Ernst Strüngmann Forum

 

Disease Eradication in the Context of

Global Health in the 21st Century

Stephen L. Cochi, Chairperson

August 29–September 3, 2010

Frankfurt am Main, Germany

Program Advisory Committee:

Bruce Aylward, Global Polio Eradication Initiative, World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland
Stephen L. Cochi, National Center for Immunization and Respiratory Diseases, Centers for Diesease Control and Prevention, 1600 Clifton Road, NE, Mailstop E-05, Atlanta, GA 30333, U.S.A.
John O.Gyapong, University of Ghana, School of Public Health, Department of Epidemiology and Disease Control, P.O. Box LG 13, Accra, Ghana
David Molyneux, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, U.K.
Eric A. Ottesen, Filariasis Support Center, Task Force for Child Survival and Development, 325 Swanton Way, Decatur, GA 30030, U.S.A.
Regina Rabinovich, Global Health Program, Bill and Melinda Gates Foundation, P.O. Box 23350, Seattle, WA 98102, U.S.A.

Background, Purpose, and Need for this Forum

Mankind will always have a fascination with the eradication of diseases and scourges from the human population. Disease eradication was achieved for the first (and only) time in 1980 when the World Health Assembly declared the world free of smallpox following a campaign lasting more than ten years. Success in eradicating smallpox worldwide led to an increasingly intensive examination of the concepts and definitions associated with disease eradication with development of general and specific criteria as predictors of success for particular candidate diseases. The Carter Center International Task Force for Disease Eradication initiated a formal review of candidate diseases in 1988 and is currently completing a second review. The criteria for eradication were comprehensively examined at a workshop in 1997 on The Eradication of Infectious Diseases (Dowdle and Hopkins 1998), followed in 1998 by an expanded global forum on Disease Eradication and Elimination as Public Health Strategies (WHO 1998). More than a decade has passed since the basic eradication concepts and issues have been systematically addressed. Meanwhile, considerable experience has been gained in efforts to eradicate polio and dracunculiasis; and in efforts to eliminate such diseases as measles, maternal and neonatal tetanus, onchocerchiasis, and lymphatic filariasis. Concepts of disease eradication have continued to evolve, influenced by scientific advances, field experiences, societal issues, and economic realities.

The need to convene a workshop on disease eradication is especially timely since heightened interest in the potential eradication of various infectious diseases is once again moving front and center. For example, at the May 2008 meeting of the Executive Board (EB) of the World Health Assembly, the Board requested that WHO examine the feasibility of global measles eradication and report back to the EB in 2010. Also in 2008, both WHO and the Bill and Melinda Gates Foundation publicly called for development of a program of work to achieve malaria eradication in the longer term. These examples are illustrative of the ongoing fascination with the concept of eradication. They also demonstrate the continuing need to ensure that such initiatives are carefully considered based on a full understanding of the biological, political, social, and economic complexities associated with a successful eradication program. With increasing interest in identifying candidate diseases for eradication, these complexities need to be addressed for the benefit of public health decision-makers, politicians, scientists, and the world at large. The proposed workshop can provide a forum to develop a framework for a priority-setting process to identify the most worthy candidates for disease eradication (the "what?") and the critical factors for success (the "how?"). The rapid accumulation of knowledge since the 1990s, together with radical changes in the global landscape, requires an in-depth, systematic reassessment and re-examination of eradication in the context of global health in the 21st century.

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Group 1: What are the critical components of the investment case for eradication and/or elimination initiatives?

  • What should the time horizon be for evaluating the economics of the investment?
  • How do you value/measure the direct benefits of disease eradication/elimination?
  • How do you value/measure the indirect benefits especially to the health system?
  • Can we create a methodology for developing the investment case? Do the concepts of a global public good provide a useful framework for developing an investment case?
  • How should the ethical and equity principles implicit in the concepts of eradication and elimination be built into the investment case?
  • How do we evaluate the tradeoffs in impact?
  • How much emphasis should be given to upstream research needed to develop the technologies necessary to facilitate eradication/elimination of important diseases for which such tools do not currently exist?
  • How can we ensure that eradication programs do not dislodge the already dire human resource challenges many health systems face?

Group 2: : What organizational arrangements and institutional obligations are appropriate to disease eradication, elimination, or control initiatives?

  • In light of experience over the last decade, do we need to refine the terms disease eradication, elimination, and control?
  • What are the appropriate institutional arrangements (e.g., alliances, partnerships) for eradication or elimination initiatives, and how do we optimize? (Who provides independent oversight? Is it needed? Who is "accountable"?)
  • How do we maximize their synergies and complementary strengths?
  • What institutional arrangements will best support monitoring, evaluation, and oversight that are truly independent of program implementation?
  • How do you optimize utilization of human and financial resources to keep pace with the changing needs of an ever-evolving program?
  • How do you ensure that the appropriate research investments are incorporated into the eradication/elimination effort?
  • How does one effectively communicate the concepts of disease eradication or elimination to politicians, non-scientists, and others outside the health field?

Group 3: What are the critical factors for assessing the feasibility of achieving an eradication and elimination goal, and how should they be assessed and monitored?

  • In light of experience over the last decade, do we need to refine the terms disease eradication, elimination, and control?
  • Should the 3 traditional criteria (biological, cost-benefit, societal/political) for assessing the feasibility of eradication of a disease be expanded in light of the experience over the last 10 years? What are critical success factors?
  • Is the weakest link approach a useful tool to approach the assessment of these criteria for eradication? For elimination?
  • What are the major political challenges in current eradication/elimination initiatives, and how can we improve the mapping and engagement of the leadership needed?
  • Are there new understandings of social/community mobilization that can be built into future eradication/elimination initiatives?
  • How does change in technology affect feasibility of eradication/elimination initiatives?

Group 4: How can an eradication or elimination program be designed to interface effectively with the health systems in which it is operating?

  • How can eradication programs best serve the health system? What are the optimal relations between disease eradication/elimination programs and the national health systems?
  • What mechanisms are needed at the international, national, and community levels to ensure an ongoing dialog between the eradication/elimination programs and the health systems?
  • What indicators can be used to measure impact (positive and negative) on the health system?
  • What are the mutual benefits of eradication initiatives and a functioning community health delivery system?
  • How can co-implementation of health interventions support, or not undermine, the success of eradication/elimination initiatives?
  • What is the optimal use of human resources and need for capacity development?
  • How can we ensure that eradication programs do not dislodge the already dire human resource challenges many health systems face?
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