House of Lords - Intergovernmental Organisations Committee

Select Committee on Intergovernmental Organisations Minutes of Evidence

Annex A

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 it 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?

Some of the diverse range of micro-organisms which cause infectious diseases have proved extraordinarily resilient to our attempts to conquer them. The discovery and development of effective antibiotics, and increasing success with vaccination probably contributed to much of the early optimism in the post-WWII era. However, new challenges have arisen, including the difficulty in developing effective vaccines against some agents, the emergence and spread of drug-resistance, and the emergence of new diseases. These factors, combined with others such as increasing travel and migration, and the increasing vulnerability to infection of some population groups, demonstrate that efforts to control infectious disease increasingly require co-ordinated global action. The ability of national and intergovernmental organisations to work together effectively and respond rapidly to the threats presented by infectious diseases will become increasingly important. The global situation is not necessarily deteriorating, but it is changing.

2. 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?

For AIDS, TB, and Malaria it is difficult to obtain reliable data. In most low income countries, there is no vital statistics system. There are no data for registering deaths, particularly cause of death, and where they exist the data are incomplete. As a result, the most reliable data on health come from large household surveys, in particularly, the Demographic and Health Survey (DHS) (funded by USAID), which has long-term data on fertility, and infant, child, and maternal mortality. More recently, the DHS has expanded into HIV/AIDS.

For TB, it is uncommon enough that household surveys are not appropriate for measuring TB. Instead, countries are dependent on administrative data from national TB programmes. These data are better for cure rates, but incidence data are problematic because they will depend on whether people seek treatment. Since many people do not access care, estimates for the disease will be under-estimated. As a result, the TB programmes use modelling to predict the rate of tuberculosis complemented by administrative data.

For malaria, the data on incidence are problematic since it is difficult to know who exactly has malaria. Malaria is often over-diagnosed and many people with fever think that they have malaria, but they do not. There are need developments in malaria surveillance such as disease specific surveys and greater use of rapid diagnostic tests.

For HIV/AIDS, there are great difficulties in measuring the disease at the population level. Particularly when the disease is concentrated in marginalized populations such as drug users, it is notoriously difficult to measure. Often, HIV/AIDS is measured using women attending ante-natal clinics. This often is not representative and therefore cannot be extrapolated. There is a need for sentinel surveillance sites.

There is a real need to improve data in developing countries including vital statistics, but also sentinel surveillance for communicable diseases such as HIV/AIDS.

Because of lack of information, WHO uses modelling to predict HIV/AIDS, TB, and malaria. All of these models depend on good data to drive the models, but for many countries this does not exist. The World Health Report, first published in 1995, is WHO's leading publication. Each year the report combines an expert assessment of global health including the amount of disease, disability and death in the world today that can be attributed to a selected number of the most important risks to human health.

TB is of concern in the UK as an ongoing public health problem. Surveillance of TB is undertaken by the HPA, the National Public Health Service in Wales, the Communicable Disease Surveillance Centre (Northern Ireland) and Health Protection Scotland. The Health Protection Agency (HPA) contributes to international surveillance in collaboration with EuroTB (WHO Collaborating Centre), European Centre for Disease Control (ECDC) and WHO.

Malaria is not transmitted in the UK but around 1,500 to 2,000 cases are reported each year in travellers returning from endemic areas.[10] Data on malaria are reported by the HPA's Malaria Reference Laboratory[11] which is based at the London School of Hygiene & Tropical Medicine. This laboratory provides diagnostic and reference services for imported malaria reported in the UK.

In their latest Annual Report[12] on HIV and sexually transmitted infections (November 2007) the HPA estimated that at the end of 2006, 73,000 people (of all ages) were living with diagnosed or undiagnosed HIV in the UK. Approximately 31% were estimated to be undiagnosed. The number of new HIV diagnoses in 2006 was estimated to be 7,800. The major factor contributing to the rapid rise in the number of new HIV diagnoses since 1999 has been increased diagnosis of infections acquired through heterosexual contact in high prevalence areas, mainly Africa. The estimate for new diagnoses for 2006 was similar to estimates for 2004 and 2005 indicating that the annual number of new diagnoses is stabilising. Men who have sex with men (MSM) remain the group at highest risk of acquiring HIV in the UK and there were an estimated 2,700 diagnoses in MSM in 2006.

The number of people infected globally with H5N1 can be obtained through either the European Centre for Disease Prevention and Control (ECDC) or the WHO; however, the system is only as good as input from the member countries.

The International Health Regulations (2007) place an obligation on signatories to notify the WHO of any event—irrespective of its cause—which occurs within its territory, which may constitute a public health emergency of international concern. Annex 2 has a list of factors to consider in deciding whether an event should be notified to the WHO. It also states that any case of "human influenza caused by a new subtype" must be notified.

As at 17 January 2008, there have been 350 confirmed cases of H5N1 infections since 2003, and 217 of these have been fatal, demonstrating the high fatality rate of 62%. The majority of human cases have been as a result of direct close contact with sick or dying infected poultry; unfortunately, the nature of back yard flocks living in close juxtaposition with people means that further spread and human cases are likely to continue to occur. To date avian flu viruses, including the H5N1 strain, do not pass the species barrier easily, and where person to person spread has been reported in relation to H5N1, it has been very limited and unsustained.

