Memorandum by World Health Organisation
Question 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?
1.1. Given available information at the
time, post-war optimism was not totally unfounded. Great progress
has been made in reducing morbidity and mortality from infectious
diseases, especially in less developed countries. There has been
a major reduction in the incidence and mortality from vaccine-preventable
diseases. However, there was also an unrealistic expectation that
once morbidity and mortality from communicable diseases were reduced,
they would not return. Constant vigilance, surveillance, and prevention
are required to keep old infectious diseases under control and
to prevent new ones emerging. Experience in Africa with malaria
illustrates this point.
1.2. Post-war optimism did not recognize that
many transmissible diseases were endemic in resource-poor settings
with health systems that were too limited to effectively control
and then eliminate many infectious diseases
1.3. The premise also was that social
and economic conditions would dramatically improve and hasten
the reduction in burden of infectious diseases. This patently
has not happened in many poor countries and changing socio-economic
conditions, especially globalization, which have developed since
the war have facilitated the emergence of new pathogens such as
HIV, SARS, Ebola, avian influenza (AI) and MDRTB. Changes in population
growth, migration, urbanization, persistent poverty, and environmental
change, among other factors, have resulted in conditions which
facilitate spread of old pathogens such as dengue fever and influenza
and promote the emergence and spread of new ones. The threat of
climate change on human health, as reported by WHO in 2003 (http://www.who.int/globalchange/publications/climchange.pdf)
has recently been brought to the fore as a result of it's likely
social, economic and human health consequence.
1.4. There is limited evidence that the
global situation is actually deteriorating, but conditions are
changing and infectious disease threats have certainly not lessened.
1.5. Prevention and control strategies
for major disease killers such as malaria and HIV have improved,
but implementation of sustainable programs incorporating these
advances lags behind.
1.6. A major challenge is to improve
our ability to detect and rapidly respond to the emergence of
these pathogens.
1.7. Without ability to detect and respond
to these pathogens throughout the world, then it would not be
an exaggeration to call the current situation a crisis, the weakest
link in the chain being a threat to all. For example, extensively
drug-resistant tuberculosis (XDR-TB) could spread widely in Africa
without being detected, and this could be a severe threat to health
elsewhere in the world.
Question 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?
2.1. For the last five years, because of
the degree of uncertainty in the data, HIV/AIDS epidemiological
estimates have been published by WHO and UNAIDS with ranges.
2.2. Methods and tools for estimates have
been improved over the last few years. More and better data are
available in many countries thanks to efforts to strengthen HIV
surveillance systems, especially in countries with generalized
epidemics.
2.3. At global level, WHO and UNAIDS have
revised the estimation of the global number of people living with
HIV/AIDS to 33.2 million (30.6-36.1), two thirds of them living
in Sub-Saharan Africa.
2.4. The global HIV epidemic seems to have peaked
at the end of the nineties, including in Africa. However in groups
of high risk populations the HIV epidemic continues to increase
in some countries.
2.5. HIV has become an endemic disease in
some settings. Even high income countries have difficulties in
reducing significantly the annual number of new cases; therefore
the perspectives of reaching zero growth in new HIV infections
in the short run are not realistic.
2.6. Overall at a global level the percentage
of women infected is 50%. The proportion of women infected in
different regions may increase slightly as more men are infected
and sexual transmission rates increase in countries with concentrated
epidemics.
2.7. The main mode of transmission in the African
region is heterosexual contact and will remain so, even though
there are increasing pockets of IDUs in some countries, especially
those with major ports and transport hubs. Overall, patterns of
transmission and epidemiology are not likely to change substantially
in the near to mid-term future. HIV will remain a threat to specific
vulnerable populations such as IDUs, sex workers and their clients,
and men who have sex with men (MSM). The HIV epidemic among MSM
is likely much more global than has been realized and has been
inadequately addressed.
2.8. WHO estimates that one third of the
world's population is infected with the mycobacteria that causes
tuberculosis, and nearly nine million people newly fall ill with
active TB disease each year. Based on a strong surveillance system
with 200+ countries reporting annually on TB case notification,
WHO estimates that worldwide TB incidence (new TB cases per capita)
is now beginning to fall, although levels are largely stable in
Africa and Eastern Europe after very rapid increases over the
past 15 years, and falling far too slowly in all regions.
