HIGH FLYERS THINK TANK

Emerging diseases – Ready and waiting?

The Shine Dome, Canberra, 19 October 2004

Group A: Human health

Rapporteur: Dr Mark Schembri

The first thing that came through in our group is that we didn't really discuss the specifics, perhaps, of some of the diseases but we talked more generally about what we need to do to be able to control and react to these diseases on a more general basis.

Human
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In the first instance we talked about disease: what do we need to know as far as the disease is concerned? This is all very general. We need to know the source of the infecting organism, we need to be able to predict the scale of infection and have models predicting the outcome of the disease, and we need to be able to respond appropriately.

What are some of the mechanisms that are going to enable us to achieve this? First is understanding some of the risks from wildlife in combination with increasing populations. Everyone agreed that this was a very important point and it is something where we really questioned how much time and effort is being spent on such a thing. It was brought up, for example, about viruses: how many viruses are we really aware of in comparison with those that are out there and have the capacity, perhaps, to infect humans?

We need to understand the organism – basic mechanisms of virulence, transmission, different hosts, environment – and to do this we need a better understanding of basic science. We have some of this in place already, but everyone questioned whether what we have in place is sufficient.

We talked about some of the skills and infrastructure that we need in order to carry out some of the main points that are mentioned above.

Public education was mentioned. We need to make the public aware so that we don't create panic situations and so that the public respond in an educated and informed manner.

We also need to have strong interactions with government, because obviously that is where the dollars are coming from and that is where international networks and response mechanisms are coordinated.

Multi-disciplinary response
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One of the things that we talked about is the need for a multidisciplinary response. So rather than, perhaps, having groups of scientists from very similar disciplines put together and saying, ‘This is what we need in order to deal with this infection,' perhaps we need to go broader. Here we discussed the potential of having basic clinical, social and political sciences or groups involved as part of this response. So we are really tackling the issue from a number of different ways, rather than, perhaps, from the medical perspective.

We need to be able to facilitate the formation of such groups. Do our national research priorities and our granting schemes actually facilitate the formation of these research groups? We questioned whether they do. We do have groups in place, and so one of the things that we did not really touch on, but we don't really know, is how many of us in our groups are actually aware of what measures are in place already. Is it just a few people in Australia at that level that are aware of it? And do we need to educate others so that we can generate a better response?

We need to maintain a broad skill base. This may require a change in research culture with regard to funding, because maybe we need to go back and fund some of the basic sciences a little bit more. Maybe we need to fund some of the so-called blue sky research a little bit more to give people the opportunity to identify some of these emerging pathogens and some of the problems that may eventuate in the future.

The last point that was brought up is that all universities, if we treat them as basic research institutes – and I did not include research institutes themselves that we have – can't be good at everything, and so they will need to focus on and specialise in what they are good at. Then we need better collaboration between these institutes in order to generate a better response.

What else can we do?
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What else can we do as far as our response is concerned? We talked about public health laws. This is something that we perhaps often might ignore, but it becomes a real situation if an emergency does arise. We need to be aware of that, and we need to have infrastructure in place.

Human culture will often determine what we can and can't do successfully, so we need to perhaps take preventative measures and educate people.

That comes down to the fourth point there (Slide 3), public education. So, for example: what can we learn with the way that we have responded to AIDS in Australia? Can we actually document the whole process and how we have gone, and how we have progressed in being able to deal with this disease, and can we learn from that if we encounter a future such problem?

Risk management: we need to have studies which identify risks, and especially risks – I go back to the first point (Slide 3) again – associated with increasing populations that are going to encroach upon areas in Australia that previously haven't been populated.

And also we need a basic understanding of the general mechanisms involved.

Management
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As far as management is concerned, we need to have monitoring systems in place. We discussed some so-called keywords: syndromics, diagnostics and reporting.

Response was mentioned, and in particular grading of importance. If you have a response that is treated as being significant by the government, then they are going to move fast. If this is a response that the government treats as a minor point, then we can't really expect any rapid prevention measures.

Control and prevention and prediction of impact I have already touched on.

Access to resources: do we have the resources to cover and be able to respond adequately if we do encounter a major incident? For example, do we have laboratories that can do the testing if we need them? Do we have hospitals that can take in the extra patients that we might need to put into the hospitals? And not even just the hospitals, but do we have the sections within hospitals to isolate patients and be able to contain such a situation?

Do we have dialogue between both government and scientists that is going to enable this whole procedure to work optimally?

Summary
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To finish off: in the booklet we were asked to give a bit of a rating with regard to surveillance, prevention, response and recovery, as far as emerging infections in humans are concerned.

Generally, the group thought that the response to all of those was medium to patchy, and it really depends on the agent and the impact of that agent.

I mentioned before about the structure that we have now, and how many of us are aware of what is in place. As I said, we do have measures in place and so we can't ignore that, and many of them are working reasonably well. But are they good enough, and how can we make them better? Is it just a select few that are aware of them, or do we need to broaden the scope, the number of people that are aware of this?

Discussion

Jim Peacock – I'd like to ask a question. Are viruses our major threats for human diseases? Are they the principal disease threats in Australia?

Mark Schembri – Well, it's difficult to say that. I suppose it is difficult to rank whether it is viruses or bacteria that are the major threats. And you might get differing opinions, depending on who you asked, probably, in the audience. So that is a hard one for me to answer directly.

