EINet Alert ~ Mar 27, 2009

*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:

1. Influenza News
- Cumulative number of human cases of avian influenza A/(H5N1)
- Global: Influenza A(H1N1) virus resistance to oseltamivir--2008/2009 influenza season, northern hemisphere
- Global: International business trade group urges pandemic contingency planning
- France: LPAI outbreak reported in decoy ducks
- Indonesia: Two-year old boy dies of suspected avian influenza H5N1
- North Korea: Reports avian influenza H5N1 strategies
- Viet Nam: Reports further infections and deaths due to avian influenza H5N1
- USA: Type B viruses rise as overall seasonal influenza activity declines

2. Updates

3. Articles
- A Unique Intervention to Increase the Influenza Vaccination Rate of Healthcare Workers at an Academic Medical Center
- Factors Associated with Increased Healthcare Worker Influenza Vaccination Rates: Results of a National Survey of University Hospitals and Medical Centers
- Epidemiology of Acute Respiratory Illness (ARI) in Healthcare Workers (HCWs) During a Winter Season in Canada

4. Notifications
- Feds issue pandemic guidance for cargo transport crews
- Influenza in the Asia-Pacific
- Conference: ICU Infection in an Era of Multi-Resistance
- NPHIC offers pandemic influenza resources online
- Conclusions from WHO’s regional workshop on research priorities in communicable diseases

1. Influenza News

Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)

China/ 7 (4)
Egypt/ 8 (0)
Viet Nam/ 2 (2)
Total/ 17 (6)

***For data on human cases of avian influenza prior to 2009, go to:

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 412 (256).
(WHO 3/23/09 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO:
http://www.wpro.who.int/sites/csr/data/data_Graphs.htm (WHO/WPRO 3/11/09)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 3/18/09): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 3/23/09):


Global: Influenza A(H1N1) virus resistance to oseltamivir--2008/2009 influenza season, northern hemisphere
During the weeks from 28 Dec 2008-24 Jan 2009, the level of overall influenza activity in the world increased. In Europe, most countries reported regional or widespread activity with influenza A(H3) viruses predominating. Widespread influenza A activity (H1 and H3) was reported in Japan. In Canada, Hong Kong SAR, and the United States, influenza activity increased but remained relatively low. Sporadic influenza activity was observed in Brazil (A), Croatia (H1, H3, B), Greece (H1, H3, B), Iran (H1, H3), Mongolia (A), Portugal (H1, H3, B), Serbia (H1, H3, B), Singapore (H1, H3, B), Slovakia (H3), and Turkey (H3, B).

During this period, a total of 30 countries from all WHO regions reported oseltamivir resistance for 1291 of 1362 A(H1N1) viruses analyzed. The prevalence of oseltamivir resistance was very high in the following countries/territory: Canada (52 of 52 tested), Hong Kong SAR (72 of 80), Japan (420 of 422), the Republic of Korea (268 of 269), and the USA (237 of 241).

The resistance prevalence was relatively low in China (6 of 44 tested). In Europe, H1N1 circulation was low during this period while the resistance prevalence was high: France (12 of 12 tested), Germany (66 of 67), Ireland (9 of 10), Italy (16 of 16), Sweden (11 of 12) and the United Kingdom (61 of 62).

Additional information available at the WHO Epidemic and Pandemic Alert and Response (EPR), Influenza website: http://www.who.int/csr/disease/influenza/H1N1webupdate20090318%20ed_ns.pdf.
(ProMED 3/25/09)


Global: International business trade group urges pandemic contingency planning
An international trade group for the insurance and financial industries issued a report urging its members to consider the future impact of an influenza pandemic, which could, for example, prompt a range of issues, from liability issues related to event cancellations to civil unrest. The report, from the London-based Chartered Insurance Institute (CII), also urged companies to draw up their own pandemic plans, which should include gauging the impact of reduced service levels, ensuring staff safety, and providing cross-training and telecommuting opportunities.

Report available at http://www.cii.co.uk/downloaddata/TP_15_Maynard.pdf.


Europe/Near East
France: LPAI outbreak reported in decoy ducks
France has reported an outbreak of H5N1 low pathogenic avian influenza (LPAI) in decoy ducks in Calvados and a second outbreak of H5 (not N1) in decoy ducks in Pas-de Calais. The site in Calvados contains 45 ducks in two aviaries covered with fencing and kept by one hunter. Two of 10 ducks tested positive for H5N LPAI. The second premises in Pas-de-Calais contained 563 ducks in 32 adjacent aviaries owned by a hunter cooperative.

During routine surveillance, five ducks each from three of the 32 aviaries tested for avian influenza. Two ducks from one aviary were positive, while the other 10 ducks from the two aviaries were negative. Both the infected premises have been placed under surveillance, and biosecurity has been increased, but other disease controls have not been applied, and the affected birds were not culled (European Commission 2009).

