Memorandum by the Academy of Medical Sciences
1. The Academy welcomes the opportunity
to respond to the House of Lords Ad Hoc Committee on Intergovernmental
Organisations following its call for evidence on "Acting
through Intergovernmental Organisations to Control the Spread
of Communicable Diseases". The Academy of Medical Sciences
promotes advances in medical science and campaigns to ensure these
are translated as quickly as possible into benefits for society.
The Academy has previously addressed issues relating to pandemic
influenza in its joint report with the Royal Society Pandemic
Influenza: Science to Policy,[1]
and recent follow-up symposium (a report of which will be published
in Spring 2008). Our Fellows have a wealth of expertise in basic
and clinical malaria, TB and HIV research. We have chosen to address
specific questions, with reference to each communicable disease
where possible. We would be pleased to expand on any other points
made in this submission.
2. A recent report on Communicable Diseases
by the UK Department of Health stated that "post-war optimism
that their conquest was near has proved dramatically unfounded".
What is your assessment of the overall position? More specifically,
is it simply that not enough progress is being made in reducing
the spread of such diseases? Or is the global situation actually
deteriorating? Is it exaggeration to talk of a crisis? (1)
With regard to avian influenza, the Academy
considers that greater effort is required at an international
level to prevent spread of avian disease. A recent symposium,
held by the Academy of Medical Sciences and Royal Society, identified
the need for particular efforts in South East Asia and Africa,
where poultry and humans live in close proximity and live poultry
markets are thought to contribute to the maintenance and dissemination
of avian influenza viruses. With avian influenza endemic in poultry
in three continents, management and control of this reservoir
is key to managing pandemic potential. Thus, we recommend investment
in avian vaccines, particularly standardisation of antigen content,
in combination with greater research into new vaccines. Consistent
use of the chosen vaccine must also be ensured. In addition, it
may be necessary to improve surveillance and monitoring systems
in African countries, where levels of infection in animals and
birds are unknown. To date, surveillance via detection of H5N1
in dead birds has proved to be useful; support is needed for monitoring
efforts in all countries.
3. The Academy is aware that progress has
been made in reducing TB infection in some regions (Asia, Latin
America and the Caribbean)[2]
through the implementation of highly effective "Directly
Observed Treatment Short Course" (DOTS).[3]
This has been supported by the World Health Organisation (WHO)
and the International Union Against Tuberculosis and Lung Disease
(IUATLD), together with strong commitment, dedicated funding and
co-ordinated action of global networks and organisations including
the "Stop TB Partnership" and the "Global Fund
to fight AIDS, TB and Malaria". However, successes in certain
areas are offset by the increase in TB infections in Sub-Saharan
Africa.[4]
Predisposition to TB by HIV is a key determinant of global spread
and progress has been held back by the marked global rise in HIV
infection. It is clear that greater progress in control of HIV
is a crucial step in limiting the spread of TB infection. Moreover,
the rise in the spread of the multi-drug resistant TB strains,
MDR and XDR, should be urgently addressed. The development and
spread of TB strains resistant to all antibiotics would lead to
a public health crisis. Efforts to stem this rise, through improved
monitoring of infection, expansion of DOTS and the development
of more potent drugs that would reduce the duration of treatment
and thus improve adherence, are imperative.
4. Significant funds and efforts are being
directed towards a reduction in HIV infection and data indicate
downwards trends in prevalence in some countries.[5]
However, sustained and co-ordinated support will be crucial to
prevent further rises in infection. The roll out of effective
antiretroviral therapy (ART) has made an impact on mortality and
morbidity in developed countries and progress in reducing/stabilising
mortality is beginning to become evident in resource poor countries
where the programmes are effective.[6]
However, the major disadvantage of ART is that treatment must
be continued for life, thus development of resistance is a serious
risk if adherence to treatment is poor. Additionally, in the absence
of improvements in infrastructure necessary to ensure accessibility
of HIV treatments, HIV and TB infection rates in developing countries
will increase.
