Third Meeting of the Asia Pacific Technical Advisory Group on Emerging Infectious Diseases, Kuala Lumpur, Malaysia, 16-18 July 2008 : report

(WP) 2008/CSRfDCC/03 Reports series number: RS12008/GE/29 (MAA)

English only

REPORT

J'JHRD MEETING OF THE ASIA PACIFIC TECHNICAL ADVISORY GROUP // ON EMERGING INFECTIOUS DISEASES

Convened by:

WORLD HEALTH ORGANIZATION

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World Health Organization Regional Office for the Western Pacific Manila, Philippines 16to 18 July 2008

NOTE The views expressed in this report are those of participants, and consultants in the Third Meeting of the Asia Pacific Technical Advisory Group on Emerging Infectious Diseases and do not necessarily reflect the policies of the World Health Organization.

This report has been printed by the WHO Regional Office for the Western Pacific for the participants in the Third Meeting of the Asia Pacific Technical Advisory Group on Emerging Infectious Diseases, held in Kuala Lumpur, Malaysia, from 16 to 18 July 2008.

TABLE OF CONTENTS

PAGE

SUMMARY

1. 2. 3.

INTRODUCTION ............................................................................................................ 1 PROCEEDINGS ............................................................................................................... 2 CONCLUSIONS AND RECOMMENDA TIONS ........................................................... 27

ANNEXES ANNEX 1 - PROGRAMME OF ACTIVITIES ........................................................................... 33 ANNEX 2 - LIST OF PARTICIPANTS ...................................................................................... 40

SUMMARY

The Third Meeting of the Asia Pacific Technical Advisory Group on Emerging Infectious Diseases was held in Kuala Lumpur, Malaysia, from 16 to 18 July 2008. The objectives of the meeting were: (I) to provide updated information on emerging infectious diseases in the Asia Pacific Region; (2) to review progress of pandemic preparedness and implementation of the Asia Pacific Strategy for Emerging Diseases and International Health Regulations (2005), in particular, the achievements and areas for further improvement at country level with focus on surveillance and response; and (3) to make technical recommendations on future steps on emerging infectious diseases prevention, preparedness and response in the Asia Pacific Region. Emerging infectious diseases remain a significant threat to public health and to the economic well-being of the Asia Pacific Region. While the region has accumulated considerable experience and expertise in the management of emerging infectious diseases, they continue to remain at the forefront of global concerns about pandemic influenza. For these reasons, ongoing and active collaboration between the WHO Regional Offices for South-East Asia and the Western Pacific, in conjunction with other regional and global partners, is a vital element of the overall strategy to manage the risks associated with emerging infectious diseases. The Asia Pacific Strategy for Emerging Diseases (APSED) and the International Health Regulations (2005), or IHR (2005), provide mutually supportive frameworks that mandate and inform continued efforts to strengthen the planning and delivery of core public health functions - functions that contribute directly to infectious disease prevention, preparedness and response. The implementation of APSED also provides opportunities for ongoing flexibility, allowing for adaptations to accommodate changing circumstances and priorities. Progress made on the previous Technical Advisory Group (TAG) recommendations was reviewed across the five APSED programme areas and generally was found to be significant. However, one area where progress was less than hoped for was in relation to infection control. In this area, it was proposed to scale back from a comprehensive programme, and to focus instead on a more targeted, structured approach. This type of approach was considered to be more likely to deliver tangible results in the short to medium term. The meeting's conclusions and recommendations included guidance on each of the five APSED programme areas:

Surveillance and response - To improve sensitivity and early warning capability, surveillance systems should incorporate event-based surveillance into more established surveillance platforms, such as indicator-based surveillance. The combined surveillance system should be closely linked to the response function at both the 10caVdistrict and national levels. Ongoing support, including field epidemiology training and associated resourcing, should be at least maintained, or preferably enhanced. Laboratory capacity - To ensure accurate, safe and timely diagnosis, countries should promote biosafety practices and encourage inter-laboratory networking, collaborative research programmes, and the development and implementation of national strategies for laboratory capacity-building, targeting specific diseases of national public health relevance.

Zoonoses - Strengthening coordination between the human and animal health sectors remains a priority. This should include risk reduction initiatives, information sharing and alerts, and opportunities to collaborate on training and research priorities. Infection control - The meeting acknowledged that this area remains an ongoing challenge. Following regional consultation and a review of progress, it is proposed that future efforts should focus on a more limited number of objectives. A more targeted approach would include a national structure to provide leadership for infection control and an associated resource centre. A related theme was to reflect the broader concept of "health facility preparedness". Risk communication - Increased capacity-building in risk communication at the country level, including use of WHO resource documents, was encouraged. Communication strategies, including risk communication plan, should be included in outbreak response plans as well as in national workplans. Both APSED and the IHR (2005) underpin pandemic preparedness at the regional and country levels. Countries were encouraged to adopt a whole-of-government, whole-of-society approach to pandemic preparedness. This approach will be endorsed in WHO's revised pandemic planning guidelines, which will be issued before the end of 2008. Countries were also encouraged to employ a two-tiered approach to pandemic preparedness, reflecting both a planning cycle model (developing, testing and revising pandemic plans) and also a focus on increasing readiness. Increased readiness includes a mix of pandemic specific preparations as well as strengthening routine public health capacities. Countries may also consider it appropriate to use guidelines developed by WHO in reviewing and harmonizing epidemiological and virological surveillance systems and in conducting influenza disease burden studies. Other examples of priorities for pandemic planning include greater engagement with local government and promotion of business continuity planning for both government services and the private sector. To support the strengthening of local- and district-level capacities for outbreak detection and response, the corresponding national systems should be reviewed and enhanced. IHR event communication protocols, mechanisms for interagency collaboration, the arrangements for the National IHR Focal Point responsibilities and for ensuring public health measures at the border and associated points of entry should be further strengthened to meet the IHR requirements.

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1. INTRODUCTION

The Asia Pacific Technical Advisory Group (TAG) on Emerging Infectious Diseases (EIDs) held its third meeting in Kuala Lumpur, Malaysia from 16 to 18 July 2008. This meeting reviewed progress in implementing the Asia Pacific Strategy for Emerging Diseases (APSED) and the Intemational Health Regulations (2005), and recommended further priority actions on their ongoing implementation. Immediately prior to the third TAG meeting, on 15 July 2008, the Technical Advisory Group members held a preparatory meeting. The subsequent full meeting was attended by more than 25 representatives from 17 Member States, as well as the core TAG group, donors, partners and the WHO Secretariat. Since the TAG's second meeting in New Delhi, India, from 18 to 19 July 2007, much progress has been made to implement its recommendations on: pandemic influenza; implementation of the WHO APSED workplan to meet the IHR core capacity requirements; and compliance with other IHR obligations. Dr Takeshi Kasai (Responsible Officer for the meeting), Regional Adviser in Communicable Disease Surveillance and Response, WHO Western Pacific Regional Office, gave a brief introduction on the meeting objectives and expected outcomes. The meeting's programme of activities and list of participants are attached in Annexes I and 2, respectively. 1.1

Objectives (I) To provide updated information on emerging infectious diseases in the Asia Pacific Region. (2) To review progress of pandemic preparedness and APSED/IHR implementation, in particular, the achievements and areas for further improvement at country level with focus on surveillance and response. (3) To make technical recommendations on future steps on emerging infectious diseases prevention, preparedness and response in the Asia Pacific Region.

1.2

Openingremarks

Dr Han Tieru, WHO Representative in Malaysia, Brunei Darussalam and Singapore, on behalf of the WHO Regional Offices for South-East Asia and the Western Pacific Region, thanked the Ministry of Health Malaysia for supporting this meeting and noted that this Third Meeting of the Asia Pacific Technical AdVisory Group on Emerging Infectious Diseases would provide an important opportunity to continue to build national and regional capacities in a systematic way. The meeting would also provide a forum to review progress in the context of the significant threats posed by avian influenza and other emerging infectious diseases. As well as posing threats to national, regional and global health security, these diseases also have the potential to adversely impact on economic development and social and political stability. The IHR (2005) provide a shared framework for WHO Member States to anticipate and respond to a wide range of public health risks, including but not limited to those associated with infectious disease. To assist countries meet health challenges and discharge their obligations under the IHR (2005), APSED was developed and endorsed by both Regions in September 2005. The core goal is that "all countries and areas of the Asia Pacific Region will have the minimum capacity for epidemic alert and response by 2010". To this end, APSED identifies five

-2critical programme areas for planning and implementation. These areas address capacity-building for surveillance and response, laboratory, zoonoses, infection control and risk communication. This TAG meeting aimed to review progress in these areas and to chart the steps that need to be taken as countries across the region move towards ensuring that the key capacities are in place over the next two to three years. Dato' Dr Haji Ramlee bin Haji Rahmat, Deputy Director-General of Health, Ministry of Health, Malaysia, thanked WHO for holding this important meeting in Kuala Lumpur. He noted a number of ongoing regional threats associated with emerging infectious diseases, especially those that might arise in, or have serious impacts for, the Asia Pacific Region. The focus on APSED workplans to develop core public health capacities at the country level is a key step to strengthening public health functions and will also contribute to the requirements of the IHR (2005). Malaysia itself has recently experienced the social and economic effects from outbreaks of infectious disease. Globalization, climate change and governance will be key themes for future planning and will help shape collective responses to common threats. Foremost among these is the threat posed by pandemic influenza. Malaysia has a comprehensive, multi-stage and multisectoral pandemic plan to prepare for and manage the response to any such pandemic. A national centre for disease control would help to provide leadership and technical expertise in this regard. Global health threats require global responses, and this meeting of eminent public health experts will make a contribution towards this objective. In particular, the meeting would assist with the further implementation of the specific requirements of the IHR (2005) and APSED framework. 1.3 Organization of the meeting

The meeting comprised a series of presentations that updated participants on emerging disease threats, the International Health Regulations (2005), pandemic preparedness and progress with implementation across the five APSED programme areas. Group breakout sessions were conducted for countries from the South-East Asia and Western Pacific Regions. Breakout sessions were also held by donors and partners and the members of the Technical Advisory Group. Dr Donglou Xiao, Deputy Director-General, Bureau of Disease Control, Ministry of Health, China, was appointed Chairperson for the meeting. Professor Angus Nicoll, CBE, Senior Expert _ Influenza Coordination, European Centre for Disease Prevention and Control, was appointed as Rapporteur. Chairpersons and Rapporteurs were also appointed for each of the six sessions.

2. PROCEEDINGS

2.1

Session 1: Emerging disease threats and APSED approach

The Chairperson, Dr Donglou Xiao, introduced the first session, noting that while considerable progress had been made, the ongoing challenges of emerging infectious diseases and the continued threat associated with events of international significance meant that countries should redouble their efforts.

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2.1.1 Global update on EIDs and mR (2005) implementation Dr Maxwell Hardiman, World Health Organization, Geneva While the International Health Regulations (2005) address a wide range of potential public health risks, it was emerging infectious diseases in particular that were the driving force behind the development of the revised lHR. The APSED strategy - its objectives and five programme areas - contributes directly to achieving the purpose of the IHR (2005) to prevent and manage the spread of disease threats between countries. National Focal Points have been appointed in all but one WHO Member State (Somalia) and this facilitates communications with WHO and also directly between countries. For example, 75% of Member States are using the WHO event information system. Over the last year, a number of events, including food safety alerts (lNFOSAN), avian influenza, drug resistant tuberculosis and a major CONVEX exercise have all put various IHR systems to the test. Assessments of core capacities at points of entry have been undertaken and guidelines issued to support capacity-building. Legal implementation is also progressing well, with only two countries lodging reservations to the IHR (2005) and 85 countries having assessed their legislation against IHR requirements. The World Health Assembly (WHA) also considered implementation progress reports provided by Member States in May 2008. 2.1.2 Update on EIDs in the Asia Pacific Region Dr Khanchit Limpakarnjanarat, South-East Asia Regional Office The Asia Pacific Region covers a vast area, contains 50% of the world's population and has a relatively high population density of 226 persons per square kilometre. Travel and trade are at high levels and both continue to trend upwards. Following the severe acute respiratory syndrome (SARS) multicountry outbreak in 2003, a number of significant disease outbreaks have occurred, including cholera, dengue, Nipah and continuing human cases of avian influenza (AI). Experience to date with AI suggests that young adults and children are most susceptible. The interaction between wild birds and domestic species continues to be a concern, along with the close proximity of people and domestic birds. The H5Nl virus is continuing to evolve and remains a significant concern. Additionally, mosquito transmitted diseases such as chikungunya and dengue fever appear to be increasing, with the latter affecting many countries in the Region. Bats are also involved in the transmission of other diseases in the Region. Hand, foot and mouth disease (HFMD) has also been a recurring problem, requiring attention and resources. In conclusion, emerging infectious diseases remain a leading cause of sickness and death and continue to pose a significant emergency threat. 2.1.3 APSED implementation progress since the Second Meeting of the Asia Pacific Technical Advisory Group on Emerging Infectious Diseases in 2007 Dr Takeshi Kasai, Western Pacific Regional Office Across the Asia Pacific Region, all five APSED programme areas have made progress over the last 12 months, although some have made more progress than others. Given the wide range of challenges, particularly avian influenza, the five APSED objectives not only address pandemic preparedness, but also contribute to IHR (2005) requirements. A two-tiered approach to pandemic preparedness involves the preparation and review of a country-level plan of action as well as a strong focus on increasing readiness within the health sector and other sectors, in particular, local government.

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The five APSED programme areas continue to provide the framework for planning and capacitybuilding: (I) "Surveillance and response" includes both event- and indicator-based surveillance, both of which should be closely linked to the response function.

(2) "Laboratory" ensures accurate, safe and timely diagnosis and strengthening laboratory networking. (3) "Zoonoses" addresses risk reduction, information sharing and alerts, and with opportunities to collaborate on training and research priorities. (4) "Infection control" is an area where further progress is especially needed. Following consultation and a review of progress, the intention now is to concentrate on achieving progress on a more limited number of objectives. Such a targeted approach would include a national structure for infection control, a resource centre and a single point of contact. (5) "Risk communication" includes operational communication and outbreak communication.