2.9. HIV infection was the main cause for
the rapid increase in TB rates in Africa at the end of the 20th
century along with weakened health systems and social crises.
The levelling off is linked to the associated peaking of the HIV
epidemic. In the countries of Eastern Europe, TB disease and multidrug-resistant
TB rapidly emerged with the breakdown of the Soviet Union due
to high underlying levels of TB infection, the breakdown of health
systems, especially drug supplies and service financing, dire
conditions in large prison populations, and high population-wide
levels of substance abuse. Improving economic conditions are likely
contributing to the stabilization of incidence, although multidrug
resistant TB is a large and worsening threat in much of region.
Asia, given its vast populations, still carries the greatest burden
of TB although rapid scale up of TB control services has seen
a major improvement in treatment success and treatment coverage
in that region.
2.10. Malaria data is difficult to capture
due to the rural and inaccessible nature of many of those infected.
In addition, in some countries up to 60% of malaria cases are
treated in the private sector making it difficult to track cases.
Treatment based on clinical diagnosis of those most severely affected,
namely children under five years of age, is yet another complicating
factor.
2.11. The difficulty in estimating the numbers
not captured by the public health system remains problematic.
However, malaria incidence is estimated to have remained mostly
stable since the 1990s because of lack of access to effective
treatment as well as to preventive measures sufficient to cover
at least 80% of entire communities and increasing resistance to
commonly used drugs (particularly chloroquinine).
2.12. With the introduction of effective
antimalarial drugs (artemisinin-based combination therapies (ACTs)),
concentrated efforts to distribute preventive measures (particularly
long-lasting insecticidal nets (LLINs)) and the reintroduction
of indoor-residual spraying, many countries are beginning to show
some success in the response to malaria.
2.13. The main underlying causes of malaria
infection are 1) the continued reservoir of the parasite in the
human body—ie lack of sufficient treatment to eliminate
the parasite from the bloodstream of infected individuals within
biting range; 2) the continued presence of infected vectors; and
3) the lack of sufficient infrastructure to ensure sufficient
community wide coverage both with effective treatment and preventive
measures.
2.14. Data for AI infection are not definitive
but provide an indication of the human impact. The most severely
symptomatic cases are likely to be identified. The number of people
with acute illness and laboratory confirmed H5N1 infections occurring
since 2004, is 350. Human infections with H5N1 occur where poultry
are infected. H5N1 infections tend to be more common in the winter
months of the Northern Hemisphere and the virus is unusually persistent
in animal populations.
2.15. Massive and intense agricultural control
programmes have reduced human infections with H5N1. Notable examples
are China, Thailand and Vietnam. However H5N1 infections have
continued to occur in some of those countries. The widespread
persistence of H5N1 continues to increase the chance that a mutation
will occur and the virus becomes more easily transmitted among
people. If this occurs, H5N1 will move from being primarily an
animal infection that sometimes infects people to a human virus
with the capacity of infecting most of the world's population.
Question 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?
3.1. Due to the long silent period of the
virus in the human body and limited access to early testing, early
warning of outbreaks of HIV is limited internationally.
3.2. Countries have endorsed Second Generation
Surveillance System as the strategy to monitor HIV infection.
It includes surveys among vulnerable populations or populations
with high risk behaviours, and attempts to link behavioural data
with biologic measurements. Adequacy of the system depends on
availability of resources.
3.3. There is a strong global surveillance
system for TB control with over 200 countries annually providing
standardized routinely-collected age and gender-specific data
from primary health services around the globe.
3.4. WHO also leads a global TB drug-resistance
surveillance network that will produce in 2008 a comprehensive
global analyses of baselines and trends in prevalence of multidrug
resistant TB. This latest report includes the largest ever cohort
of surveys and data on the emergence of extensively drug-resistant
TB, a highly lethal form of disease. The surveillance network
includes "supranational" laboratories, based in national
public health services in selected industrialized and developing
countries, across all six WHO regions, which offer quality assurance
services and help build capacity and laboratory safety standards
in requesting countries. Many countries, especially in Africa
have yet to initiate their first surveys. This region faces a
substantial threat of rapidly emerging drug-resistant TB which
could be disastrous for those already vulnerable with high HIV
infection levels. Surveillance data is urgently needed to help
African countries prepare for prevention and treatment needs.