5. In contrast to TB and HIV, progress in
reducing malaria-related mortality and morbidity is evident in
a number of countries, such as Vietnam and South Africa [7][8]
and use of insecticide-treated bednets has increased in many African
countries.[9]
Continued provision of effective prevention and control measures,
including combination antimalarial chemotherapies and insect control,
will be essential to continue this trend and to reduce the disease
burden where transmission rates and infection levels remain high.
6. What reliable data exist regarding the
numbers of people infected globally with the four diseases on
which the Committee is focusing particular attention? What trends
are discernible in both the numbers infected and the patterns
of infection? And what are the main underlying causes of infection
and of any changes in its incidence and pattern? (2)
Where communications are good, WHO data regarding
cases of human influenza infection are reliable, although infection
data are difficult to obtain from more remote rural areas of some
Asian and African countries. Extensive surveillance efforts and
early reporting of confirmed cases is needed to ensure full reliability
of data. As mentioned above, there is little information regarding
prevalence of influenza infection in mammals, such as pigs, and
greater efforts are required to assess infection levels in birds
and animals in Africa.
7. In well-resourced countries, data for
TB, malaria and HIV infection are reasonably reliable. For instance,
data have demonstrated an increase in TB infection rates in the
UK over recent years.[10]
Yet, latent TB infection may be carried for many years before
visible disease occurs and skin tests designed to detect latent
infection lack specificity and sensitivity. Infection figures
could thus be far higher than currently thought. Full validation
and development of new diagnostic tests are essential to ensure
improved accuracy of data.
8. Additionally, reliable data are lacking
where fewer resources are dedicated to TB surveillance. The accuracy
of infection data and temporal patterns will only be increased
if diagnostic methodologies for malaria and TB improve and are
taken up more widely. Similar reliability problems compound data
collection for HIV infection, given its latency in earlier stages
of infection, such that most data are based on cases of HIV-related
disease, rather than initial latent infection. In the absence
of improved surveillance, testing and adherence to treatment in
many developing countries, it is likely that infection will increase.
9. What intergovernmental surveillance systems
exist to give early warning of outbreaks? Are these systems adequate?
And what improvements might be made? (3)
What intergovernmental action is planned
or in hand for early detection of avian flu transmission from
birds to humans and from human to human in potential source countries—is
this sufficiently effective to prevent a pandemic? What more could
be done? (11)
WHO is responsible for oversight of global influenza
surveillance systems (through the WHO Collaborating Centres and
the Global Outbreak Alert and Response Network [GOARN]), setting
international recommendations for surveillance and investigating
and responding to clusters of disease. We consider this to be
an effective system.[11]
GOARN provides the response arm for global outbreaks and has responded
to a number of events in over 20 countries.[12]
We are aware that steps are being taken to improve surveillance
and welcome such activity.
10. The Academy notes that the Global Early
Warning and Response System for Major Animal Diseases, including
Zoonoses (GLEWS) surveillance system, operated through the Food
and Agriculture Organisation of the United Nations (FAO), World
Organisation for Animal Health (OIE) and WHO, plays a key role
in worldwide avian influenza monitoring. However, although information
is received through National Influenza Centres, there is an urgent
need to support improvements in the capacity of infrastructure
of national surveillance systems around the world.
11. Improvements could also be made to ensure
that surveillance is carried out in healthy animals including
pigs, wild birds and poultry, in farms, back yards and live poultry
markets. The latter are of particular importance since they are
thought to maintain, amplify and disseminate avian influenza viruses
and the FAO could focus more heavily on this issue. The Academy
considers it important to strengthen worldwide surveillance structures
for cluster and syndromal detection and we welcome the steps taken
by WHO to address this. By inclusion of a requirement for member
countries to develop their core capacity, the International Health
Regulations may help to develop these systems where required.[13]
However, we consider that improvements in multilateral funding
may be required for such developments in capacity and infrastructure.