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?

International disease surveillance takes place at both the global and the European level. The UK also conducts its own surveillance as a contribution to the international system. International surveillance is a complex and evolving architecture and the UK is keen to see it operated in a coherent way.

At the global level, WHO has a new system to monitor outbreaks of disease, drawing on the pioneering work of the Canadian Public Health laboratory that used web-search methods to monitor epidemics. This surveillance is now enshrined in international law through the International Health Regulations (IHR).

WHO's Epidemic and Pandemic Alert and Response (EPR) programme has six core functions:

— To support Member States for the implementation of national capacities for epidemic preparedness and response in the context of the IHR(2005).

— To support training programmes for epidemic preparedness and response.

— To coordinate and support Member States for pandemic and seasonal influenza preparedness and response.

— To develop standardized approaches for readiness and response to major epidemic-prone diseases (eg meningitis, yellow fever, plague).

— To strengthen biosafety, biosecurity and readiness for outbreaks of dangerous and emerging pathogens outbreaks (eg SARS, viral haemorrhagic fevers).

— To maintain and further develop a global operational platform to support outbreak response and support regional offices in implementation.

This programme includes a Global Outbreak Alert & Response Network (GOARN)—a technical collaboration of existing institutions and networks who pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance. Notification of avian influenza in animals takes places through the World Organisation for Animal Health (OIE).

Within the EU, the Network for the Surveillance and Control of Communicable Diseases seeks to promote cooperation and coordination between the Member States, with the European Commission, with a view to improving the prevention and control of communicable diseases. The Network includes an Early Warning and Response System (EWRS). The European Centre for Disease prevention and Control (ECDC) will assist the Commission in operating the EWRS. The ECDC also produces a communicable disease threat report (CDTR), which is intended as a tool for European epidemiologists in charge of epidemic intelligence activities in their national surveillance centre. The European Commission also has a role in the notification of avian influenza in animals. The National Microbiology Focal Points have also been established and will collaborate with ECDC to improve the comparability of data across member States and to agree the criteria for diagnostic testing as necessary.

At a national level, Defra's International Disease Surveillance team monitors occurrence of major animal disease outbreaks (including avian influenza) worldwide as an early warning to assess the risk these events may pose to the UK. One of the most important outcomes of this surveillance work are Qualitative Risk Assessments which are designed to give a balanced account of the threat to the UK of the disease incidence. Two of Defra's qualitative risk assessments have significantly contributed to development of the World Organisation for Animal Health international standards on notifiable avian influenza.

All these systems are only as accurate as the information that is input. In many developing countries surveillance of infectious disease is not routine, nor can there be complete reliance upon the diagnoses given nor the cause of death. In developing countries, epidemiological studies are not routinely conducted thoroughly in connection with outbreak to identify the source. Improvements in capacity and capability within countries is still the pre-requisite for good diagnostics and surveillance and consistency of data.

4. 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?

The eight UN Millennium Development Goals[13] (MDGs) range from halving extreme poverty to halting the spread of HIV/AIDS and providing universal primary education, all by the target date of 2015 and form a blueprint agreed to by all the world's countries and all the world's leading development agencies. Goal 6 is to halt and begin to reverse the spread of HIV/AIDS, and the incidence of malaria and other major diseases. DFID leads for the UK on the MDGs but the Health Protection Agency/NHS contribution is technical support and expertise in the control and treatment of HIV/AIDS, malaria and TB.

The Global TB programme is well organised and poised for making great progress. The Global Plan to Stop TB 2006-15[14] is a comprehensive assessment of the action and resources needed to make an impact on the global TB burden.

There is renewed interest in malaria and especially in expanding access to existing effective interventions particularly insecticide-treated bednets, indoor residual spraying of insecticides, and treatment with Artemisinin Combination Therapy (ACT). This would significantly decrease mortality from malaria, but is not sufficient to eradicate it in sub-Saharan Africa.

Despite significant inter-governmental efforts, H5N1 avian flu in birds is endemic in several countries and continued transmission from poultry to people is likely as local farming practices are too embedded to expect changes in the next few years. Spread from wild birds into poultry is also likely to continue. Several other strains of avian flu are endemic in wild bird populations, with wild water fowl playing a major part in providing a reservoir of infection for the circulation of avian flu viruses globally via migratory birds. Any one of these virus strains could be the origin of a pandemic flu virus in the next 10 years and wild bird surveillance is important in monitoring the pattern of virus circulation.

5. 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-coordinated intergovernmental action?

Weak and underfunded developing country health systems lie at the heart of the problem. Global prevention and control is hindered by poor surveillance infrastructure, laboratory capacity, and containment mechanisms, uneven access to affordable medicines and vaccines, by a lack of transparency over competition and pricing down the medicines supply chain. In addition there is a lack of clarity around the use of intellectual property, unsystematic research and development priority-setting including innovatory approaches.

Progress against AI, specifically, is hampered by difficulty in changing local farming practices in poor countries, wide prevalence of viruses in wild birds, the economic importance of poultry, leading to vaccination options over culling, the difficulty in management of animal hygiene in live bird markets and in control of cross-border informal trade in some world regions.

