Indonesia’s challenges and needs in improving national capabilities for disease surveillance, detection and diagnosis and public health systems:
National capabilities in public health systems – Indonesia perspective � Problems with emerging and reemerging infectious diseases � Most caused mainly by environmental, ecological or demographic factors spread by travel and trade – Indonesia is a maritime country with 17.504 islands, 17608 ethnics, 700 languages Problems with people movement Recognize the need to develop, strengthen and maintained the capacity to detect, report and respond to public health events
Indonesia – A rapidly developing country with serious problems in Infectious disease Malaria: 15 million cases and 42,000 deaths/year (2005) - highest case number and fatality rate in the world; increasing drug resistant parasites Tuberculosis: ranked third in TB burden following India and China - TB is third major causes of mortality Estimation: 269 TB cases/100,000 Dengue : Most important viral borne disease In 2004: 78,690 cases (CFR- 1.2%) In 2007: 123,174 cases,1,251 deaths Hepatitis B: 10% of population are carriers Moderate-to-high endemic (WHO) Avian Influenza: 133 positive cases (CFR: 80%) - highest case number and fatality rate in the world
DENV serotype distribution in Indonesia – – showed diversity showed diversity DENV serotype distribution in Indonesia Management of Disease is not Simple, Need a Strong Disease Surveillance and Fundamental Research Palembang 1998 Jayapura 1994 Jakarta 2004 8% 8% Yogyakarta 1996 20% 19% 42% 41% Merauke 2001 Bandung 2002 32% 30% Four antigenically distinct serotypes: 4 1 Makassar 2007-2008 infection with one serotype does not 3 2 N = 111 provide protection to the other three Serotype Legend Corwin 2001; Suwandono 2006; Porter 2005; Graham 1999; Richards 1997; Sukri 2003
National actions to promote capacity building WHAT ARE WE FACING? Indonesia – A rapidly developing country with serious challenges in infectious disease WHAT ACTIONS SHOULD BE TAKEN? I. Maintain a safe, secure and sustainable capacity II. Best practices on biological safety and security III. Build and improve capacity to detect, diagnose and track outbreaks of highly infectious diseases IV. Build effective and sustainable partnership between developed and developing countries
I. Laboratory capacity Capacity, Quality and Safety • Laboratory services are essential to identify and confirm the causes of outbreaks “ infectious disease outbreaks can BSL3 facilities be contained and suppressed through early detection, immediate 4 2 response and cooperation and support at the national…level” • Basic cell and molecular biology play an important role in building manpower and capacity in detection of diseases
I. Laboratory capacity � Biosafety guidelines and SOPs developed – will be disseminated � Relevant staff are trained (biosafety officers and engineers) � Specimen collection and transport –training for safe shipment according to international standards (limited) � Laboratory biosafety and biosecurity practices are in place – TOT, committee in IBA will be designated � BSL3 networking is established (research institution, universities, ministries, industries) - � Ensure a suitable infrastructure - certification
II. Tools that would help to better prepare for alleged use of biological or toxin weapons – best practices � New tool has been introduced to implement biosafety, laboratory biosecurity and biorisk management – � International recognition and certification of laboratories: CEN Laboratory Biorisk Management Standard CWA 15793:2008
Routine training with significance topics are needed : Training for BSL3 Manager and Staff : The Science and Safety BSL3 Program, Emory University; Atlanta, USA (2009); Introduction to Practices and Principles of Containment level 3 Design, Working Practices and Management; Porton Down, Salisbury, UK (2009); Behavior-based Trainer Preparation Program at Emory University; Atlanta, USA (2010) Infectious Substances Shipping Training Course, Biorisk Assessment Training Course, Train the Trainer Course in Laboratory Biosafety Principles and Practices, Singapore, 2010 Training for Engineer: Operations and Maintenance Workshop, Winnipeg, Canada (2008, 2010)
III. Improve capacity for disease surveillance, detection and diagnosis � 44 Reference laboratories for emerging infectious diseases were developed to increase national capacity in detection and diagnostic – response to avian flu � Serological and molecular diagnostic were established � RT - PCR assay for molecular identification � DNA Sequencing analysis also used for confirmation � Detection of viral sequence changes will indicate possibility of outbreaks
Science and technology in health security – preparedness for pandemic Risk Assessments � Molecular Epidemiology : • Cluster of viral isolates will indicate the presence of new strain • Surveillance - tracing sources of infection � Characteristics of Virus • Alteration of interaction with host receptors - pandemic need changing in specificity of avian type receptor into human-type • Change of virulence • Drug resistance
National Capacity in Diseases Diagnostic and Laboratory Network � 44 Reference laboratories for emerging infectious diseases were developed: 2 National Reference Laboratories: Eijkman Institute (separate unit) National Institute of Health Research and Development (NIHRD) of MOH 5 Microbiology Lab at Provincial School of Medicine 3 MOH Hospital laboratories in large cities 34 District laboratories – lack of basic molecular biology Message: Quality control and sustainability of the district laboratories is a big problem!
REGIONAL (Indonesia) project on life science research � Raising awareness and inform on the importance of life science research – the early detection of outbreaks is closely related to the ability of laboratories to conduct early diagnosis of diseases Message: Accurate diagnosis and pathogen characterization is a cornerstone in the control of disease. Improvements to detection and diagnostic capabilities are important.
REGIONAL (Indonesia) project on life science research � Raising awareness and education on risk management for the accidental or potential misuse of the outputs of life science research: - new technology i.e. the use of DNA based technology and molecular methods - dual use and code of conduct will be introduced to academicians, researcher, laboratory staff, and the future generation (Project of Indonesian Academy of Sciences)
Higher education programs in Indonesia who are involve in teaching life sciences – spread, diverse in quality and culture – Academy need a good strategy Public Universities 110 Accredited Institutions of higher education – 69 Faculty Medicine (microbiology as one curricula)
Assistance and coordination in the case of alleged use of biological or toxin weapons – the need for international collaboration in building the national capacity • Education and awareness raising – Dual use and code of conduct (funding unconfirmed), on-line training • Capabilities in disease surveillance, detection and diagnosis and preparedness - training programs by countries: USA, UK and Japan • Infrastructure support of BSL3 – BEP (USA), JICA (Japan) • Operational assistance grant – BEP (USA) • Training and advocacy on biosafety and biosecurity – by countries such as USA and Norway, international organization: WHO, APBA • Discussion on the EU project on the Center for Excellence on Biosafety and Biosecurity and other (?) currently on-going
Conclusion – Improving National Capacity � Ensure the sustainability of maintenance and management – Continuous funding support, maximize existing resources and facilities to enhance effectiveness and efficiencies � Strengthening and improving laboratory biosafety practices and biosecurity– long term commitment � Ensuring quality performance of laboratory – QA/QC � Expand the use of safe and modern diagnostics – need to build national capacity in fundamental and translational research through joint activity � Raise awareness of biologically threats globally - introduce Dual Use and Code of Conduct through academic curricula
Herawati Sudoyo MD, PhD Eijkman Institute for Molecular Biology Indonesian Academy of Sciences Indonesian Biorisk Association
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