12. Further to cluster detection, an additional
sentinel system could be useful to join farming communities or
areas where pigs, poultry and people live in high density so that
outbreaks can be identified before they spread to other areas.
13. Within the UK, the Academy considers
that the Department of Health (DH) and Department for Environment,
Food and Rural Affairs (DEFRA) must continue to work closely with
WHO to enable effective surveillance and diagnosis of cases of
influenza. In the long-term, this capacity might be relevant to
other infectious diseases. In the event of outbreaks and/or a
possible pandemic, we recommend that collection and sharing of
data in real time is co-ordinated through intergovernmental organisations
at the EU, EU-G8 and WHO/UN level.
14. Given the continuance of current or planned
intergovernmental programmes to prevent or control the four diseases,
what predictions can be made of their likely spread and pattern
over the next 10 years? (4)
Whilst mathematical modelling is able to give
quantitative estimates of the pattern and speed of spread of a
pandemic strain of avian influenza once it has emerged, spread
will depend largely on the extent to which surveillance networks
and control measures are implemented and/or developed around the
world. Whilst the UK and many EU member states may have well-developed
pandemic response frameworks, outbreaks in rural African or South
East-Asian countries could spread extensively prior to detection
or treatment. Variation in monitoring and preparedness make predictions
of likely spread difficult.
15. Through the influence of national and
international programmes to control the spread of malaria through
interventions such as insecticide-treated bednets, indoor spraying
and Arteminisin-based combination therapy, it could be predicted
that spread of malaria may decrease over the next 10 years. However,
a key determinant of the likely pattern of malaria spread will
be the drug resistance profile of the parasites in different parts
of the world. Areas that have seen significant reductions in disease
through national and international programmes could see a re-emergence
of infection if Artemisinin-resistance becomes established. Similarly,
drug resistance significantly affects control of TB and HIV infection.
Although new HIV drugs are in development, there is concern that
strains that have become resistant to current ART drugs may transmit
widely in the population.
16. Within the UK, the likely pattern of
spread of TB will depend to a large extent on the political commitment
to focus on issues such as diagnosis, control programmes, treatment
regimens and poverty. The frequency of migration of individuals
from areas of high endemicity to low endemicity may also affect
further spread.
17. What do you consider to be the principal
blockages to achieving progress in the prevention or control of
the four diseases? And how might these blockages be removed by
more, or better targeted or better co-ordinated intergovernmental
action? (5)
One blockage to progress in control of influenza
is the lack of a unified and standardised approach to influenza
virus vaccination timings and doses. This is, in part, through
a lack of opportunities for comparing one formulation directly
with another, which prevents awareness of the benefits of particular
approaches. We recommend that WHO leads an initiative to ensure
that samples are shared and that comparative experiments are carried
out to encourage development of a standardised approach.
18. The overall intensity of effort in preparing
for an influenza outbreak serves as a model to demonstrate how
preparedness can be heightened in both resource-rich and poor
countries. Thus giving similar priority to infectious diseases
such as TB and malaria could be of significant benefit. Establishing
a panel, similar to the inter-governmental panel on climate change,
would enable similar approaches to be used to manage threats from
communicable diseases.
19. In TB infection, the main blockages
are the difficulty in diagnosis, the lack of a universally effective
vaccine and the need to treat for six months or longer for resistant
strains. There is a critical need to encourage medical research
to develop new treatments to counter the rise in multi-drug resistance
and simultaneously to utilise currently available diagnostic and
treatment tools as effectively as possible. Continued funding
is required, combined with technical expertise and implementation
of diagnostic and control measures. Whilst collaboration between
TB and HIV services has not been successful in the past, owing
to concerns that the stigma surrounding HIV infection would prevent
people from attending a clinic for TB treatment, the Academy considers
that improvements in collaborative activity between these services
could be strengthened.
