust is established. If you have the opportunity to work long-term on a program, there is satisfaction in the long view back, where friendships have been forged, colleagues gained, and the path toward change is being realized.

interventions to local needs in sub-Saharan Africa and Thailand: evaluating findings from Project Accept (HPTN 043). *BMC Public Health* 12:459. doi: 10.1186/1471-2458-12-459

Varmus, H. (2014). *Medical Research Centers in Mali and Uganda. Science and Diplomacy, AAAS*. Available at: http://www.sciencediplomacy. org/article/2014/medical-research-centers-in-mali-and-uganda

**Conflict of Interest Statement:** The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2015 Horn. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Biosurveillance in Central Asia: Successes and Challenges of Tick-Borne Disease Research in Kazakhstan and Kyrgyzstan

*John Hay1 \*, Kenneth B. Yeh2 \*, Debanjana Dasgupta2 , Zhanna Shapieva3 , Gulnara Omasheva3 , Pavel Deryabin4 , Talgat Nurmakhanov4 , Timur Ayazbayev5 , Alexei Andryushchenko5 , Asankadyr Zhunushov6 , Roger Hewson7 , Christina M. Farris8 and Allen L. Richards8*

#### *Edited by:*

*Nathan Wolfe, Metabiota, USA*

#### *Reviewed by:*

*Li Xu, Cornell University, USA Brad S. Schneider, Metabiota, USA*

#### *\*Correspondence:*

*John Hay<EMAIL_ADDRESS>Kenneth B. Yeh<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Infectious Diseases, a section of the journal Frontiers in Public Health*

*Received: 29 May 2015 Accepted: 11 January 2016 Published: 01 February 2016*

#### *Citation:*

*Hay J, Yeh KB, Dasgupta D, Shapieva Z, Omasheva G, Deryabin P, Nurmakhanov T, Ayazbayev T, Andryushchenko A, Zhunushov A, Hewson R, Farris CM and Richards AL (2016) Biosurveillance in Central Asia: Successes and Challenges of Tick-Borne Disease Research in Kazakhstan and Kyrgyzstan. Front. Public Health 4:4. doi: 10.3389/fpubh.2016.00004*

Frontiers in Public Health | www.frontiersin.org

*1State University of New York, Buffalo, NY, USA, 2MRIGlobal, Rockville, MD, USA, 3Scientific Practical Center for Epidemiological Expertise and Monitoring, Almaty, Kazakhstan, 4Kazakh Scientific Center for Quarantine and Zoonotic Diseases, Almaty, Kazakhstan, 5Uralsk Anti-Plague Station, Uralsk, Kazakhstan, 6Biotechnology Institute, Bishkek, Kyrgyzstan, 7Public Health England, Salisbury, UK, 8Naval Medical Research Center, Silver Spring, MD, USA*

Central Asia is a vast geographic region that includes five former Soviet Union republics: Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. The region has a unique infectious disease burden, and a history that includes Silk Road trade routes and networks that were part of the anti-plague and biowarfare programs in the former Soviet Union. Post-Soviet Union biosurveillance research in this unique area of the world has met with several challenges, including lack of funding and resources to independently conduct hypothesis driven, peer-review quality research. Strides have been made, however, to increase scientific engagement and capability. Kazakhstan and Kyrgyzstan are examples of countries where biosurveillance research has been successfully conducted, particularly with respect to especially dangerous pathogens. In this review, we describe in detail the successes, challenges, and opportunities of conducting biosurveillance in Central Asia as exemplified by our recent research activities on ticks and tick-borne diseases in Kazakhstan and Kyrgyzstan.

Keywords: tick-borne diseases, TBE virus, *Rickettsia*, *Coxiella*, Kazakhstan, Kyrgyzstan, biosurveillance

## BACKGROUND

Biosurveillance research and environmental monitoring have been conducted in Central Asia since the Russian anti-plague (AP) network in the 1890s set up by Czar Nicholas II (1). This network was originally organized geographically, to conduct surveillance of local diseases, such as plague, and to prevent introduction of diseases with no natural foci, such as cholera (2). During the Soviet era, the AP network evolved into a highly structured organization that included over 100 facilities: observational, field, regional stations, and institutes, across the 11 republics that were administered by the Union of Soviet Socialist Republics' Ministry of Health (3). After the Soviet Union collapsed, each country maintained its own AP system that varies by country (4). All have experienced challenges of limited funding and lack of training for their specialists, while competition for limited funds has decreased collaboration as well as development of programs fostering peer-reviewed quality research and related funding.

Two countries that exemplify the current status of biosurveillance in Central Asia are Kazakhstan and Kyrgyzstan. Kazakhstan (2.7 million square kilometer; 18 million people) has national wealth in the forms of oil, natural gas, and mineral resources1 but still relies heavily on imported expertise and technology to further develop their resources (5). Kyrgyzstan (0.2 million square kilometer; 5.7 million people) has no oil or natural gas but has mineral resources (see text footnote 1), and also relies on imported expertise and technology (6) (**Figure 1**). In addition to commercial ventures with foreign petroleum companies, aid to both countries has come from the United States Department of Defense (US DoD) cooperative threat reduction (CTR) program, through the 1991 Soviet Nuclear Threat Reduction

1https://www.cia.gov/library/publications/the-world-factbook/geos/kg.html

Initiative. The governments of both countries are cooperating on biological threat reduction efforts, with an emphasis on disease surveillance, biosafety, and biosecurity. As with other supporting nations, aid from the United States (US) first requires a formal government-to-government (umbrella) agreement, which establishes diplomatic intent and cooperation. Next, an implementing agreement is established with a specific US government agency. In Kazakhstan, an umbrella agreement was signed in December 1993 and the implementing agreement was signed in 1995. The cooperation includes a broad range of nuclear security and non-proliferation topics. Kyrgyzstan has also signed bilateral investment and trade agreements with the US. In Kyrgyzstan, multiple foreign agencies have been involved in projects utilizing the country's AP system and run through the Republic Center of Quarantine and Especially Dangerous Infections (RCQEDI) (4). For example, International Science and Technology Center (ISTC), Civilian Research and Development Foundation (CRDF) Global, United States Department of State (US DoS), and the

United Kingdom Ministry of Defense (UK MoD) have all set up collaborative biosurveillance projects with local scientists.

Historically, tick-borne diseases have been important public health issue in Central Asia, and biosurveillance has involved regular collection and archiving of tick samples. Collection locality information associated with these samples has already contributed to vector biogeography databases, such as VectorMap.2 Analyses of these frozen tick samples (e.g., molecular testing for evidence of infection by pathogens) offer numerous opportunities for additional research and collaboration, some examples of which are described below. In a recent paper, Han et al. (7) predicted the existence of a large reservoir of undiscovered zoonotic infections in this part of the world.

As examples of the accomplishments and challenges of biosurveillance research conducted in Central Asia we present below, as case studies, our work on ticks and tick-borne diseases conducted in Kazakhstan and Kyrgyzstan over the past decade. This work includes studies of tick-borne encephalitis (TBE) in both counties and of rickettsial diseases, Q fever, Crimean Congo hemorrhagic fever (CCHF), and hemorrhagic fever with renal syndrome (*Hantaviruses*) in Kazakhstan. For reasons of space limitation, we will not discuss the CCHF (8) or *Hantavirus* work in Kazakhstan (9) here.

## TICK-BORNE ENCEPHALITIS

Tick-borne encephalitis is caused by a flavivirus (TBEV); there are three types: European, Siberian, and Far-Eastern. Of these, the Far-Eastern strain causes the most serious disease. Infection is spread to humans through tick bites and through ingestion of raw milk and milk products (10). Wild and domestic animals may be hosts for the virus (10). TBE is endemic in a wide range of European and Asian countries, and effective vaccines are available in many countries (11). Anecdotal information and papers in the local literature suggested that the virus and the disease may be more widespread than was understood, in particular, that the virus may range in more southerly locations in Asia (11, 12).

Based on this, we initiated a series of studies in Kyrgyzstan. We found TBEV in the taiga tick (*Ixodes persulcatus*) and in rodents including the Himalayan field mouse (*Apodemus pallipes*), a previously unknown TBEV host (13). Sequencing studies showed this Kyrgyz virus to be a close relative of a Siberian strain from Novosibirsk (13). We also identified the virus in a sample from a fatal case of TBEV involving a hiker who had visited an area where we found the virus in ticks (13). Thus, TBEV and TBE appear to occur much further south (42.6°N) and at much higher altitudes (~2,100 m) than previously believed (13).

Following this, we extended our TBE/TBEV research into Kazakhstan to identify and characterize TBEV there. This work, part of collaboration with Kazakhstani colleagues from three government agencies, has yielded several interesting findings over the past decade. Using modern molecular methods and an epidemiologically based approach, we tested human and animal samples from selected areas where TBE is known or suspected to occur and found strong evidence that TBEV does circulate in Kazakhstan Scientific colleagues from the Kazakh Scientific Center of Quarantine and Zoonotic Diseases (KSCQZD), Scientific Practical Center for Sanitary Epidemiological Expertise and Monitoring (SPCSEEM), and Uralsk Anti-Plague Station (UAPS) collaborated to provide samples and associated collection data, and assist with diagnostics. UAPS staff focused its work on tick samples from West Kazakhstan and Aktobe oblasts; KSCQZD staff collected ticks from Almaty, Kostanay, Kyzylorda, Mangystau, South Kazakhstan, and Zhambyl oblasts; and SPCSEEM staff obtained ticks from Atyrau, East Kazakhstan, Karaganda, North Kazakhstan, and Pavlodar oblasts. Collectively, tick samples included over 40,000 specimens collected from 13 of Kazakhstan's 14 oblasts (i.e., provinces). Samples from captured rodents and stored human sera were shared by staff of UAPS and SPCSEEM, respectively. Our US-based staff provided technical guidance to Kazakh to facilitate confirmation of morphological tick identification by molecular methods [e.g., polymerase chain reaction (PCR) and pooling and testing of ticks for infection by TBEV, CCHFV, and *Rickettsia* spp. by enzyme-linked immunosorbent assay (ELISA) and quantitative real-time PCR (qPCR)].

As we hypothesized, TBEV is more widespread in Kazakhstan than was previously believed. Areas in the southern and eastern regions harbor infected ticks (14). Unfortunately, we were unable to get material from the western region, where we have strong suspicions that the virus also circulates. In the southern and eastern regions, data from 2005 to 2014 show, on average, 35 cases or 0.22 cases per 100,000 per year (15). This burden of disease apparently occurs in spite of the fact that up to 50,000 doses of vaccine are administered in endemic areas each year. Additionally, we found evidence of TBEV infection in ticks in the genera of *Dermacentor*, *Hyalomma*, and *Haemaphysalis* (14, 16, 17)*.* The collective range of these ticks is much broader than that of *I. persulcatus*, suggesting that residents of a much broader area of Kazakhstan may be at risk for exposure to the virus (14). We are currently investigating the role of raw milk and cheese in the spread of TBE.

