The Principles of Disease Eradication in the 21 st Century

1. The Principles ofDisease Eradication in the 21st Century Ernst Strüngmann Forum 29 August – 3 September 2010

2. Forum Definitions 1. place of assembly for the people (as in ancient Rome) 2. an outlet for discussion of matters of interest to a given group

3. The Forum • Intensive 5-day workshop • Diverse group of 32 experts from academia, govt/research agencies, int’l multilateral org, NGOs, foundations--from around the globe • Disciplines: infect dis, PH/prev med, health policy, program management, health economics, health systems, medical ethics, epidemiology, virology

4. What to be thinking about on the way to “The Forum”

5. The Forum Four Work Groups: • Critical Issues in Determining Feasibility of Eradication • Developing an Eradication Investment Case • Governance • Disease Eradication and Health Systems

6. Eradication To “root out, destroy completely, get rid of” * *The Oxford [English] Dictionary and Thesaurus

7. Evolution of Current Definitions1997 Dahlem Workshop Elimination of disease: Reduction to zero of the incidence of a specified disease in a defined geographic area as a result of deliberate efforts; continued intervention measures are required. (model: neonatal tetanus) Elimination of infection: Reduction to zero of the incidence of infection caused by a specific agent in a defined geographic area as a result of deliberate efforts; continued measures to prevent reestablishment of transmission are required. (model: 1994 declaration of the Americas as polio-free)

8. Evolution of Current Definitions1997 Dahlem Workshop (cont.) Eradication: Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed. (model: smallpox)

9. Definitions from the Forum (1) Intent: • Identify shortcomings of the Dahlem definitions • Offer possible solutions • The Forum has no formal authority to establish a consensus document Definitions are, and will continue to be, established through broad acceptance and popular usage.

10. Definitions from the Forum (2) Global Eradication: The worldwide absence of a specific disease agent in nature as a result of deliberate control efforts that may be discontinued where the agent is judged no longer to present a significant risk from extrinsic sources. (example: smallpox)

11. Definitions from the Forum (3) Regional or National Eradication: The absence of a specific disease agent in a defined geographic area* as a result of deliberate control efforts that must be continued to prevent reestablished endemic transmission. (example: polio, measles, rubella, guinea worm) *Assumption: “defined geographic area” is substantially large and populous to give credibility to the claim that sustained eradication has been achieved.

12. Definitions from the Forum (4) Elimination: The absence of a disease caused by a specific agent in a defined geographic area as a result of deliberate control efforts that must be continued in perpetuity to prevent reemergence of disease. (example: neonatal tetanus)

13. Eradication occurs through a constellation of 4 favorable conditions • Biologic and technical feasibility • Public health infrastructure • Funding /Economic considerations • Sustained political /societal will

14. Where the constellation exists regional/national eradication occurs • Examples: -smallpox (~85% of countries by 1967) -polio (~50% of countries by 1990) -guinea worm -measles (Americas) -yaws (India 2006)

15. Regional Eradication Requires filling the gaps in the disease-specific constellation in all remaining countries of a region

16. Global Eradication Requires filling the gaps in the disease-specific constellation in all remaining regions of the world

17. The attraction of global eradication • Positive benefit-cost analyses • Advances a culture of prevention • Improves acceptance of other disease interventions • Builds health infrastructure • Provides social justice and health equity worldwide • The ultimate in public health goals

18. Current Global Eradication Initiatives Poliovirus Guinea worm

19. Diseases with proposederadication potential • Short term - measles - rubella • Long term - cysticercosis - lymphatic filariasis - malaria* - onchocerciasis* - yaws* *Not on list of International Task Force for Disease Eradication

20. Issue: is a global resolution needed for measles/rubella eradication? • No:-polio initiative is still ongoing -low political will in developed countries -inadequate funds -control is working in Africa • Yes:-highly cost beneficial - know more about M/R than any candidates - integrated program can improve routine and polio immunization - assures present momentum

21. Issue: are global resolutions needed for long term candidates? • No: -premature in terms of knowledge and timing -may cause more harm than good • Yes:-stimulates basic and operational research -justifies long-term planning -provides national and regional guidance

22. The Proceedings of theErnst Strüngmann Forum To be published by MIT Press in September 2011

23. A WHA resolution is a license for eradication,not a commitment

24. Each disease candidate is different, but all eradication, like all politics, is local.

25. No Togas Required!

26. Thank you !