3.5. Where not impeded by lack of financing,
civil strife or other causes for lack of infrastructure, most
countries have in place a system for malaria surveillance. However,
in many poor countries, there are insufficient resources—both
human and financial—to ensure adequate monitoring.
3.6. Countries in the pre- or elimination
phase are most at risk from lack of surveillance as malaria is
easily reintroduced particularly given difficulties in eliminating
the malaria vector. Entomologists and malaria specialists are
in short supply and re-emphasis of training in these disciplines
would also help to improve malaria surveillance.
3.7. Epidemiologic capacity in developing
countries is seriously inadequate. Much more investment in all
aspects of strategic information, including conducting surveys
more regularly, is critically needed.
3.8. The WHO Global Alert and Response System
works and uses many innovative tools and networks to detect, verify,
assess and respond to outbreaks under the framework of the International
Health Regulations (2005). However there is gross underinvestment
in this system and it depends on strong, capable and transparent
national systems which again are subject to underinvestment.
3.9. For zoonotic diseases the Global Early
Warning System for Major Animal Diseases, including zoonoses (GLEWS)
was officially instituted in Feb 2007.
3.10. The Global Polio Eradication Initiative
(GPEI) has established an international surveillance and laboratory
network which has the goal of detecting and investigating sufficient
cases of "acute flaccid paralysis (AFP)" to identify
and track all chains of wild poliovirus transmission in the world.
The GPEI's AFP network has been successfully expanded in most
areas of the world to facilitate the investigation of other communicable
disease outbreaks such as H5N1 Influenza, SARS, Marburg Fever,
cholera and Ebola.
Question 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?
4.1. Projections for the HIV epidemic are
uncertain in the long-term, as they depend on increased survival
resulting from treatment coverage, and on the success of prevention
programmes in reducing the number of new infections.
4.2. Different factors are converging to
influence trends towards continued growth albeit slow in the overall
number of people living with HIV: more people are being treated
with ARV and live longer; prevention programs are poorly or insufficiently
planned and carried out; progress in HIV vaccine research is limited
and prospects to implement an efficacious vaccine in the short-mid
term are remote.
4.3. Some pockets of new HIV infections
can occur in countries with drastic social changes, lack of prevention
activities or failure of the health services to carry out proven
effective preventive actions.
4.4. Fewer HIV infections in children are
expected as PMTCT program coverage increases over the next few
years.
4.5. Vigorous implementation of programs
for female sex workers and for drug injectors is capable of reducing
or preventing HIV epidemics in these populations. Success has
been much more limited among MSM, in whom a resurgence of unsafe
behaviour and perhaps HIV transmission is being witnessed in the
industrialized world.
4.6. Eight countries in Southern Africa
with a general population prevalence in excess of 15% account
for about one third of the global burden of HIV/AIDS. An extraordinary
and special effort will be required to impact on the epidemic
in these countries.
4.7. The Global Plan to Stop TB, 2006-2015
includes epidemiological projections documenting the potential
to reach the 2015 Millennium Development Goal of reversing TB
incidence, and halving both TB mortality and TB prevalence globally.
If the plan's agenda is followed, which lays out the implementation
approach for the WHO Stop TB Strategy, then at least 14 million
lives could be saved by 2015 and the targets can be reached. If
not, then there is major risk of a renewed deterioration in TB
indicators especially in the poorest and most vulnerable populations,
and for an increase in rich and poor countries alike of multidrug-resistant
TB. The greatest challenges across regions are to maintain the
scale up of good quality TB services while also expanding those
services to adequately address TB/HIV and MDR-TB treatment and
first and foremost ensure that poor and unsafe services are halted
to pre-empt the further emergence of drug-resistant strains.
4.8. Based on recent successful country
experiences, evidence is accumulating that the global burden of
malaria could be reduced by at least 70% in the next 3—5
years, if there were sufficient resources (financial, human and
technical) devoted to malaria control. However, a concerted push
will need to be made to ensure adequate and sufficient coverage
of entire populations with malaria treatments (eg ACTs) and preventive
tools (esp. LLINs and IRS).
Question 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?