Also, not all countries have the resources or capacities to put in place a seasonal influenza vaccination policy and, in the event of an influenza pandemic, it is also recognised that current stock will not meet world-wide demand.[15] There needs to be an improvement to rapid response strategies in poorer, more vulnerable, countries.

These blockages might be removed by:

— Increased commitments by developing countries to prioritise their own health financing at national level and strengthen systems. Intergovernmental organisations can help by reinforcing this message to health, planning and finance ministries. The International Health Partnership (IHP) is developing a model for health systems strengthening support.

— Better priority setting for R&D backed by predictable funding, including firm commitments to existing mechanisms and to develop innovative financing mechanisms to promote the development of, and access to, new health technologies.

— Global commitment to improving pricing policies, for example through the Medicines Transparency Alliance being launched in a number of countries with WHO and the World Bank.

— Intergovernmental organisations that are best placed to utilise the intellectual property system to promote both innovation and access and monitor the impact of intellectual property provisions on both.

— Further implementation of the WHO's Global pandemic influenza Action Plan to increase vaccine supply, which aims to substantially increase vaccine supply capacity. The UK Government donated £2 million to the development of the Plan in November 2007.

— Further deployment of the €2.7b pledged by the international community to fight avian and pandemic influenza.

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 Department of Health is the lead policy department on combatting these diseases in England. (This role is carried out by the Scottish Executive Health Department, the Welsh Assembly Government and the Northern Ireland Department of Health, Social Services and Public Safety in Scotland, Wales and Northern Ireland respectively). In addition the Department of Health works closely with and through the Health Protection Agency (HPA) and intergovernmental organisations, in particular the WHO, to promote an effective international response to these diseases.

The HPA's role as a non-departmental public body is to provide an integrated approach to protecting UK public health, with communicable disease as a key part of its remit. (The HPA will be responding separately to this call for evidence.)

DFID works closely with a range of intergovernmental organisations who take action in response to some or all of these four diseases including the World Bank and UN agencies (WHO, UNAIDS, UNFPA, UNDP and UNICEF), and non UN agencies, such as the Global Fund (GFATM), GAVI Alliance (on vaccines) and UNITAID (medicines). DFID increasingly works closely with the agencies to improve their effectiveness in delivery of their objectives.

Defra monitors the spread of animal diseases globally and carries out risk assessments and puts in place measures to minimise the risks of the spread of exotic disease to the UK. Defra also provides technical support to other government departments (principally DfID) to assist in their programmes with the intergovernmental organisations.

FCO supports the work of other government departments overseas and helps in the delivery of health policy through its network of posts eg. lobbying and advocacy at country level on HIV/AIDS issues.

While the Government believes that the UN and the various global partnerships make a significant contribution to health and HIV/AIDS, there is duplication, overlap and competition between agencies which leads to inefficiencies. In health the UN is particularly fragmented. The former UN Secretary General's High Level Panel on System Wide Coherence, of which the Prime Minister was a member, recommended the UN should be reorganised to achieve better results. The resulting "One UN" model is now being piloted in eight countries.

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 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? And what more needs to be done? Do you consider that there is sufficient "joined-up" thinking in approaching the problem?

This is a huge subject: many factors influence the spread of disease. We would single out three for specific attention here: social inequality, poor infrastructure and climate change.

— The reasons why poor people in low income countries suffer from high rates of illness, particularly infectious disease and malnutrition are fairly clear: little food, unclean water, low levels of sanitation and shelter, failure to deal with the environments that lead to high exposure to infectious agents, and lack of appropriate medical care.

— Inadequate health systems and general infrastructure, and poor farming practices, contribute to the cause and spread of disease. Poor border controls over the movement of birds, for example, facilitate spread amongst poultry flocks.

— Exposure to projected climate change is likely to affect the health status of millions of people worldwide, through increases in malnutrition, in death, disease and injury due to extreme weather events, in the burden of diarrhoeal disease, in the frequency of cardio-respiratory diseases, and through altered distribution of some infectious disease vectors.

The UK firmly believes that multisectoral action is needed to tackle these multisectoral issues. Our forthcoming Global Health Strategy will look at action across Government to promote good global health. We are tabling a resolution on the health impacts of climate change at this year's WHO Executive Board. We await with interest the report of the WHO Commission on the Social Determinants of Health which will report later in the year.

8. Cases of Tuberculosis 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 Tuberculosis infections in Britain? And how could intergovernmental action help to reverse the trend?

The HPA has provided detailed figures on TB in the UK in 2006.[16] 8,497 TB cases were reported in 2006 in the UK, a rate of 14.0 per 100,000 population. TB in England was at its lowest level in 1987 (5,087 cases in England), and since early 1990s, there has been an upwards trend. However, both the number of cases and the rate in 2006 were very similar to those for 2005. Further years of data are nevertheless required to assess whether these results indicate a slowing in the overall trend of increasing numbers of cases. The London region accounted for the largest proportion of cases (40%) and had the highest rate (44.8 per 100,000). 72% of cases were non-UK born. The proportion of drug resistant cases of TB has stayed relatively stable with multi-drug resistance remaining at about 1%.