In summary, we have substantial new data on a serious tick-borne disease in Central Asia, of importance both to local and global public health authorities, as well as the US DoD. Acknowledging these successes, and the essential collaboration of the Kazakhstani and Kyrgyz authorities and our scientific colleagues, there are nevertheless issues that impede further development of our novel findings; these issues are discussed in the Section "Conclusion: Accomplishments and Challenges" below.

#### RICKETTSIAL DISEASES

Historically, tick-borne rickettsial diseases in Kazakhstan were attributed solely to Siberian tick typhus. Siberian tick typhus is caused by *Rickettsia sibirica* subsp. *sibirica* that is transmitted by ixodid ticks (i.e., *Dermacentor* and *Haemaphysalis* spp.) (18). Between 2007 and 2012, 1,247 registered cases of Siberian tick typhus were recorded in Kazakhstan, with the highest prevalence (65%) occurring Kyzylorda and North Kazakhstan Oblasts (17). Whether these cases were truly due to Siberian tick typhus and/or other rickettsioses was not clear, because serological assays are cross-reactive for antibodies

<sup>2</sup>http://www.vectormap.org/dataportal.htm

against the spotted fever group rickettsiae (SFGR) (19). Indeed, recent tick surveys have identified four additional SFGR species that may be responsible for rickettsial diseases in Kazakhstan (18, 20–22). These four agents, *Rickettsia conorii* subsp. *caspia*, *Rickettsia slovaca*, *Rickettsia raoultii*, and a *Rickettsia aeschlimannii*-like organism, were identified in collaborative studies between Russian and Kazakhstani scientists (18, 20–22).

Additional studies performed in Kazakhstan confirmed the presence of tick-borne rickettsiae among ticks collected through tick drags and small mammal trapping. During the spring of 2004, a study conducted by the UAPS in the southern tip of West Kazakhstan Oblast collected 33 *Rhipicephalus pumilio* ticks. Two ticks (6%) were positive for rickettsial DNA and data from subsequent sequencing analyses identified the agents as *R. conorii* subsp. *caspia*, the causative agent of Astrakhan spotted fever (17). Assessment of 330 ticks collected by tick drag in Karaganda Oblast in Central Kazakhstan by SPCSEEM determined that they were all *D. marginatus*. Of the 33 pools of these ticks tested for infection by rickettsial pathogens (10 ticks per pool), 2 from the Abai Rayon were positive (17).

Most recently (2012–2014), one large tick surveillance study supported by US Defense Threat Reduction Agency (DTRA) was conducted in Kazakhstan. One aspect of the investigation focused on detecting tick-borne rickettsiae and involved ticks collected in seven oblasts: Atyrau, East Kazakhstan, Zhambyl, Karaganda, Kyzylorda, Pavlodar, and West Kazakhstan involving SPCSEEM staff in Almaty (17) and UAPS staff in Uralsk (17, 23). The project explored both the identification of tick species and the detection of *Rickettsia* positive ticks by qPCR and multilocus sequencing typing (MLST); data analysis is ongoing.

## Q FEVER

Q fever is caused by the Gram-negative bacterium, *Coxiella burnetii*, and is found all over the world (24). More than 40 species of ticks are known to be naturally infected with *C. burnetii*, and though tick-to-human transmission does occur it is only thought to be responsible for a small subset of infections (25). The most common route of human infection is through the inhalation of aerosolized particles, generally the result of the aerosolization of dried parturition materials from infected animals (26). Infected animals also shed *C. burnetii* in urine, feces, and milk, the last of which may cause infection when consumed without pasteurization (25). Q fever has been reported in Kazakhstan since the early 1950s (27). Currently, UAPS is conducting a study supported by DTRA assessing the presence of *C. burnetii* in unpasteurized milk in the West Kazakhstan Oblast utilizing a qPCR assay targeting IS1111 DNA (28).

## CONCLUSION: ACCOMPLISHMENTS AND CHALLENGES

#### Accomplishments

During the last decade in Kazakhstan and Kyrgyzstan, we have carried out extensive training and research work in collaboration with our local colleagues. These efforts have led to enhanced biosafety and biosecurity practices, successful implementation of field and laboratory techniques, and awareness and compliance with regulatory standards. Modern rodent capture methods were also introduced, which included training on the use of live capture traps and safe rodent handling. As a result, we have been able to develop technical presentations in a number of research areas, many of which are cited in the reference list.

Our collaborative studies have also generated extensive collections of field samples and associated analytical datasets. For example, we now have over 40,000 ectoparasites from tick drags and vertebrate hosts, many of which have been identified both by morphological and molecular means. Data, including tick species, location (GPS coordinates), and date of collection were recorded and shared via public databases.

In the laboratory, enhanced sample processing and use of molecular diagnostics were emphasized. Safe and proper procedures for bead-beating tick samples were employed, and nucleic acid extraction (DNA and RNA) was performed on those samples before qPCR determination of bacterial and viral identity. We also demonstrated and implemented methods that comply with Federal Wide Registration (FWA) standards for testing of stored human sera.

Finally, between 2011 and 2014, our work in central Asia produced 20 scientific papers presented at 11 professional conferences. These presentations were developed in collaboration with our in-country colleagues. In addition, one peer-reviewed manuscript based on this work has been published to date (8).

Overall, these considerable accomplishments have resulted in a better trained and aware scientific workforce in Kazakhstan and Kyrgyzstan. Our central Asian colleagues have been exposed to modern scientific methodology and perspectives and have been able to present their work in several major international forums. This has led to significant findings in public health in this part of Central Asia, which will increase awareness of important infections locally and globally. Finally, this work will provide a solid basis for future planning for infectious disease surveillance and research in Central Asia.

### Challenges

In the course of all the successful work described above, we encountered a number of challenges that are being addressed to facilitate continued progress in Kazakhstan and Kyrgyzstan. From the literature, one can see that only a few surveyed locations in this region are reported in peer-reviewed international journals. Even from the last large study that surveyed many oblasts, the number of rayons (i.e., county or district) studied within each oblast was limited, and thus the overall investigation is constrained. An obvious solution would be to continue and expand biosurveillance studies, varying the sites over time, but is time consuming and expensive.

Another issue is the limited submission of research results to peer-review, high impact international journals, especially English language journals, by local scientists. Scientists around the world are developing the scientific credentials through successful submission of their results to peer-review journals. This submission process needs to be encouraged for scientists in Central Asia, especially in regards to writing detailed results and statistics required for publication in peer-reviewed, international journals. In addition, the development of this writing skill and the publication of notable results will enhance the success at developing and submitting proposals for local and international grant funding.

A further crucial area for improvement is the development of technical skills for assessing and developing assays and methods, as well as data analysis. Lack of standard operating procedures in Russian, Kazakh, and Kyrgyz languages, and trained technical personnel are other problems. Current reliance on commercial test assays is costly and unsustainable. Possible solutions to these problems include developing reagent/equipment procurement streams via known in-country and/or regional commercial entities and developing in-house assays that can be compared with currently accepted commercial assays. Increasing molecular diagnostics capabilities at institutions, including government, university, and commercial entities, would also be useful, particularly if these could be shared with among institutions. Limited submission of samples for analysis and verification to outside institutions lessens future progress. This issue can only be solved by allowing scientists to bring or send test sample material to foreign institution; this will not be simple to resolve and will require substantial political will on the part of the local authorities.

Finally, there are many communication barriers to overcome. This would be helped by including each level of work group (including technicians, scientists, managers, and directors) in

## REFERENCES

discussions of research activity, as well as encouraging clear communication within organizations to improve research and planning. In our work, we found that direct communication, especially face-to-face meetings and conference calls, was most effective and decreased the need for written correspondence that required language translation.

Overall, the accomplishments in the biosurveillance studies conducted in Kazakhstan and Kyrgyzstan presented here demonstrates that significant work can be achieved despite existing challenges. With time and continued collaborative efforts, we believe that these challenges will overcome, leading to even more progress in the future. Current interest in global health security activities coupled with the historic zoonotic diseases in this part of the world provides ample opportunities for further studies.

### ACKNOWLEDGMENTS

We gratefully recognize the United Kingdom Ministry of Defence Biological Engagement Programme, US Defense Threat Reduction Agency, and the US Department of State for funding the research described in this review. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Navy, Department of Defense, or the United States Government. This is the work of US government employees (AR and CF) work unit number A1266 and may not be copyrighted (17 USC 105). We extend special thanks to Kavita Berger, Charles Buck, and Barry Atkinson for their invaluable insights and suggestions in developing this manuscript.

collected in Russia and Kazakhstan. *J Clin Microbiol* (2004) **42**:2221–3. doi:10.1128/JCM.42.5.2221-2223.2004

ruminants using real-time PCR. *Vet Rec* (2010) **167**:965–7. doi:10.1136/ vr.c4040

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The Reviewer Brad S. Schneider and handling Editor Nathan Wolfe declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.

*At least a portion of this work is authored by Allen L. Richards and Christina M. Farris on behalf of the U.S. Government and, as regards Dr. Richards, Dr. Farris and the US government, are not subject to copyright protection in the United States. Foreign and other copyrights may apply. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Biosafety initiatives in BMena region: identification of gaps and advances

*Erum Khan1 \*, Nayla Ahmed1 , Khalid R. Temsamani2 , Atef El-Gendy3 , Murray Cohen4 , Ariba Hasan1 , Hilliard Gastfriend4 and Jennifer Cole4*

*1Aga Khan University Karachi, Karachi, Pakistan, 2 Faculté des Sciences de Tétouan Mhannech II, University Abdelmalek Essaadi, Tétouan, Morocco, 3Bacteriology Section, Naval Medical Research Unit 3 (NAMRU-3), Cairo, Egypt, 4 Frontline Foundation, Atlanta, GA, USA*

#### *Edited by:*

*Jeanne Marie Fair, Defense Threat Reduction Agency, USA*

#### *Reviewed by:*

*Tim Trevan, Chrome Biorisk Management, USA Maureen O. Leary, Dartmouth College, USA*

> *\*Correspondence: Erum Khan<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Infectious Diseases, a section of the journal Frontiers in Public Health*

*Received: 06 August 2015 Accepted: 04 March 2016 Published: 24 March 2016*

#### *Citation:*

*Khan E, Ahmed N, Temsamani KR, El-Gendy A, Cohen M, Hasan A, Gastfriend H and Cole J (2016) Biosafety Initiatives in BMENA Region: Identification of Gaps and Advances. Front. Public Health 4:44. doi: 10.3389/fpubh.2016.00044*

Keywords: biosafety, biosecurity code of conduct, survey research, BMENA region, biorisk management

## INTRODUCTION

Recent advances in biotechnology have provided a quantum leap in the application of biological sciences in all fields, including health, agriculture, environment, and energy development. Biotechnology tools and protocols are globally available and are increasingly being used and seen as potential investments. However, with rapid advancement, widespread use, and investment, comes the possibility of exploitation of research and risk of misuse of the research outcomes for nefarious purposes. The most concerning issue remains the lack of expertise and awareness of risk management systems for the mitigation of such risks in the biological sciences, despite extensive and well-developed relevant engineering and scientific methods for containment, detection, diagnosis, treatment, and recovery as well as human behavior and performance science in other fields, such as aviation, nuclear power, petrochemicals, etc. This concern has been raised globally and has intensified since the events of 9/11 and the anthrax-in-the-mail terrorism of 2001. This has led to international focus on means for combating bioterrorism, especially in countries with the backdrop of disturbed geopolitical situations (1–5).