5.1. The coverage of prevention interventions
remains inadequate. Few countries have set targets and indicators
for prevention programmes and systematically increased coverage
of prevention interventions in the public and private sector.
5.2. In HIV, the lack of coverage can be
addressed through addressing better-targeted prevention programmes
aiming at saturation coverage of populations at high-risk first
while preparing for saturation coverage of prevention interventions
to other vulnerable populations such as young people and migrants.
5.3. In malaria, coverage with long-lasting
insecticidal nets (LLINs) is still generally extremely low, even
though this is the best protection available, and rapid progress
is being made in some areas. Many countries do not have adequate
resources—particularly human—to manage distribution
campaigns.
5.4. Likewise, indoor residual spraying
(IRS) is the most effective means of rapidly reducing malaria
parasite transmission. However IRS is labour intensive, requiring
good planning and effective deployment to achieve rapid reductions
in malaria morbidity and mortality. Many countries do not have
the internal capacity to plan and implement spraying campaigns
even if provided the necessary equipment.
5.5. Ensuring that effective treatment for
HIV/AIDS, TB and malaria is available at all levels of service
delivery down to the community can in many situations be extremely
difficult. In TB control, for example, many private sector institutions
are offering inadequate and often unsafe TB treatment which can
lead to treatment failure and drug resistance.
5.6. TB tools in widespread use today are
40-125 years old. Drug-resistant TB and HIV-associated disease
are woefully addressed with these old tools.
5.7. For avian influenza, lack of action, transparency
and intersectoral collaboration of Ministries of Agriculture and
in some cases Ministries of Health (MOH). Although MoHs have become
much more responsive and engaged in human AI. There needs to be
fundamental investment if surveillance, preparedness and response
architecture at national regional and global level for avian influenza,
pandemic influenza and other severe emerging and epidemic-prone
diseases. Member States are committed to achieve this through
the implementation of the IHR (2005).
5.8. Significant blockages to control of
the four diseases can be addressed by:
— Strengthening health systems to:
improve access to well-staffed quality services and health systems
overall in the poorest areas of the world; expand uptake of proven
strategies; and engage the private sector, as well as affected
communities themselves to increase impact.
— Financing public health institutions
and control programs that provide essential surveillance, stewardship,
capacity-building, robust programme assessments and other analytic
functions.
— Supporting research and development
for new diagnostics, drugs and vaccines.
Question 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?
6.1. WHO plays its essential functions,
including articulating policy options, setting norms and standards,
shaping the research agenda, providing technical support to countries,
assessing epidemiologic trends, monitoring and evaluation and
harmonizing and aligning partner implementation strategies and
goals with national health sector plans and initiatives.
6.2. WHO works in collaboration with governments,
bilateral donors, civil society, the private sector, multi-lateral
organizations and partnerships including GFATM, UNAIDS Secretariat
and cosponsors, the Roll Back Malaria Partnership, the Stop TB
Partnership and UNITAID, which it hosts.
6.3. Overall, there is a strong level of
synergy in the actions of the range of partners, but synergy is
not complete. WHO plays a key role in developing a global vision
for responding to the four diseases and assuring strong coordination.
6.4. WHO needs additional high-quality technical
personnel and more flexible funding to be able most meaningfully
to deal with its global mandate.
6.5. There is an imbalance between specified
funds which tend to focus on a limited number of well funded activities
(eg HIV drug resistance, provider initiated testing and counselling)
and unspecified funds critically needed for core WHO mandate activities,
including surveillance and strategic information which currently
are insufficiently funded.
6.6. WHO's offices at global, regional and
country level comprise a strong network which is well structured.
However the network is inadequately staffed, especially at country
level. There are increasing demands for implementation support
from governments, other technical agencies, NGOs and civil society
partners, as well as donors supporting disease control at country
level.
Question 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?
7.1. Population increase, persistent poverty,
gender inequality, urbanization, wars, disasters, food insecurity,
increased international travel, migration, lifestyle changes,
other forms of economic globalization, social and economic crises,
changing farming practices and other environmental changes contribute
to the spread of HIV, TB and malaria as well as to the emergence
and/or spread of more lethal forms of them.
7.2. International cooperation is absolutely
necessary to effectively respond to the four diseases.