UK Visas works with the International Organization for Migration to screen migrants for infectious TB in certain high-risk countries. Residents of 16 countries must undergo this pre-screening test if they are applying for a visa to visit the UK for six months or more. This scheme, which is still in its early stages, is designed to test the effectiveness of methods for detecting infectious TB in people wishing to travel to the UK. It should also enable a more effective international response to the spread of TB, and encourage individuals to seek early treatment. Passengers from other countries which are high risk for TB are subject to screening on-entry. Asylum seekers accommodated by the Home Office are offered a health check, including TB screening, as part of their induction process, which almost all accept.

Whilst the overall rate in the UK is low, TB is still a public health problem and rates are high in certain inner city areas and in people born abroad. Incidence is also high in certain other hard-to-reach, or hard-to-treat groups.

We look to the Global Plan to Stop TB to contribute to global reductions in TB, from which we expect resultant benefits in the UK.

9. Tuberculosis is potentially curable by long-term antimicrobial therapies. Yet the numbers of reported cases worldwide seem to be rising. Are the necessary medicines not getting through to patients? What are the barriers to effective long-term therapy? Are we now seeing infections which stem from other conditions—eg HIV/AIDS? Or are there other reasons why a treatable disease should be spreading? How might intergovernmental action help to deal with this situation?

There are a number of barriers in tackling TB that include the following:

— Treatment requires long-term, regular antibiotic use for it to be effective.

— Long incubation periods of TB mean that patients may carry latent infection for years before they develop active disease.

— The emergence of drug resistance and co-infection with HIV poses special challenges.

— Health systems must be able to cope with demand.

— Health care workers must be properly educated in TB prevention and control.

It is estimated that one third of the world's population are infected with the TB bacillus. However, only 5-10% of these will go on to develop disease, although rates are much higher for people co-infected with HIV. People living with HIV are more susceptible to developing TB disease and TB is the leading infectious killer of people with HIV/AIDS globally.

First-line TB treatment requires the use of four drugs over a period of six to nine months. This places a significant burden on patients and on health infrastructure and resources in many countries. Failure to complete a course of treatment can result in poor health outcomes and the development of drug resistant TB. HIV treatments interact poorly with a key first-line TB drug (Rifampin), complicating the treatment of people co-infected with HIV and TB.

TB management requires effective case identification and access to treatment programmes. Directly Observed Therapy (DOTS) provides an internationally recognised detection, treatment and management strategy for TB. Over 89% of the world's population live in countries that have adopted the DOTS approach. The UK uses DOTS in specific cases following a risk assessment for drug adherence of patients.

Treatment of drug resistant TB is more complex, requires longer treatment courses and is many more times more expensive than treatment with first-line drugs. The development of new drugs that are easier to take, over a shorter course of treatment, could make a significant contribution to reducing the cost and complexity of TB programmes and increase their reach and impact.

The Global Plan to Stop TB 2006-2015[17] sets out an ambitious and comprehensive programme to achieve the MDG 6 goal of "halting and beginning to reverse the incidence of TB" by 2015. It includes actions to support equitable access to TB drugs and diagnostics for all and for development and introduction of new drugs (by 2010), field diagnostics (by 2010) and vaccines (by 2015). If fully implemented, it is estimated that 14 million lives will be saved between 2006-15.

10. To what extent do you believe that the 2004 Stockholm Convention limiting the use of DDT against Malaria-carrying mosquitoes has been a factor of increases in the spread of the disease? Has any risk analysis been carried out comparing the relative dangers to human health posed by DDT and Malaria?

The Stockholm Convention does not prevent the use of DDT for malaria vector control and does not limit the use of DDT against malaria-carrying mosquitoes. Therefore it cannot be considered a contributing factor to the increase in the spread of the disease.

There is no risk analysis comparing the relative dangers to human health of DDT and malaria. It would be impossible to carry out such an analysis in a meaningful way. Malaria is one of the leading causes of death in Sub-Saharan Africa and targets young children. The effects are acute. DDT is considered an endocrine disrupter and studies point to reproductive disorders in men from exposure to DDT. It does persist in the environment for many decades, has been found in human tissues such as breast milk and it may be transported around the globe ending up in environments where it has never been used such as the Arctic. The toxic effects of DDT are chronic and, given the persistence of the chemical in the environment, it could take years and even generations for the resulting effects to materialize.

While the Stockholm Convention does not prevent the use of DDT for malaria control, it does encourage the development and implementation of alternative products, methods and strategies. A number of partnership initiatives have been established to promote such alternatives, including collaboration with the World Health Organisation.

11. What intergovernmental action is planned or in hand for early detection of the transmission of Avian Flu from birds to humans and of human-to-human transmission in potential source countries? Is this proving sufficiently effective to prevent an Influenza pandemic? What more could be done?

Within Europe, EC Directive 2005/94/EC for the control of avian influenza in birds applies. Internationally, the multi-lateral agencies including the WHO share information on animal zoonotic diseases under the Global Early Warning and Response System (GLEWS).

In relation to suspected avian influenza in humans, confidence in national surveillance and detection varies according to country. Inter-governmentally, under the International Health Regulations, governments are required to notify WHO of any event that they assess (using the algorithm set out in the IHR) as a potential public health emergency of international concern (PHEIC). Human Influenza caused by a new subtype has to be notified under the IHR as a potential PHEIC. WHO, working with the European Centre for Disease Prevention and Control and other specialised agencies, under the Global Outbreak Alert and Response Network (GOARN) system mobilises experts from around the world to support countries in investigating and controlling significant outbreaks of any infectious disease including avian influenza in humans; this could be with surveillance, detection, rapid response, and treatment. In addition, avian influenza viruses appearing in humans that have spread to humans should be shared with the WHO Global Influenza Surveillance Network (GISN) for surveillance, risk assessment, and preparation for vaccine seed. WHO reports confirmed cases of avian influenza in humans on their website, and has produced and updated guidance on rapid response and containment which applies in any country, including Europe.