Of TAG's seven general recommendations, Dr Kasai reported that two have been completed and five are in progress. Twenty-six countries within the Asia Pacific Region have completed capacity assessments using the APSED-lliR checklist. Overall, there has been good progress, but there remains much to be done. It was noted that this meeting would help to frame the priorities for the coming year. The Chairperson invited comments and questions: o

Is there evidence from recent outbreaks where APSED has directly helped with an improved response? In the Lao People's Democratic Republic, training has been provided specificaJly on avian influenza, but several events involving other diseases were able to be effectively investigated by field staff using their new skills. Also, in Thailand, there have been instances of improved response to disease outbreaks attributable to APSED capacity-building. The formality of the IHR means that some events, about which information is being circulated, are not being recorded on the WHO Event Information Site. What can WHO do about this? The Event Information Site (EIS) is not for all events. It primarily contains material that is able to be shared, based on the agreement of the Member State(s) concerned. However, WHO will often be investigating and assessing a number of events, even though these may not (yet) be on the Event Information Site.

o

2.1.4 Joint mid-term review of APSED approach and monitoring tool in the Lao People's Democratic Republic Dr Bounlay Phommasack, Ministry of Health Lao People's Democratic Republic Both the APSED framework and the mid-term review were fortunate to receive high-level political interest from the outset, and this was helpful to the review process. The APSED monitoring tool was employed to assess core capacities and progress with implementing the National Workplan for EIDs. Capacity gaps had previously been identified in the APSED baseline assessment. The main findings were threefold: (1) that clinical management has been somewhat neglected in the process to date; (2) that workforce shortages are significant in some areas: and (3) that workforce development across a range of activities and areas, particularly field epidemiology training, is a priority. The National Workplan has been shared with key stakeholders and partners and has helped resource

-5mobilization and donor coordination. Workforce shortages continue to be a significant challenge for implementing the National Workplan. Progress made to strengthen capacities for avian influenza has had a positive spill-over effect on the management of other EIDs. The National Workplan has proved to be valuable in securing the involvement of other government agencies and for working with international partners. The review process also highlighted the importance of working with different ethnic groups so that cultural factors are adequately considered and are addressed. Based on this experience, the APSED tool should be widely used and adapted in each country to ensure relevance to local circumstances. 2.1.5 Joint mid-term review of APSED approach and monitoring tool in Sri Lanka Dr Paba Palihawadena, Ministry of Health Sri Lanka The review process was systematically applied to a range of settings and functional areas. In relation to legislation and national policy, a National Focal Point has been identified for IHR purposes and legally mandated disease surveillance has been in place since 1897, with the list of notifiable diseases periodically updated. Interagency coordination mechanisms have been established, including a national steering committee on avian influenza. New disease surveillance and response mechanisms were introduced, including updated manuals and event-based surveillance. Surveillance and response operates at local, district and national levels, with field investigations undertaken within seven days of notification by health inspectors. Laboratory capacities have been updated for EIDs such as leptospirosis, and pandemic preparedness remains a priority. However, laboratory capacity remains limited at the regional and provincial level. Multidisciplinary infection control committees are operational in all major hospitals. Guidelines and system operation procedures have been developed for key diseases (including AI, cholera and dengue), and hospital staff has been trained. It was noted that waste management in hospitals remains an ongoing concern. Sri Lanka has two main international points of entry. The seaport receives some 12 to 15 vessels daily and these are processed by medical officers and technical staff. The airport receives approximately 20 international flights per day, for which there is voluntary reporting of health risks to medical officers and health inspectors. Stocks of personal protective equipment were found to need upgrading. For the surveillance and control of zoonoses, commercial pOUltry farms have been registered, imported chicks are quarantined and information-sharing mechanisms are in place between the Ministries of Health and Agriculture. A comprehensive risk communication plan has been developed and communication channels between the National Focal Point and key stakeholders established. The Chairperson invited comments and questions: o The Republic of Korea relies on a wide range of surveillance strategies, including medical practitioners and the provision of incentives to reporting. Feedback on surveillance findings is provided weekly to both the public and other stakeholders. There was some agreement with the suggestion from the Lao People's Democratic Republic about including clinical management. However, someone asked how the reviews could be undertaken in countries without the same comprehensive level of support as was the case with the Lao People's Democratic Republic and Sri Lanka. Dr Kasai noted that the experience of the two countries would be used in the reviews for other countries and that WHO would appreciate further advice on how to strike a balance between a comprehensive, but resource-intensive and time-consuming, review and a less intensive review that might still be almost as informative.

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The experience gainedfrom the Lao People's Democratic Republic and Sri Lanka, two very different countries, was very useful, but how were they selected? They were nominated by WHO. The Lao People's Democratic Republic was the first to conduct the baseline APSED assessment and to develop a plan, so the prospect of detailed review was an opportunity to build on that existing momentum.

2.2

Session 2 - Update on the International Health Regulations (2005)

2.2.1 Regional progress on IHR implementation in the Asia Pacific Region Dr Khanchit Limpakamjanarat, South-East Asia Regional Office Under the IHR (2005), State Parties are required to submit reports to the World Health Assembly on their progress with implementing the IHR (2005). This requirement applied for the first time in 2008, and 36 out of 37 Member States in the two regions prepared such reports. By submitting the reports, these countries demonstrated that they had established a functional National IHR Focal Point. Collectively, the two regions made a total of 22 notifications to WHO of events that met the Annex 2 criteria for notification as potential public health emergency of international concern (PHEIC). The information provided by Member States suggests that while progress has been made with the identification of competent authorities, designation of points of entry and assessment of core capacities and legislative compliance, further work is still needed for implementation to reach required levels. Given that this year's reports were the first to be prepared, they should be interpreted carefully, and seen as providing a baseline for measuring subsequent progress. However, point-of-entry capacity-building in particular still requires further work. It was also noted that while APSED includes a focus on surveillance and response, it does not explicitly recognize points of entry, legislative preparedness and chemical and radiological hazards. 2.2.2 Outcome ofinformaI consultation on points-of-entry capacity Dr Li Ailan, Western Pacific Regional Office The effective and ongoing implementation of public health measures at points of entry will contribute significantly to minimizing the risk of international disease spread. The IHR (2005) specify two types of core capacities for points of entry, i.e. those that must be in place "at all times" and others that must be operable when responding to a public health event, particularly one that may constitute a public health emergency of international concern. WHO has supported Member States in the Region with guidelines and training sessions. These occurred after consultation with countries to ascertain their needs and to provide an opportunity to share experiences and practices. Key findings were as follows: (I) The importance of routine public health measures, as the ability to meet public health objectives on a day-to-day basis, underpins the capacity to respond to more significant events.

(2) Disease event reporting must occur in a timely fashion and must be supported by a robust initial response capacity. (3) Emergency preparedness should involve all relevant stakeholders.

Addressing these issues calls for active interagency coordination at the border. It is recommended that existing structures be used to improve communication and collaboration, both at individual points of entry and at the national level. Additionally, coordination between competent authorities and hospitals is also required, for example to plan for the processing and treatment of travellers and exit screening, should this be required.

-72.2.3 International Health Regulations (2005) implementation in Thailand Dr Kumnuan Ungchusak, Ministry of Health Thailand The inter-dependencies between economic security and health security were emphasized, and for this reason it was noted that 18 ministries in Thailand are involved with IHR implementation. Rapid response teams are operational at the national, regional, provincial and district levels to support surveillance and response capacities. Using these systems, 495 events have been detected and investigated. Thailand has used IHR mechanisms to share information with other states and has also cooperated with other countries in the investigation and management of events involving tourists from a number of countries. A significant cholera outbreak, linked to shellfish, affected both Thailand and neighbouring countries - several of which were invited to participate in the investigation and the response. Thailand has 60 points of entry and has an Infectious Disease Act 1980 that provides for indicator-based surveillance and also a full range of lawful responses to public health threats. The concept of "leading from behind" was discussed. This concept involves encouraging a focus on core public health capacities, and in partiCUlar promoting improvements to surveillance and response, but not necessarily confusing or distracting other stakeholders with the detailed requirements of IHR compliance.

2.2.4 Core capacity at designated points of entry - Kuala Lumpur International Airport Dato Dr Hasan Bin Abdul Rahman, Ministry of Health Malaysia Kuala Lumpur International Airport (KLIA) processes an average of 30000 passengers per day, which equates to about 10 million per year. Given this volume of travellers, the requirements relating to points of entry and the need to assess core IHR capacities was considered essential for this major international airport. The absence of explicit assessment standards led to the development of a framework covering 11 areas, including Ministry of Health capacity, environmental sanitation, medical facilities, vector control, and health education. The airport itself maintains a well-coordinated incident response capability that operates on a 24 hours, seven days a week basis. A referral system is available for ill travellers. A strong environmental health programme and specific pandemic influenza plan are in place; although a generic public health emergency response plan has not yet been developed. There are clear lines of communication for event reporting to the Airport Operating Centre, but it was noted that it was not always clear to airport staff what kind of health events should be reported. Overall, while KLIA provides a high standard for core capacities, interagency communications and contingency plans for emergency public health responses have been identified as areas for further development.

2.2.5 WHO operating procedures for managing acute public health events under the IHR (2005) Dr Thomas Grein, World Health Organization, Geneva Since June 2007, when the IHR (2005) entered into force, WHO has been subject to very specific obligations in relation to some of its activities such as information sharing and the verification of, and international response to, significant public health events. This includes explicit roles and responsibilities for the Director-General. To support these activities, WHO has developed a single, reproducible process for managing acute events, including SOPs, for use throughout all six Regions. This includes procedures for risk assessment and verification of events with Member States. Event Management Groups include staff from Headquarters and regional offices. These Groups undertake a structured risk assessment that makes full use of the expertise available in other WHO technical units and also in the WHO country offices, where appropriate. In addition to the primary communications via the National Focal Point, the relevant WHO technical units may also maintain direct communications with their counterparts in Member States, to ensure that all lines of communication remain open. The Event Management System oversees this work, which in tum informs the content of the Event Information Website. The Event Management System is also linked to the Global Outbreak Alert and

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Response Network (GOARN) and is able to make full use of its expertise and networks. Key challenges include the consistent application of evidence-based processes for risk assessments, and striving to ensure consistency of approaches across chemical, radio-nuclear and food safety/product recall events. 2.3 Session 3 - Pandemic preparedness

2.3.1 Revision of pandemic influenza preparedness guidance Dr Sylvie Briand, World Health Organization, Geneva Pandemic preparedness first emerged as a major focus of activity in 1997, primarily as a result of the first H5N1 outbreak in Hong Kong (China). WHO's fust pandemic guidance document was published in 1999. Since then, the level of risk has fluctuated, but the overall risk has not diminished. The H5Nl virus continues to circulate among agricultural and wild birds and is still evolving. WHO continues to keep the guidelines under review and revised them in 2005. To maintain their relevance, WHO considers that the guidelines now require further revision to reflect developments such as the entry into force of the new IHR (2005), the benefits of sharing innovative approaches to pandemic preparedness at country level and the increased availability of vaccines and antivirals. The new guidelines will use preparedness activities as one focused approach to strengthen generic public health capacities that are relevant to public health emergencies more broadly. It is intended to retain the six pandemic phases, but to provide revised definitions and clarify the implications and key actions associated with each. The revised guidelines will also adopt a more "whole of society" approach and include provision for rapid severity assessments. Previous pandemics have been of variable severity, in terms of both human health impacts and other effects. Severity assessments will help Member States to make informed decisions about some of the difficult choices they will face. For example, whether to implement disruptive control measures such as school closures, while still recognizing that at any given time, circumstances will vary between regions and between countries (and even within countries). 2.3.2 Avian influenza task force on research Dr Richard Brown (on behalf of Prof NK Ganguly), South-East Asia Regional Office The rationale for a research strategy came from extensive pOUltry outbreaks of H5N 1 and also the very high case fatality rates observed to date. A meeting was convened in Bali in March 2008 to develop a framework for research that will span all emerging infectious diseases. Within this broad context, the primary focus will continue to be on avian and human influenza. Knowledge gaps and research priorities were identified and consideration was given to areas for capacity-building. Future work should seek to build on existing national structures and regional networks. Member States were asked to consider task force recommendations when formulating their own research priorities. WHO was asked to develop a strategy to support capacity-building, develop an inventory of ongoing research projects and coordinate networking. While EIDs are by definition unpredictable, the task force and its recommendations contribute to what might be called "research preparedness". 2.3.3 The state of regional progress on pandemic influenza preparedness Dr Satoko Otsu, Western Pacific Regional Office While the intensity of media attention has declined in recent months, the threat of a pandemic remains as relevant as ever. The WHO framework takes a multi sectoral approach. concentrating on averting avian influenza, rapid containment and pandemic response. Member States are encouraged to take a two-tiered approach to planning, the first tier being the development, testing and ongoing refinement of an over arching plan - what to do? The second tier is about increasing readiness to implement the plan - how to prepare? In other words, how to anticipate and effectively manage the

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social and economic disruption associated with a pandemic, where to pre-position stockpiles of personal protective equipment (PPE) and other supplies, and how to distribute them when required. Issues such as outbreak response logistics must be addressed in advance to support these and other response strategies. A further consideration is that the various forms of local government within Member States are expected to significantly influence local resilience during the management of a pandemic. Countrylevel pandemic plans will also need to be reviewed and revised following the release of the new pandemic guidance from WHO. Continued use of APSED checklists and planning frameworks will also help to contribute to pandemic preparedness. 2.3.4 Rapid containment exercise in the Philippines Dr Lyndon Lee Suy, Department of Health Philippines The Philippine pandemic preparedness plan was developed in 2005. This plan provided the country-level framework for a rapid containment exercise, involving multiple agencies, held in March 2008. The National Disaster Coordinating Council (NDCC) was activated as part of the exercise, as were regional and national offices of the Department of Health. Decision-making processes, pharmaceuticals and non-pharmaceutical interventions, such as movement restrictions, and the rapid mobilization of investigative and response capacities were tested within the scope of the exercise. Key lessons learnt were: a sufficient workforce (both capacity and capability) is needed to implement a rapid containment plan; and liaison between the central control and regional players is essential for an effective response. Risk communication and consistent, coordinated messages should be well understood. Countries should be ready with a national rapid containment plan as a separate or part of the larger national pandemic preparedness plan. Functional exercises will also benefit other partners, especially local government unit (LGU) partners; multilevel and multi sectoral participation in a pandemic exercise preparedness should be aimed as soon as possible. 2.3.5 Rapid containment exercise in Indonesia Dr Andi Muhadir, Ministry of Health Indonesia This exercise was of special importance given Indonesia's place in the epidemiology of avian influenza. Goals were to test system operation procedures, assess coordination capabilities and raise awareness and enhance motivation among stakeholders. Draft protocols were prepared and tested during the exercise, which involved over 900 personnel. The exercise involved coordination with the local governor and extensive roles for the health agencies (including contact tracing, isolation of cases, quarantine of contacts and infection control in health care facilities). The police were engaged to assist with maintaining the containment perimeter and related social distancing measures. Risk communication functions were also employed to encourage voluntary compliance by the public. The key finding from the exercise was that 'trigger points' for control measures should be clearly defined in advance so as to support local decision-making at key stages in the evolution of the response. 2.3.6 Review of readiness: results of pandemic preparedness assessment in 2008 Dr Bee Lee Ong, Western Pacific Regional Office In addition to the first tier of pandemic preparedness, i.e. preparation of pandemic plans, the second tier comprises a strong focus on readiness. Increasing readiness should address issues related to specific events as well as components based on routine activities. Eight developing and seven developed countries self-rated their capacities on a four point scale in June 2008. The ratings were applied to three main stages of intervention - averting avian influenza, rapid containment and pandemic response - across each of the five APSED areas of activity. The results showed some progress from the first (but simpler) baseline assessment.