This study was undertaken to identify and assess the impact of capacity-building biosafety initiatives and programs that have taken place in broader Middle East and North Africa (BMENA) region between 2001 and 2013, and to highlight gaps that require further development. The project had two components: (a) a review of biosafety and biosecurity initiatives in the region and (b) assessment of the impact of these initiatives on scientists at local/regional levels. This study was part of a larger project titled "*Scientific Engagement Defining Gaps and Creating Opportunities for Cooperative Research and Global Security in the Broader Middle East and North Africa Region*" to assess the overall impact of global biosecurity capacity-building initiatives undertaken in recent years in the BMENA region and to then apply the knowledge gained from this assessment to suggest sustainable ways to build cooperative regional biosafety opportunities.

## MATERIALS AND METHODS

The project co-PIs, based in Pakistan and the U.S., worked closely with two Regional Coordinators in North Africa (Morocco and Egypt) to recruit a project coordinator in each of the 24 countries participating in the project. A cross-sectional descriptive study was designed consisting of two steps: (1) a desktop review/literature search for all biosafety- and biosecurity-related initiatives that were reported from the BMENA region between 2001 and 2013 using commercial search engines and (2) building a survey instrument in the commercially available SurveyMonkey (SM) platform and administering it independently to scientists in the study countries.

A database was created according to the type of initiatives each study country in the region had, the scope of the activity, institute(s) involved, and type of funding/donors, etc. Great care was taken to develop a sampling process that would protect the confidentiality of survey participants and their responses. A cross-sectional online survey was conducted throughout the region. The survey questions sought to collect broad observations about overall capacity needs or gaps in biorisk management systems in the BMENA study countries. It included questions about technically skilled human resources in various aspects of biosafety management systems, availability of sustainable training programs, and challenges such as lack of human resources, monetary funds, specific bio risk management skills, etc. Questions were also developed to assess capacity for biorisk management and oversight regulation, such as availability of national/institutional biosafety committees and scientist/professionals for regulatory compliance assistance. Institutional Review Board approval was obtained through the Aga Khan University in Karachi, Pakistan. Survey subjects were identified by the country coordinators.

## Subject Inclusion Criteria

The following member countries as per World Health Organization (WHO) definition of BMENA region were included in the study: Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Pakistan, Qatar, Saudi, Sudan, Syria, Tunisia, Turkey, United Arab Emirates (UAE), and Yemen. Members of biosafety associations of these countries were invited by the study country coordinators to participate in the survey. In countries without biosafety associations, members of other scientifically related associations were invited. Thirty members of these various associations from each country were identified by random selection to receive the survey questionnaire *via* email.

#### Analysis

Data from desktop review were entered and analyzed using Microsoft Excel (Windows XP 2008). Results were analyzed as categorical data. The biosafety initiatives reported from member countries were categorized as per the following headings: (a) general awareness sessions: activity conducted to raise general knowledge/education of biosafety and biosecurity among the scientific community; (b) human resource development: activity that translated into hands-on training of the scientists in a particular aspect of biosafety and biosecurity with an aim to transfer technology and to provide expertise at local or regional levels; (c) institutional capacity building: activity that resulted in development of network/association/foundation that would foster the biosafety and biosecurity development at the local/regional levels; (d) scientific collaborations between the member countries or with international communities which included initiatives such as regional conferences/meetings; and (e) sustainable collaborative projects at regional levels such as infectious disease surveillance, formal laboratory biosafety and biosecurity training, responsible science/bioethics and scientific cooperation, student exchange, etc. Additional information where available was recorded regarding the duration of activity, funding support, and feedback from participants of the activity.

The survey was kept open for a duration of 10 working days, and responses were directly downloaded from SM and analyzed/ graphed in Microsoft Excel. The survey results were analyzed as ordinal data, responses to various survey questions were recorded as ordered categories (excellent to poor). Frequencies of the responses were generated as percentages of excellent, good, average, and poor categories of resource availability.

## RESULTS

#### Desktop Review

A total of 1832 biosafety/biosecurity initiatives were recorded from 97 web links that were reviewed, after removing the duplicate, 60 web links (1–60) were used for analysis. It was encouraging to note that every country listed in the BMENA region had some initiatives related to biosafety/biosecurity between 2001 and 2013 (**Figure 1**). The focus of these initiatives was found to be general awareness in the field of biotechnology and biomedical laboratories with particular interest in risk assessment and

mitigation 13% (*n* = 239), followed by awareness of genetically modified organisms (GMOs) 9.17% (*n* = 168). Very little data were available for initiatives for other areas of significant biosafety concern, such as animal health sciences, chemical industry, or radiological industry.

When categorized into types, most of the initiatives were found to be in the category of general awareness and information exchange workshops at country level 70.68% (*n* = 1295). The topics most commonly addressed in these awareness sessions included basic biosafety, biosecurity, biocontainment, and biorisk management in biomedical and biotechnology laboratories (6–39). Other aspects included bioterrorism and means to combat it, as well as bioethics and dual use resebiosafety, biosecurity, biocontainment, and biorisk management in biomedical and biotechnology laboratories (6–39). Other aspects included bioterrorism and means to combat it, as well as bioethics and dual use research of concern and other ethical dilemmas (21, 34, 38, 40–44). Scientific conferences and meetings on GMOs and other biotechnology-related topics (31, 45–49) were the next most frequently conducted initiatives at 18.5% (*n* = 339) (see **Figure 2**).

Capacity building was defined for this project as any initiative focused on technology transfer, hands-on training, and assistance in development of national framework, i.e., development of national/institutional biosafety committees or sustainable scientific projects with common regional issues and long-term measureable outcome, such as infectious disease surveillance/ laboratory diagnosis, etc., in the region (**Figure 3**). Of the initiatives reviewed, 2.67% (*n* = 49) were in the category of hands-on training. Very few initiatives were identified using key words "student exchange program, regional training centers, and disease surveillance" against collective term BMENA, representing the region (50, 51).

An increased international donor interest was noted in the BMENA region for biosafety and biosecurity initiatives post 2000; 80% of the initiatives reviewed were funded by international donor/scientific agencies such as the United Nations WHO and the Environment Programme (UNEP), the International Council for Life Scientists (ICLS), and CRDF Global. United States sponsored/funded biosafety activities organized in 2001–2013 in the BMENA region included the Department of State Cooperative Biosafety Engagement Program (CBEP) and the American Association for the Advancement of Science-Center for Science, Technology, and Security Policy (AAAS-CSTSP).

Jordan appeared to be the hub in the region for biosafety, biosecurity, and biorisk management activities with (*n* = 179), followed by Pakistan (*n* = 162), Morocco (*n* = 109), Iraq (*n* = 68), Iran (*n* = 66), and Egypt (*n* = 60). This involved organization and hosting of national and international conferences, seminars, and training workshops on general awareness aspects of biosafety and biosecurity (**Table 1**).

#### Online Survey

The survey was administered to the life scientists identified for each participating country using the commercially available MailChimp software program within the SM platform, an internationally recognized leader in online surveying technology. SM offers state-of-the-art features in both survey design and delivery capabilities. In order to help manage panels of potential survey respondents, SM has developed a dedicated email service called MailChimp, which allows for targeted delivery of survey requests for participation.

of workshops and seminars.

The survey was initially released as a pilot, using Pakistan as the test group. The pilot survey was released on June 5, 2013: 50 requests to participate were sent out, with 25 participants opening the request, and 23 agreeing to participate. As per the IRB protocol, respondents were required to agree to take the survey once they understood any potential harm by participating before they could proceed to the questions within. Thus, they could open the survey, agree to the human ethics considerations, and then view the remaining questions. At this point, most respondents stopped participating. A disclaimer was introduced at this point stating that all data will be confidential and anonymous.

The final survey was released on June 30, 2013. Approximately 215 survey invitations were sent out among 11 countries (some country associations had less than 30 members). Twenty-eight recipients reviewed the survey, and 23 agreed to participate.

#### TABLE 1 | Country list of institutes/organizations that conducted or collaborated toward biosafety and biosecurity initiatives in the BMENA region 2001–2013.

This 11% participation rate was less than desired, although we expected a high response rate to be difficult from the countries in this study. Generally online survey responses would be expected to be in the 15–20% range, but cultural differences, possible fear of responding (despite statements declaring that all data were confidential and anonymous), and lack of experience with this type of information gathering might account for the lower rate. As a result, hard copies were posted to the country coordinators to send to their colleagues, but the response rate to the requested hard copies survey was also very poor. Iraq, Afghanistan, Sudan, Yemen, Algeria, and Syria had requested hard copies so that potential respondents would have access to all survey questions to determine if the survey was too dangerous or risky for participation. In the main release, 18% of respondents viewed the survey but did not answer the questions.

Although the response rate was lower than desired, the respondents were people with relevant background. Fifty-two percent of the respondents had worked as laboratory directors/ managers in their fields and 70% of these were directly involved in biorisk management activities of their institutes. The survey results are reflective of the desktop review. Seventy-one percent of the respondents marked yes to the question about initiatives on general awareness on biosafety and biosecurity in their country. Of the respondents, 52% felt that biosafety initiatives in their countries were organized by NGOs, including professional/ scientific societies, while 23.8% believed they were organized by the government ministries in their country. Fifty-two percent responded in the negative to the questions asking if the international initiatives were demand driven and sustainable.

**Table 2** shows the results of direct questions related to the availability and reliability of different technical skills for biorisk management in the respective countries, on the scales of excellent to poor. The scale was defined as *excellent* where the technical expertise was easily available and considered highly reliable by the local scientists; *good* where technical expertise was available but was not very actively sought by local scientists (i.e., marginally reliable); *average* was defined as very limited or scarce local

#### TABLE 2 | Survey results of respondents from 11 member countries of BMENA region 2013–2014.

expertise and that was not very credible (i.e., marginally reliable); and unavailability of any local expertise was rated as *poor*.

Survey results were in accordance with the desktop review findings of biosafety initiatives during the 2001–2013 time period. We found initiatives to be largely focused on general awareness or on introductory courses on biosafety with limited human resource training and technology transfer opportunities. Consequently, there was a dearth of skilled human resources in the region as evident from survey results.