20. It will also be necessary to address
the stigma surrounding HIV to improve attendance at TB treatment
centres, but also to encourage a greater proportion of individuals
to be tested specifically for HIV—the main blockage to better
control of HIV infection. Further blockages in developing countries
that should be addressed urgently include the implementation of
prevention techniques that have the acceptance of the relevant
populations and meeting the cost of sustaining effective ART programmes
(both in terms of providing drugs and human resources for dispensing
and monitoring of patients).
21. Many of the same factors are also blockages
to progress in malaria control. Widespread access to effective
treatment, monitoring and diagnosis, adequate funding and sustained
efforts are required. Co-ordinated efforts to monitor the development
of parasite resistance (through WHO) and to support research into
the next generation of antimalarial treatments are urgent priorities.
22. In all cases, intergovernmental action
can encourage co-ordinated and continued funding and efforts on
the part of governments in developing and developed countries.
It can also encourage best use of scientific advances in policy
and the provision of policy guidance. Furthermore, intergovernmental
action can encourage the development of internationally agreed
targets, implementation of prevention and control strategies in
health programmes, data collection and monitoring of disease and
management of drug supplies. Moreover, intergovernmental organisations
can effectively bring together non-governmental organisations
(NGOs), technical experts, governments and other stakeholders
to manage any blockages and make the best use of resources.
23. What are the main non-health causes (eg
global warming, poverty, changes in land use, international travel,
lifestyle, population) of the spread of the four diseases? To
what extent can intergovernmental action in non-health fields
contribute to alleviation of their spread? What action is taking
place or planned in these areas? What more needs to be done? Do
you consider that there is sufficient joined-up thinking in approaching
the problem? (7)
The link between climate change and human health
is being increasingly recognised. Vectors of disease, including
the Plasmodium parasite responsible for transmission of malaria,
are increasingly able to invade previously void areas with a steady
alteration of temperature and/or meteorological conditions. Moreover,
global trade is increasing the volume and speed of movement of
people and animals, thereby increasing the likelihood of rapid
spread. The SARS outbreak of 2003 was limited by quarantine measures
but an outbreak of pandemic influenza, if it was only detected
after it had become established, could have dire consequences.
24. Lifestyle and cultural factors are also
critical in affecting the spread of these diseases. For instance,
whilst education may be a key component of control measures, it
remains difficult to change behaviour about the risks of influenza
transmission from proximity to farm animals, when risks are not
perceived as related to exposure. Overcrowding and poor nutrition
increase the risk of TB infection and progression to disease and
the stigma of HIV can prevent people presenting for treatment
of their TB. Good leadership, education and engagement with technical
experts are necessary, in combination with sufficient funding.
Multi-disciplinary approaches to containment are essential and
depend on co-ordinated efforts.
25. Cases of TB fell progressively in the
UK until the mid-1980s but started to rise again in the early
1990s. Around 6,500 cases are now reported each year, an increase
of about a quarter since the early 1990s. What are the main factors
of the revival of TB infections in Britain? And how could intergovernmental
action help to reverse the trend? (8)
Within the UK, immigration and international
travel strongly influence TB infection rates. For instance, rates
of infection between 2000 and 2004 increased in the non-UK born
population but remained stable in the UK-born population. The
majority of cases were reported in individuals from South Asia
or sub-Saharan Africa.[14]
As described above, inadequate adherence to treatment and the
difficulty of diagnosing a latent infection, which does not present
with symptoms for many years, have also played a role in encouraging
a rise in infection. In particular, poor adherence to treatment
encourages the transmission of multi-drug resistant strains.
26. What interchange exists between states
in regard to knowledge of and training in the diagnosis and treatment
of the four diseases or regarding preparations for dealing with
outbreaks? What improvements might be made through intergovernmental
action? (15)
The main source of education and co-ordination
of knowledge regarding TB has been through WHO and the IUATLD,
whilst the International AIDS Society, Global Fund to Fight AIDS,
TB and Malaria, WHO, the United States President's Emergency Plan
for AIDS Relief (PEPFAR) and the Joint United Nations Programme
of HIV/AIDS (UNAIDS) are all actively involved in training in
the diagnosis and treatment of HIV. We consider that the link
between training in TB and HIV could be strengthened in order
to address the growing burden of these increasingly linked diseases.