7.3. The Global Outbreak Alert and Response
Network needs to be strengthened and governments need to work
together at the regional and global levels.
7.4. Other work by WHO and partners has
reinforced the lessons learnt on how poverty breeds HIV, TB and
malaria and how they lead to further impoverishment of families,
as well as how disease control efforts can dovetail with poverty
alleviation and human rights initiatives. More explicit attention
to disease prevention and rights to health care in prison reform,
refugee response, oversight of labour conditions, gender equity
efforts, immigration, and substance abuse policies all can make
a difference.
7.5. High density populations combined with
subsistence husbandry of mostly small livestock with poor sanitary
infra-structure are key drivers of H5N1. This is exacerbated by
traditional close contacts between humans and poultry with often
shared housing environment and by the widespread small scale and
home slaughtering of poultry or in wet markets. The movement (legal
and illegal) of poultry, poultry products and captive wild birds
and migration of wild birds that act as reservoirs for influenza
viruses without necessarily showing signs of disease can also
contribute to the spread of the disease.
7.6. While climate change is sometimes quoted
as an underlying reason for the spread of malaria, the evidence
is patchy. While the rise of average temperatures (in particular.
of the average minimum night temperature) may cause malaria transmission
to move to higher altitudes, there are as a rule many confounding
factors to which change can also be attributed. Changes in rainfall
patterns are more conclusive, such as the 1997 (El nin®o)
rains in Kenya which led to major malaria outbreaks—so in
this context, extreme weather conditions are important in the
intensification of malaria transmission.
Question 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?
8.1. Important contributors include: urban
deprivation and poverty; high rates of immigration from high incidence
countries; an increasing refugee population; HIV; and inadequate
public health infrastructure to deal with TB in hard-to-reach
populations.
8.2. Intergovernmental action can help:
(a) ensure timely surveillance data to monitor trends in TB control
globally and in Europe specifically, as well as trends in drug-resistant
TB; (b) increase preparedness and response when facing incidents
of travel into or through the UK of persons with MDR/XDR-TB that
could pose especially significant risks to public health; (c)
increase consensus-building and fast adoption of effective global
policies for improved TB prevention, treatment and control; and,
(d) enable far earlier development and introduction of new tools
to fight TB.
8.3. A study published in 2005 in the New
England Journal of Medicine estimated the substantial health sector
savings in the United States and Canada if investments were made
in TB control in the top countries of origin of the rising share
of foreign-born TB patients in Canada and US. UK aid to global
disease control and surveillance efforts and in-kind UK institutional
support (eg engagement of top public health laboratories, academic
institutions, development agencies, and the corporate sector in
the UK) are important contributions.
Question 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?
9.1. WHO estimates that globally the new
TB case rate has peaked, and in most regions it is beginning to
fall albeit too slowly. In Eastern Europe and Africa, case rates
have stabilized after rapid increases over more than a decade,
due principally to economic/social transition in the former Soviet
Union, and due to the HIV epidemic in Africa.
9.2. Over 30 million people worldwide were
treated over the last 11 years applying the DOTS approach and
treatment success globally is now near the target of at least
85%, proving TB is largely curable even in the poorest settings.
Globally, DOTS-based programs are reaching almost two-thirds of
estimated cases globally (compared with less than 10% a decade
ago). Anti-TB drug supplies have greatly improved for patients
in the public sector in low-income countries, due to increased
financing sources, domestic policies and the Global TB Drug Facility.
9.3. The WHO Stop TB Strategy lays out the
proven approaches to reach more persons ill with TB and making
treatment less onerous including: community-based care; better
diagnostic capacity for earlier identification of drug-resistant
TB and HIV-associated TB; better treatment protocols; and strengthened
health systems for more truly free TB care and earlier service
access. Overall, WHO estimates that for 2008 alone there remains
about a 50% gap in financing for TB control implementation of
over US$2 billion, for national control efforts and global technical
assistance.
9.4. Globally, under 5% of the TB burden
is attributable to HIV infection, but up to 70% of TB patients
are HIV+ in the African countries hardest hit by HIV infection.
Policies and field best practice models of integrated TB/HIV care
are being applied but need faster scale up and high level commitment
to make a difference in the highest HIV burden settings. Tobacco
use is linked to increased TB disease and mortality given prior
TB infection. Other immune-compromising diseases such as diabetes
and malnutrition also contribute to the TB burden.