These systems have worked reasonably well to date in avian influenza human outbreaks. However, we rely on the quality of surveillance, investigation and reporting in countries such as China, Indonesia and others. Improvements need to be made in surveillance, detection, laboratory capacity, and containment strategies, as well as general infrastructure. Communication and responses need to be regularly tested, WHO run regional exercises to test various aspects of detection and response. Of course, not only will the quality of detection and containment mechanisms play a vital role in the early stages of preventing/containing a pandemic, the nature of the virus and location of the virus will also play its part.

One particular serious issue since the beginning of 2007 relates to the very limited sharing by Indonesia of its avian influenza viruses found in humans with the GISN. Indonesia is seeking rights to control who should have the virus taken from individuals in Indonesia, as well as the purpose of its use. WHO and its member countries are currently addressing this, including providing more equitable access to vaccines and other benefits for the more vulnerable countries.

More clearly needs to be done to improve detection, surveillance, and general response capacity building. The UK gave £2 million in November last year to further develop the WHO Global pandemic influenza Action Plan to increase vaccine supply. This plan strives to increase capacity building in the more vulnerable countries. Also, there have been various international conferences to mobilise pledges of financial support to tackle avian and human influenza, notably in Beijing in January 2006, in Bamako in December 2006 and in Delhi in December 2007. In all, some $2.7 billion has been pledged, with the UK pledging £35 million (in addition to substantial contributions via the European Commission)—the largest pledge by an EU Member State. Some of this money is administered by the World Bank by means of a trust fund; some is administered bilaterally whilst some is channelled through multi-lateral organisations. The United Nations System Influenza Co-ordinator and the World Bank have produced a forward look of gaps to direct future spend, as well as progress reports addressing where the money has been spent.

At the Delhi Conference, the UK was instrumental in calling for proposals for a 3-5 year International Forward Strategic Plan to build on and strengthen efforts to date and to drive inter-governmental action, both for the control of avian influenza and to ensure a better readiness for a possible pandemic. This will be presented to the next major international conference, scheduled for October 2008 in Cairo.

Although WHO prepare regional Exercises, and the EU has run a pandemic preparedness Exercise too, an international Exercise centrally co-ordinated by WHO, with all WHO regions, the EU, and selected countries would be an excellent way of testing how a global response would work, and would no doubt highlight many lessons to be learned.

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?

In general, resistance to antibiotics is not currently a primary driver of transmission for the four diseases. However, resistance is already a major problem causing increased morbidity and mortality and raising the complexity and costs of disease management for AIDS, TB and malaria.

Concerted action is needed to support the proper selection, management and use of drugs and other health commodities to prevent, diagnose and treat the four diseases by health professionals. Increased efforts are needed to improve health system capacity and availability of predictable financing to ensure the reliability, coverage and consistency of drug and commodity supplies and to deliver training on best practice to health professionals and education on treatment and prevention to communities. Surveillance systems to monitor the spread of drug resistance must be improved. Initiatives are needed to make second-line treatments for HIV, TB and malaria more affordable and available when required. Investment in R&D for new treatment and prevention options is essential for sustainable responses to communicable diseases.

WHO plays central role in providing accurate information and technical support on the emergence of, and response to, drug resistance for the four diseases.

DFID is a major contributor to the Global Fund for AIDS, TB and Malaria (GFATM) (£360 million to the GFATM (2008-10) as part of a long-term commitment of £1 billion through to 2015) and UNITAID (a 20 year commitment of up to £760 million, subject to performance review) that provide considerable funding to support reliable access to quality medicines and health commodities.

DFID is leading the development of the Medicines Transparency Alliance (MeTA), which will work with partners internationally to strengthen pharmaceutical systems and reliable access to quality and affordable medicines. MeTA will be launched in 2008.

Also, DFID invests just under £25 million each year in product development partnerships to develop new drugs for malaria, TB and other tropical diseases and for the development of vaccines and microbicides to prevent HIV transmission.

Malaria

In highly endemic countries, treatment of malaria does not play a significant role in limiting transmission but is central to reducing illness and mortality. There are considerable global levels of resistance to traditional treatments, such drugs are cheap, but ineffective in many parts of the world, resulting in wasted resources and poor health outcomes. Artemisinin Combination Therapies (ACTs) are effective but currently more expensive than established drugs and coverage, particularly in sub-Saharan Africa is low. DFID supports a number of initiatives to accelerate the uptake of ACTs and to help ensure their proper use, thereby delaying the emergence of resistance. WHO has issued guidance to countries recommending that ACTs are adopted as first treatment for malaria. The GFATM, UNITAID and the US President's Malaria Initiative are providing resources to support ACT adoption. Intensified pressure on the malaria parasite will increase the potential for resistance to existing drugs and insecticides. It is essential that sustainable malaria efforts include investment in the development of new drugs, insecticides and, ultimately, a vaccine. DFID has provided matched funding of £10 million with the Wellcome Trust over five years to the Medicines for Malaria Venture and is considering options to support incentives to encourage industry development of malaria vaccines.