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While there was some variability between developing and developed countries, the overall findings were as follows. (I) surveillance and response - there is a need to strengthen the ability of Member States to detect and respond to suspected avian influenza cases by formalizing their surveillance and response systems, training response teams and increasing coordination with local government; (2) zoonoses - there is a need to improve intersectoral collaboration, information sharing, risk assessment and coordinated responses during the averting AI stage; (3) laboratory - increased training is needed for the collection, transport, storage and handling of specimens and further strengthening of communication between laboratories and outbreak response teams; (4) infection control - the provision and availability of supplies, safe hospital environments and standard IC training to staff need to be ensured for all three intervention stages; (5) risk communication - Member States need to strengthen capabilities for risk communication during the rapid containment stage and develop protocols for multi agency collaboration during both the rapid containment and the pandemic response stages. 2.3.7 Panel discussion: pandemic preparedness Facilitated by Professor (Dr) Hitoshi Oshitani, Tohoku University Graduate School of Medicine, Japan

The participants and panel fielded a range of questions and comments, particularly on matters related to pandemic phase six (full pandemic). A key theme was recognition that the ability of central governments to effectively manage all aspects of the response to a pandemic is likely to be diminished, and that local government structures might therefore be expected to playa correspondingly greater role. To cover staff shortages, epidemiologists and surveillance specialists may be co-opted to other areas, for example to provide clinical care. However. in the case of a pandemic, they must be available to plot its course and gather intelligence to inform decisions on management options. Consideration should be given, country by country, to what core activities and key skills need to be given priority for the purposes of resourcing and continuity, for example, continuing business as usual for key elements of the health sector such as maternity services and accident and emergency services for road crash victims, while perhaps considering deferrals to some elective services. In phase six, countries should be clear as to what information needs to be gathered locally and

reported to the appropriate national centre. This will be compounded by staff shortages affecting the entire health sector. In short, what minimum data sets are required, and can be supported, to provide essential information? The importance of working from existing procedures was stressed, for example, reducing surveillance information to cover just the bare minimum such as data on the number of cases, sex and age, and omitting all the other information that would normally be provided. Local governments should be provided information in advance as to the sorts of roles and responsibilities that may be devolved from central governments (and the associated triggers for this) so as to manage the situation locally during a pandemic response. Possible roles and responsibilities that would require enhanced ability include: working with health care facilities, collaborating with local public health officials on risk communication, and making decisions in relation to social distancing measures such as the enforcement of possible school closures etc. While local government structures

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may be affected by staff shortages, they will still need to provide for continuity of the services and functions for which they are routinely responsible. Local governments, because of their resources and important operational functions, may be expected to support, or even lead, the local management of the pandemic, particularly in relation to social services and assistance to communities. Local governments may be more supportive of pandemic preparedness activities if they are presented as just another form of emergency management - generic emergency management being a role with which local government is often familiar, and with which they have considerable expertise and experience. This can help to reduce the likelihood that pandemic preparedness is seen as a problem that concerns only the health sector. This can also help to create some political interest and momentum at the local government level. Existing generic emergency management plans generally include clear roles for local government, and these can provide a useful starting point for a greater role for local government in the context of a pandemic situation, where the central Government may have a reduced capability to perform some of its usual functions. Also, rather than focusing exclusively on pandemic preparedness, it may be useful to frame the role of local government in relation to a wider range of public health emergencies, of which influenza is just one. For whole-of-government planning, it is important to provide briefings and secure political support at the highest possible level of the central Government, so that all agencies are expected to be involved in pandemic preparedness. It can be useful for the Ministry of Health to seek out and support (for example with information and briefings) champions in other key government agencies. This can take the form of special briefings for Treasury and encouraging business continuity in the private sector as well as in other government sectors (e.g. "How will your company or department provide for business continuity when 20%-40% of your staff may be away from work, possibly for many weeks?"). APSED can provide some guidance as to priorities, as well as generic emergency management planning frameworks. Similarly, exercises in which the health sector works closely with local government may also be useful in promoting greater awareness of their potentially important role. 2.4 Session 4 - Progress in the five APSED areas of work

2.4.1 Laboratory 2.4.1.1 Progress in laboratory capacity strengthening in the Asia Pacific Region Dr Christopher Oxenford, Western Pacific Regional Office Any effective surveillance system must be supported by a functional laboratory with the capacity to provide reliable, accurate and timely results. Such a capacity should also ensure the safety of staff and the security of the specimens. TAG has previously identified biosafety and quality assurance as priority areas for further development. The following key elements were discussed: (I) Accuracy - continuing support for quality assurance is vital, including external quality assurance for influenza A (H5Nl) detection and programmes for specimen handling and transport; (2) Safety - a Biosafety Consortium has helped to ensure that the promotion of biosafety will continue to receive priority attention; (3) Surveillance - A Practical Guide to Harmonizing Virological and Epidemiological Influenza Surveillance has been published;

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(4) Laboratory - networking takes place at both national and international levels, e.g. GOARN and the Association of South East Asian Nations (ASEAN); (5) Research - In some countries there is considerable research occurring, and this may benefit from improved coordination to avoid duplication. For the future, there is a need to build capacity beyond the current focus, which is, understandably, influenza. Other areas that require attention include network strengthening at all levels and training for laboratory engineering and maintenance capacity, which are often neglected. 2.4.1.2 Outcome of the Second Biregional National Influenza Centres Meeting Dr Luo Dapeng, Office of the WHO Representative in Mongolia, on behalf of Dr Zhou Weigong, Western Pacific Regional Office The Second Bi-regional Meeting of National Influenza Centres was held in Japan in April 2008. The meeting built on the developments from the first meeting, held in Australia in 2007, and in particular the development of a workplan to strengthen national influenza surveillance systems. Progress was noted in the following areas: (1) A Practical Guide to Harmonizing Virological and Epidemiological Influenza Surveillance was developed following consultation with experts and other stakeholders. This guide includes event-based surveillance for early warning purposes.

(2) A Practical Guide for Designing and Conducting Influenza Disease Burden Studies was developed and reviewed. An implementation workshop is planned for late 2008 or early 2009.

(3) Laboratory database software to support national influenza centres (NICs) has been developed and has received considerable interest from National Influenza Centres (NICs). A training workshop is also proposed. (4) Regional training has been conducted on avian influenza bioinformatics and genomic analysis, antiviral resistance monitoring and Hands - on EQAP. (5) Next steps include polymerase chain reaction (PCR) training in collaboration with REDI Centre and Singapore Ministry of Health/NIC, planned for September 2008, and rapid response and containment training in the Pacific, planned for November 2008. A Third Biregional National Influenza Centre Meeting, to further review progress across the two regions, is scheduled for Beijing in May 2009. The Chairperson invited comments and questions: o It was suggested that it may be useful to have a laboratory focal person as a single national point of contact for laboratory issues. It was noted that in Australia there is a public health laboratory network that can fulfil this role, but for some countries this may not be appropriate. Laboratory capacity in developing countries is a significant and ongoing issue. For example, promoting coordination between the clinical and public health functions can require active efforts. Additionally. timely testing for emergency response purposes can also be a particular challenge.

o

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o

There is a support network coordinated by ASEAN + 3 countries in collaboration with WHO and the Ministry of Health, Malaysia to support EID related laboratory capabilities. The Japanese WHO collaborating influenza reference laboratory can potentially assist with training. Serological testing and sub-clinical testing, and the desirability of standardizing testing, will be important. Europe has National Microbiological coordinating points. These use the model of the IHR National Focal Point, have agreed terms of reference and help to collate and disseminate information.

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2.4.2 Surveillance and response 2.4.2.1 Regional progress on strengthening surveillance in the Asia Pacific Region Ms Amy Cawthorne, Western Pacific Regional Office The goal is for each Member State to have reliable systems for the accurate and early detection of public health risks. While indicator-based surveillance (such as the systematic reporting of notifiable diseases) continues to play an important role, the emphasis over the last year has been to improve eventbased surveillance and to strengthen links between surveillance and response functions. A practical guideline was developed on how to set up and implement event-based surveillance. In response to requests, WHO has supported Member States to further develop this capacity: (I) Mongolia has moved to pilot event-based surveillance after initially seeking political support for this approach.

(2)

India is developing event-based surveillance, building on existing structures and systems.

(3) In Myanmar, as a result of cyclone Nargis, community-based event surveillance was implemented. A continuing challenge is to more closely link surveillance and response, and this is stressed in the guidelines and explicitly addressed in evaluations - for example, what happens to alerts once they are received? Member States will continue to benefit from ongoing support in the development, review and refinement of event-based surveillance systems. 2.4.2.2 Regional progress on strengthening outbreak response capacity in the Asia Pacific Region Dr Suzanne Westman, South-East Asia Regional Office TAG previously recommended that priorities should include strengthened response capacities and efforts to link these capacities to surveillance functions. Most Member States in the Region have established Rapid Response Teams (RRTs) at the national level. Training of RRTs, primarily focusing on avian influenza (AI), has resulted in the training of approximately 12000 personnel. In Thailand, for example, there are now RRTs in every district. In the Lao People's Democratic Republic, RRTs, supported by WHO, have responded to dengue, cholera and AI outbreaks at the national, provincial and district levels. In Myanmar, RRTs trained for AI purposes were mobilized to support the response to cyclone Nargis. RRT training in many Member States has included clinical management and infection control as well as epidemiological investigation. Generic training modules for field epidemiological training are being developed so that the traditional two-year programme is not the only training that is available. Mongolia, Thailand and India have established "operations rooms" at their national centres

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for communicable diseases to coordinate outbreak responses. A further guide on early warning and response is being produced. A key conclusion from the work to date is that the links between surveillance, investigation and response should be further strengthened and maintained so that integration becomes routine. Creating RRTs is the easy part; the challenge is ensuring that they are closely linked to surveillance systems and receiving ongoing training and logistical support. 2.4.2.3 Strengthening GOARN in the Western Pacific Region Professor John MacKenzie, Curtin University of Technology, Australia The Global Outbreak Alert and Response Network (GOARN) is a technical partnership initiated by WHO in 2000 as a "network of networks" covering 150 institutions to support surveillance and early warning at a regional and local level. GOARN serves to assist countries to investigate and characterize events and to control disease outbreaks and related events. By supporting information exchange and access to technical expertise, GOARN also helps to support the objectives of the IHR (2005). Responses are triggered by a request from a country, and the network can then be used to help generate a rapid response team. GOARN covers all hazards and has links to world-class expertise and resources. It was stressed that consistency in the investigation and verification of public health events is an important challenge and that performing this function reliably and in a transparent manner is often vital to maintaining the trust and confidence of stakeholders. Three meetings have been held in the Western Pacific Region to raise awareness of GOARN, to identify options for collaboration and training opportunities and to develop further links with regional partners such as ASEAN + 3. GOARN also supports APSED because of its direct applicability to emerging infectious diseases. The Chairperson invited comments and questions: o It was noted that there is "pandemic fatigue" in the media. It is important not to lose momentum for capacity-building in emerging infectious diseases, including influenza. China strengthened its national and provincial surveillance systems in 2004 following its experience with SARS. Capacity-building measures included a major investment in training staff in surveillance and response, including field epidemiology. A philosophical decision was made to focus on "learning by doing" with a strong emphasis on practical experience. Rapid response teams in Sri Lanka are trained in clinical management of cases as well as infection control practices, so they can support the treatment aspects of a disease event as well as the public health dimension. A key issue for rapid response teams is the matter of ongoing support. For example, after teams have been established and trained, they must continue to be supported, staff must be retained and further training opportunities must be provided. Based on the success with the 12 000 trainees, should targets be set for further training of rapid response teams and the uptake of field epidemiology training courses? It was noted that there had been a relative lack of engagement in GOARN by the South-East Asia Region and that this might be tied to a lack of institutional memory and the recent focus on the legal requirements of the IHR (2005). In this context, recognition of the value of the "network of networks" might have faded, and perhaps there is now an opportunity to correct this. GOARN should certainly not be seen as a separate framework.

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o

There is considerable knowledge and experience in the two Regions, with threats such as SARS, avian influenza and dengue being cited. Perhaps GOARN could be used to promote greater information sharing and to foster good practices within the countries and areas of the Region, so as to make the best use of this expertise. Surveillance and response are clearly important, but have we focused too much on formal capabilities at the national level and perhaps neglected the administrative and other resources needed to support technical and operational decision-making capacities, particularly in rural areas and at the district level?

o

As zoonoses are, and will probably continue to be, of considerable public health significance, we need to promote greater collaboration with the Food and Agriculture Organization (FAD) and World Organization for Animal Health (DIE), as they also have their own surveillance and response networks. o ASEAN is exploring the possibility of developing rapid response training for generic emergency management purposes. To this end, the Western Pacific Regional Office has been asked to provide some training on GOARN.

2.4.2.4 Training of rapid response teams in Myanmar Dr Soe 00, Department of Health, Union of Myanmar Myanmar has a population 56 million, of which 70% live in rural environments. Health services are organized at a national level, and then by states, districts and townships. The central Epidemiology Unit of the Ministry of Health is responsible for coordinating surveillance and response nationally. The Unit's functions include emergency management and pandemic preparedness. Following SARS, a national plan was developed to set out the responsibilities for all relevant components of the health system. In early 2006, this plan was tested when outbreaks of H5Nl were detected in pOUltry. FAD and DIE were alerted and rapid response teams were despatched to the affected villages, in particular to investigate reports of suspected influenza-like illness. A human case of avian influenza was detected and, following isolation, contact tracing and administration of Tarniflu, she recovered. The case was reported to WHO within 24 hours of confirmed laboratory results. Following this experience, exercise drills have been held for human influenza. The current focus is on establishing and training rapid response teams in all states, strengthening infection control in hospitals, working towards full IHR (2005) compliance, updating and testing the national pandemic plan, and strengthening surveillance and early warning systems. Cyclone Nargis showed the importance of ensuring that early warning information (in this case meteorological) is able to be quickly communicated down to the village level along with meaningful information on appropriate precautions - this lesson is also relevant to responses to emerging infectious diseases. 2.4.2.5 Planning for a field epidemiology training programme (FETP) in Viet Nam Dr Thanh Dong Le, Department of Preventive Medicine and Environmental Health, Viet Nam In 2007, following engagement with multiple partners, including universities and public health institutes, Viet Nam identified a need for both a short and long course in field epidemiology training. The FETP office was formally opened in February 2008. The three-week field epidemiology training short course will begin in September 2008. The curriculum for the two-year post-graduate long course was approved in early 2008, with the first cohort to start later this year. The long course will be available in two "tracks". Track 1, funded by the Asian Development Bank (ADB), is a classroom-based academic course that will provide specialty training for medical graduates; Track 2 is competency-based, in-service training and is linked to a Masters degree. Key challenges

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have included gathering support from, and meeting the expectations of, multiple stakeholders, finding suitable candidate students and identifying trainers and field supervisors. Opportunities include using students for surge capacity in outbreak responses, and learning from more established programmes and regional networking, for example, with Thailand and the Philippines. The Chairperson invited comments and questions: o There was favourable comment about how Myanmar had been able to mobilize its rapid response teams, prepared with avian influenza in mind, to assist with the response to the devastating cyclone. For field epidemiology training in Viet Nam, how are students supported during training? For short courses, there is usually support provided, but for the long course, this issue has not yet been resolved. Emerging infectious diseases require more than just a primary health care model for adequate management, particularly where high infectivity and case fatality rates are involved. It was suggested that it may be preferable to concentrate on a small number of diseases, and so provide a sharper focus for indicator-based surveillance, in order to complement event based surveillance.