9.5. TB breeds in settings of poverty, overcrowding,
economic and social instability and where migration and travel
are rapidly increasing. Good TB control practices need to be scaled
up further especially in the poorest countries, and new tools
are needed to ensure patients are detected earlier and treatment
barriers are reduced.
9.6. Intergovernmental action is already
making a profound difference through commitments, including by
the UK Government, technical agencies, academics and civil society
organizations, to the Global Plan to Stop TB, 2006-2015. Intergovernmental
collaboration with partners supports: national scale-up of proven
control policies; harmonized approaches aligned with national
health sector plans and initiatives; coordinated technical assistance
that meets the demands of recipients; strengthened surveillance;
awareness raising and urgently needed research.
Question 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?
10.1. The Stockholm Convention only allows
the use of DDT for public health purposes such as vector disease
control. Therefore, the Convention cannot be a factor causing
increase in the spread of malaria. Rather, it has helped to focus
on the options for vector control in support of reducing the burden
of malaria.
10.2. No risk analysis has been carried
out comparing the relative dangers to human health posed by DDT
and Malaria. WHO continues to coordinate international research
and monitoring of the risks posed by DDT to human health.
Question 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?
11.1. The recognition through modelling
that it may be possible to prevent the development of a pandemic
of influenza has led to the development of a Rapid Containment
Protocol including the use of non-pharmaceutical interventions
such as isolation, quarantine and social distancing, anti-virals
for treatment and prophylaxis of contacts and vaccine if available.
Question 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?.
12.1. Increased drug resistance is not driving
an increase in the incidence of HIV infection. While a certain
proportion of new infections (5-20%) in industrialized countries
are with viral isolates showing some genotypic resistance, there
is no obvious evidence as yet of an increasing rate of premature
treatment failure.
12.2. Drug resistance is immensely important
in tuberculosis, and manifests as resistance to single drugs,
multidrug-resistance, and extensive drug resistance. Antituberculous
drug resistance, including MDR and XDR, has been associated with
HIV infection in some settings. HIV-infected people, once exposed
to tuberculosis, including drug-resistant strains, are vulnerable
to rapid progression to disease following infection. Drug resistant
tuberculosis is therefore an important threat to HIV-infected
persons, especially in congregate settings such as prisons and
hospitals, and can result in tuberculosis outbreaks in such settings.
This has likely happened in South Africa in recent time.
12.3. WHO has not found that overall TB incidence
trends nationally and globally have been affected by rising levels
of drug-resistant TB. However, the overall control of TB is at
great risk, as well as public safety, if drug-resistant TB is
not prevented, quickly identified and contained. Global efforts
are focusing on: providing effective TB treatment to prevent the
emergence and spread of drug-resistant strains; large-scale improvements
in laboratory networks worldwide; introduction of new diagnostics
and research; surveillance to monitor the emergence and trends
of drug-resistant TB locally, regionally and globally; and expanding
treatment of drug-resistant TB.
12.4. Resistance has developed to almost
all of the previous antimalarial medicines that were used, sometimes
taking just a few years to spread worldwide. Therefore it is critical
that the efficacy of artemisins, the only effective medicines
against drug resistant parasites, be protected. Malaria-bearing
mosquitoes are also becoming resistant to the insecticides deployed
to kill them.
12.5. WHO is stringently monitoring drug
and insecticide resistance, and is working closely with countries
to implement systems to avert these
Question 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?
13.1. HIV and TB may be acquired within
a hospital or other medical facility by either health care workers
(HCWs) or patients.
13.2. HCWs, due to exposure to infected
body fluids, are at risk of acquiring multiple types of infection
from patients, including HIV.
13.3. It is estimated that approximately
327,000 HCWs throughout the world are percutaneously exposed to
HIV with the highest numbers of exposures being in sub-Saharan
Africa and South-east Asia, where HIV testing and post-exposure
prophylaxis are far less readily available. An estimated 4% of
HIV infections in HCWs may occur from occupational exposure.