## DISCUSSION AND RECOMMENDATIONS

Significant advancements in the field of biotechnology in the late 1990s and early 2000s raised international concerns for biosafety related to biodiversity, particularly pertaining to risk assessment and risk mitigation regarding the impacts of new research products. These concerns were more pronounced in the agriculture field with development of Bt. cotton (GMOs) and its impacts on natural plants and the environment. These international concerns, at the forefront in the United Nations Conference on Environment and Development (UNCED), were formally recognized in what became the first Earth Summit, held in Rio de Janeiro in June 1992 (1, 2). This resulted in the Convention on Biological Diversity, from which originated the 1993 Cartagena Protocol of Biosafety. The terms biosafety and biosecurity, thereafter, gained much popularity and focus among the scientists and policy makers globally. In the BMENA region, biosafety-related initiatives can be traced back to as early as the year 2000 (1), as shown in **Figure 1**. We found the Cartagena protocol to be a catalyst for the serious initiatives in the capacity-building efforts in the BMENA region. However, most of the early initiatives were focused on national frameworks for biotechnology, aspects such as control GMOs and living modified organisms (LMOs), and environmental effects of agricultural products, such as Bt Cotton, perhaps because of its wider impact at the global level (2). We found 18% of total initiatives to be focused on biosafety issues related to LMOs. Although these are encouraging figures, the BMENA region is the most water-scarce and dry region worldwide. Countries across the region, especially those around the Mediterranean Sea which are highly dependent on agriculture, are tempted to use GMOs to meet consumer food demand. Therefore, more concentrated efforts are required to initiate open forums to discuss current controversies related to the pros and cons of the use of LMOs and GMOs, as well as the long-term effects on local biodiversity. The future of genetically engineered foods and crops in BMENA region will depend heavily on choices governments make regarding the regulation of this technology; therefore, coordinated and strong regional efforts are urgently required. The BMENA Organization for Economic Co-operation and Development (OECD), a forum in which BMENA governments work together to share experiences and seek solutions to common economic problems, can perhaps be an effective forum to raise the concern about the local legislations, uses, and transportation of LMOs in the region.

Post 9/11 and anthrax in the mail bioterrorism in 2001, the focus on biosafety initiatives in the BMENA region broadened to include other sciences, mainly biomedical sciences and to some extent veterinary sciences, bioengineering, chemical/nuclear sciences, and agricultural sciences, especially in countries with the backdrop of dynamic or unstable geopolitical circumstances (46–49). With the support of international organizations that focus on biosafety and biosecurity, a number of biosafety initiatives took place after 2000 in the scientific community of the BMENA region. These initiatives were primarily focused on raising awareness about biosafety and biosecurity.

Seventy percent of the total initiatives recorded fell in the category of general biosafety awareness sessions, which is an encouraging finding. However, interpreting these results at the country level is most challenging and complicated because of the diversity of the population strata, cultures, socioeconomic statuses, availability of funds, and development needs of study countries. For example, disparity is noticeable in terms of number of initiatives when compared with the per capita population of member countries. The 162 initiatives in Pakistan, the sixth most populous country in the world with an estimated population of 184.35 million, was desperately low as compared to 109 initiatives in the country of Morocco and 62 for Qatar with populations of 32 and 2.27 million, respectively. Thus, more sophisticated studies are required at individual country level for representative situational analysis.

Capacity-building activities were difficult to assess, as it is more of a conceptual approach and varies country to country depending upon needs to successfully execute the biosafety and biosecurity activities. For this, project capacity building was defined as any initiative that was focused on technology transfer, hands-on training, and assistance in development of national frameworks or sustainable scientific projects, with common regional issues and long-term measurable outcomes such as infectious disease surveillance/laboratory diagnosis. Initiatives to develop local expertise by providing hands-on training to professionals in the region were found to be significantly lacking during 2001–2013; this was also evident from the findings of the online survey. The majority of the responses to the direct questions in the survey about the availability of reliable expertise in various technical components of biorisk management were rated as average to poor. Thus, success of sustainable biosafety progress in the region demands strengthening the expert human resource training to provide the region with a wider group of local experts with sound skills in biorisk management. Such a group of skilled professionals would then be able to create guidelines and standards uniquely suited to their circumstances. Such efforts would foster a sense of ownership of guidelines; local solutions to local problems would raise the confidence and reliance on local experts by the regional scientific community.

The noticeable general trend was the international donor interest in the BMENA region in 2001–2013. Multiple donor agencies from around the globe either funded or collaborated with the biosafety initiatives in the region. However, we found that most of the efforts had been at the individual country level and not at a regional level, resulting in some duplication of efforts. For example, six separate UNEP-funded biosafety and biosecurity awareness initiatives were recorded from individual countries between January 2002 and December 2003, including Algeria, Iraq, Iran, Turkey, Egypt, and Syria. Such duplication can best be avoided in the future by working more closely with regional groups in order to coordinate efforts and focus on regional needs. Moreover, international donor funded activities related to human resource training in some study countries were coordinated through local government authorities, such as the Ministry of Agriculture of Lebanon, the Ministry of Regional Municipalities Environment and Water Resources of Oman, and the National task force in Pakistan. Successful completion of such projects was found to be dependent on political relationships between the donor and recipient country, and was often subjected to premature termination (personal communications with the country collaborators).

Another trend noticeable from the desktop review was that countries with actively functional NGOs working as Biosafety Associations, and/or those with institutes with biosafety missions, had far more initiatives on general awareness of biosafety-related issues than those without such associations. These countries hosted biosafety programs, reflecting the heightened concern in the region. Future initiatives fostering private–public partnership are strongly recommended for successful and sustainable outcomes. Successful public/private partnership models that currently exist include the International Council for the Life Sciences (a U.S.-based non-profit agency), working in collaboration with the Royal Scientific Society of Jordan (RSS), the Biosafety and Biosecurity International Consortium (BBIC, a network of concerned individuals from 22 countries in the region), and the Moroccan Biosafety Association (MOBSA) that have developed successful sustainable projects since 2005.

Conducting the online survey related to biosafety and biosecurity issues was the most complicated endeavor in this study. Obtaining statistically significant survey data in this field, and in this region, is very difficult. The participants who did respond were relevant professionals actively involved in biorisk management activities within their respective countries; thus, the responses were considered credible and are reported herein. However, the biggest challenge, and hence a limitation of this study, was the low response rate of the online survey. Regional diversity, including differences in culture, languages, dialects, and most importantly sociopolitical unrest and perception that participation in an internationally funded survey might be harmful, resulted in a sense of fear in participants despite statements declaring that all data were confidential and anonymous.

Promoting trust between funders, regional scientists, and cooperative partners, and improving open communication about intentions and objectives for the bioengagement activity (i.e., transparency) in the region is of utmost importance. Bioengagement programs can greatly benefit by incorporating such efforts into mainstream national health and science programs, such as global aid programs focused on public health: malaria, soil and water parasitism, tuberculosis, vector-borne viruses, and HIV/AIDS. These programs over the years have gained the trust of scientific individuals and national governments; these programs can be used as a bridge in strengthening regional initiatives.

## CONCLUSION

There has been a concerted effort to enhance the general awareness of biosafety and biosecurity in the life sciences in the BMENA region over the last decade. Our study findings suggest that to date, efforts have largely been focused on raising general awareness among the broad scientific community. Also, countries with actively functional Biosafety Associations and other scientifically related associations had far more such initiatives than those without such associations, but much duplication of efforts and inefficiencies of scale have been seen over the past decade. Continuing international donor interest providing opportunities for future assistance in the development of technical expertise can lead to development of local guidelines related to issues unique to the region. Given the differences across the region, local solutions are important. Country-level analyses of the local capacity-building needs are, therefore, recommended.

This study provides considerable vital information for those planning biorisk management initiatives in the region. Risk assessment and mitigation in life sciences research should be made known to a broader scientific audience, as much can be gained from similar expertise in other disciplines such as engineering, chemistry, and health physics. Efforts by donor nations and agencies to sustainably support these associations and provide biosafety trainings to their broad scientific communities may be the most efficient and effective way to build cooperative regional biosafety opportunities.

## AUTHOR CONTRIBUTIONS

EK and MC conceived the idea for this project. Literature search was conducted by NA and AH, and was reviewed and analyzed by EK, JC, AE-G, KT, and MC. The survey software was developed by HG. EK analyzed survey results and overall developed the manuscript. All authors reviewed the final manuscript.

## ACKNOWLEDGMENTS

We acknowledge efforts and time dedicated by country collaborators toward this project. Special thanks to the following country coordinators: Sonia Mediene from Algeria, Aly Omar from Egypt, Nisreen AL-Hmoud from Jordan, Sabah Al Momin from Kuwait, Mustapha Ennaji from Morocco, Eltayeb Ali from Sudan, Amel Benammar-Elgaaied from Tunisia, Ahmed Bashir and Mohammad Nasim Sabir from UAE, and Karim Nasher from Yemen for their personal insight to the situation and advice when required. We are also thankful to Mr. Faisal Malik and Aamir Lakhani for the secretarial assistance and coordination of activities.

## FUNDING

The study was part of a larger project titled "*Scientific Engagement: Defining Gaps and Creating Opportunities for Cooperative Research and Global Security in the Broader Middle East and North Africa (BMENA) Region*" and was funded by the American Association for the Advancement of Science (AAAS) Grant # 2492 – Pat – ERC . Components of this manuscript may be found as part of the final report that was submitted to the funding agency at the end of the project. The publication of this article is to reach a wider audience and for proper recognition of the efforts by the project team.

## REFERENCES

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2016 Khan, Ahmed, Temsamani, El-Gendy, Cohen, Hasan, Gastfriend and Cole. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Implementation and evaluation of a training program as part of the Cooperative Biological Engagement Program in Azerbaijan

#### April Johnson<sup>1</sup> \*, Gulshan Akhundova<sup>2</sup> , Saida Aliyeva<sup>3</sup> and Lisa Strelow<sup>4</sup>

*<sup>1</sup> Signature Science, LLC., Baku, Azerbaijan, <sup>2</sup> Technology Management Company, Baku, Azerbaijan, <sup>3</sup> Civilian Research Development Foundation, Baku, Azerbaijan, <sup>4</sup> Bechtel National Inc., Baku, Azerbaijan*

A training program for animal and human health professionals has been implemented in Azerbaijan through a joint agreement between the United States Defense Threat Reduction Agency and the Government of Azerbaijan. The training program is administered as part of the Cooperative Biological Engagement Program, and targets key employees in Azerbaijan's disease surveillance system including physicians, veterinarians, epidemiologists, and laboratory personnel. Training is aimed at improving detection, diagnosis, and response to especially dangerous pathogens (EDPs), although the techniques and methodologies can be applied to other pathogens and diseases of concern. Biosafety and biosecurity training is provided to all trainees within the program. Prior to 2014, a variety of international agencies and organizations provided training, which resulted in gaps related to lack of coordination of training materials and content. In 2014 a new training program was implemented in order to address those gaps. This paper provides an overview of the Cooperative Biological Engagement Program training program in Azerbaijan, a description of how the program fits into existing national training infrastructure, and an evaluation of the new program's effectiveness to date. Long-term sustainability of the program is also discussed.

Keywords: Cooperative Biological Engagement Program, training, Azerbaijan, Ministry of Health, Ministry of Agriculture

#### Introduction and Program Background

The Cooperative Biological Engagement Program (CBEP), under the US Defense Threat Reduction Agency's broader Cooperative Threat Reduction program, works with approximately 20 countries around the world to combat biological threats [1]. Objectives of the program are to prevent the proliferation of biological weapons; consolidate and secure collections of dangerous pathogens in central live microorganism repositories; strengthen biosafety and biosecurity of laboratory facilities; and improve partner nations' ability to detect, diagnose, report, and respond to outbreaks of disease caused by especially dangerous pathogens (EDPs). EDPs are infectious agents with the potential for use as biological weapons that may result in significant harm to people or animals.