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2.4.2.6 Event-based surveillance in Cambodia Dr Sovann Ly, Ministry of Health, Cambodia Indicator-based surveillance, such as predetermined lists of notifiable diseases, generate valuable information but have limitations. Such surveillance can be inflexible and inadequate to provide effective early warning for rare or new diseases that might still have a high public health impact. Additionally, indicator-based surveillance is not reliable for events affecting populations that are not regular users of formal health services, for example, low income groups. For these reasons, and also following earlier advice from the Technical Advisory Group, Cambodia developed a system for the rapid and organized capture of information about events that are a potential risk to public health. The system gathers information about unexpected or unusual events, including both human disease and animal health events. Surveillance information is collected through formal channels and also informally from clinicians, the media, nongovernmental organizations (NGOs), village leaders and the public via a hotline (both voice and SMS/text). This often results in unstructured reports that are not in a consistent format. Event-based information is combined with traditional indicator surveillance and closely linked to response capacities. All surveillance information is urgently assessed to determine when further investigation is warranted. Once warranted, a timely investigation is carried out to verify and, when necessary, respond to the event. The system routinely provides feedback to the information source(s) and posts updates on surveillance bulletins and a website - this reinforces reporting by recognizing its importance and providing relevant information back to those who make the reports.

2.4.2.7 Event-based surveillance in the Lao People's Democratic Republic Dr Phengta Vongphrachanh, Ministry of Health, Lao People's Democratic Republic Relatively informal event-based surveillance is already in place within the health system in the Lao Peoples Democratic Republic. Supplementary surveillance is also routinely provided from contact tracing during outbreak investigation and response. Additionally, the National Centre for Epidemiology recently established a 'hotline' to promote greater reporting (though it was recognized that the hOtline was more likely to be used by affluent urban population groups). Because health care is not provided

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free of charge in the Lao People's Democratic Republic, many people, particularly in low-income communities, do not always access the health care system. A national surveillance working group was established to strengthen event-based surveillance. This working group made it clear from the outset that event-based surveillance should not operate as a separate surveillance system and that animal health events should be captured as well. Pilot schemes are now in place in more than 200 villages across several districts. Village-based reporting systems were established using village heads, teachers, and village health volunteers as selected by each village. Initial evaluations of the pilots are expected to be available by late 2008. 2.4.2.8 Panel discussion: event-based surveillance Facilitated by Dr Thomas Grein, WHO, Geneva Conceptually, event-based surveillance is relatively straightforward, but the challenge is in the implementation, i.e. making it work in the community and at the national level, ensuring that it is sensitive and closely integrated with other surveillance systems and response capacities, and ensuring that it will operate on a sustainable basis. How can event-based surveillance that is focused on avian influenza continue to operate on a sustainable basis and also move beyond a narrow AI focus to other public health threats? Sustainability can be achieved by integrating it with other surveillance systems. In Indonesia, sustainability was ensured by involving the local government.

In China, it was recognized that an all-risks scope and the use of multiple information sources meant that event-based surveillance would provide more timely information. In tum, event-based surveillance was seen as a valuable component of the overall surveillance framework. Additionally, incorporating event-based surveillance into existing surveillance platforms helped to ensure its continuing viability. China also developed a framework to clarify which type of events should be responded to at the local, provincial and national levels.

In the Philippines, event-based surveillance was formed unintentionally, with the media and external agencies seeking and reporting information that traditional surveillance could not provide. They found out only later that it was called event-based surveillance. In terms of sustainability, eventbased surveillance must be integrated with other surveillance and response functions and proves its worth with the kind of information it is capable of providing. Sustainability is also enhanced by the informal and flexible nature of the reporting channels and types of information provided. The certainty needed for planning purposes requires the more regularized information available from indicator-based surveillance, but early warning and rapid response benefits from the timely and more sensitive information provided by event-based surveillance.

In Sri Lanka, there has been incremental growth in surveillance capacity, with a long tradition of case-based surveillance and the progressive addition of other disease specific surveillance. More recently there has been a growing role for the media and community heath workers and communities themselves. Sustainability over time is also influenced by the country's capacity to respond to and manage events; inadequate response measures can be a disincentive to further reporting. Language itself can sometimes pose challenges. For example, in developing its guidelines, the Lao People's Democratic Republic had some difficulty translating the word "event", as the intention was to capture a wide range of hazards, environmental situations, disease outbreaks and unusual events.

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Operational response capacities, informed by a full suite of surveillance sources, are crucial - otherwise, surveillance is just for policy and academic purposes. Response capabilities must be in place not only at the national level, but also at the district and local levels, as people are needed on the ground to implement the required investigation, verification and response action. These can be supported by guidelines to support field activities and linkages to treatment services. While clinicians are only a small part of the "reporting community" in New Zealand, new legislation explicitly mandates them to report events, e.g. a case or disease cluster or other event that may be of potential public health significance. This legal authority is intended to promote sensitive, timely and all-hazards reporting, while also protecting reporting clinicians in terms of possible concerns about breaches in privacy. It is appropriate to encourage village-level reporting to health centres of any unexpected or unusual events. Event-based surveillance contributes directly to IHR (2005) requirements, particularly the Decision Instrument and the all-hazards scope. However, with animal health issues and zoonoses, the nature of events of significance may not be so clear. The characteristics of sensitivity and early warning are positive features of event-based surveillance. Public health practitioners may want to emphasize these positive characteristics when discussing surveillance system strengthening with decision-makers and donors. Event-based surveillance should be integrated with a country's existing formal surveillance infrastructure, so that it will benefit from continued access to resources and expertise. Legal requirements could be used to support IHR (2005) event-based reporting, but this should not be at the expense of discouraging community-based information flows. Overall, sustainability was not identified as the primary concern, and in some countries eventbased surveillance has been in place for some time, but under a different name (or without a name). The key issues are to ensure that it is recognized as particularly valuable for early warning and response purposes, to be aware that event-based surveillance generates a lot of 'noise', and to ensure it is structured into the overall surveillance framework and resourced accordingly. Robust response measures and the provision of feedback to reporters and communities are essential to keep reports rolling in. Summary of panel discussion: o Event-based surveillance is not necessarily a new approach, but it must be integrated with response capabilities and with other surveillance systems in terms of expertise and infrastructure, so as to give confidence to decision-makers and donors. Where event-based surveillance is in place, acceptance and integration are critical to maintaining its ongoing effectiveness, as is the involvement of local government and villagelevel engagement. Keep it simple and do not worry too much about the terminology. Countries should categorize resource response roles and responsibilities at local, district and national levels.

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2.4.3 Infection control

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2.4.3.1 Progress on infection control activities in the Asia Pacific Region Dr Richard Brown, South-East Asia Regional Office Historically, the Regional Offices have experienced constructive biregional collaboration, including the development of generic guidelines. Both regions have completed assessments of existing capacities, using similar but not identical formats. Most countries have national structures and policies for infection control. Indonesia, in particular, has a well-developed national training programme for infection control because of its experience with avian influenza and support from donors. The baseline reviews informed needs assessments covering topics such as infrastructure, logistics and human resources. The next step is the development of country-specific strategies, to be implemented and monitored. WHO aims to provide infection control champions with the tools and support they need to build capacity in-country. There is some evidence that the preparation of guidelines alone has relatively little impact. Hence, the key themes underling the current work programme are a strong focus on training and generic respiratory infection control - even promoting simple hygiene practices. such as regular hand-washing can make a difference.

2.4.3.2 Infection control in the Western Pacific Region Miss Sandra Montes, Western Pacific Regional Office The TAG has previously advised that progress with strengthening infection control practices was variable, and that overall progress was less than satisfactory. To help map the way forward, in January 2008, the Western Pacific Regional Office convened a meeting in Hong Kong (China) to seek a consensus from regional experts on the next steps. Needs identified included patient safety, IHR (2005) compliance, safer environments, workplace health and safety, trained human resources and data analysis. One of the conclusions was that limiting the focus to a more modest range of initiatives might be more productive in the short term. It was suggested that this might be preferable to pursuing a comprehensive strategy that, while sound in theory, might not deliver the desired outcomes in practice. The proposed minimum components at the country level would include the establishment of: (1)

a national infection control coordination committee to oversee activities and set policies;

(2) a national infection control resource centre to develop guidelines, training curriculum and educational materials, and to manage supplies and associated logistics; (3) a national infection control focal point within the Ministry of Health to function as a single point of contact to coordinate the educational activities, disseminate information, and oversee infrastructure of health care facilities and the availability of supplies and equipment; and (4) formal infection control training for the leaders to be appointed to lead the infection control activities. Infection control is universally recognized as important, but it does not always receive the priority it deserves. For this reason, a more structured approach to infection control is needed at the country level if front-line progress is to be achieved. The Chairperson invited comments and questions: o Providing information about the importance of infection prevention and control and associated advocacy can be used to help secure agreement from decision-makers.

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Infection control for avian influenza, which is particularly complex, is now included in case management protocols. In hospital settings, it is sometimes assumed that infection control is inherent in all practices, but in reality this is not always the case. Extra investment, resources and leadership will be needed to ensure that infection prevention and control do not continue to lag behind.

o

2.4.4 Zoonoses collaboration 2.4.4. I Progress on zoonoses collaboration in the Asia Pacific Region Dr G N Gonga!, South-East Asia Regional Office Since most emerging infectious diseases arise from wild or agricultural animals, the TAG has previously recommended that structured, multi sectoral approaches should be pursued. The APSED zoonoses work programme focuses on the development of zoonotic disease collaboration mechanisms between the animal and human health sectors at both regional and country levels. The four main objectives address risk reduction, surveillance and the exchange of zoonotic disease information, coordinated responses to animal disease outbreaks and collaborative research. A two-phased approach has been developed. The first phase is the development region-wide mechanism involving FAD, DIE and WHO, which includes linked communications channels between the agencies' regional offices and support for country-level projects. The second phase centres on country-level coordination mechanisms. Following planning and consultation meetings in 2007, an interim Guide to Establishing Animal and Human Health Sectors Collaboration at Country Level was published in January 2008. The interim Guide will be piloted and evaluated in the Lao People's Democratic Republic and the Philippines, after which it will be revised and finalized. Additionally, risk reduction measures have been implemented in the Lao People's Democratic Republic, Myanmar and Indonesia in the traditional live-bird market. Risk assessment tools have also been developed. Work to date suggests that the promotion of country-level collaboration between the human and animal health sectors will require ongoing investment. While the current focus is on avian influenza, it should be broadened to cover other significant zoonotic diseases. 2.4.4.2 Pilot study on zoonoses collaboration in the Philippines Dr Lyndon Lee Suy, Department of Health, Philippines The Philippines, having experience with its rabies programme and the avian influenza task force, and being guided by the APSED National Workplan on Zoonoses, has embarked on piloting a study that will strengthen collaboration between animal and human health sectors. This pilot study will attempt to establish the framework of zoonoses collaboration especially in the areas of surveillance, information exchange, coordinated response and risk reduction. A Philippine Council on Zoonoses has been created. It consists of technical experts and a steering committee and receive advice from WHO, FAD and DIE. The terms of reference and workplan for 2008 and 2009 were developed with respect to the mandates, roles and responsibilities of each sector. The Chairperson invited comments and questions: o Based on Malaysia's experience, it is important to have intersectoral collaboration committees in place to support interagency communication, coordination and cooperation at all levels. The Lao People's Democratic Republic has expanded collaboration between the Ministries of Health and Agriculture as a result of lessons learnt from avian influenza. Memoranda of

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Understanding will be signed and follow-up meetings held, to which all relevant partners will be invited. o

In consultation with Member States, OlE has been working on projects related to migratory birds - a complex subject area. ASEAN has supported regional zoonoses projects. ASEAN plans to strengthen zoonotic programmes so as to supplement, rather than duplicate, existing efforts.