13.4. To lessen infection in health care
settings, WHO develops or shares intergovernmental knowledge by:
issuing guidance on evaluating risk of HIV infection from exposure
to body fluids and the use of post-exposure prophylaxis; performing
annual global surveys of blood collection, blood screening and
transfusion practices; providing guidance on means of lessening
risk of HIV infection via blood transfusion; hosting the Global
Collaboration for Blood Safety (GCBS) an international network
of all major international organizations working on global blood
safety to improve safety of blood and blood products, and to promote
safe and rational blood transfusion practices; hosting the Safe
Injection Global Network (SIGN), an international effort to decrease
the use of injections and eliminate unsafe injections, and to
enhance safety of the health care setting; hosting the World Patient
Safety Alliance which aims to coordinate, disseminate and accelerate
improvements in patient safety worldwide; providing guidance on
precautions to lessen exposure to body fluids in health care settings.
13.5. Recent evidence in Southern Africa
has shown that the spread of extensively-drug resistant TB (XDR-TB)
in hospitals serving as antiretroviral treatment sites can be
highly lethal. WHO is leading work with a wide range of partners
to rapidly provide updated policies for infection control engineering,
health worker practice and overall models to reduce the need for
in-patient or ambulatory TB care in concentrated congregate settings.
Question 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?
14.1. There are no new drugs for tuberculosis
near readiness for introduction to the market so there are no
patent/IP issues yet, but if early trials of new drug compounds
are successful, in the next decade these issues may become highly
relevant for TB control. Too few R&D firms are engaged in
TB and malaria drug research relative to the vast need.
14.2. It is important to note that of the
various ACTs available only Coartem© produced by Novartis
is under patent. However, generic copies have been produced in
various centres worldwide. There are currently only three Long
Lasting Insecticidal Nets (LLINs) which are quality approved by
WHO (Olyset©, Permanet© and Interceptor©) of which
Permanet©, produced by Vestegaard-Fransen and Interceptor
produced by BASF are under patent. At present, given the complexity
of the technology to produce actual long-lasting nets no generics
which pass the quality tests—duration of insecticidal activity,
durability of the material, etc.—to qualify as LLINs have
been produced.
14.3. The 2006 report of the WHO Commission
on Intellectual Property Rights, Innovation and Public Health
(CIPIH) concluded that although intellectual property rights (IPR)
provided important incentives for the development of new medicines
and medical technologies, IPR do not provide an effective incentive
when patient populations are small or poor.
14.4. The Commission's recommendations resulted
in creation in 2006 of the Inter-Governmental Working Group on
Public Health, Innovation and Intellectual Property. The Working
Group's mandate is to draw up a global strategy and plan of action
aimed at, inter alia, securing an enhanced and sustainable basis
for needs-driven, essential health research and development relevant
to diseases that disproportionately affect developing countries,
and submit this to the Sixty-first World Health Assembly in May
2008.
Question 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?
15.1. WHO sets global standards and provides
technical collaboration with member states at the global, regional
and country levels for diagnosis, prevention, treatment and control
of the four diseases, including dealing with outbreaks.
15.2. While great progress has been made
in establishing a global framework for detecting and responding
to treatment, prevention and control, increased intergovernmental
collaboration and cooperation are needed at the regional and country
levels to strengthen surveillance and disease control activities.
15.3. The UK has in the past seconded staff
to WHO which have made significant contributions to the different
diseases. More could be done to facilitate and support such secondments—particularly
from academic and public health institutions. Policies need to
support incentives that increase the pool of public health and
clinical expertise in the four diseases and sustain engagement,
particularly in developing countries.
15.4. In the short term, ongoing support
to WHO and national technical agencies to continue to hold consultations,
to sift through the scientific and other relevant literature and
experience, and to make this information understandable, is critical.
15.5. To ensure sustainable outcomes, intergovernmental
action must continue enabling poorer countries to build their
own technical capacity to directly access (and produce) scientific
and technical information and to communicate this to their populations.
15.6. States should share experiences and
data related to: the analysis of historical health-facility data
and if possible data derived from prevention means and case management
at community level; method for calculation of thresholds; agreed
set of data/indicators to be collected and the meaning of representative
data and the periodicity of reporting and feed back; standardized
case definition, diagnosis (laboratory services quality) and treatment;
improvements in public health surveillance for trend monitoring
and early detection; past experiences in dealing with outbreaks
(timely response, human and financial resources capacity, commodity
accessibility, use of health facilities, and educational messages).