Antimalarial drug resistance hinders malaria control and is therefore a major public health problem. The WHO publication Drug Resistance in Malaria[18] describes the state of knowledge about this problem and outlines the current thinking regarding strategies to limit the advent, spread and intensification of drug-resistant malaria. There is also further information on drug resistance on the WHO website[19] and the Secretariat of the Roll Back Malaria Partnership facilities access to quality affordable antimalarial medicines including combination therapies and other essential supplies through the commodity services unit[20].

The UK has committed to provide £360 million to the GFATM (2008-10) as part of a long-term commitment of £1 billion through to 2015. 17% of GFATM expenditures are on TB. DFID has committed nearly £9 million to the funding of the Stop TB Partnership from 2002-08. DFID is providing £6.5 million (2005-08) to the Global AIliance for TB Drug Development to accelerate the research and development for new TB drugs that will reduce treatment complexity and duration.

The HPA National Mycobacterium Reference Unit (MRU) and regional reference laboratories in England, Wales and Northern Ireland provide drug susceptibility data on TB. The MRU is a WHO SupraNational Reference Laboratory and European Co-ordinating Center within the Global Programme on Drug Resistance and operates an External Quality Assurance programme for drug resistance on behalf of the WHO.

HIV

Successful treatment of HIV requires 95% adherence to treatment regimes. Over time, most patients will develop resistance to anti-HIV drugs requiring access to second and third line therapies, which are routinely available in developed countries like the UK. While the cost of first line HIV therapies available in least developed countries has fallen as low as $100 in recent years, second line treatment regimes may cost between four and more than 10 times this. The onset of resistance can be delayed by ensuring that patients have reliable access to affordable treatment services that are suitable to their circumstances. WHO has developed and updates guidelines for the treatment of HIV, including strategies to change drug regimes when resistance emerges.

The transmission of drug resistant HIV (primary drug resistance) is recognised as a problem in developed countries. There is limited evidence of levels of primary resistance in developing countries. There is no evidence that drug resistance is itself driving transmission, although it is true that the risk of HIV transmission increases if individual viral loads are high, for example, if treatment is not available or failing. Primary resistance limits the treatment options available to those infected, potentially increasing complexity, costs and treatment outcomes.

In 2005, the international community committed to achieving universal access to HIV and AIDS prevention, treatment and care by 2010. UNAIDS and WHO provide technical assistance and monitor progress in achieving this goal. In addition to country and bilateral expenditures, the GFATM, UNITAID and World Bank MAP programme provide substantial multilateral funding for international HIV and AIDS efforts.

As part of its Taking Action strategy on HIV and AIDS, the UK committed to spending £1.5 billion on HIV related programmes between 2005-08.

Avian Flu

In advance of a pandemic it is difficult to predict the potential role of antiviral resistance.There is some limited evidence to show the potential of the H5N1 virus to develop resistance to antivirals, which may limit its effectiveness in mitigating the consequences of infection during a pandemic. Generally, antibiotics would only be used to treat any complications arising from influenza.

13. In a number of countries, including the UK, there is a problem with hospital-acquired infections. What intergovernmental sharing of knowledge is taking place to help bring this problem under control?

There is little formal exchange of information but there are plans for an EU recommendation on hospital-acquired infections (HCAIs)—we expect something this year but have no firm timetable. There are some EU projects covering HCAIs and ECDC has an interest in surveillance but generally most international collaboration is through professionals in the field.

The WHO World Alliance on Patient Safety, chaired by Sir Liam Donaldson, has a key role in international action on hospital-acquired infections.

WHO are working with the Commonwealth Fund on an initiative to develop five safety solutions to be implemented by the participating countries. Referred to as the "High 5s" the aim of the initiative is to introduce five patient safety solutions in 10 hospitals within seven participating countries and to evaluate the effectiveness of these solutions.

England and Wales will be taking part in this initiative and the National Patient Safety Agency (NPSA) has been nominated as our lead technical agency. The NPSA has led the development of the solution on the prevention of high concentration drug errors. The four other solutions concern the prevention of hand-over errors; the prevention of continuity of medication errors; the promotion of effective hand hygiene practices; and the prevention of wrong site/wrong procedure/wrong person surgical errors.

DH holds the co-chair of the group designing the economic evaluation of the "High 5s"s, pre- and post- implementation.

There has also been a separate strand of work led by the WHO collaborating centre for patient safety solutions to develop and agree generic standardised solutions to nine known areas of risk, including hand hygiene / infection control. These were distributed to all WHO countries in May 2007, to take and build in specifics depending upon their national health systems. The overall purpose is to guide the re-design of care processes to prevent human errors from reaching patients.

14. Are there any difficulties with regard to patents or intellectual property which are impeding the flow of medicines or other control methods to those infected? Is intergovernmental action needed to improve the situation?

By conferring a temporary exclusivity, patents provide an important incentive for the development of new healthcare products where there is an assured demand for the products of research and development, as is the case in developed countries. However, in the absence of such a demand, which is the case for many products which are predominantly required in developing countries, the incentive offered by intellectual property rights is limited. That is why governments, including the UK government, have invested significantly in research and development on products needed to fight major diseases in developing countries such as HIV/AIDS, TB and malaria.