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2.4.5 Risk communication 2.4.5.1 Progress on risk communication in the Asia Pacific Region Dr Khanchit Limpakarnjanarat, on behalf of Dr Shima Roy, South-East Asia Regional Office Disease outbreaks create uncertainty, anxiety and the risk of inappropriate actions by individuals and communities. The provision of accurate, practical and timely information from a trustworthy source is an important component of an effective response. Regional activities have focused on workshops and training on risk communication as part of the field epidemiological training programme. In particular, training has occurred in Japan, the Republic of Korea, China and the Pacific for National llfR Focal Points. The South-East Asia Regional Office undertakes regionwide media monitoring on a daily basis for rumours of outbreaks. For in-country training, role-playing has proved to be effective in promoting an awareness of, and skills in, risk communication. Country-level activities have included the development of material for specific topics, e.g. malaria and dengue, with particular target audiences in mind. Challenges for the future include building capacity in risk communication at the country level and in developing communication strategies, which will be incorporated into outbreak response plans as well as national workplans. In conclusion, risk communication may need the attention after this TAG meeting. The Chairperson invited comments and questions; o China commented on the usefulness of the WHO outbreak communication document but noted that more support from WHO for training in this area would be beneficial. It was noted that ASEAN is facilitating risk communication planning for countries in its region.

o o

WHO and the United Nations Children's Fund (UNICEF) have expertise in risk communication and should coordinate their resources and roles in terms of agency responsibilities. It is very important to identify spokespersons at both the national and local levels, and to ensure that they receive appropriate training. Sri Lanka noted that UNICEF has studied community behaviour on avian influenza and that educational materials specific to the pandemic influenza phases have been developed. Session 5 - APSED implementation and monitoring

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2.5.1 Framework of APSED monitoring MrWayne Antkowiak, Western Pacific Regional Office The Asia Pacific Strategy for Emerging Diseases has three main monitoring elements, i.e. the annual TAG meetings to review progress, baseline assessments and now a new monitoring tool. The

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original checklist was helpful for the baseline assessments, but its "yes / no" framework restricted the review of each of country's progress. Hence, a more sophisticated monitoring tool was developed to measure the varying degrees to which countries had key capacities in place. Both regional offices adapted this tool to reflect regional conditions and to meet the needs of Member States. The tool was then piloted to determine its suitability and help with refinements. This work built on the experience gained with the original baseline assessments and country workplans. The intention is to help countries and the Asia Pacific Region to track towards developing the capacities against the 2010 deadline. The monitoring tool does not focus on outcomes, but rather reviews processes, structures and the status of specific capabilities. Countries were asked to convene national workshops in 2008 and 2009 to assess the results of the monitoring to date and the progress made with their country-level workplans. 2.5.2 Tools for monitoring APSED and IHR (2005) implementation Dr Suzanne Westman, South-East Asia Regional Office The implementation of any strategy should be seen as a dynamic process that evolves to keep pace with changing needs, circumstances and priorities. Monitoring progress is intended to inform decision-making to improve implementation of the strategy. But monitoring progress also provides important confidence to treasury funders and external donors. Progress indicators should have face validity, should be based on available data, should be simple to collate and analyse. and should be acceptable to stakeholders. Simple "yes / no" monitoring can help in initial stock-takes but can also sometimes mask important variations in the quality of capabilities. Hence, monitoring tools should use scales to reflect the degree to which a capacity has been achieved. The key question to be asked in the development of a monitoring framework is: Does this approach help us to understand and improve our ability to detect. respond to and report a significant public health event? The Chairperson invited comments and questions: o The two countries that undertook full mid-term reviews noted that the process was useful. In particular, it proved valuable to involve partners in the review of progress so as to spotlight achievements and identify barriers still to be overcome. Both regions envisage a simpler, self-assessment tool for wider use by other Member States. The Republic of Korea commented that for surveillance systems the single most important variable for monitoring and evaluation purposes is timeliness. Monitoring requires consistent interpretation and application of the assessment tool. Use of too many indicators can be counter-productive. Additionally, indicators can tell you where you are, but not necessarily how to move forward.

o o

o o

- 232.6 Session 6 - Key points and suggestions from the breakout sessions

Group A - South-East Asia Region o The group comprised participants from Member States in the South-East Asia Region. The group discussed and identified priority activities for APSED implementation in the South-East Asia Region in 2008-2009. The group also discussed the roles of Member States and the WHO Regional Office. The group agreed on the following: all Member States should develop a national plan for APSED that covers IHR and points of entry (POE); the National Influenza Pandemic Preparedness Plans (NIPPP) should be revised based on the updated 2008 guidelines within next two years; and Member States should continue to improve their readiness for pandemic preparedness and strengthen minimum core capacity in all areas in an integrated manner. Specific activities may include: (I) identifying barriers to linking surveillance with response; (2) strengthening national laboratory capacity; (3) facilitating intersectoral collaboration for zoonotic diseases; (4) endorsing and implementing a regional work plan on infection control and (5) strengthening and testing countries' risk communication plans. In addition, the group considered the development of a Simplified and harmonized monitoring tool to track progress towards development of APSEDIIHR minimum core capacities.

o

Group B - Western Pacific RegionChaired by Dr Bounlay Phommasack, Ministry of Health, Lao People's Democratic Republic Objectives o o o To report on IHR event communications in the Western Pacific Region since June 2007. To share country experiences on IHR event-related communications. To explore possible options for strengthening IHR event communications

Overview of IHR events in the Western Pacific Region o More than 20 events have been communicated by National IHR Focal Points to the WHO IHR Contact Point since June 2007.

Key points o Eighty per cent of the events communicated by National IHR Focal Points to the WHO IHR Contact Point were infectious disease events. Main types of communication were consultation, information sharing, reporting and notification.

o

Country experiences o Country experiences in IHR implementation were presented and shared, including: NFP exercise, detection and notification of imported polio case in Australia (July 2007)

- 24-

strengthening of surveillance system, IHR communication mechanism and infonnation sharing (avian influenza, cholera) in the Lao People's Democratic Republic; and

IHR event communication in Viet Nam, its regional collaboration, and the involvement in Public Health Security Exercise organized by WHO (June 2008). o Issues raised and discussed: maintenance of database for surveillance system integration and infonnation sharing of different kinds of surveillance system (e.g. traditional national surveillance system and syndromic surveillance system) threshold for IHR notification (mandatory/optional, confidential/public) international contact tracing (e.g. cost for imported polio case in Australia) experience of event management in China (database system, public information! press release) requirement of IHR "legal & health security expert" (soon-to-be-released WHO national legislation toolkits) WHO event information site (EIS): accessibility, web security questions raised with regard to WHO standard operating procedures for managing acute PHE under IHR.

IHR notification (according to Annex 2) versus infonnal discussion (whatever and whenever felt necessary) role of country offices in IHR communication Main challenges for IHR (2005) implementation:

o o

interpretation of Annex 2 and sample risk assessment from previous events concerns of potential socioeconomic consequences of IHR notification (or consequences of "non" notification) confidentiality of information legislation expertise support from WHO (e.g. Cambodia) consideration of computerized IHR Decision Tree (Annex 2) and electronic tool

o o o

- 25 -

Summary

o o

Importance of exercises and drills to test IHR mechanism Implementation of IHR procedure and/or documentation of IHR communication, when necessary a good opportunity for bilateral communication fast approval mechanism for IHR reporting IHR notification to country offices, Regional Offices, Headquarters (to be clarified) difficulties with using IHR Decision Tree (Annex 2) encouragement of using IHR as starting dialogue IHR informal communication through consultation importance of standard operating procedures in some countries language barrier in communication (translation)Recommendations to WHO

o o o o

Assist in IHR event communication exercise. Update the list of people who can access the IHR event information site. Facilitate information and data sharing (including website links) among countries. Continue to sensitive information to minimize negative impacts and provide technical advice on events notified.

Group C - Interagency Coordinating Committee (ICC) Chaired by Dr Jacques Jeugrnans, ADB The ICC group recognizes the importance of the following:

o o o

broadening the scope of coordination mechanisms set up for avian influenza and/or pandemic influenza at country level to include EIDs; promoting multi sectoral (health and non-health), multilevel (central and public private) partnerships, including business continuity planning; and increasing efforts for better donor coordination at country and regional levels in line with the Paris Declaration for Aid Effectiveness.

- 26The ICC group recommends that WHO:

o

consolidate the monitoring and evaluation tools developed by the Regional Offices for South-East Asia and the Western Pacific into one comrnon tool that can be applied to APSED; introduce monitoring indicators that reflect progress toward achieving outcomes; and help countries identify mechanisms that will ensure sustainability of APSED in the longer term, beyond 2010 (reducing reliance on donors' support).

o

o

The ICC group recommends that TAG: o

enhance its technical support in zoonoses, risk communication, and monitoring and evaluation, including, if necessary, using consultants; and advise and help regional organizations to adopt a progressive programmatic approach for APSED, as opposed to a project-by-project approach to implementation.

o 2.7

Concluding remarks

The Chairperson noted that while significant progress has been made in relation to emerging infectious diseases, the Region still faces major challenges in the months and years ahead, and much more remains to be achieved. In this, we should alI work together. On behalf of the Regional Offices for South-East Asia and the Western Pacific, Dr Kasai expressed his appreciation to the Government of Malaysia for hosting the event and all the participants for their hard work. He thanked the TAG members for their expert advice and encouragement. He thanked the partners for their continuing support. He paid tribute to WHO Headquarters staff for their considerable input to the substance of the meeting. He expressed his appreciation to the Member States for their engagement and the progress they have made. More specifically, on behalf of the Western Pacific Region, he thanked the Regional Office staff working behind the scenes for the preparations and smooth running of the meeting. Dr Limpakarnjanarat thanked his hard-working staff. He noted that the TAG process requires everyone to work together and learn from one another as approaches are harmonized across the two Regions. He noted that the cooperation between the two Comrnunicable Surveillance and Response (CSR) units provides a good model for the coordination of other WHO activities. He also thanked the TAG members, partners, donors and, in particular, the Member States, without which the progress could not have been achieved. And, finalIy, he noted that he is looking forward to the forth TAG meeting, to be held in mid-July 2009, with the venue provisionally scheduled for Thailand. The Chairperson, on behalf of all the participants, thanked the WHO Regional Offices for South-East Asia and the Western Pacific and the Ministry of Health Malaysia as hosts and acknowledged the value to Member States of the briefings received from WHO staff. He concluded that there was plenty of information to digest. In closing the meeting, he also reiterated that much work stilI lies ahead, and that he is looking forward to reviewing further progress on APSED implementation in 2009.

- 27 -

3. CONCLUSIONS AND RECOMMENDATIONS

The conclusions of the meeting and recommendations for the period July 2008 to June 2009 are as follows: 3.1 (1)

Main findings and conclusions Member States and WHO have made substantial progress in implementing and monitoring the Asia Pacific Strategy for Emerging Diseases (APSED) and the International Health Regulations (2005) over the past 12 months. While ensuring that the best features are retained, the APSED framework should continue to remain flexible, so as to adapt to changing circumstances and priorities. Recognition of the interdependencies between APSED, pandemic preparedness and the International Health Regulations (2005), also known as IHR (2005), allows Member States to tailor their planning and implementation activities to their own unique needs and resource constraints, while still strengthening core capacities. Progress has been made to strengthen the National IHR Focal Point function by ensuring that basic means of communication are in place and conducting exercises, and this is reflected in the formal IHR communications made by the WHO South-East Asia and Western Pacific Regions. The main challenges identified include interpretation and use of the IHR Decision Instrument, management of confidential information, legal support, procedures, and language barriers in communication. Following a regional informal consultation on infection control in February 2008, it may be appropriate for Member States to identify a limited number of specific priorities, rather than seek to implement a comprehensive programme, i.e. to focus on the minimum components needed to take basic infection control forward in the short term. The Asia Pacific Region has accumulated considerable expertise and experience in the surveillance, management and research of zoonoses, and this should continue to be fostered and shared widely within and beyond the Region. General recommendations on APSED Member States without an APSEDIIHR plan of action for emerging infectious diseases should develop a national plan before June 2009, and those countries with such national plans should continue to aggressively implement their plans using the APSEDIIHR framework. Member States should, as a cross-cutting theme, strengthen collaboration between clinicians and public health in relation to APSEDIIHR implementation at the national and regional levels, for example, to promote "health facility preparedness". Member States and WHO should broaden the scope of coordination mechanisms developed for avian and pandemic influenza at the country level to include other emerging infectious diseases.

(2)

(3)

(4)

(5)

(6)

3.2 (1)

(2)

(3)

- 28 -

(4)

Member States, WHO and partners are encouraged to develop a research strategy, including operational research, to support APSED/IHR. WHO should continue to collaborate with Member States in completing capacity assessments and developing national plans where strengthening of the core capacities is required. Pandemic preparedness Member States should continue to strengthen pandemic preparedness by revising national pandemic preparedness plans based on the updated 2008 WHO guidance for pandemic preparedness, as well as the lessons learnt from exercises. Member States should ensure that pandemic preparedness plans are updated and tested, and that clear roles and responsibilities for all relevant government departments, and in particular for local government, are specified and that core capacities in all five APSED programme areas continue to be strengthened with a view to meeting all the minimum capacity requirements. Member States should use the survey tool for pandemic preparedness to assess the level of capability (readiness) in pandemic preparedness before June 2009. Member States and WHO should further enhance national and regional logistic capacities and mechanisms in particular for rapid containment based on the "Outbreak Response Logistics" framework. WHO should support Member States in continuing to work across sectors (all relevant government departments) and at both central and local government levels for pandemic preparedness and private partnerships, for example, to encourage business continuity planning for power supply, drinking-water infrastructure, food security and telecommunication. Surveillance and response Member States should continue to improve event-based surveillance systems, identify any barriers to integration and continue to strengthen links between event-based surveillance (including zoonoses and animal health events), indicator surveillance and response, such as through the establishment of a central surveillance and response unit. Selected Member States should evaluate selected indicator-based surveillance systems in 2009 to strengthen surveillance and response. Member States should strengthen response capacity, starting with the national and then subnational capacities, by 2009. Member States should foster joint training with animal health practitioners to help foster shared skill sets and greater collaboration in surveillance and response situations. WHO should support Member States to implement the above recommendations, including, for example, supporting Member States in the development of field epidemiology training that is designed specifically to meet the needs of individual Member States.

(5)

3.3 (I)

(2)

(3)

(4)

(5)

3.4 (I)

(2)

(3)

(4)

(5)

- 29-

3.5 (I)

Laboratory capacity Member States should strengthen national, and where appropriate, subnational capacity to collect, transport and test specimens according to international standards. Member States should strengthen and coordinate laboratory and epidemiological contributions to national surveillance systems, for example in support of vaccine-preventable disease control programmes. Member States should identify official country-level focal points for laboratory issues to collate and disseminate information to all relevant laboratories. Such focal points may be the National IHR Focal Points. Member States that do not have effective legislation for supporting biosafety and biosecurity should consider developing such legislation. Member States and WHO should support implementation of biosafety and biosecurity programmes at national public health or reference laboratories that can act as a model for other facilities in their countries. WHO and Member States should support national laboratories to participate in national and international laboratory networks and joint research projects. WHO should assist Member States to develop, endorse and implement a national strategy for laboratory capacity-building, targeting specific diseases of national public health relevance (particularly those that are epidemic prone) which must be supported by accurate, safe and timely diagnosis through internationally recognized external quality assurance programmes (EQAP). Influenza Member States should review and strengthen their influenza surveillance systems, for example by using the new influenza surveillance guidelines, A Practical Guide to Harmonizing Virological and Epidemiological Injluenza Surveillance, which not only emphasizes harmonization of virological and epidemiological surveillance, but also encourages inclusion of surveillance for severe acute respiratory infection and event-based surveillance. Member States are encouraged to conduct influenza disease burden studies according to the guidelines, A Practical Guide for Designing and Conducting Injluenza Disease Burden Studies, and to implement influenza immunization where it is appropriate. WHO should support developing countries financially and technically in conducting influenza disease burden studies, developing vaccine policy and carrying out cost-benefit analyses, if requested. Member States with national influenza centres are encouraged to participate in the review of influenza surveillance in the Asia Pacific Region, which will be developed and presented at the third national influenza centre meeting in 2009. The WHO EQAP provides a means for monitoring and improving laboratory performance. National influenza centres are encouraged to continue their participation in EQAP.