I think that between the groups of bacteria and viruses the threats are very different. There are some viruses, such as the influenza virus that we discussed, such that if we were hit with a highly infective organism, then who knows what might happen. It might wipe out millions throughout the world. So I would have to say that I doubt if a single bacterium would have such an impact. But then is TB any less important for us to go and be monitoring and be aware of?

Jim Peacock – I was just wondering, with viruses: you didn't mention any new science, new ways of tackling these things. Does our growing awareness of RNAi and mechanisms associated with it give us real hope of a completely new way of tackling some of the viral diseases, in particular?

Mark Schembri – I would prefer it if a person who was a bit more of an expert on virology could answer that.

Jim Peacock – Does anyone want to tackle that? I just wondered whether, with these new scientific developments, particularly for the human diseases, there is scope for new international focus on some of the major viral diseases.

Jeff Cowley – Certainly all of the kind of antiviral technologies based on specific interactions of RNA with viral RNA have significant promise. Whether they can be generically applied in every case, we will have to wait and see. But certainly I think, as you said, Jim, it is a revolutionary technology, it is really being pushed very hard to see what its potential is, and I think that potential could be realised for a lot of the human pathogens – as well as a lot of viral pathogens in animals and other species. So yes, I think it has got great potential.

Mark Schembri – I can mention, perhaps, as a general response to that as well: we did discuss the development of new treatments and there was a general consensus among the group that there are some things that prohibit the rapid development of these – the length of time, the costs associated, and not just the costs in research but the cost of new over-the-counter drugs as well. So there are perhaps a number of issues that we need to deal with to take some of these highly promising and new technologies and maybe push them through a little faster. Maybe we should look at some of those taking higher levels as far as research priorities are concerned.

Tom Faunce – One point we were discussing in the talk, which I think was implicit in what was presented, was the fact that if you look at a lot of the hosts for the zoonotic diseases – say, avian influenza, like the Hong Kong epidemic in 1997 – one of the strategies that we may need to look at is facilitating incentives for countries that are hosts for those diseases being able to implement measures at source so we are not left with a sort of a secondary response in this country. It is not easy for them. They don't have, in many cases, the same access to resources that we do. So continual engagement with those countries, and facilitating and understanding that if they do implement those measures then restrictions on trade would be removed, could be very useful.

In terms of responses in this country, another thing we mentioned was the that difficulty we may face, if we do actually come up with reasonably expensive solutions in terms of therapeutic substances for some of these diseases, will be actually being able to compulsorily license them, in order to deal with the cost structures. So it may be necessary – this is just a suggestion – for people researching in this area to describe what is going on as something of extreme urgency, because that may be a crucial distinguishing feature which will allow the country to respond.

I guess the last point that some of us raised, actually in a subgroup afterwards, was that the US in particular has been very active in creating modelling exercises of emerging disease outbreaks. Perhaps this is something that as a nation we should spend a bit more attention on: looking at all the different social, legal, scientific ramifications of various types of outbreaks – not just bio-terrorism but also rapid spread of avian influenza and those types of diseases.

Julie Campbell – Mark, did your group look at all into diseases that are not spread by viruses or bacteria, for example the emerging diseases that we have imposed on ourselves in relation to our lifestyle, such as obesity and, with that, things like diabetes? They are with us now, but they are emerging diseases that have come from our own lifestyle. There are also the diseases that are related to the fact that we are living longer, such as Alzheimer's and the neuro-degenerative diseases that we are increasingly getting more of in Western society.

Mark Schembri – We did discuss some of those as short points. They were brought up and they certainly weren't downgraded in comparison to this. I suppose we tried to keep a general theme on emerging infectious diseases, but we certainly did not forget that these diseases are around and probably having an even greater impact. Perhaps in many ways the society accepts them a little bit more, I suppose, in the sense that the point was brought up that a few kids die of meningococcal disease and we respond in a dramatic way, yet we have these other diseases that are killing people within the community at high rates and we don't treat them with the same sort of impact and the attention that we need to.

Jim Peacock – Just a comment there: I have noticed in the last couple of years, at several points around Australia, that medical faculty researchers are working with plant scientists, for example – things that didn't happen before – just around some of these lifestyle diseases and modification of the plant foods. The two groups of scientists are coming together, and I think that is an important development.

Aileen Plant – I would just like to pick up a little bit on your first comments, about some of the newer technologies. It really impinges on something that Frank Fenner was talking about. We know a lot about the viruses in particular, but not the organisms generally that infect wildlife, and the fact is that our burgeoning human population is increasingly in contact with wildlife. The potential for things like microarray technology not to be at home at the University of Queensland or QIMR or CSIRO but to actually be used in the field where outbreaks are occurring, is incredibly important.

The other thing is the background technology in Australia. So, for instance, we talked about the fact that we know there is a large number of arboviruses and we know that we must be able to identify more. The question is whether they are important for either animal or human health, and we may find out more as there is more pressure for either animals or humans to interact with those viruses. How much better it is if we know about them in advance, we know something about their science. Then we are one step ahead, should they subsequently become an emerging infectious disease. Then we have benefited from training, we have benefited from the knowledge and we are one step ahead if it becomes an emerging infectious disease.