The CBEP was first started to be implemented in Azerbaijan in 2007. Bechtel National, Inc. (BNI) has been working as the integrating contractor there since 2011. The CBEP works primarily with the Ministry of Health (MoH) and State Veterinary Control Service (SVCS) within the

#### Edited by:

*Hillary H. Carter, Office of Cooperative Threat Reduction, USA*

#### Reviewed by:

*Li Xu, Cornell University, USA Jennifer Gaudioso, Sandia National Laboratories, USA*

#### \*Correspondence:

*April Johnson, Cooperative Biological Engagement Program, Azerbaijan, 44 Jafar Jabbarly, Baku, AZ 1065, Azerbaijan<EMAIL_ADDRESS>
#### Specialty section:

*This article was submitted to Infectious Diseases, a section of the journal Frontiers in Public Health*

Received: *19 June 2015* Accepted: *18 September 2015* Published: *09 October 2015*

#### Citation:

*Johnson A, Akhundova G, Aliyeva S and Strelow L (2015) Implementation and evaluation of a training program as part of the Cooperative Biological Engagement Program in Azerbaijan. Front. Public Health 3:228. doi: 10.3389/fpubh.2015.00228* Ministry of Agriculture. MoH and SVCS administer the national surveillance systems for human and animal diseases, respectively, and are therefore the main recipients of program support as the implementing agencies. CBEP funded the construction or renovation of biosafety level 2 (BSL-2) laboratories throughout the country—five for human health [four regional and one Republican (national) level] and six for animal health (five regional and one Republican level). Modern diagnostic equipment was provided for these twelve laboratories (one additional laboratory for Ministry of Defense), as was training on facility and equipment maintenance, training on equipment use, and Biosafety and Biosecurity (BS&S) training. The MoH is constructing a combination BSL-2/BSL-3 Republican-level laboratory in Baku with their funds that will serve as the Central Reference Laboratory for Azerbaijan. CBEP is assisting with construction oversight and training at this facility. Construction completion is expected in 2016.

Several EDPs are endemic in Azerbaijan. There are approximately 300–500 human cases of brucellosis reported annually [2, 3]. Anthrax cases continue to be reported, in spite of livestock vaccination campaigns [4]. In a recent study, human volunteers were seropositive for tularemia [5]. One study found that not all people who are ill will seek healthcare, so reported cases of EDPs may be underestimated, as the country relies on passive surveillance from the healthcare system for disease detection [6]. Strengthening recognition of EDP cases by healthcare workers and animal health workers becomes even more important for detecting outbreaks if few people seek medical care for infectious diseases. The CBEP provides training aimed at improving rapid recognition, diagnosis, reporting, and response among key members of the Azerbaijani surveillance systems, including infectious disease specialists, human and animal clinicians, epidemiologists, and laboratory staff.

CBEP training in Azerbaijan has been delivered in two phases. From 2007 to 2010, training in clinical recognition of diseases, epidemiology, and laboratory diagnostics was provided by several agencies and organizations including the US Army Medical Research Institute of Infectious Disease, Walter Reed Army Institute of Research, US Centers for Disease Control and Prevention, UK Public Health England, and UK Animal and Plant Health Agency. The integrating contractor Black and Veatch introduced (and continues to train on) the Electronic Integrated Disease Surveillance System, which is an electronic disease reporting system integrated into the MoH and Ministry of Agriculture disease surveillance systems.

In 2011, BNI conducted a training gap analysis to establish the baseline knowledge of Government of Azerbaijan staff and the broader facility capabilities associated with CBEP in Azerbaijan. Gaps between training provided through 2010 and the competencies necessary to fulfill CBEP goals and ensure program sustainability were identified and taken into consideration when developing the new training program. Among other gaps, the analysis identified inconsistencies in materials, as well as topics that were not rigorously addressed in the original program, such as sample packaging and transport. A new training program aimed at addressing identified gaps was implemented in 2014. In the context of this new CBEP training program, BNI is delivering clinical disease recognition, epidemiology, and laboratory training in partnership with Government of Azerbaijan trainers, and continuing to provide BS&S training.

This paper describes the implementation and evaluation of the new training program developed by BNI in collaboration with the Defense Threat Reduction Agency and the Government of Azerbaijan from 2014 to 2015. Data from trainings conducted between September 2014 and April 2015 and annual BS&S trainings conducted in 2013–2014 are included in the evaluation of the program.

## Methods

#### Implementation of Training

The CBEP training program was developed by BNI in collaboration with the governments of the US and Azerbaijan. The following disciplines, targeting both human and animal health workers, were chosen for inclusion: Clinical Recognition of Infections Caused by EDPs, Epidemiology, and three Laboratory disciplines (Bacteriology, Serology, and PCR). With the exception of Clinical trainings, Basic and Advanced level courses are being taught for each discipline, based on a needs assessment to identify appropriate trainees for the advanced courses. Since both ministries agreed to a One Health approach to Epidemiology training, the trainee pool for this discipline comprises an equal number of participants from the MoH and the SVCS. The Epidemiology courses include a mixture of joint lectures and exercises, as well as separate Ministry-specific breakout sessions. BNI has provided annual biosafety and biosecurity (BS&S) training for laboratory staff since 2013, and will deliver Biosafety Officer training to designated trainees. Together with Black & Veatch, BNI will also provide BS&S training to Central Reference Laboratory staff.

To ensure that all Azerbaijani training needs were taken into account in the CBEP training program, training sub-working groups (TSWGs) were established with both Ministries. These groups met twice monthly between April and September 2014. The TSWGs consisted of four individuals from SVCS and nine individuals from MoH. The working groups identified subject matter experts for each discipline (Clinical, Epidemiology, Bacteriology, PCR, Serology, and BS&S) to assist with material development and review. Using pre-qualification criteria that were developed for each subject discipline, the working groups also identified the trainees who would most benefit from the training and represent the broader target audience geographically.

#### Training Materials

Training materials are based on modules previously developed by CBEP subject matter experts and provided to BNI as Government-furnished information adapted for use in Azerbaijan. BNI also developed training materials when previously developed materials were not available. Subject matter experts identified by the TSWGs reviewed the training materials, adapting them and providing examples specific to Azerbaijan as needed. All materials were approved by the Defense Threat Reduction Agency, MoH, and SVCS before training implementation. Efforts were made to use the most up-to-date information available in the English language scientific literature, and to reference international standards where applicable. Trainees are encouraged to report inaccurate translations or other errors noted during training on comment forms, so as to improve materials for future delivery. Relevant consensus changes suggested by trainees and trainers will continue to be incorporated into the materials throughout delivery of the courses.

All trainees are provided with a hard copy of the training materials to use during the training and will receive electronic versions of the materials once all training is delivered and the materials are finalized (i.e., no further translation changes are made during course delivery). At the request of MoH, training materials (slides and slide notes, plus additional background materials) will also be compiled into bound booklets to serve as a reference for future trainers.

#### Trainers

Prior to training implementation in September 2014, the MoH and SVCS identified co-trainers to administer training alongside BNI. The training program will transition entirely to the Government of Azerbaijan in January 2016, so it is important to help develop the Government of Azerbaijan trainers quickly. All Government of Azerbaijan co-trainers participated in an Adult Learning Principles course conducted by BNI to improve their training skills and to ensure a consistent approach to training delivery among all trainers. After observing one course delivered exclusively by a BNI expatriate trainer, these Government of Azerbaijan trainers co-deliver an increasing proportion of course content with each subsequent training event until they are training 100% of the course. This occurs during the last scheduled course, if not sooner. Individual co-trainers will have covered every topic in the discipline by the end of the scheduled trainings, and will continue to deliver this training beyond CBEP's period of engagement, ultimately sustaining the training program in Azerbaijan for years to come.

Training events are delivered by a team comprising one BNI expatriate trainer, 1–3 local national BNI training facilitators, and 1–4 Government of Azerbaijan co-trainers. The total number of trainers for any given event depends on the course discipline and number of trainees. Prior to each event, the training teams meet to allocate assignments, review course material as needed, and to clarify any logistical issues. During the training, teams meet as necessary to address any training or logistical issues and to discuss how the training delivery and training materials can be improved.

Training conducted by expatriate trainers requires interpretation from English; training conducted by local national facilitators and Government of Azerbaijan trainers is conducted in Azerbaijani. The MoH-identified co-trainers are authorized by the Azerbaijani State Doctors Improvement Institute (SDII) to provide continuing education course credit to doctoral level staff who successfully pass CBEP post-training tests. MoH co-trainers who are registered with the Baku Base Medical College #2 (BBMC2) are likewise authorized to provide continuing education course credit to laboratory technician level staff who successfully pass CBEP post-training tests.

#### Trainee Identification

Trainees were selected by the TSWGs at the start of the program, with changes made as necessary based on trainee availability. To cover the widest geographic area in a limited amount of time, trainees from each rayon (region) were chosen for each discipline (clinical human, clinical vet, human epidemiology, and veterinary epidemiology) based on their job duties; more than one individual was targeted in each rayon to provide redundancy in the event that a trainee leaves the system. Four individuals per laboratory were targeted for Basic training in each discipline; from this pool, two trainees will be selected for advanced training based on individual job duties and performance during the Basic level course. Trainees are expected to train eligible participants in their rayons or laboratories who did not participate in CBEP training events.

Pre-qualification criteria were developed to identify the most appropriate trainees. For example, Epidemiology trainees must be (1) employed by the relevant ministry, (2) responsible for conducting epidemiological investigations of EDP cases, (3) responsible for data entry into the Electronic Integrated Disease Surveillance System, (4) responsible for advising on and implementing prevention and control measures against EDPs for the rayon, (5) 60 years of age or less, and (6) willing to train others. Similarly, Clinical trainees must be (1) employed by the relevant ministry, (2) responsible for diagnosing cases of disease suspected to be caused by EDPs, (3) 60 years of age or less, and (4) willing to train others.

#### Training Delivery

A comprehensive training schedule covering 15 months (September 2014–November 2015) was developed by BNI in collaboration with the MoH and SVCS. Training events for the laboratory disciplines are held at the 12 CBEP-engaged laboratories. This includes five regional veterinary laboratories (Zonal Veterinary Laboratories), four regional human health laboratories (Anti-Plague Division Laboratories), and three laboratories in Baku (the Republican Anti-Plague Station, Republican Veterinary Laboratory, and the Ministry of Defense Center for Sanitary-Epidemiological Control Laboratory). Clinical and Epidemiology trainings are held in conference rooms in hotels in five cities throughout Azerbaijan (Baku, Ganja, Guba, Gakh, and Lankaran). Trainees who live more than 1 h from the site are provided with lodging at the hotel where the training will take place. Laboratory course size is limited to approximately four trainees for Basic and two trainees for Advanced courses. Clinical courses are limited to approximately 20 trainees. Epidemiology trainings are conducted for approximately 16 trainees at a time, half of whom are human health epidemiologists and half of whom are veterinary epidemiologists. Annual BS&S training takes place at each of the 12 laboratories for an average of 10 trainees per laboratory.