(2)

(3)

(4)

(5)

(6)

(7)

3.6 (I)

(2)

(3)

(4)

- 303.7 (1) Zoonoses WHO, in collaboration with the Food and Agriculture Organization of the United Nations and World Organization for Animal Health, should promote the use of a new guideline, namely Zoonotic Diseases: A Guide to Establishing Animal and Human Health Sectors Collaboration at the Country Level, for intersectoral collaboration to strengthen zoonoses coordination mechanisms, including publication of relevant documents and support the use of in-country mechanisms for intersectoral collaboration to address other zoonoses control programmes in addition to avian influenza. The inclusion of wildlife species and their ecology, as well as diseases that impact food production animals, should be encouraged in zoonotic surveillance, vector surveillance and associated research. WHO and Member States should further develop their focus on priority zoonotic diseases in the region, such as rabies, Nipah virus, Japanese encephalitis and leptospirosis, as well as chronic zoonoses such as brucellosis. Infection control Member States should endorse and implement a regional workplan on infection control, which has been developed based on an informal technical consultation in 2008, and that: • • designates a national infection control focal point within the Ministry of Health; establishes or strengthens a national infection control advisory and coordination committee; and establishes, designates or strengthens a national infection control resource centre.

(2)

(3)

3.8 (I)

• (2)

Member States should collaborate with existing programmes within WHO on infection control, including infection control assessment and training modules. Member States should focus on the minimum components needed to take basic infection control forward in the short term. For example, involve senior hospital management and clinical leaders in promoting infection control, including nosocomial infection prevention and control, and training, so as to pave the way for further improvements and greater health facility preparedness in the medium term. Given the significance of influenza and tuberculosis, including drug resistance and co-infection with HIV, to the region, an initial priority should be the implementation of the guidelines for infection control for respiratory diseases. Risk communication Member States should strengthen and test through exercises their outbreak communication system and capacity as a priority, including identification and training of risk communication officers at the national level and development of a national outbreak communication plan. Given that event-based surveillance is often media driven, Member States may consider using actual outbreaks to audit the risk communication function.

(3)

3.9 (1)

(2)

- 31 -

(3)

Member States and WHO should use WHO documents to foster a common understanding of risk communication principles and practice, and WHO should consider conducting a workshop for this purpose.

3.10 WHO regional functions (I) (2) WHO should further strengthen regional disease and event-based surveillance systems. WHO should continue to support countries in strengthening national systems and capacities in all the APSED five areas of work. WHO should seek to further strengthen regional outbreak alert and response systems and operational capacities using existing networks, in particular the Global Outbreak Alert and Response Network. WHO should strengthen regional risk communication capacity in time to assist Member States in "catching up" this area of work, especially outbreak communication. WHO should assist regional organizations to progressively develop a programmatic APSED approach rather than rely on a project-by-project basis.

(3)

(4)

(5)

3.11 (1)

IHR - National Focal Point functions and points of entry Member States should further strengthen the National Focal Point functions through: • • relevant exercises; the development of rapid IHR event communication mechanisms and operating procedures, where necessary; and the use of the IHR Decision Instrument to determine whether events warrant notification to WHO officially.

•

(2)

Member States should ensure that all the designated points of entry meet IHR requirements through: • • • making advance and practical arrangements with relevant agencies; establishing interagency communication and coordination mechanisms; and planning for implementation of certain points of entry measures (e.g. entry/exit screening) .

(3)

WHO should provide Member States with technical guidance and assistance in developing and testing IHR event communication procedures, when required, and continue to improve and sustain the WHO IHR communication and duty officer system. WHO should generate information on and audit the types and numbers of public health events that are being detected and reported in different regions, and if possible, by country.

(4)

- 32-

(5)

WHO should organize a regional meeting to facilitate sharing of information, country experience and practice in making practical arrangements and strengthening interagency communication and collaboration to meet the IHR requirements for points of entry.

3.12 APSED/IHR monitoring and evaluation (1)

Member States should monitor their progress, and consider using a simplified and harmonized monitoring tool as a device to track progress, towards development of APSEDIIHR minimum core capacities to be achieved by 2010, and have a procedure to drive further implementation planning. WHO should be available to support Member States in their utilization of the monitoring tool, specifically in relation to monitoring and planning procedures.

(2)

- 33 -

ANNEX I

PROGRAMME OF ACTIVITIES

Day 1-16 July (Wednesday)

08:30-09:00 Registration 09:00-10:00 Opening session Opening remarks - The WHO Representative of Malaysia Welcome speech - The Ministry of Health, Malaysia

Self Introduction Meeting objectives and agenda - Dr Takeshi Kasai, Regional Adviser, CSRlWHO/wPRO Announcement of meeting Chairs, Vice-chairs and Rapporteurs Administrati ve announcements - CSRlWHO/wPRO Group photograph 10:00-10:30 Coffee break

10:30-12:10

Session 1 -Emerging Disease Threats and APSED Approach Chair: Dr Xiao Dong/ou Vice-Chair: Dr Jongkol Lertiendumrong

10:30-10:45 Global update on EIDs and IHR (2005) implementation - Dr Maxwell Hardiman, EPRlWHOIHQ

10:45-11 :00 Update on emerging infectious diseases (EIDs) in the Asia Pacific Region - Dr Khanchit Limpakarnjanarat, Regional Adviser, CSRlWHOISEARO

11 :00-11 :20 Progress of implementation of the 2nd TAG meeting on EIDs - Dr Takeshi Kasai, Regional Adviser, CSRlWHO/wPRO

11 :20-11:30 Questions and clarifications 11:30-11:45 Outcome of APSED joint mid-term review in Lao PDR - Dr Bounlay Phommasack, Lao PDR

11 :45-12:00 Outcome of APSED joint mid-term review in Sri Lanka - Dr Paba Palihawadana, Sri Lanko

12:00-12: 10 Questions and clarifications 12:10-13:30 Lunch break

- 34-

13:30-14:30 Session 2 - Update on International Health Regulations (IHR) Chair: Professor John Mackenzie (on behalf of Dr Shiv LAL)

Vice-Chair: Dr Poh-Lian Yap Lim

13: 30-13:40 Regional progress on lHR implementation in the Asia Pacific Region (Based on the State Parties' Reports) - Dr Khanchit Limpakarnjanarat, CSRlWHO/SEARO

13:40-13:50 Outcome of informal consultation on points of entry capacity in the region - Dr Li Ailan, CSRlWHOIWPRO

13:50-14:10 Country progress on lHR (2005) implementation (1) lHR implementation in Thailand (10 min) - by Thailand

(2) Core capacity at designated points of entry (e.g. KLIA) in Malaysia (10 min) - by Malaysia

14: 10-14:20 Questions and clarifications 14:20-14:30 WHO Operating Procedures for managing acute public health events under lHR - Dr Thomas Grein. ARO, EPRlWHOIHQ

14:30-17:30 Session 3 - Pandemic Preparedness Chair: Professor Angus Nicoll (on behalf of Prof N. K. Ganguly)

Vice-Chair: Professor Angus Nicoll

14:30-14:45 Update of WHO guidelines on pandemic preparedness - Dr Sylvie Briand. GIP, EPRIWHO/HQ

14:45-15:00 Avian influenza Task Force on research (Bali, March 2008) - Prof N.K. Ganguly, TAG member, WHO/SEAR (Dr Richard Brown, CSRlWHO/SEARO, on behalf of Professor Ganguly)

Questions and clarifications 15:00- 15:20 Coffee break

- 35 15:20-16:00 Regional progress on pandemic influenza preparedness (1) Regional progress on pandemic influenza preparedness (10 min)

- Dr Satoko Otsu, CSRlWHO//wPRO

(2) Rapid containment exercise in Philippines (10 min) - by Philippines

(3) Rapid containment exercise in Indonesia (10 min) - by Indonesia

Questions and clarifications 16:00-16: 10 Review of readiness: Results of the pandemic preparedness assessment - Dr Bee Lee Ong, CSRlWHO/wPRO

16: 10-17:30 Panel discussions: pandemic preparedness - India, Indonesia, Japan, Lao PDR, Malaysia, Singapore and Thailand - Facilitator: Professor Hitoshi Oshitani

18:30

Reception

Day 2 -17 July (Thursday)

08:30-08:40 Wrap-up of Day I on EIDs, pandemic preparedness and IHR - by Rapporteur

08:40-14:00 Session 4 - Progress on the five APSED areas of work Chair: Dr Anne Schuchat

Vice-Chair: Dato' Dr Hasan Bin Abdul Rahman, MOH, Malaysia

08:40-09:20 4.1 Laboratory (1) Progress in laboratory capacity strengthening in the Asia Pacific Region (10 min) -Dr Christopher Oxenford, CSRlWHO/wPRO

(2) Laboratory capacity strengthening in India (10 min) - by India

- 36 -

(3) Outcome of the Second Bi-regional National Influenza Centres Meeting (10 min) - Dr Luo Dapeng, WHO/Mongolia (on behalf of Dr Zhou Weigong, CSRlWHOIWPRO)

Questions and discussions 09:20-12:30 4.2 Surveillonce and response 09:20-09:30 Regional progress on strengthening surveillance in the Asia Pacific Region - Ms Amy Cawthorne, CSRlWHOIWPRO

09:30-09:40 Regional progress on strengthening outbreak response capacity (including FETP) in the Asia Pacific Region - Dr Suzanne Westman, CSRlWHO/SEARO

09:40-09:50 Strengthening GOARN in the Region - Professor John Mackenzie, Australia

09:50-10:00 Questions and discussions 10:00-10:30 Coffee break

10:30-11 :00 Strengthening outbreak response capacity at country level (1) Training of RRTs in Myanmar (10 min) - by Myanmar (2) Planning for a country FETP in Viet Nam (10 min) - by Viet Nam

Questions and discussions 11:00-12:30 Panel discussion: Establishing and strengthening EBS at country level - Cambodia, China, Indonesia, Mongolia, Lao PDR, Philippines and Thailand - Facilitator: Dr Thomas Grein 12:30-13:30 Lunch break

13:30-14:00 4.3 Infection control (1) Progress of infection control activities in the Asia Pacific Region (10 min) - Dr Richard Brown, CSRlWHO/SEARO

- 37 -

(2) WHO work plan for infection control in the Western Pacific Region (10 min)

- Ms Paola Montes, CSRlWHOIWPRO Questions and discussions 14:00-14:50 Session 5 - APSED implementation monitoring

Chair:

MsAnnMoen

Vice-Chair: Dr Nobuhiko Okabe (1) Framework of APSED implementation monitoring

- Mr Wayne Antkowiak, CSRlWHOIWPRO (2) Monitoring process (tools)

- Dr Suzanne Westman, CSRlWHO/SEARO Questions and discussions 14:50-15: 10 Coffee break 15: 10-17: 10 Breakout sessions (1) Group A: Countryforum (SEAR)

Chair: Dr Andi Muhadir Group rapporteur: Dr Paba Palihawadena Facilitator: Dr Suzanne Westman (2) Group B: Country forum (WPR) - Chair: Dr Bounlay Phommasack, Lao PDR - Agenda: • IHR event communication (15: /0-16:00) o Review of IHR event communication over the past year - Dr Li Ailan, CSRlWHOIWPRO

o

Country experience and SOPs(5-10 min/each) - Australia -LaoPDR - Viet Nam

•

Discussions(16:00-17: 10) - Facilitators: Dr Thomas Grein

- 38-

(3) Group C: ICC (donorslparlners'forum) - Chair: Dr Jacques Jeugmans, ADB - Facilitator: Wayne Antkowiak, CSRlWPRO - Agenda:

• • •

Donor support in the Region, including national plan implementation (by Mr Wayne Antkowiak, CSRlWHO/wPRO) Financial/fund support from individual donors (by individual donor) Discussions (donors' role in supporting national workplan implementation)

(4) Group D: Meeting of TAG members - Chair: - Agenda: Dr Xiao Dong/ou

• • Day 3 -18 July (Friday)

Main findings and conclusions Possible TAG recommendations

08:30-08:40 Wrap up of Day 2 on the five APSED programme areas - by Rapporteur

08:40-09:30 Session 4 - Progress on the five APSED areas of work (continue) Chair: Dr Anne Schuchat

Vice-Chair: Dato' Dr Hasan Bin Abdul Rahman, MOH, Malaysia

08:40-09: 10 4.4 Zoonoses collaboration (1) Progress on zoonotic disease collaboration in the Asia Pacific Region (10 min)

- Dr G.N. Gongal, CSRlWHOISEARO

(2) Country experience: Pilot study - zoonoses collaboration in Philippines (l0 min) - by Philippines

Questions and discussions

- 39-

09: 10-09:30 4.5 Risk communication Progress on risk communication in the Asia Pacific Region (10 min) Ms Shima Roy, CSRlWHO/SEARO

Questions and discussions 09:30-12:30 Session 6 - Conclusions and recommendations Chair: Dr Xiao Donglou

Vice-Chair: Professor John Mackenzie

09:30-10:30 Group feedback ofthe breakout sessions (by 10 min each group) Questions and clarifications Comments on the breakout sessions from TAG members 10:30-11:00 Coffee break

11 :00-12:00 Meeting conclusions and TAG recommendations

- by Chair

The announcement of the Fourth TAG meeting in 2009 - by WHO/SEARO

12:00-12:30 Closing

- 40-

ANNEX 2

PROVISIONAL LIST OF TECHNICAL ADVISORY GROUP, RESOURCE PERSON, CONSULTANTS, PARTICIPANTS, OBSERVERS AND SECRETARIAT

I. TECHNICAL ADVISORY GROUP

Dr 10ngkol LERTIENDUMRONG, (Representing Dr Viroj Tangcharoensathien). International Health Policy Programme, Ministry of Public Health, Tiwanon Road, Muang District, Nonthaburi Province, 11000, Thailand, Tel. No.: (66) 25902371. Fax No. : (66) 25902385, E-mail: jongkol@ihpp.thaigov.net Dr Poh-Lian Yap LIM, (Representing Dr Brenda Ang), Senior Consultant, Department of Infectious Diseases, Head, Travelers' Health and Vaccination Clinic, Tan Tock Seng Hospital Ministry of Health, II lalan Tan Tock Seng, Singapore 308433, Singapore, Tel. No.: (65) 81263253, (65) 6357 7919, Fax No.: (65) 62524056, E-mail: Poh_Han_lim@ttsh.com.sg;Lim_poh_lian@moh.gov.sg Professor John Sheppard MACKENZIE, Emeritus Professor and Professor of Tropical Infectious Diseases, Curtin University of Technology, P.O. Box 8362, Armadale, Victoria 3143, Australia Tel. No.: (614) 398 75697, Mobile: (614) 39875697, Fax No.: (618) 9266 1640, E-mail: j.mackenzie@curtin.edu.au Professor Angus NICOLL, CBE, Senior Expert - Influenza Coordination, European Centre for Disease Prevention and Control, Tomtebodavagen IIA, 17183 Stockholm, Sweden, Tel. No.: (46) 858 601213, Fax No.: (46) 858 601001, E-mail: angus.nicoll@ecdc.europa.eu Dr Nobuhiko OKABE, Ph.D, (Representing Dr Tatsuo Miyamura), Director of Infectious Disease Surveillance, National Institute of Infectious Diseases, 1-23-1 Toyama Shinjuku-ku, Tokyo 162-8640, Japan, Tel. No.: (813) 5285 1111 (office), Fax No.: (813) 5285 1129, E-mail: okabenob@nih.go.jp Dr Anne SCHUCHAT, RADM US Public Health Service, Director, National Centre for Immunization and Respiratory Diseases, Centres for Diseases Control and Prevention, 1600 Clifton Road, Mail Stop E-05, Atlanta, GA 30333, United States of America, Tel. No.: (404) 639 8200, Fax No: (404) 639 8626, E-mail: acsl@CDC.GOV Dr Donglou XIAO, Deputy Director-General, Bureau of Disease Control, Ministry of Health 1 Xizhimenwai, South Road, Beijing 100044, People's Republic of China, Tel. No.: (8610) 6879 2050, Fax No.: (8610) 6879 2514, E-mail: xiaodl@moh.gov.en