Crucial to these efforts will be sustained, consistent activity
by all organisations involved and a focus on surveillance, for
cases to be detected at all.
The Academy of Medical Sciences is particularly
grateful to Sir John Skehel FRS FMedSci, Professor Janet Darbyshire
OBE FMedSci and Professor Sanjeev Krishna FMedSci for their contribution
to this response.
THE ACADEMY
OF MEDICAL
SCIENCES
The Academy of Medical Sciences promotes advances
in medical science and campaigns to ensure these are converted
into healthcare benefits for society. Our fellows are the UK's
leading medical scientists from hospitals and general practice,
academia, industry and the public service.
The Academy seeks to play a pivotal role in
determining the future of medical science in the UK, and the benefits
that society will enjoy in years to come. We champion the UK's
strengths in medical science, promote careers and capacity building,
encourage the implementation of new ideas and solutions—often
through novel partnerships—and help to remove barriers to
progress.
The Academy's Officers are:
Professor Sir John Bell PMedSci (President);
Sir Michael Rutter CBE FRS FBA FMedSci (Vice-President); Professor
Ronald Laskey FRS FMedSci (Vice-President); Professor Ian Lauder
FMedSci (Treasurer) and Professor Patrick Maxwell FMedSci (Registrar).
1 February 2008
1 Academy of Medical Sciences and Royal Society (2006).
Pandemic Influenza, Science to Policy. www.acmedsci.ac.uk/p99puid89.html Back
2
DFID (2007). Tuberculosis (TB). http://www.dfid.gov.uk/Pubs/files/mdg-factsheets/tuberculosisfactsheet.pdf Back
3
WHO and Stop TB Partnership (2006). The Stop TB Strategy. Building
on and enhancing DOTS to meet the TB-related Millennium Development
Goals. http://www.who.int/tb/publications/2006/who
htm tb 2006 368.pdf Back
4
http://www.dfid.gov.uk/Pubs/files/mdg-factsheets/tuberculosisfactsheet.pdf Back
5
UNAIDS and WHO (2007). AIDS Epidemic Update.http://data.unaids.org/pub/EPISlides/2007/2007
epiupdate en.pdf Back
6
Ibid. Back
7
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/
DH 4985739 Back
8
Sharp, Kleinschmidt, Streat et al., (2007). Seven Years of
Regional' Malaria Control Collaboration Mozambique, South Africa
and Swaziland. Am J Trop Med Hyg 76(1): 42-47. Back
9
UNICEF (2000). Malaria and Children. Progress in Intervention
Coverage. http://www.unicef.org/health/files/MalariaOct6forweb
final.pdf 10 Back
10
HPA (2006). Tuberculosis Update
http://www.hpa.org.uk/infections/topics az/tb/pdf/newsletter
2006 pdf; Euro Surveill (2006). Epidemiology and response
to the growing problem of tuberculosis in London. http://www.eurosurveillance.org/em/v11n03/1103-228.asp) Back
11
Royal Society and Academy of Medical Sciences (2006). Pandemic
Influenza: Science to Policy. www.acmedsci.ac.uk/p99puid89.html Back
12
Merianos A and Peiris M (2005). International Health Regulations
(2005). Lancet 366:1249-1251 Back
13
http://www.who.int/csr/ihr/capacity/en/index.html Back
14
HPA (2006). Migrant Health. Infectious Diseases in non-UK born
populations in England, Wales and Northern Ireland. A baseline
report. http://www.hpa.org.uk/publications/2006/migrant
health/default.htm; French CE, Antoine D, Gelb D et
al., (2007). Tuberculosis in non-UK-born persons, England and
Wales, 2001-2003. Int J Tuberc Lung Dis 11(5): 577-84. Back
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