Letter from Liverpool School of Tropical
Medicine
Thank you for the opportunity to provide a response.
This response is sent on behalf of the Liverpool School of Tropical
Medicine. We provide brief responses to many of the questions
below. We would also like this opportunity to factually correct
one of the statements in your introduction in Paragraph 6. There
is no evidence that Anopheles mosquitoes are spreading—the
potential link between climate change and increased malaria transmission
is that the increased temperature will allow the parasites to
develop at a more optimum rate for transmission within the mosquitoes.
The Anopheles mosquitoes already cover most of the world and probably
did so prior to human habitation.
Responses below are brief due to time constraints
but can be expanded in the verbal submission we have been invited
to make.
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?
1. A number of infectious diseases are clearly
increasing. TB specifically is increasing again in many countries.
HIV, Malaria and TB all remain major problems in the heartlands
of their transmission in the tropics. Other diseases specifically
those spread by highly mobile bird or mosquito vectors are by
their very nature difficult to contain and always have been. We
do not however believe that this should be viewed as a crisis.
2. What reliable data exist regarding the
numbers of people infected globally with the four diseases[1]
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. Malaria—NOBODY accurately knows
the numbers of people infected or actually dying of this disease.
There have been recent re-estimates of transmission intensity
which suggests levels are much higher than previously thought.
TB and HIV global estimates are probably more realistic. Poverty
is the route issue for much of the world's malaria transmission,
both TB and malaria infection rates have increased due to HIV.
HIV has also changed the demographic patterns of malaria infection.
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?
3. Surveillance is very poor for many viral
diseases where early warning of outbreaks is the key to successful
control. Better diagnostics, improved communications and sentinel
site monitoring could all be improved.
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?
4. Large scale programmes should give us
a much better handle on this over the next few years.
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?
5. Blockages to progress include; poor co-ordination
of fragmented competing initiatives in many areas, lack of human
capacity in many countries where transmission is endemic or likely
to originate, poor use of available technology to accurate collect,
assess and disseminate data. Leadership in Global health is a
tricky issue at present. The mandate for this should reside with
the World Health Organisation but this organisation has had obvious
major failings for many years. Organisations such as the Bill
and Melinda Gates Foundation are increasingly driving policy and
practise through the force of funding without necessarily having
an internationally agreed mandate to do so.
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?
6. The Liverpool School of Tropical Medicine
has major programmes in malaria from genomics through drug discovery,
better treatment, improved policy and practise to technical assistance
at country level. For HIV and TB we are active mainly in the policy
and practise and better clinical treatment arenas although currently
moving into the TB drug area. We do not deal with Avian Flu, other
than through helping internationally to pull together the evidence
on best practise to guide policy making. We have major programmes
in the Neglected Tropical Infectious Diseases outside this and
feel strongly that these should not be ignored. Indeed integrated
control activities that target multiple diseases are likely to
be as if not more successful than disease specific vertical programmes.
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?
7. Poverty, urbanisation, travel, agricultural
practices in that order of priority.
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?
8. HIV, TB multi-drug resistance and migration.
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?
9. The long term treatment regimen, the
time lag between presentation and diagnosis, the link with HIV
and drug resistance are all major and growing issues in TB treatment.
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?
10. DDT is not an issue as stated as its
use is allowed for malaria control and its use is actually increasing.
The loss of effective public health insecticides per se is an
issue against the trend for increasing indoor residual spraying
in many countries. All risk analysis to date show malaria a far
greater human risk factor than DDT.
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?
11. No response.
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?
12. Resistance is a factor with malaria,
TB and will increasingly become a factor with HIV.
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?
13. There will undoubtedly be further animal
to human transmission, it is however difficult to predict when
this will occur and the severity of the resultant disease.
24 January 2008
1 HIV/AIDS, Tuberculosis, Malaria and Avian Influenza. Back
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