#### Evaluation of Training

The most widely used method for evaluating training programs is "The Four Levels of Learning Evaluation" developed by Kirkpatrick in 1959 and later revised [7]. The four levels of evaluation are Reaction, Learning, Behavior, and Results. Reaction was assessed by administration of anonymous trainee evaluation forms that were filled out daily during training events. Learning was assessed by way of pre- and post-training test scores. Behavior and Resultsrequire long-term evaluation and are further addressed in the Discussion Section.

Complete data is available for courses administered by BNI between September 2014 and April 2015 for the Clinical, Epidemiology, and Laboratory disciplines, as well as annual BS&S training events conducted in 2013 and 2014.

#### Reaction

The first level of learning represents the satisfaction of the trainees with the training. This was evaluated by means of anonymous trainee evaluation forms. Standardized questionnaires were developed and are administered to trainees at the end of each training day to solicit their opinions on the content of the training, quality of the training, and knowledge and skill levels of the trainers on a five-point scale (Poor/Below Average/Met Expectations/Above Average/Excellent). Three-point scales (Enough/Just Right/Not Enough, Basic/Appropriate/Too Advanced, and Yes/Not Sure/No) are used to determine if allotted time, content, and practical exercises were sufficient; if the material was too basic or advanced; and if the material is relevant to their current positions. Open-ended questions provide an opportunity for trainees to comment on the lectures they liked most or least, and to seek input on how to improve the training. Input was sought daily while the information was fresh, rather than waiting until the end of the event, when trainees would be less likely to recall earlier trainers and lectures. Input from each day was summarized and compiled for a complete evaluation of each event. The data presented herein is derived from overall summaries of trainee evaluations from Clinical, Epidemiology, and Laboratory trainings conducted between September 2014 and April 2015.

#### Learning

Pre- and post-training tests were used to evaluate the knowledge gained during a given course. A pre-training test was administered on the first day of the course to gauge baseline knowledge, and the same test was administered at the end of the course to evaluate knowledge gain. Tests are usually 25 questions in length (range 15–30 questions) and are comprised of multiple choice and some true/false questions. Data from trainees who did not complete both the pre- and post-training tests are not included in the summary.

#### Results

#### Implementation of Training

Planning for the BNI training program began in April 2014. A total of 74 training events (targeting 584 total trainees) were planned from September 2014 to December 2015 in the Clinical

TABLE 1 | Especially Dangerous Pathogens (EDPs) covered in the CBEP training program.

TABLE 2 | Total number of MoH and SVCS co-trainers active in the program as of April 2015.

Recognition of Infections caused by EDPs, Epidemiology, Bacteriology, Serology, and PCR disciplines. EDPs covered in the training program are listed in **Table 1**. Between September 2014 and April 2015, 46 training events were conducted for 386 trainees. From 2013 to 2014, 24 BS&S annual refresher training events were held for a total of 196 participants.

The list of co-trainers identified by the Government of Azerbaijan evolved over the course of the program, as competing responsibilities arose or trainers left their job posts. As new trainers were identified, additional courses in Adult Learning Principles were provided to ensure that all trainers were equipped to provide training, and all materials were provided well in advance of training to allow trainers to gain familiarity with the materials. A total of six events in Adult Learning Principles were provided to small groups of Government of Azerbaijan cotrainers. Refer to **Table 2** for the numbers of Government of Azerbaijan trainers in the program.

## Evaluation of Training

#### Reaction

Since evaluation forms were requested to be filled out daily, response rates tended to be fairly high. However, trainees did not always answer every question, as noted by the variable numbers of responses in **Figures 1**–**6**.

Overall, approximately 97% of trainees felt that the training covered topics that would be useful for them in their daily work, and 78% felt that the level of the material was appropriate (neither too advanced nor too basic). About 80% felt there was

sufficient time to cover the material being presented, and that the amount of content and practical exercises was sufficient. Results of questions on course content and quality and trainee perceptions of the knowledge and skill levels of both BNI and Government of Azerbaijan trainers can be found in **Figures 1**–**6**.

#### **Clinical training**

Between September 2014 and April 2015, 13 courses in Clinical Recognition of Infections Caused by EDPs were delivered, seven for physicians and six for veterinarians. A summary of trainee feedback is shown in **Figures 1**, **2**. Over 80% of trainees responded that the course content, quality, and discussions were excellent. 65% of trainees felt that the practical exercises were excellent in quality and usefulness, while about 24% responded Not Applicable (N/A). Hands-on practical exercises for Clinical courses are challenging to implement since human patients

#### FIGURE 3 | Epidemiology training evaluation by trainees (n = 1018–1107 total daily responses for each question). Note that no

responses were marked as poor or below average so those categories are not shown.

cannot be used and animals cannot be brought to training sites; therefore, practical exercises for this discipline are limited to case studies and scenario exercises.

#### **Epidemiology**

Seven courses in Epidemiology were conducted between September 2014 and April 2015 for mixed audiences of human and veterinary epidemiologists. Practical exercises in this course included case studies and exercises. Overall, trainees were satisfied with the course content and quality (**Figure 3**). They enjoyed the joint One Health approach and asked for additional lectures to be provided as joint trainings. Trainees were very satisfied with the knowledge and skills of both the BNI and Government of Azerbaijan trainers (**Figure 4**).

marked as poor or below average so those categories are not shown.

#### **Laboratory training**

Nineteen Laboratory training events were conducted between September 2014 and April 2015. Practical exercises were conducted to reinforce skills in pipetting, setting up and running assays, and interpreting results. About 87% of trainees rated the exercises as excellent in terms of quality and usefulness and 90% or more felt that the course content and quality and trainer knowledge and skills were excellent (**Figures 5**, **6**).

#### Learning

Of 386 trainees, pre- and post-training test scores were available for 375 trainees (97%). Overall, post-training test scores were higher than pre-training scores (**Table 3**), indicating an increase in trainee knowledge. Due to the small class sizes, data from the MoH and SVCS trainees were combined for the Laboratory disciplines.

#### **Annual biosafety and biosecurity refresher training**

From 2013 to 2014, 196 total trainees from the twelve CBEPengaged laboratories participated in annual BS&S refresher training (97 in 2013 and 99 in 2014). The median scores and interquartile ranges from pre- and post-training tests are shown in **Figure 7**. The median pre-training test score in 2013 was 30% and the median post-training test score was 75%. In 2014, the test scores increased from a median of 57% on the pre-training test to 82% on the post-training test.

## Discussion

Since the beginning of CBEP engagement in Azerbaijan, 1710 individual human and animal healthcare workers and laboratory staff have received training. Since implementation of the new training program in September 2014, the program has trained 32 Government of Azerbaijan trainers, including at least two trainers for each discipline from each ministry. Between September 2014 and April 2015, 386 MoH, and SVCS staff members were trained in Clinical Disease Recognition, Epidemiology, and Laboratory disciplines. An additional 400 trainees are expected to have received training by the end of 2015.

#### Evaluation of the Training Program

Trainees rated the training program content and quality highly on anonymous feedback forms and the majority felt the information trained would be useful in their work. Their responses to open-ended questions showed which topics were of most interest and use to the trainees. Many respondents asked for additional trainings in the future.

Overall, median scores for pre-training tests increased for each discipline. Median Epidemiology test scores are uniformly lower than those in other disciplines, and especially for veterinary staff; the median Epidemiology post-training test scores fell below CBEP's threshold for a passing grade (70%). During the training events, it became evident that the epidemiology content was new to most of the trainees and that the concepts discussed were not routinely used in daily activities. As a result, further discussions were held with both ministries to identify the most effective approach to follow-on training.

Annual BS&S training pre-training test scores increased from 30% in 2013 to 57% in 2014. Fifty-three percent of those trained in 2014 were also trained in 2013. This increase in scores from 2013 to 2014 suggests that there might be some residual knowledge from the previous years' training or shared knowledge by trained staff to new staff; data from annual BS&S training events in 2015 will be analyzed to see if pre-training test scores continue to rise within this trainee pool.

Training programs should result in behavior change and positive outcomes, which are the third and fourth levels of Kirkpatrick's training evaluation model and are more difficult to assess than the first and second levels [7]. There are six local national BNI staff members who visit the twelve CBEPengaged laboratories twice a month to observe regular laboratory practices and behaviors, to provide mentorship as necessary, and to administer proficiency testing in Laboratory disciplines. A laboratory assessment tool was recently implemented to

TABLE 3 | Median pre- and post-test scores for training events between September 2014 and April 2015, with 25–75% interquartile ranges.

\**Tests were administered each week of a 2-week course; scores represent an average of the two pre-training test and the two post-training test scores.*

later determined to be due to an inability to read Azerbaijani. Following this result, a Russian translation was also made available, or the tests were read aloud to individuals who could not read Azerbaijani. Excluding this individual, the lowest score on a post-training test was 30%.

quantitatively assess performance over time, but only at the laboratory level and not at the individual trainee level. The PCR proficiency testing program was re-implemented by BNI in October 2014; the proficiency testing programs in Bacteriology and Serology are scheduled to begin in June 2015. The proficiency testing program allows ongoing assessments of individual trainee performance and behavior in the areas of BS&S and laboratory diagnostic testing. Assessing behavior change among Clinical and Epidemiology trainees is more challenging, as BNI interacts less frequently with those individuals and they are more geographically dispersed. BNI plans to administer post-training questionnaires and tests to evaluate learning retention, and to assess attitudes and practices in these trainee pools.

One goal of the CBEP training program is a surveillance system that can rapidly and effectively recognize, report, diagnose, and respond to EDPs; adherence to appropriate BS&S practices is another critical result. EDP outbreaks occur only sporadically—it is therefore problematic to measure success of such outcomes in a natural setting. However, several cases of EDPs have been diagnosed by Government of Azerbaijan personnel at the CBEP-engaged laboratories using techniques introduced by CBEP. In addition, the Defense Threat Reduction Agency assessed a vertical slice of the human and animal disease surveillance systems by means of an operational demonstration in March 2014. In this exercise, a hypothetical anthrax outbreak scenario was presented to veterinary and human clinicians and epidemiologists to assess how they would respond. The assessment included their ability to gather appropriate physical exam histories; create a differential diagnosis; collect appropriate diagnostic samples in a safe manner; package and transport the samples; and to correctly report the disease in the Electronic Integrated Disease Surveillance System. To demonstrate diagnostic and biosafety practices, laboratory staff were assessed on how they tested non-pathogenic samples of the specific disease agent using CBEP-trained techniques. Overall, although both the human and animal health systems were found to be acceptable, areas for additional training were identified and incorporated into the current training program or are being addressed via mentorship visits.

#### Training Challenges

There are several obstacles to the long-term success of the CBEP training program in Azerbaijan including an aging workforce, a limited pool of qualified trainers, a lack of a post-graduate training entity for SVCS staff, and limited resources designated for EDP training.