Because they allow firms to price their products above cost in order to recoup the cost of their research and development programmes, patents can also be one of several contributory factors in determining the price of medicines and other healthcare products in developing countries. In recent years the international community has taken a number of steps to address this issue. These include the World Trade Organization Declaration on the TRIPS Agreement[21] and Public Health agreed in Doha in 2001 which stated that the TRIPS Agreement "does not and should not prevent Members from taking measures to protect public health . . . and, in particular, to promote access to medicines for all". The Declaration highlighted the flexibilities that exist in TRIPS to facilitate access to medicines. As a result of the Declaration, WTO members are now in the process of ratifying an amendment to the TRIPS Agreement which allows countries without manufacturing capacity to import generic medicines from other countries under a compulsory licence. It also allowed least developed countries not to enforce patent protection for pharmaceuticals until at least 2016.

The Government supports the right of developing countries to use compulsory licensing provisions in order to facilitate access to medicines. The Government considers that a principal purpose of compulsory licensing provisions is to bolster the ability of countries to negotiate effectively with providers of patented medicines, and the actual use of compulsory licensing provisions should be judicious.

Apart from these actions, many pharmaceutical companies have instituted differential pricing policies for selected products and countries under which they charge lower prices in least developed and low income countries in particular for drugs targeted at HIV/AIDS, TB and malaria.

Although a considerable amount has been achieved, further intergovernmental action is underway. In 2006, WHO established the Intergovernmental Working Group on Public Health, Innovation and Intellectual Property to draw up a global strategy and plan of action aimed at securing an enhanced and sustainable basis for needs-driven, essential health research and development relevant to diseases that disproportionately affect developing countries. This is due to report to the World Health Assembly in May 2008.

In respect of avian flu, WHO has held a series of meetings to consider the issues associated with the sharing of influenza viruses and access to vaccines and other benefits, in particular the impact of intellectual property rights on access to vaccines. Further work in this area is planned.

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?

The main interchanges with other countries in which the UK is currently involved relate to preparation for pandemic influenza. The exchanges of information and learning that take place can then be shared more widely through intergovernmental mechanisms such as the WHO.

The European Union, through the Health Security Committee and the EU Presidency, WHO and the Global Health Security Action Group[22] (GHSAG) and the International Partnership on Avian & Pandemic Influenza (IPAPI, a group set up by the USA) are the key vehicles through which information and best practice is shared and compared, and a global response for dealing with outbreaks, affecting human health, is co-ordinated.

WHO actively trains clinical people in the regions by sending in response teams when a cluster of human avian flu cases are found; the European Centre for Disease Prevention & Control (ECDC) is also involved in the field, in facilitating the exchange and assessment of good practice, and in providing technical input. The WHO have also produced treatment and diagnosis guidelines and recommendations for human cases of H5N1.

Defra funded Veterinary Laboratories Agency (VLA), Weybridge, is recognised by the World Organisation for Animal Health as the World Reference Laboratory for avian influenza. VLA is a leading research and laboratory organisation in avian influenza and supplies diagnostic reagents to many laboratories worldwide.

The GHSAG was set up following the attacks on the World Trade Centre on 11 September 2001, to develop proposals and actions to improve global health security[23]. The network has been designed to respond swiftly in the event of a crisis; it has a Pandemic Influenza Working Group which meets to share information via regular international conferences, meetings, and on-going exchanges of information about pandemic planning.

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?

The new IHR were adopted by the World Health Assembly in 2005, but came into global effect in June 2007. Prior to formal commencement, member states had agreed that they would endeavour, within their existing legislative frameworks, to implement key aspects of the IHR that would be helpful in the event of a pandemic flu outbreak. The UK was already well-advanced in its flu planning, but instituted forthwith the UK's "IHR National Focal Point" (IHRNFP—a key formal function defined in Article 4 of the IHR 2005) by administratively designating the Health Protection Agency as holding this function. This designation was later formalised in The Health Protection Agency (Amendment) Regulations 2007 (SI 2007 No. 1624), which came into force in July 2007. The Government has also brought forward the Health and Social Care Bill which updates the existing Public Health (Control of Disease) Act 1984 in several respects, including enabling the Government to take (if it considers it appropriate to do so) actions that might be recommended by WHO.

As at December 2007, the new IHR have thus been in full effect for only six months. They have not been put to a serious test in that time, so it may be premature to reach conclusions on their effectiveness. However the Government strongly supports the IHR 2005, and is satisfied with the functioning of the UK's IHRNFP, which has exercised the procedures laid down in the IHR on a number of occasions.

Recent global initiatives on avian influenza have contributed to on-going improvements in timely notifications of outbreaks in animals to the World Organisation for Animal Health.

17. What intergovernmental planning has been undertaken to cope with the impact of an outbreak of infectious disease caused by deliberate release of micro-organisms 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?

Regular and on-going risk assessment is undertaken across all government departments—coordinated by the Cabinet Office—to prepare for, and plan against, the effects of a deliberate release of micro-organisms into the environment. The Home Office leads particularly on CBRN (chemical, biological, radiological and nuclear) issues.

