Memorandum by the Wellcome Trust
INTRODUCTION
The Wellcome Trust is the largest charity in
the UK. It funds innovative biomedical research, in the UK and
internationally, spending around £600 million each year to
support the brightest scientists with the best ideas. The Wellcome
Trust supports public debate about biomedical research and its
impact on health and wellbeing.
We are pleased that the Committee has chosen
to examine the important topic of controlling communicable diseases.
We would be happy to discuss any of the issues raised in our response
in further detail if that is helpful.
1. 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 if simply that not enough progress is being made in reducing
the spread of such diseases? Or is the global situation actually
deteriorating? Would it be an exaggeration to talk of a crisis?
Although great progress was made to reducing
human mortality from infectious disease over the course of the
20th century, it is unrealistic to expect the "conquest"
of communicable diseases in the foreseeable future. The adaptation
of microorganisms to infect humans and evade anti-microbial agents
means that new treatments and/ or vaccines must continually be
developed and delivered. In those places where HIV/AIDS has drastically
reduced life expectancy in the space of several decades, crisis
is an accurate description. Other infectious diseases have the
potential to cause crises in other parts of the world, in ways
that we cannot foresee. International collaboration on monitoring
and research is essential to stay ahead of this threat, and to
prepare ourselves to meet it.
New infectious diseases are constantly emerging—many
arising from the transmission of animal diseases to humans. Indeed,
two of the four diseases that the Committee identified as special
interests have jumped the animal-human species barrier within
the past 100 years (ie, HIV/AIDS and influenza). Improving our
understanding of animal diseases is one of the best ways to prepare
for the emergence of new infectious diseases in humans.
2. What reliable data exists regarding the
numbers of people infected globally with the four diseases (HIV/AIDS,
TB, Malaria and Avian Influenza) on which the Committee is focusing
particular attention? What trends are discernible in both the
numbers of people infected and the patterns of infection? And
what are the main underlying causes of infection and of any changes
in its incidence and pattern?
HIV/AIDS: UNAIDS coordinates the global estimates
and the underlying data provided by countries is improving.
Tuberculosis: WHO collects and makes available
this data on global TB incidence.
Malaria: There is a lack of good information
on malaria incidence across much of Africa. Until the recent increase
in donor funding for malaria treatment, epidemiological data on
malaria in Africa was of mostly academic interest and good systems
were not developed for collecting it. Now, with funding for malaria
interventions available from the Global Fund and other international
sources, there are greater opportunities for delivering prevention
and treatment programmes. Better data on the distribution of infections
is needed to target these resources effectively and track progress.
The Wellcome Trust is funding the Malaria Atlas Project[51]
to develop a detailed model of the special limits of P. vivax
and P. falciparum malaria at a global scale and its rate of
occurrence within this range. This is a joint project between
the Centre for Geographic Medicine in Kenya and the University
of Oxford in the UK.
Avian Influenza: Cases are reported to WHO.
3. What intergovernmental surveillance systems
exist to give early warning of outbreaks of infectious diseases?
Are these systems adequate? And what improvements might be made?
The World Heath Organization's International
Health Regulations (2005) provide the framework for global infectious
disease surveillance and response. The International Health Regulations
2005 (IHR 2005) replaced and improved upon the previous International
Health Regulations, which had been last updated in 1969. The IHR(2005)
seek to identify an outbreak of infectious disease at its source
and to control it before it has a chance to spread. This is a
marked improvement over the earlier approach, which sought to
stop infectious diseases from spreading across national borders
by focusing on ports of entry. The IHR(2005) require countries
to report to WHO any "public health emergency of international
concern", which can include infectious diseases as well as
other threats such as release of chemical or radiological material.
In a break from the previous International Health Regulations,
the IHR(2005) also give the WHO new powers to take action based
on information from non-state entities. This can be important
if governments are reluctant to publicise health problems for
fear of economic or political damage.