As salaries are low in comparison with non-state sectors and recruitment/retention of newly graduated or young staff is consequently difficult, resulting in a workforce with many staff members close to retirement age. An initial cutoff of 50 years of age was proposed for trainees in Clinical Recognition and Epidemiology disciplines, but neither ministry felt that they could identify sufficient numbers of trainees under 50 years of age. The gap analysis conducted in 2011 found that 42% of 110 human and veterinary facility staff who volunteered their age was over the age of 50. As existing personnel retire and new personnel are hired, ongoing training will be necessary to bring new staff up to speed.

The turnover of Government of Azerbaijan trainers in the training program observed to date presents an ongoing risk to training continuity if the trend continues. There is a small pool of qualified trainers, many of whom have competing responsibilities as part of their routine work duties. Of 27 trainers initially identified by MoH in fall of 2014, only 13 are still trainers; two new trainers have also been added. The SVCS has likewise made several changes to the trainer list: of 20 originally trainers, five were removed and three were added, one of whom was subsequently removed. Such ongoing changes reduce the amount of time available for newly identified trainers to gain familiarity with the materials and build experience in delivering training before the transition of the CBEP training program to the Government of Azerbaijan.

At present, the SVCS has neither designated an institute to provide continuing education for veterinarians, nor mandated a certain amount of regular continuing education. SVCS epidemiologists and veterinarians are only trained during veterinary school. Veterinary epidemiologists receive most of their training on-the-job, and neither group receives any formal continued education (unlike the MoH doctors, who must receive training every five years at the SDII). This lack of a formal post-graduate training program means that veterinarians are not receiving refresher training or keeping up with new advancements in the field. Additional efforts will be needed to ensure that the CBEP-provided EDP training courses continue.

Resources for training are limited, and therefore additional funding must be requested for ongoing training to be sustained by each Ministry starting in 2016. BNI is working with the ministries to provide budget estimates for the training program in order to ensure that sufficient funds are requested.

#### Future CBEP Training

The MoH has identified two training entities to continue the CBEP trainings. The SDII provides ongoing continuing education to physicians, epidemiologists, and laboratory doctor level staff, and serves as the licensing agency for human healthcare workers. Doctors receive training and take the licensing examination every 5 years. As of September 2014, all MoH trainees in CBEP disciplines (see **Table 3**) who receive a post-training test score of 50% or more receive SDII credit. MoH plans to continue training CBEP-provided courses through SDII with the use of MoH trainers starting in September 2015. Similarly, the BBMC2 serves as the post-graduate training entity for MoH laboratory technicians. One MoH trainer in each discipline is registered with BBMC2, which allows them to provide course credit to laboratory technician trainees. These trainers will continue to provide training to these individuals at the Anti-Plague Division regional laboratories since the BBMC2 does not have the same diagnostic equipment as the CBEP-engaged laboratories. Training at BBMC2 is traditionally theoretical and not practical, so training at the laboratories will allow technicians to continue to receive practical hands-on training in EDP diagnostic testing.

As previously discussed, the SVCS does not have a postgraduate training institute, although the issue has been raised with the Minister of Agriculture. In the meantime, the SVCS plans to request funding to start conducting training using the CBEP-trained trainers and possibly top-performing trainees from the training events conducted during the current CBEP training program. Without a designated training institute, it will be more challenging to continue the training program after transition of the training program to SVCS.

All relevant CBEP training materials and records will be provided to each ministry. Training materials will be finalized in conjunction with Government of Azerbaijan trainers to ensure that materials are comprehensive and sufficiently detailed that newly identified trainers can easily pick up the materials to conduct training. Azerbaijan-specific and regional examples are being included to ensure that the materials are relevant.

An electronic training database will also be shared with each ministry. The database outlines all the trainings conducted to date, the trainees who participated, and pre- and post-training test scores. This will not only pertain to the recent CBEP training program, but to all trainings conducted to date by CBEP collaborators and integrating contractors. Training records will help the Government of Azerbaijan to identify participants for future training events and to record progress.

## Conclusion

Overall the CBEP training program has been successful, as evidenced by positive trainee feedback, Government of Azerbaijan's desire to continue training CBEP courses in the future, and MoH's willingness to integrate CBEP training into current national training curricula. Improvements in pre- and post-training test scores also indicate that training has been effective. Ongoing evaluation will help to identify changes in behavior and in the ability of the human and animal disease detection and response systems to recognize and respond to EDP outbreaks. Continued training will ensure that newly hired personnel are integrated into the surveillance system, that Government of Azerbaijan trainers maintain their training skills, and that those engaged in surveillance activities maintain their ability to respond to EDPs in the future.

## Acknowledgments

This work was funded by the Defense Threat Reduction Agency through the Collaborative Biological Engagement Program. The authors express their gratitude to Dr. Viktor Gasimov (Ministry of Health) and Dr. Siala Rustamova (State Veterinary Control Service under the Ministry of Agriculture) for program support. The authors are grateful to the AJ scientists engaged in the CBEP research program for their productive work. The authors would also like to acknowledge Sonya Narodny for assistance with review and formatting of the manuscript.

## References

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2015 Johnson, Akhundova, Aliyeva and Strelow. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

#### *Mahdi F. H. Al Jewari1 and Gregory D. Koblentz2 \**

*<sup>1</sup> Iraqi National Monitoring Authority, Ministry of Science and Technology, Baghdad, Iraq, 2School of Policy, Government, and International Affairs, George Mason University, Fairfax, VA, USA*

Since 2004, the Republic of Iraq has undertaken a concerted effort to comply with all of its international obligations to prevent the proliferation and the use of chemical, biological, radiological, and nuclear (CBRN) weapons. A centerpiece of this effort is Iraq's development of a National Biorisk Management System. The Iraqi National Monitoring Authority (INMA), which is responsible for CBRN security and non-proliferation in Iraq, has played a key role in establishing this system. This article provides an overview of Iraq's international non-proliferation commitments, describes the legal and organizational steps it has taken to implement these commitments, and examines current initiatives to strengthen Iraq's biosecurity.

#### *Edited by:*

*Jeanne Marie Fair, Defense Threat Reduction Agency, USA*

#### *Reviewed by:*

*Paras Jain, Albert Einstein College of Medicine, USA Joe Posid, Centers for Disease Control and Prevention, USA*

#### *\*Correspondence:*

*Gregory D. Koblentz<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Infectious Diseases, a section of the journal Frontiers in Public Health*

*Received: 14 August 2015 Accepted: 08 February 2016 Published: 26 February 2016*

#### *Citation:*

*Al Jewari MFH and Koblentz GD (2016) Strengthening Biosecurity in Iraq: Development of a National Biorisk Management System. Front. Public Health 4:25. doi: 10.3389/fpubh.2016.00025*

Keywords: Iraq, biosecurity, public health, bioengagement, biodefense, global health, biosafety, biorisk

## IRAQ'S IMPLEMENTATION OF ITS NON-PROLIFERATION COMMITMENTS

Since 2004, Iraq has strengthened its commitment to the non-proliferation of CBRN weapons. Iraq is now party to all of the major international non-proliferation treaties (see **Table 1**). Iraq welcomed the adoption of United Nations Security Council Resolution (UNSCR) 1540 and submitted its first National Report to the 1540 Committee on April 13, 2005. In 2014, Iraq submitted a report to the committee on its experiences, best practices, and lessons learned from implementation of UNSCR 1540 (1).

Iraq has taken a series of practical steps to implement its obligations under international nonproliferation treaties to prevent the proliferation of weapons of mass destruction and their means of delivery to states and non-state actors. Article 9, paragraph e of Iraq's constitution, adopted by popular referendum in 2005, states that: "the Iraqi government shall respect and implement Iraq's international obligations regarding the non-proliferation, non-development, non-production and non-use of nuclear, chemical and biological weapons and shall prohibit associated equipment, material, technologies and delivery systems for use in the development, manufacture, production, and use of such weapons."

In 2006, Iraq began developing national legislation to implement and enforce its treaty and constitutional commitments to prevent the proliferation of CBRN weapons and their means of delivery. The draft law was reviewed by the International Atomic Energy Agency (IAEA) and the Organization for the Prohibition of Chemical Weapons (OPCW), the international organization in charge of implementing the Chemical Weapons Convention (CWC). The Iraqi parliament passed the National Monitoring Authority for Non-Proliferation Act No. 48 (2012) on February 16, 2012 and the legislation went into effect on September 1, 2012. The Act prohibits the development, production, possession,

TABLE 1 | Iraq's non-proliferation commitments.

transfer, or use of CBRN weapons and their means of delivery and establishes a system to control the import, export, and transfer of dual-use materials. Violations of the law can be punished by fines of up to 200 million Iraqi dinars and life imprisonment.

## IRAQI NATIONAL MONITORING AUTHORITY

The National Monitoring Authority for Non-Proliferation Act No. 48 (2012) established the INMA, part of the Ministry of Science and Technology, as the main agency charged with implementing the new legislation. INMA was formed on the basis of the National Monitoring Directorate that had been created in 1993 to serve as Iraq's official liaison with the IAEA and the United Nations Special Commission (UNSCOM), the organization charged by the United Nations Security Council after the 1991 Persian Gulf War with overseeing Iraq's disarmament in the fields of missiles and chemical and biological weapons. INMA's overarching goal is to establish and maintain a national system of monitoring, investigation, and inspection that enables Iraq to comply with its national and international non-proliferation obligations. INMA is organized into five main functional departments (Nuclear, Biological, Chemical, Means of Delivery, and Import/Export) and a number of supporting units (Operations, Research and Studies, Administrative, Legal and Financial, Public and International Relations, and Chairman's Office).

Iraqi National Monitoring Authority has three primary functions: compliance, monitoring of dual-use materials, and capacity building. First, INMA is the lead agency for interacting with international non-proliferation organizations and is responsible for ensuring Iraqi compliance with its international non-proliferation commitments. To achieve this objective, INMA is the designated point of contact for the OPCW, the BWC's Implementation Support Unit (ISU), the IAEA, the 1540 Committee, and the Comprehensive Test Ban Treaty Organization. INMA is also responsible for preparing declarations and reports required by these organizations and accompanies inspection teams from these organizations during their visits to Iraq. In the context of the BWC, INMA compiles and submits annual confidencebuilding measure reports to the ISU and participates in meetings of experts, meetings of state parties, and review conferences (2).