- 41 -

RESOURCE PERSON

Ms Ann MOEN, Associate Director for Extramural Programmes, Influenza Division, National Centre on Immunization, and Respiratory Centres for Disease Control and Prevention, 1600 Clifton Road MS G-16, Atlanta, GA 30333, United States of America, Tel. No.: (1404) 639 4652, Fax: No.: (l 404) 639 2334, E-mail: ALC3@cdc.gov 2. CONSULTANTS

Mr Andrew FORSYTH, Team Leader (Public Health Legislation Review), Health & Disability Systems Strategy Directorate, Ministry of Health, P.O. Box 5013, Wellington. New Zealand Tel. No.: (644) 8164429, Fax No.: (644) 8162191, E-mail: andrew_forsyth@moh.govt.nz Dr Hitoshi OSHITANI, Professor, Tohoku University Graduate School of Medicine 2-1 Seiryo-cho Aoba-ku, Sendai 980-8575, Japan, Tel. No.: (812) 2717 8210, Fax No.: (812) 2717 8212, E-mail: oshitanih@mail.tains.tohoku.ac.jp 3. PARTICIPANTS WESTERN PACIFIC REGION

AUSTRALIA

Dr Yasmine GRAY, Director, International Surveillance and Reporting Section, Office of Health Protection, Department of Health and Ageing, Canberra. Tel. No.: 61 262892737, Fax No.: 61 262892600, E-mail: yasmine.gray@health.gov.au

BRUNEI DARUSSALAM

PG Dr Khalifah PG ISMAIL, Head of Occupational Health, Department of Health Services, B.S.B. Health Centre, lalan Ong Sum Ping, Bandar Seri Begawan. Tel. No.: (673) 2230043, Fax No.: (673) 2230044, E-mail: pgkhalifah@yahoo.com Dr Sok TOUCH, Director, Communicable Disease Control Department, Ministry of Health, No. 151-153 Kampuchea Krom Avenue, Phnom Penh. Cambodia, Tel. No.: (855) 12856848, Fax No.: (855) 23 882317, E-mail: touch358@moh.gov.kh

CAMBODIA

- 42-

Dr Sovann L Y. Deputy Director, Communicable Disease Control Department, Ministry of Health, No. 151-153 Kampuchea Krom A venue, Phnom Penh, Cambodia, Tel. No.: (855) 12 825424, Fax No.: (855) 23 882317 E-mail: sovann_Iy@online.com.kh PEOPLE'S REPUBLIC OFCHNA Dr NI Daxin, Division Director, Office of Unknown cause diseases, Disease Control and Emergency Response, China Centre for Disease Control, 27 Nanwei Road, Xuanwu District, Beijing 100050, Tel. No.: (8610) 631 77356, Fax No.: (8610) 631 77356, E-mail: jsndx@vip.sina.com Dr CHEN Lei, Junior Section Chief, Office of Health Emergency, Ministry of HeaJth, No. I Nanlu Xizhimenwai,Beijing 100044. Tel. No.: (8610) 687 92647, Fax No.: (8610) 687 92646, E-mail: chenleiOIO@hotmail.com HONG KONG (CHINA) Dr LAM Man-kin Ronald, Community Physician, Community Liaison Division, Centre for Health Protection, 147C Argyle Street, Kowloon, Tel. No.: (852) 2125 2051, Fax No.: (852) 2601 4209, E-mail: ronald_lam@dh.gov.hk

MACAO (CHINA)

Dr LEONG Iek Hou, Public Health SpeciaJist, Control of Communicable Diseases, CDC-NDIV, HeaJth Bureau 7th Floor, Building "Hot Line", No. 335-341, Alameda Drive, Carlos d'Assumpcao, Macao SAR, Tel. No.: (853) 285 33525, Fax No.: (853) 285 33524, E-mail: ihleong@ssm.gov.mo Dr Kuniake MIYAKE, Deputy Director, Tuberculosis and Infectious Diseases Control Division, Health Services Bureau, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo, 100-8916, Tel. No.: (813) 3595 2257, Fax No.: (813) 3581 6251, E-mail: miyake-kuniaki@mhlw.go.jp Dr Jun-wook KWON, Director, Division of Communicable Diseases Control, Korea Centres for Disease Control and Prevention, 5 Nokbun-dong, Eunpyung-gu, Seoul Tel. No.: (822) 380 2631, Fax No.: (822) 354 2723, E-mail: kjw9925@mw.go.kr Dr Bounlay PHOMMASACK, Director, National Avian Human Influenza Coordination Office, National Animal and Human Influenza Coordination Office, Ministry of Health! Prime Minister Office, Vientiane, Tel. No.: (856) 264 324, Fax No.: (856) 264326, E-mail: BLNAHICO@laopdr.com

JAPAN

REPUBLIC OF KOREA

LAO'S PEOPLE DEMOCRATIC REPUBLIC

- 43 -

Dr Phengta VONGPHRACHANH, Director National Centre for Laboratory and Epidemiology, Ministry of Health, Km 3 Thadeua Road, Vientiane Tel. No.: (856) 21312351, Fax No.: (856) 21350209 E-mail: phengta@hotmail.com MALAYSIA Dato' Dr Hasan Bin Abdul RAHMAN, Director Disease Control Division, Ministry of Health Malaysia, Level 8, Block ElO, Complex E, Federal Government Administrative Centre, 62590 Putrajaya, Tel. No.: (603) 8883 4126, (6019) 938 5913, Fax No.: (603) 88834150, E-mail: hasar@moh.gov.my Dato' Dr Nor Shahidah Binti KHAIRULLAH, Senior Consultant Virologist, c/o Office of the Director- General of Health, Ministry of Health, Level 12, Block E7, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya Tel. No.: (603) 8883 2545, (6017) 883 3022, Fax No.: (603) 8889 5542, E-mail: Dato.drnorkhairullah@gmail.com MONGOLIA Dr Otgonbaatar DASHDAWA, Director National Centre for Infectious Diseases with Natural Foci, Ministry of Health, Government Building VIII, Olympic Street 2, Sukhbaatar District, Ulaanbaatar 51, Tel. No.: (976) I 99113549, Fax No.: (976) II 632859, E-mail: cidnf@mbox.mn Dr Altantsetseg TOGOO, General Director, National Centre for Communicable Disease, NCCD Campus, Nam-Yan-Ju Street, Ulaanbaatar 210648, Tel. No.: (976) 11 458699, Fax No.: Email: altantsetseg@nccd.gov.mo. NEW ZEALAND Dr Mark JACOBS, Director of Public Health, Health and Disability Systems, Strategy Directorate, Ministry of Health, I The Terrace, Wellington, P.O. Box 5013, New Zealand, Tel. No.: (644) 8164481, (644) 495 4481, Mobile: (027) 226 8702, Fax No.: (644) 8164477, E-mail: Mark_Jacobs@moh.govt.nz Mr Berry ROPA, National Surveillance Officer, Department of Health, P.O. Box 807, Waigani NCD, Tel. No.: (675) 301 3730, Fax No.: (675) 323 0177, E-mail: berry-ropa@health.gov.pg Dr Marlow NINAL, Chief, Public Health Surveillance and Informatics Division, National Epidemiology Centre, Department of Health, San Lazaro Compound, Rizal A venue, Sta. Cruz, Manila, Tel. No.: (632) 743 1937, Fax No.: (632) 7431937, E-mail: marlow_ninal@yahoo.com

PAPUA NEW GUINEA

PHILIPPINES

- 44-

Dr Lyndon LEE SUY, Medical Specialist IIINational Programme Manager for Dengue and Emerging Infectious Diseases, National Centre for Disease Prevention and Control, Department of Health, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila, Tel. No.: (632) 7438301 extension 2350, Fax No.: (632) 711 6808, E-mail: donleesuymd@yahoo.com VIETNAM Dr Thanh Dong LE, Chief, Department of Health Quarantine and Chemical Management, General Department of Preventive Medicine and Environmental Health, Ministry of Health, 135 Nui Truc, Ba Dinh, Ha Noi Tel. No.: (844) 8464415, Fax No.: (844) 2362853, E-mail: lethanhdong@gmail.com

SOUTH-EAST ASIA REGION

INDONESIA

Dr Andi MUHADIR, MPH, Director of Surveillance Epidemiology, Immunization and Matra Health, Directorate General of Communicable Disease Control and Environmental Health, Ministry of Health, Indonesia, Jakarta, TellFax. No.: 06221 7888 4666, E-mail: a.muhadir@yahoo.com Dr Soe ~O, Assistant Director, Central Epidemiology Unit, Department of Health, Nay Pyi Taw, The Government of the Union of Myanmar, Ministry of Health TellFax. No.: 9567420437, E-mail: soeooceu@gmail.com; soeoo 137@maiI4u.com.mm Dr Tun Aung Kyi, Deputy Divisional Health Director, Mandalay Division, The Government of the Union of Myanmar Ministry of Health, TellFax No. 95 2 33173

MYANMAR

THAILAND

Dr Kumnuan UNGCHUSAK, Director, Bureau of Epidemiology and International Health Regulation Focal Point, Department of Disease Control, Ministry of Health, Tivanonda Road, Nonthaburi 11000, Tel. No.: (662) 590 I 781, Fax No: (662) 5901 784, E-mail: kum@health.moph.go.th Dr Paba PALlHA WADANA, Deputy Epidemiologist, Ministry of Health Care and Nutrition, Government of the Democratic Socialist, Republic of Sri Lanka, Colombo. Tel. No.: 0112695112; Fax No.: 011 2096583, E-mail: paba@health.gov.lk

SRI LANKA

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4. OBSERVERS

ASIAN DEVELOPMENT BANK

Dr Jacques JEUGMANS, Practice Leader (Health), Regional and Sustainable Development Department, 6 ADB Avenue, Mandaluyong City, 1550 Metro Manila, Philippines, Tel. No.: (632) 632 6392, Fax No.: (632) 6362409 E-mail: jjeugmans@adb.org. Dr Bounpheng PHILA YONG, Assistant Director, Head, Health and Population Unit, Bureau for Resources Development, The ASEAN Secretariat, 70 A Jalan Sisingamangaraja, Jakarta 12110. Indonesia, Tel. No.: (6221) 726 2991, (62 21) 724 3372 ext 423 Fax No.: (6221) 739 8234, (6221) 7243504, E-mail: b.philavong@asean.org Dr Ma. Luningning E. YILLA, Programme Facilitator, ASEAN Plus Three Emerging Infectious, Diseases Programme Programme Facilitation Section, Health and Population Unit, The ASEAN Secretariat, 70 A Jalan Sisingamangaraja Jakarta, Indonesia, Tel. No.: (6221) 726 2991 ext 393, E-mail: luningning@aseansec.org

ASSOCIATION OF SOUTH-EAST ASIAN NATIONS

AUSTRALIAN AGENCY FOR INTERNATIONAL DEVELOPMENT

Dr Julie DELFORCE, Director, Asia Transboundary Section, GPO Box 887, Canberra, A.C.T 2601, Canada, Tel. No.: (612) 62064338, Fax No.: (612) 6206 4036, E-mail: Julie.Delforce@ausauid.gov.au Dr Jeffrey W. MCFARLAND, US CDC Influenza Coordinator, US CDC GDD Director, US CDC Country Representative, PSC 461 Box 50, FPO AP 96521, United States of America, Mobile: (86) l39 10560875, Fax No.: (8610) 6532 9908, E-mail: jwrn5@cdc.gov Dr Andrew CORWIN, US Centre for Disease Control, In-Country Coordinator, CDC-WHO Collaboration, United States Embassy, Vientiane, Lao People's Democratic Republic, Tel. No.: (856-21) 267059, Mobile No.: (856-20) 5521249 Fax No.: (856-21) 267193, E-mail: corwinal@state.gov

CENTRE FOR DISEASE CONTROL AND PREVENTION

INTERNATIONAL MEDICAL CENTRE OF JAPAN

Dr Toru CHOSA, Senior Consultant, Bureau of International Cooperation, International Medical Centre of Japan, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tel. No.: (813) 32027181 ext 2744, Fax No.: (8l3) 3205 7860 E-mail: t.chosa@it.imcj.gojp

- 46-

MEKONG BASIN DISEASE SURVEILLANCE

Dr Moe Ko 00, Mekong Basin Disease Surveillance, Regional Coordinator, MBDS Regional Coordinating Office, c/o Ministry of Public Health, Department of Disease Control, Tiwanond Road, Nonthaburi 11000, Thailand Tel, No.: (66) 2590 3343, Fax No.: (66) 25903323, Mobile: (66) 897708332, E-mail: moe@mbdsoffice.net Mr Takehiro ONO, First Secretary, Health Attache, 2-2-1 Kasumigaseki, Chiyoda-ku, Tokyo 100-8919, Japan Tel, No.: 03-5501-8000, Fax No.: 03-5501-8234, E-mail: .takehiro.ono@mofa.go.jp. Ms Maki KOBAYASHI, Counsellor (Chief of Economic Section). 2-2-1 Kasumigaseki. Chiyoda-ku, Tokyo 100-8919, Japan, Tel, No.: 03-5501-8000, Fax No.: 03-5501-8234, Dr Beom Joon KIM, Epidemic Intelligence Service Officer Korea Centres for Disease Control and Prevention, Division of Communicable Disease Control, 194 Tongil-ro, Eunpyeong-gu, Seoul 122-701, South Korea Tel. No.: (8211) 99358914, Fax No.: (282) 380 2723, E-mail: _robotcat@freechaLcom Dr Zainudin Abdul WAHAB, Deputy Director of Surveillance Section Deputy Director of Surveillance Section. Disease Control Division, Ministry of Health, 4F Block EIO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya. Malaysia, Tel, No.: (03) 8883 4370, Fax No.: (03) 9999 6271, E-mail: zainudin3w@moh.gov.my Dr Mohamed Paid YUSOF, Deputy Director of Communicable Disease Section, Disease Control Division, Ministry of Health, 3F Block EIO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya. Malaysia, Tel, No.: (03) 8883 4421, Fax No.: (03) 8888 6270, E-mail: drmdpaid@moh.gov.my Dr Zainah SAA T, Clinical Virologist, Institute for Medical Research, Ministry of Health, Jalan Pahang. 50588 Kuala Lumpur, Malaysia, Tel, No.: (03) 26162672, Fax No.: (03) 2693 8094, E-mail: zainah@imr.gov.my Dr Leong Chee LOON, Infectious Disease Physician, Sg. Buloh Hospital, 47000 Sungai Buloh, Selangor, Malaysia, Tel, No.: (03) 6145 4333, Fax No.: (03) 6145 4222, E-mail: bkho@hotmail.com