We agree with the approach of WHO's IHR(2005).
Continuous health surveillance in all countries and rapid targeting
of outbreaks is the most promising way to control the global spread
of infectious diseases. The Health Protection Agency serves this
role for the UK. However, as the WHO has recognised, countries
where infectious disease outbreaks most often occur are among
the poorest in the world, with the weakest health surveillance
systems. In order for the global surveillance network to perform
as intended, capacity for surveillance in those countries must
be strengthened. In many cases, strengthening basic health service
systems is a prerequisite for strengthening surveillance.
5. What do you consider to be the principle
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-coordinated intergovernmental
action?
The development of better medical technologies
and better health service delivery systems in resource poor countries
would help control the four diseases. It is also very important
to support research into the biological mechanisms underlying
these diseases, as this is a precursor to new interventions and
treatment strategies. Intergovernmental organisations such as
the WHO play an important role in coordinating international research
programmes. Multilateral organisations outside of the UN system,
such as the Global Fund to Fight AIDS, TB and Malaria and the
Product Development Public-Private Partnerships (PDPs), also play
a crucial role in developing and delivering interventions for
HIV/AIDS, TB and malaria. Researchers funded by the Trust found
that PDPs have proven very effective at combining the strengths
of R&D capacity in the public and private sectors, in the
North and the South to advance products that have their primary
demand in income markets.[52]
A number of PDPs are active in taking forward products to prevent
and treat HIV/AIDS, TB and malaria. However, there is now a real
deficit in funding the PDPs as they move promising products into
large-scale clinical trials. Furthermore, with about half of PDP
funding coming from just one source (the Gates Foundation) there
is an urgent need to diversify their funding base. Bilateral and
multilateral donors are needed to fill this gap.
6. What role does your organisation play in
combating the four diseases? Do you believe that it is correctly
configured and adequately resourced to do the job? With which
other organisations do you collaborate? How would you assess the
degree of synergy?
The Wellcome Trust supports a large portfolio of
basic biomedical research that aims to improve our understanding
of human health and disease. A substantial fraction of the Trust's
research investment focuses on health problems that are of particular
concern for developing countries, such as the four diseases highlighted
in this consultation. Collaborations with other organisations
are an important part of our strategy for supporting research
on global health threats. Trust-funded researchers also participate
on many WHO working groups and committees. Listed below are some
of the Trust's activities and collaborations in the context of
each of the four diseases.
Cross-cutting
— PDP Funders Group: The Trust is a
founding member of the PDP Funders Group, which brings together
government, philanthropic and corporate donors that currently
support Product Development Public-Private Partnerships. The PDP
Funders group aims to facilitate decisionmaking by individual
donors in this field and to strengthen the base of financial support
for PDPs to ensure that they achieve their goals.
HIV/AIDS
— In the five years 2002-06 the Trust
spent £59 million on HIV research.
— We have supported the UK Consortium
on HIV Vaccine Research, which is a collaboration with the UK
Medical Research Council.
— Mark Walport, Director of the Wellcome
Trust, is on the Coordinating Committee of the Global HIV Vaccine
Enterprise.
— Jimmy Whitworth, Head of International
Activities for the Wellcome Trust, serves on the UNESCO Advisory
Committee for education for prevention of HIV and STDs.
TB
— In the five years 2002-2006, the
Trust spent £39 million on Tuberculosis research. Through
a number of different grants, the Trust supports the development
of new TB vaccines (eg, support for Helen McShane of Oxford University),
new diagnostics (eg, support for David Moore of Imperial College)
and new therapeutics (eg, Doug Young of Imperial College).
— The Trust is a founding Stakeholder
of the Global Alliance for TB Drug Development.
Malaria
— In the five years 2002-06, the Trust
spent £140 million on malaria research. The Trust supports
five of the top ten most highly cited malaria researchers. In
addition to basic biomedical research on malaria and development
of new medical interventions, the Trust supports substantial health
services research and health policy research related to malaria
control.