There is considerable cross-government cooperation to ensure that workable plans are put in place, and tested on a regular basis. The Security Services report across Government on the identified risk/threats. The Joint Terrorist Advisory Committee and other agencies liaise on the intelligence available, to determine the type and extent of preparations necessary to mitigate any deliberate releases into the atmosphere.

While overall strategic planning is undertaken at the inter-governmental level, planning for the actual response to an attack is undertaken at local multiagency level—with the benefit of centrally produced guidance such as the Mass prophylaxis and Smallpox plans.

Intergovernmental bodies such as the National Security, International Relations and Development (NSID) [Prepare] and [Protect] Committees meet regularly to plan for the protection of UK citizens.

UK membership of international bodies like the European Union Health Security Committee and the Global Health Security Action Group (GHSAG) ensures cooperation with international colleagues results in a coordinated approach to meeting any terrorist threat. The UK also works on a bilateral basis with international colleagues as required.

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

The global public health threat from new and emerging infections is considered to be greatest from zoonotic infections-those that are naturally transmissible from animals to man. Since the 1970s, over 30 previously unknown infectious diseases have emerged and most of these have been zoonotic. Some of these, such as H5N1 avian influenza, do not readily pass the species barrier and are not easily spread from person to person, whereas SARS CoV spread easily in the right environment. In addition to new infections emerging, there is also the issue of known infections arising in places where they have been previously unknown. The arrival of West Nile Virus in the United States and its rapid spread across nearly all states is a good example of a vector borne zoonoses taking a country by surprise. The opportunities for new and emerging infections to be introduced by an influx of migrant workers from areas where they might have been exposed to new or emerging infections is highlighted in a recent report on migrant health.[24] Similarly, close connections between countries due to families connecting with relatives provide opportunities for rapid transfer of infection globally. However, it is changes in demography, cultural habits and tourism, with new opportunities for close contact between the animal habitats and man, that remain the main influences on the emergence and spread of new infections.

It is estimated that over 75% of new and re-emerging human diseases are zoonoses and their emergence is often linked to environmental changes brought about by human activity.

What SARS and H5N1 avian influenza have reminded us is that the emergence of infection in one continent can rapidly become a global public health threat. It is inevitable that such new and zoonotic threats will continue to occur, and what is needed to combat the threat is sound animal and human health surveillance systems, rapid reporting mechanisms and embedded diagnostic capability and capacity, particularly in those areas where it is most likely that a new zoonotic infection will occur (Asian, African and Indian continents). The importance of global collaboration on health has been recognised for a long time, but the threat of a pandemic of influenza has served to sharpen our focus on early detection and containment measures and recognition of the unimportance of national and geographical boundaries in containing the spread of disease.

The surveillance and data collection systems and international collaborations on zoonoses in particular set out above (see Q2 response) provide a firm foundation for this global approach.

For the UK, staying ahead of this potential threat relies on training clincicans to be alert to the potential for new or emerging infections and to the possibility that migrants and returning tourists might have an exotic infection. Maintaining excellent diagnostic facilities capable of detecting infections that are not native to the UK is essential, as is sound horizon scanning, such as is undertaken by the Chief Medical Officer's National Expert Panel on New and Emerging Infections (NEPNEI).

19. What resources (subscriptions, staff, training, medicines etc) does the UK Government commit to intergovernmental bodies to help in the fight against the four diseases listed?

The UK provides resources to intergovernmental bodies working on these diseases through funding (both core unearmarked contributions and specific contributions to programmes and initiatives), in-kind contributions (for example, expert input to committees, working and expert groups) and staff secondments. The Government's support for research into these diseases is also an important underpinning contribution to the work of intergovernmental bodies.

The table below lists recent relevant financial contributions to intergovernmental bodies by the UK government.


Intergovernmental body	£m
Annual core unearmarked resources (a proportion of which will be allocated to agency programmes to fight the 4 diseases):

WHO:
DH (2007)	13.6
DFID (2007)	18
UNICEF: DFID (2007)	21
UNDP: DFID (2007)	55
UNAIDS: DFID (2007)	10
UNFPA: DFID (2007)	20
Other resources:
UNFPA Global Programme to Enhance Reproductive Health Commodity Security (which will have an impact in the UN's response to HIV/AIDS): DFID (2007-12)	100
UNFPA RHCS in fragile states DFID (2007)	5
UNICEF children with HIV/AIDS programmes: DFID (2004)	44
GFATM: DFID
2008-10	330-360
2011-15	up to 640
Roll Back Malaria Partnership: DFID (1998-2007)	49
Stop TB Partnership: DFID (2002-08)	9
UNITAID international drug purchase facility (HIV, TB, malaria): DFID (over 20 years)	up to 760
Medicines for Malaria Venture: DFID (over 5 years 2005-10)	10
Drugs for Neglected Diseases Initiative: DFID (2005-08)	6.5
Global Alliance for TB drug development : DFID (2005-08)	6.5
Tropical Disease Research: DFID (2005-08) this is a special research programme of WHO	4.5
WHO pandemic flu surveillance: DH (2005)	0.5
WHO Global Pandemic Influenza Action Plan to increase vaccine supply: DH (2007)	2
WHO Total UK Government pledge to fight avian and pandemic influenza	35
Secondments from UK Government to intergovernmental organisations—avian and pandemic influenza related	0.5