MINISTRY OF FOREIGN AFFAIRS JAPAN

MINISTRY OF HEALTH AND WELFARE OF THE REPUBLIC OF KOREA

MINISTRY OF HEALTH MALAYSIA

- 47 Dr Che Zalina bt. Mohd. ZAID, Veterinary Officer, Zoonotic and Public Health Unit, Department of Veterinary Services, Wisma Tani, Block Podium, Lot 4G I, Presint 4, Federal Government Administrative Centre, 62630 Putrajaya, Malaysia, Tel. No.: (03) 88702101, Fax No.: (03) 8888 6472, E-mail: zalinamz@jph.gov.my Dr Rozaini Mohd. ZAIN, Principal Assistant Director, Infection Control Unit, Medical Development Division, 7F Block EI, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 8883 1188, Fax No.: (03) 88831176, E-mail: drrozaini@moh.gov.my Dr Sabrina Che Abdul RAHMAN, Principal Assistant Director, Medical Development Division, 7F Block EI, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya. Malaysia, Tel. No.: (03) 8883 1156, Fax No.: (03) 8883 1155, E-mail: Sabrina@moh.gov.my Dr Mariam MOHAMAD, Epidemiology Officer, National Public Health Laboratory, Lot 1853 Kg. Melayu. 4700 Sungai Buloh, Selangor. Malaysia, Tel. No.: (03) 6156 5109, Fax No.: (03) 61402249, E-mail: mariammd@moh.gov.my Dr Asiah A YOB, Epidemiology Officer, Perak State Health Department, Jalan Panglima Bukit Gantang Wahab, 3000 Ipoh, Perak. Malaysia, Tel. No.: (05) 255 2821, Fax No.: (05) 208 4200, E-mail: prkaI18@moh.gov.my Pn Zawaha Hj lORIS, Senior Information Officer,

Health Behaviour Research Institute, Jln Rumah Sakit Bangsar, 50590 Kuala Lumpur, Malaysia, Tel. No: (03) 2284 9005, Fax No.: (03) 2284 9080, E-mail: hjhzawaha@yahoo.com Dr Che Abdullah HASSAN, Senior Principal Assistant Director Communicable Disease), Disease Control Division, Ministry of Health, 3F Block ElO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 88834412, Fax No.: (03) 8888 6270, E-mail: drcheabdullah@rnoh.gov.rny Dr Rosemawati ARIFFIN, Principal Assistant Director (Surveillance), Disease Control Division, Ministry of Health, 3F Block EIO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 88834506, Fax No.: (03) 8888 6271, E-mail: rose@moh.gov.my Dr Husnina IBRAHIM, Principal Assistant Director (Surveillance), Disease Control Division, Ministry of Health, 4F Block EIO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 8883 4392, Fax No.: (03) 8888 6271, E-mail: husnina@moh.gov.rny

- 48 -

Dr Devan KURUP, Principal Assistant Director (Surveillance), Disease Control Division, Ministry of Health, 4F Block ElO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 8883 4331, Fax No.: (03) 8888 6271, E-mail: devan@moh.gov.my Dr Zairina Abdul RAHMAN, Senior Assistant Director, (Communicable Disease), Disease Control Division, Ministry of Health, 3F Block El 0, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 8883 4451, Fax No.: (03) 8888 6270, E-mail: zarina@moh.gov.my Dr Nazarudin SAFIAN, Senior Assistant Director (Surveillance), Disease Control Division, Ministry of Health, 4F Block E 10, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 8883 4394, Fax No.: (03) 8888 6271, E-mail: drnazarudin@moh.gov.my Dr Wan Noraini Wan Mohamed NOR, Senior Assistant Director (SurveiIlance), Disease Control Division, Ministry of Health, 4F Block ElO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 8883 4297, Fax No.: (03) 8888 6271, E-mail: drwnoraini@moh.gov.my Dr Roza bt. SARIMIN, Senior Assistant Director (Communicable Disease), Disease Control Division, Ministry of Health, 3F Block ElO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 8883 4508, Fax No.: (03) 8888 6270, E-mail: roza_hisham@yahoo.com.my Dr Khairul Nazim b. Abu HASAN, Senior Assistant Director (Communicable Disease), Disease Control Division, Ministry of Health, 3F Block ElO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 88834511, Fax No.: (03) 88886270, Email: dr.khairul@moh.gov.my Dr Azlan bin DARUS, Senior Assistant Director (Vector), Disease Control Division, Ministry of Health, 4F Block El 0, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 8883 4293, Fax No.: (03) 8888 6215, E-mail: azdarus@gmail.com Dr Masitah bt. MOHAMED, Senior Assistant Director (AIDS/STD), Disease Control Division, Ministry of Health, 4F Block ElO, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia, Tel. No.: (03) 8883 4373, Fax No.: (03) 8883 4285, E-mail: itaimran@yahoo.com

- 49Mrs Souphavanh PHOONSAV ANH, Programme Associate Simuong Road, Vientiane, Lao People's Democratic Republic, Tel. No.: (85621) 264324, 25, Fax No.: (85621) 264326, Mobile: (856 20) 5509456, E-mail: S.PHOONSAVANH_NAHICO@laopdr.com Dr Felix LI, M.B, B.S., FRCPC, Minister Counsellor (Health), Canadian Embassy, 19 Dongzhimenwai Dajie, Beijing 100600, People's Republic of China, Tel. No.: (8610) 5139 4058 /Mitnet 341-3205, Fax No.: (8610) 5139 4454lMitnet 341-3919, E-mail: felix.li@international.gc.ca Rodney HOFF, D.Sc., M.P.H., Executive Director, REDI Centre, 10 Biopolis Road, 02-01, Singapore 138670, Tel. No: (65) 68747030 Mobile No.: (65) 97745044, Fax No.: (65) 6874 7031, E-mail: rhoff@redi.org.sg Dr Youssouf OOMAR, UNICEF Malaysia, Wisma UN, Block C, 2nd Floor Kompleks Pejabat Damansara, Jalan Dungun, Damansara Heights, 50490 Kuala Lumpur, Malaysia, Tel. No.: (603) 20959154, E-mail: yoomar@unicef.org Dr Koji NABAE (Representing UNSIC), Avian and Human Influenza Regional Coordinating Officer, Asia-Pacific Regional Hub. UN OCHA Regional Office for Asia and the Pacific, Executive Suite, 2nd Floor, UNCC Building, Rajdarnnem Nok Avenue, Bangkok 10200, Thailand, Tel. No.: (66) 2288 2429, Fax No.: (66) 2288 1078, E-mail: nabae@un.org

NATIONAL AVIAN AND HUMAN INFLUENZA COORDINA TlON OFFICE

PUBLIC HEALTH AGENCY OF CANADA

REDICENTRE

UNITED NA nONS CHILDREN'S FUND

UNITED NAnONS SYSTEM INFLUENZA COORDINA nON

WORLD ORGANIZA TlON FOR ANIMAL HEALTH

Dr Teruhide FUJITA, OlE Regional Representative for Asia, and the Pacific, Sanseido Building, 4th Floor, 2-4-10, Kojimachi, Chiyoda-ku, Tokyo 102-0083, Japan, Tel. No.: (81) 3-5212-3191, Fax No.: (81) 3-5212-3194, E-mail: t.fujita@oie.int. rr.asiapacific@oie.int

5. SECRETARIAT WHO/wPRO

Dr Takeshi KASAl (Responsible Officer), Regional Adviser Communicable Disease Surveillance and Response World Health Organization, Regional Office for the Western Pacific P.O. Box 2932, 1000 Manila, Philippines, Tel. No.: (632) 528 9730, Fax No.: (632) 521 1036, E-mail: kasait@wpro.who.int Dr Bee Lee ONG, Zoonotic Epidemiologist, Communicable Disease Surveillance and Response, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel. No.: (632) 528 9914, Fax No.: (632) 521 1036, E-mail: ongb@wpro.who.int

- 50-

Dr Ailan LI, Medical Officer (IHR), Communicable Disease Surveillance and Response, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932 1000 Manila, Philippines, Tel. No.: (632) 528 9784, Fax No.: (632) 521 1036, E-mail: lia@wpro.who.int Dr Christopher OXENFORD, Laboratory Specialist Communicable Disease Surveillance and Response World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines Tel. No.: (632) 528 9949, Fax No.: (632) 521 1036, E-mail: oxenfordc@wpro.who.int Ms Amy CAWTHORNE, Epidemiologist Communicable Disease Surveillance and Response World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel. No.: (632) 528 9917, Fax No.: (632) 521 1036, E-mail: cawthornea@wpro.who.int Mr Wayne ANTKOWIAK, Programme Management Officer Communicable Disease Surveillance and Response World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines Tel. No.: (632) 528 9839, Fax No.: (632) 521 1036 E-mail: antkowiakw@wpro.who.int Dr Satoko OTSU, Medical Officer for Pandemic Preparedness Communicable Disease Surveillance and Response World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila. Philippines Tel. No.: (632) 528 9916, Fax No.: (632) 521 1036 E-mail: otsus@wpro.who.int Miss Sandra Paola MONTES, Infection Control Specialist Communicable Disease Surveillance and Response World Health Organization, Regional Office for the Western Pacific P.O. Box 2932, 1000 Manila, Philippines, Tel. No.: (632) 528 9918, Fax No.: (632) 521 1036, E-mail: montess@wpro.who.int Dr Sybille REHMET, Epidemiologist, Communicable Disease Surveillance and Response, World Health Organization No 177-179 corner Pasteur (51) and 254, P.O. Box 1217, Sangkat Chaktomouk, Khan Daun Penh, Phnom Penh, Cambodia, Tel. No.: (855) 23 216 610, Fax No.: (855) 23 216211, E-mail: rehmets@wpro.who.int

- 51 -

Dr Chin Kei LEE, Epidemiologist, Communicable Disease Surveillance and Response, World Health Organization 401 Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District, Beijing 1000600, Tel. No.: (855) 23 216 610, Fax No.: (855) 23 216 211, E-mail: rehmets@wpro.who.int Dr Reiko TSUYUOKA, Epidemiologist Communicable Disease Surveillance and Response World Health Organization, Ban Phonxay, 23 Singha Road, Vientiane, Tel. No.: (856) 21413 431, Fax No.: (856) 21 413 432, E-mail: tsuyuokar@wpro.who-int Dr Nirmal SINGH, Programme Management Officer Communicable Disease Surveillance and Response World Health Organization, 1st Floor, Wisma UN, Block C Komplek Pejabat, Damansara, lalan Dungun, Damansara Heights, 50490 Kuala Lumpur, Tel. No.: (603) 2093 9908, Fax No.: (603) 209 37446, E-mail: singhn@wpro.who.int Dr Luo DAPENG, Scientist (Focal point for Avian Flu), Communicable Disease Surveillance and Response, World Health Organization, Ministry of Health Government Building 8, Ulaanbaatar 13, Tel. No.: (976) II 320 183, Fax No.: (976) 11 324683, E-mail: dapengl@wpro.who.int Dr Nerissa DOMINGUEZ, National Professional Officer, Communicable Disease Surveillance and Response, World Health Organization, National Tuberculosis Centre Building, Second Floor Building 9, Department of Health, San Lazaro Hospital Compound, Sta Cruz, Manila, Tel. No.: (632) 528 9766, Fax No.: (632) 731 3914, E-mail: dominguezn@wpmwho.int Dr Sean TOBIN, Epidemiologist, Communicable Disease Surveillance and Response, World Health Organization, 63 Tran Hung Dao Street, Hoan Kiem District, Ha Noi, Tel. No.: (848) 943 3734/5/6, Fax No.: (848) 943 3740, E-mail: tobins@wpro.who.int

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Ms Maribel VILLANUEVA, Secretary, Reproductive Health, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines Tel. No.: (632) 528 9875, Fax No.: (632) 521 1036, E-mail: villanuevam@wpro.who.int

WHOSEARO

Dr Khanchit LIMPAKARNJANARAT, Regional Advisor Communicable Disease Surveillance and Response, Department of Communicable Diseases (CDS), World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, New Delhi - 110 002, India, Tel. No.: (9111) 233 90127, Fax No.: (9111) 233 90197, Mobile: (9198) 10295949, E-mail: khanchitl@searo.who.int, Dr Suzanne WESTMAN MD, MPH, Medical Officer, Outbreak Alert and Response, Communicable Disease Surveillance and Response Unit, World Health Organization, Regional Office of South East Asia, IP Estate, New Delhi - 110002, India Tel. No.: (9111)-23370804 ext. 26649, Mobile: (9199) 58590457, Fax No.: (9111)-23309195, E-mail: westmans@searo.who.int Dr G.N. GONGAL, Medical Officer, VPH, Communicable Disease Department, World Health Organization, Regional Office of South-East Asia, IP Estate, New Delhi 110002, India, Tel No.: (9111) 23370804, Fax No: (9111) 23378412, E-mail: gongalg@searo.who.int Dr Richard BROWN, Public Health Specialist, Communicable Disease Surveillance Unit, World Health Organization, Regional Office for the South East Asia, Fourth Floor, Building 3, Office of the Permanent Secretary, Ministry of Public Health, Tiwanon Road, Nonthaburi 1100, Thailand, Tel. No.: 662591 5719, Fax No.: 6625807537, E-mail: BrownR@searo.who.int

WHO GENEVA

Dr Thomas GREIN, Coordinator, Alert and Response Operations (ARO), Department of Epidemic Pandemic Alert and Response, Health Security and Environment Cluster, World Health Organization, 20 A v Appia, 1211 Geneva 27, Switzerland, Tel. No.: (4122) 791 1652, Fax No.: (4122) 791 1397, E-mail: greint@who.int Dr Maxwell HARDIMAN, Coordinator International Health RegUlations, Epidemic and Pandemic Alert and Response, World Health Organization, Geneva, Switzerland, Tel. No.: (4122) 791 2572, Fax No.: (4122) 791 4667, E-mail: hardimanm@who.int

- 53 -

Dr Sylvie BRIAND (Team leader), Global Influenza Programme (GIP), Epidemic and Pandemic Alert and Response, Department (HSEIEPR), World Health Organization, 20 Av Appia, 1211 Geneva 27, Switzerland, Tel. No.: (4122) 7912372, Fax No.: (4122) 791 4198, E-mail: briands@who.int