— The Trust provides funding for the
Medicines for Malaria Venture, a PDP create to discover, develop
and deliver new antimalarial drugs. The Trust and DFID made a
joint commitment to provide £10 million each to MMV, and
together provide approximately 18% of MMV's funding.
— The Trust also provides funding for
a programme of malaria research at the Novartis Institute for
Tropical Diseases in Singapore. This is a partnership with MMV,
the Economic Development Board of Singapore and Novartis.
— The Trust has been represented in
the WHO Malaria Vaccine Advisory Committee and in the development
of the Malaria Vaccine Technology Roadmap.
Avian Influenza
— The Trust is funding research to
advance the scientific understanding of potential pandemic strains
(eg H5N1) and the medical technology available to prevent and
treat an emergent pandemic. In October 2005, the Trust adopted
procedures to fast-track funding for urgent influenza research.
— The Wellcome Trust's Major Overseas
Programme in Vietnam has been an important site of research on
H5N1 avian influenza in humans. Jeremy Farrar, the Vietnam Programme
Director, is a leading expert on the virus.
— The Trust is an international partner
in the Southeast Asia Clinical Research Network, a multi-lateral,
collaborative partnership of hospitals and institutions in Indonesia,
Thailand, United Kingdom, United States, and Vietnam. Other international
partners in the network include the WHO, the US NIH and Oxford
University.
— Following on from discussions of
the Heads of International Research Organisations (HIROs) group,[53]
the Trust is hoping to fund an Influenza Research Coordinator
on behalf of the group, to map out what influenza research is
already taking place and what more needs to be done.
7. 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 disease? 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? And what more needs to be done? Do you
consider that there is sufficient "joined up" thinking
in approaching the problem?
These four diseases, as well as other health
problems in developing countries, are driven by a combination
of factors—many falling outside of the health sector. There
does need to be more "joined up" thinking in approaching
these problems. To advance this at a UK level, we welcome the
newly established UK Collaborative on Development Sciences (UKCDS),
of which the Trust is a founding member. UKCDS provides a framework
to better coordinate development science research for the UK and
with international partners, in order to support sustainable improvements
in the lives of the poorest people and countries. Founding members
include the Research Councils (MRC, ESRC, BBSRC, NERC), the Department
for Innovation, Universities and Skills, and the Department of
Health, with the Gates Foundation as an observer.
UKCDS has identified climate change as one of
its first areas of work. Climate change is likely to have a particularly
strong impact on vector-borne infectious diseases, including malaria.
The Intergovernmental Panal on Climate Change (IPCC), in its fourth
assessment report, concluded with very high confidence that climate
change will have mixed effects on malaria; in some places the
geographical range will contract, elsewhere the geographical range
will expand and the transmission season may be changed.
Modelling of the health impacts of climate change
remains very limited. The IPCC and WHO, in its report "Climate
change and human health—risks and responses" (2003),
have identified a number of research priorities to improve the
modelling and better inform the development of adaptation policies.
There are still significant gaps in the evidence base for developing
countries, and the scenario models for African countries especially
are particularly poor.
A range of other factors will also affect the
transmission of malaria—these may be socio-economic (for
example increasing population movements, the use of control interventions,
drug resistance); or environmental (including changes in land
use, deforestation, changing agricultural practices and water
management, or increasing urbanisation). The interaction between
these factors is often complex.
12. To what extent do you consider that the
rise in infections in the four diseases is attributable to increased
microbial resistance to antibiotics? What intergovernmental action
is taking place in this area?.
The continual evolution of microbial resistance
is a real problem for HIV (resistance to antiretrovirals), TB
(resistance to antibiotics) and malaria (resistance of malaria
parasite to antimalarial drugs). There are treatment strategies
that slow the development of drug-resistance, but the development
of drug resistance is difficult to block entirely. For this reason,
we are likely to need continual research and development of new
treatments. In addition to our investments in HIV/AIDS, TB and
malaria research & development discussed previously, the Trust
and GSK have recently entered into a partnership for gram-negative
antimicrobial development.[54]
15. 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?