Iraqi National Monitoring Authority's second major function is to develop regulations and mechanisms to monitor the production, use, storage, import, export, and shipping of dual-use materials to ensure their safe, secure, and peaceful application in accordance with national and international laws and standards. INMA, in cooperation with other Iraqi ministries, has developed a national system to control the import, export, and movement of dual-use materials. Iraq's list of controlled dual-use materials is based on lists maintained by the Missile Technology Control Regime, Nuclear Suppliers Group, Australian Group, Wassenaar Arrangement, and EU Law No. 2000/1334. All Government institutions and private sector companies and individuals who intend to import or export dual-use items must obtain a license from the Ministry of Trade (MOT). MOT is responsible for checking the accuracy of the information and forwarding the information to INMA for registration. If INMA grants permission for the requested license, MOT sends a copy of the license to the General Authority for Customs (GAC). GAC matches the shipping manifests of dual-use materials being transferred with the information in the license and informs its inspectors at border crossings who are responsible for checking the imported or exported materials against the license. If the license is for an import, INMA conducts a follow-up inspection with the end user of the material and makes any declaration required under international non-proliferation treaties. The Ministry of Transportation issues instructions regarding the transfer of chemical, biological, radioactive, and hazardous materials, ensures carriers comply with safety and security standards, and reports any transfers or retransfers of dual-use materials to INMA.

Iraqi National Monitoring Authority's third major task is to develop and implement capacity building programs to enhance Iraq's ability to prevent the proliferation of CBRN weapons to states and non-state actors and strengthen Iraq's preparedness for responding to the use of such weapons. To fulfill this function, INMA has started to hold workshops for managers and staff of different Iraqi ministries to raise awareness of the threat of CBRN weapons, the identification of dual-use materials, and implementation of UNSCR 1540. INMA has also launched several projects, in cooperation with foreign partners, including the United States, Switzerland, Netherlands, Norway, Germany, and Jordan, to enhance Iraq's capacity to detect and respond to man-made and naturally occurring biological threats.

## INITIATIVES TO STRENGTHEN BIOSECURITY IN IRAQ

In 2012, INMA proposed the creation of a high-level interagency coordinating body to create a comprehensive National Biorisk Management System in Iraq. INMA worked with the Public Health Directorate of the Ministry of Health to identify institutions that should be represented on this committee and to determine the committee's goals for strengthening Iraq's preparedness for natural and man-made disease outbreaks. On May 1, 2012, the General Secretariat of the Council of Ministers issued order No.18778 which established the National Biorisk Management Committee (NBMC). The NBMC is chaired by the Ministry of Health and is composed of representatives from the following ministries: Agriculture, Defense, Interior, Higher Education, Finance, Planning, Industry, Prime Minister's Council, Science and Technology, Environment, Prime Minister's Advisory Commission, Trade, and Water Resource and Irrigation. Additional ministries participate as is necessary.

The NBMC has identified four priorities for strengthening Iraq's national capacity to counter biological threats: establishing a national pathogen list, building laboratory capacity, developing the capability to conduct joint law enforcement–public health investigations, and establishing a biorisk management law. The NBMC has established sub-committees charged with developing new policies and programs to achieve these four objectives.

### National Pathogen List

The NBMC is leading the development of a comprehensive list of human, plant, animal, and zoonotic pathogens that will serve multiple purposes in Iraq's National Biorisk Management System. The national pathogen list will become part of the system regulating the import, export, and transfer of dual-use materials. In addition, the list will be used to determine appropriate biosafety and biosecurity measures that laboratories will need to implement. Finally, the list will be used to guide bioterrorism preparedness and response activities. A subcommittee of the NBMC, which is composed of INMA, the Ministry of Public Health, and the Ministry of Agriculture, has worked on developing the list since the beginning of 2014. The subcommittee has used pathogen lists developed by other countries and international organizations, including the United States, European Union, and Australia Group, as a starting point for its work. However, these lists are shaped by national security, public health, agricultural, and economic factors unique to each country and organization. For example, foot-and-mouth disease (FMD) is viewed as a top bioterrorist threat by the United States due to the high vulnerability of its cattle to this disease and the severe economic consequences that an FMD outbreak would have (3). By contrast, FMD is endemic in Iraq and to cope with recurrent major FMD outbreaks, Iraq has developed a robust veterinary and vaccine response strategy (4). Therefore, imposing tight biosecurity limits on FMD virus would not make sense for Iraq. Instead of incorporating an existing pathogen list directly into its National Biorisk Management System, the subcommittee has sought to identify key criteria used to develop these lists and adapt them to Iraq's unique situation. During the spring of 2015, one of the authors served as an CRDF Global Iraqi Bioscience Fellow at George Mason University where he evaluated the criteria used by the United States and European countries to assess and rank the safety and security risks posed by different pathogens. Based on this evaluation and other biorisk assessment exercises, the NBMC is considering applying the following criteria to generate its national pathogen list: pathogenicity, mode of transmission, route of exposure, level of morbidity and mortality, degree of antibiotic resistance, local availability of effective treatments and preventive measures, local diagnostic capabilities, potential economic losses caused by animal and plant agents, and the potential impact on the health-care system.

## Building Laboratory Capacity

A strong public health laboratory system is the foundation for an effective defense against naturally occurring infectious diseases and bioterrorism. The Ministries of Health and Agriculture maintain networks of laboratories to conduct surveillance, detection, and diagnosis of human, animal, and plant disease outbreaks (5). These ministries operate laboratories at biosafety level 1 and 2, which limits Iraq's capability to safely conduct diagnostic tests on viruses such as highly pathogenic H5N1 avian influenza (6). Since 2009, the INMA has engaged in cooperative programs with Switzerland and the United States to rebuild Iraq's public health laboratory capacity with the ultimate goal of establishing a biosafety level 3 laboratory. Iraqi officials and scientists from the Ministries of Agriculture, Health, and Science and Technology have received training on biosafety, biosecurity, emergency preparedness and response, and biorisk mitigation. Iraq has received assistance from the United States in the areas of disease surveillance, detection, diagnosis, biosafety, and biosecurity. To guide this work, INMA established an interagency technical working group to review Iraq's biosurveillance capabilities, identify gaps, and propose solutions. The United States is in the process of upgrading the equipment at Iraqi public health and veterinary labs and linking provincial-level labs into a nation-wide network to improve Iraqi biosurveillance capabilities for human and animal disease outbreaks. This initiative helps Iraq meet its commitment under the 2005 International Health Regulations to develop core capacities in laboratory services and disease surveillance. In addition, the United States has provided some Iraqi laboratories with upgrades to their physical security, including the installation of electronic door locks to prevent unauthorized access to pathogen collections. Areas in need of further investment include improving biological waste management systems at public health labs, developing education and training curriculum, standardizing laboratory protocols, and developing an indigenous capability to maintain and repair biosafety equipment.

## Public Health–Law Enforcement Investigation

The potential for terrorists to employ CBRN weapons poses new challenges to both law enforcement and public health. Of all of the CBRN threats, biological weapons are the most difficult to investigate because of the potentially long delay between when an attack occurs and when the government becomes aware that an attack has taken place. Since it can be difficult to initially determine if a suspicious outbreak is natural or deliberate, public health authorities need to know when and how to contact law enforcement agencies if they suspect an outbreak is not natural. Likewise, law enforcement agencies need to be aware of the types of information that could indicate a terrorist group is interested in, has acquired, or has released biological agents and have procedures for sharing such information with public health authorities. Once it has been confirmed that an attack has occurred, public health and law enforcement agencies will need to coordinate their investigations to ensure that they collect and share the right information in a timely manner (7). The Ministry of Interior (MoI), which is in charge of investigating acts of terrorism, does not have a history of working with either the Ministry of Health or Ministry of Agriculture. Although MoI has extensive experience dealing with conventional improvised explosive devices and explosive ordnance disposal, it does not have any capacity for dealing with CBRN weapons or contaminated evidence. INMA is working to establish a joint public health–criminal investigative capacity in Iraq by holding interagency meetings, workshops, and training sessions to develop plans and procedures for information sharing and investigation in the event of a CBRN incident.

#### Biorisk Management Law

Iraq lacks a legal framework for regulating the full range of biological risks, including disease outbreaks caused by natural sources, terrorists, and laboratory accidents, which threaten Iraq's health and security. The NBMC has formed a subcommittee headed by INMA to draft a new law to provide a legal umbrella for the implementation of biorisk management policy in Iraq, including the national pathogen list, associated biosafety and laboratory security regulations, and the roles and responsibilities of different Iraqi ministries in strengthening Iraq's preparedness for natural and deliberate disease threats. The NBMC's goal is to issue the new law within 2–3 years.

## CONCLUSION

Since 2004, Iraq has made significant progress in improving its capacity to prevent the proliferation of CBRN weapons and their

## REFERENCES

means of delivery in accordance with its legal, constitutional, and treaty obligations. Iraqi efforts to strengthen its preparedness for natural and deliberate disease threats has received valuable assistance from foreign partners who have engaged in collaborative capacity building activities over an extended period of time. A major challenge facing Iraq is the need to sustain these capabilities over time, especially if foreign assistance declines. Iraq will need to continue making investments in infrastructure, information technology, and human capital to ensure that its biosafety, biosecurity, and biosurveillance systems remain effective. The INMA has played a key role in Iraq's development of a National Biorisk Management System, but achieving the four objectives established by the NMBC will require further interagency cooperation among Iraqi ministries as well as continued support from Iraq's foreign partners. Only by working together can Iraq and the international community reduce the risks posed by infectious diseases, bioterrorism, and the misuse of biology.

## AUTHOR CONTRIBUTIONS

All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.

## FUNDING

MA was funded by CRDF Global through the Iraqi Biosciences Fellowship Program.

**Conflict of Interest Statement:** MA was a Visiting Fellow at George Mason University during the Spring 2015 semester on a CRDF Global Iraqi Bioscience Fellowship. GK has no conflict of interest to declare.

*Copyright © 2016 Al Jewari and Koblentz. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

*Claire J. Standley, Erin M. Sorrell, Sarah Kornblet, Julie E. Fischer and Rebecca Katz\**

*Global Health Security Program, Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA*

Cooperative bioengagement efforts, as practiced by U.S. government-funded entities, such as the Defense Threat Reduction Agency's Cooperative Biological Engagement Program, the State Department's Biosecurity Engagement Program, and parallel programs in other countries, exist at the nexus between public health and security. These programs have an explicit emphasis on developing projects that address the priorities of the partner country as well as the donor. While the objectives of cooperative bioengagement programs focus on reducing the potential for accidental or intentional misuse and/ or release of dangerous biological agents, many partner countries are interested in bioengagement as a means to improve basic public health capacities. This article examines the extent to which cooperative bioengagement projects address public health capacity building under the revised International Health Regulations and alignment with the Global Health Security Agenda action packages.

#### *Edited by:*

*Nathan Wolfe, Metabiota, USA*

#### *Reviewed by:*

*Michael Jeroen Adjabeng, Ghana Health Service, Ghana Ben Oppenheim, New York University, USA*

> *\*Correspondence: Rebecca Katz<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Infectious Diseases, a section of the journal Frontiers in Public Health*

*Received: 19 June 2015 Accepted: 28 September 2015 Published: 13 October 2015*

#### *Citation:*

*Standley CJ, Sorrell EM, Kornblet S, Fischer JE and Katz R (2015) Implementation of the International Health Regulations (2005) through cooperative bioengagement. Front. Public Health 3:231. doi: 10.3389/fpubh.2015.00231*

Keywords: International Health Regulations, Global Health Security Agenda, biological threat reduction, cooperative bioengagement, health systems strengthening

## INTRODUCTION