Question 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?
16.1. The International Health Regulations
(2005) (IHR) are a legal framework to better manage the collective
defences against acute public health risks that can spread internationally
and have devastating impacts on human health as well as unnecessary
interference on trade and travel. They are binding on all WHO's
Member States. Given that IHR (2005) only took effect in June
2007, evaluation would be premature, however, their broad global
acceptance greatly enhances the potential for effective world
wide impact.
16.2. The IHR provisions addressing the
detection, assessment, reporting and response to public health
events are generally formulated to complement and support the
WHO global alert and response system. The IHR provide specific
mandates for WHO in this context, including access to critical
public health information about emerging events.
16.3. Under IHR, WHO member states have
a responsibility, not only to develop their own infrastructure
but also to help less developed countries do the same.
16.4. The World Health Report 2007 states
that "A more secure world that is ready and prepared to respond
collectively in the face of threats to global health security
requires global partnerships that bring together all countries
and stakeholders in all relevant sectors, gather the best technical
support and mobilize the necessary resources for effective and
timely implementation of IHR (2005)".
Question 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?
17.1. WHO has issued preparedness guidance
for public health in the event of a bioterrorist release and has
developed operational protocols for its own actions during such
events. WHO continues to liaise with military and policing organizations
to ensure that its public health mandate can be delivered during
such an event and adequate arrangements for co-ordination are
in place.
Question 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.
18.1. The most significant new, emerging
diseases that have occurred mostly during the past ten years,
have been of zoonotic origin. These diseases have been transmitted
to humans mostly by close contact with affected live animals or
their carcasses, or through the consumption of their tissues.
The trend is likely to continue in the foreseeable future. It
is very difficult to predict the outcome on public health of these
emerging zoonotic diseases both before their zoonotic nature is
confirmed and even after since transmission patterns are not always
sufficiently understood to assess this impact accurately. The
financial losses of zoonotic diseases (recorded in both human
and animal health) and also the societal non-monetary losses caused
by these diseases is usually very high as demonstrated by the
bovine spongiform encephalopathy, severe acute respiratory syndrome
and avian influenza epidemics.
18.2. Altering human behaviours, environments,
human and animal movement trends, extent of food trade, adaptation
and evolution of infectious pathogens are just a few reasons that
impact the fluid phenomenon of emergence and re-emergence of zoonotic
diseases eg SARS. History shows we cannot fully predict occurrence
and spread of disease that is why early warning systems and emergency
preparedness are so important. Dealing with a disease epidemic
in its early stages is easier and more economical than when it
is widespread. Sometimes signs in animals pre-empt human disease
and so early warning in animals is an efficient way to avoid human
disease occurrence.
18.3. Health threats arising from natural
disasters, technological incidents (eg chemical or radio-nuclear
accidents) and from conflict and terrorism are common. This burden
and global health security threats can be greatly reduced if countries
have in place measures to prevent, prepare for and respond to
such events.
Question 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?
19.1. WHO receives funding from DFID for
Avian Influenza. However, the main investment by the UK in international
alert and response is through contributions of science and public
health agencies and institutions acting as WHO Collaborating Centres,
and provision of experts to committees, reference services and
staff who go to the field as part of Global Outbreak and Response
Network (GOARN) teams.
19.2.
|
| UK Contrubitons
|
| Disease | 2004-2005 biennium
| 2006-2007 biennium*
| Other |
| WHO-HQ
| PAHO | WHO=-HQ
| PAHO |
|
|
| HIV/AIDS | $13.42m
| $1.44 million | $13.14 million
| $1.34 million | 1 Sr
Secondment
|
| TB | $344,018 (ncluding $176,367 for Stop TB Partnership)
| $30,600 | $43.4 million (including $42.9 million for Stop TB Partnership
| $13,900 | |
| Malaria | $957,855
| $£13,900 | $2.1 million (including $1.6 million for RBM Partnership)
| $272 | |
|
| * (estimated, pending closure of accounts).
|
Question 20: Do you wish to provide any other relevant
information in addition to what you have said in answer to the
above?
1 February 2008
1
HIV/AIDS, Tuberculosis, Malaria and Avian Influenza. Back
| 