Efforts to build capacity in developing countries
for diagnosis and treatment of the four diseases identified in
this consultation must continue to increase. Although targeted
efforts to build capacity for diagnosis and treatment of those
focal diseases may be helpful in some situations, they must be
integrated into a more general programme of health system strengthening
in order to be effective.
Capacity strengthening partnerships in which
the Trust is involved include:
— The Health Research Capacity Strengthening
Initiative in Kenya and Malawi initiative aims to strengthen
the capacity for the generation of new health research knowledge
within Kenya and Malawi, and to improve its use in evidence-based
decision making, policy formulation and implementation. This initiative
began with an agreement between the Wellcome Trust and DFID to
commit £10 million each towards a join programme of health
research capacity strengthening in Africa. The International Development
Research Centre, Canada (IDRC) joined the initiative as a funder
and implementing partner. In Kenya and Malawi the initiative funds
nationally-led health research grant-giving bodies which aim to
meet local health research needs. National task forces established
work plans, now signed off by the Trust and DFID.
— The Wellcome Trust has just launched
an Research Capacity Strengthening in Africa. This funding
scheme aims to support the creation of consortia and networks
that will link African universities and research institutes with
institutions in the UK (or in other countries with a developed
market economy). The aim is to forge partnerships between institutions
with complementary scientific, clinical or administrative strengths
that can add significant value and create a robust research environment
to strengthen the research-base in Africa, particularly in African
Universities. Consortia will be Africa-led and include a mix of
African institutions with well-established research activities,
as well as promising African institutions that are developing
their research potential.
16. The International Health Regulations 2005
are intended to provide a global framework for the rapid identification
and containment of public health emergencies. How effective do
you consider this response system to be? Do improvements need
to be made?
As discussed in our response to question 3,
the IHR(2005) provide a good framework for global information
sharing. However, as mentioned above in response to question 3,
quick identification and containment of infectious diseases requires
stronger health systems than are yet available in many developing
countries. Capacity building in these countries is needed to help
the global system function well.
Resource poor countries need to have confidence
that participating in the global system of information sharing
and collaboration will benefit their own efforts to contain public
health emergencies. As demonstrated by Indonesia's refusal to
share all of its Avian Influenza samples on the basis that it
may not have access to a resultant vaccine, this can be a problem.
17. What intergovernmental planning has been
undertaken to cope with the impact of an outbreak of infectious
disease caused by deliberate release of microorganisms into the
environment? Is there adequate liaison between the various agencies
involved, including intelligence, law enforcement and health care
professionals? How could action by intergovernmental bodies help
further?
Identifying and coping with the impact of infectious
diseases caused by deliberate release of microorganisms requires
similar systems and strategies as coping with natural diseases
outbreaks. Strong monitoring and response systems are the foundation
for both.
18. Though our remit is focused specifically
on known infectious diseases, we would be interested to know how
you view the global threat from new or previously unrecognised
ones and from the transmission of infections from animals to humans.
As discussed in our response to question 1,
we view the threat from emerging infectious diseases to be very
serious—particularly the risk of animal diseases crossing
the species barrier to infect humans. Humans and animals live
in extremely close proximity in many parts of the world, making
this essentially inevitable.
January 2008
51 Malaria Atlas Project website: http://www.map.ox.ac.uk/MAP_overview.html Back
52
Mary Moran et. al. (2005) "The New Landscape of Neglected
Disease Drug Development" http://www.wellcome.ac.uk/assets/wtx026592.pdf Back
53
This is an informal group that brings together the major government
and philanthropic biomedical research funders from around the
world. Back
54
Project description: http://www.wellcome.ac.uk/doc%5Fwtx037132.html Back
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