Decoy ducks are used as captive birds to lure wild birds to a shooting area for hunting. They are kept tethered when they are taken out to water and have little direct contact with wild birds. The French authorities will continue to conduct surveillance for the time being. As there are no commercial poultry premises within a one-km radius of the two premises, no restriction zones have been imposed.

According to EU rules, immediate culling of birds infected with LPAI is not required, but they must be kept under restrictions.

There have been previous reports of LPAI H5N1 being detected in wild birds in Italy and France. Laboratory tests of these viruses suggested there was no relationship to Asian HPAI H5N1 strains.
(ProMED 3/22/09)


Indonesia: Two-year old boy dies of suspected avian influenza H5N1
A two-year-old boy suspected of contracting bird flu died at Arifin Achmad Public Hospital in Pekanbaru, capital of Indonesia's Riau Province on 26 Mar 2009. The boy died after suffering a respiratory problem and falling unconscious, Dr Azizman Saad, coordinator of bird flu control at the Arifin Achmad hospital, said. However, the hospital could not confirm the cause of the boy's death, as the hospital was still waiting for the result of laboratory tests.

In addition, a resident of Desa Mangun Jaya, Kecamatan Anjatan, Indramayu, West Java, is suspected of contracting bird flu. The victim was brought to Indramayu regional hospital due to high fever and prolonged breathing difficulty. The 33-year-old victim was admitted to hospital on 25 Mar 2009 after being treated at Anjatan public health center. He is now in a special observation room with intensive treatment. The patient had contact history with dead chickens before admission. A blood sample has been sent to the Indramayu Health Service laboratory. A team at Indramayu regional hospital is still observing the patient, and no confirmation has been issued yet.

Meanwhile, the Garut Health Service in West Java province has recorded 46 cases of bird flu in Garut District up to 23 Mar 2009. Dr Hendy Budiman, head of the Garut health service, said on 26 Mar 2009 that the 46 cases included one surviving and four dead confirmed bird flu victims. He believes that there are 36 surviving and 5 dead bird flu suspects in total.
(ProMED 3/26/09)


North Korea: Reports avian influenza H5N1 strategies
North Korea said on 25 Mar 2009 that its nationalized approach to preventing avian influenza has helped it avoid outbreaks and infections, despite the circulation of the H5N1 virus in other nations, Korea News Service (KNS) reported. North Korea has conducted bird surveillance in winter migration areas, developed rapid detection systems, educated the public and medical workers about how to prevent the disease, and set up medical checkpoints in densely populated areas to monitor and treat people who are sick. The nation also said it would continue its close contacts with the United Nations Food and Agriculture Organization.
(CIDRAP 3/26/09)


Viet Nam: Reports further infections and deaths due to avian influenza H5N1
The three-year old Vietnamese boy from Southwestern province Dong Thap of Viet Nam confirmed of being infected H5N1 virus died, a local doctor from the Ho Chi Minh Hospital of Tropical Diseases stated on 19 Mar 2009. The infected patient died due to severe breathing difficulty caused by H5N1 virus, said the doctor. The boy had been taken to the Ho Chi Minh Hospital of Tropical Diseases on16 Mar 2009 with symptoms of bird flu. He had contact with ducks raised by nearby farms before developing symptoms, said his family member.

In addition, veterinarians have quarantined and disinfected hamlet 23 in Chau Hung commune, Thanh Tri district, Soc Trang province, after a female villager suspected of contracting H5N1 virus died in hospital on 20 Mar 2009. According to Vo Ngoc Linh, head of the Chau Hung commune medical centre, the 26-year-old woman ate sick ducks in late Feb 2009. She was admitted to the general hospital of Bac Lieu province on 16 Mar 2009 with symptoms of headache, exhaustion, and coughing. The patient died early in the morning of 20 Mar 2009. The result of blood tests will be announced in the coming days.

Meanwhile, another suspected case in the southern province of Dong Thap has tested negative for the virus, according to doctors from the Hospital for Tropical Diseases in Ho Chi Minh City.
(ProMED 3/20/09, 3/21/09)


USA: Type B viruses rise as overall seasonal influenza activity declines
The second week of March 2009 brought a slight decline in influenza activity across the country, with 30 states still reporting widespread cases, down from 35 states a week earlier, according to the US Centers for Disease Control and Prevention (CDC). As overall activity has decreased, however, the season has seen an increase in the proportion of influenza B viruses, the one type of flu that is not very well-matched by the 2009 vaccine, the CDC reported. The spread of B viruses also poses a challenge for decisions about antiviral treatment, the agency said.

Eighteen states reported regional flu activity, and two—Utah and West Virginia—reported only local activity. Seven percent of all deaths reported through the CDC's mortality reporting system were attributed to pneumonia and influenza, which is below the epidemic threshold of 8%. However, the proportion of medical visits attributed to flu-like illness in the CDC's flu surveillance network was 2.9%, still above the national baseline of 2.4%.

Six more flu-related deaths in children were reported, bringing the total for the 2009 season to 32, the CDC report said. That compares with 88 fatal cases in children in 2007-08 and 78 in 2006-07. The six deaths occurred between Feb 15 and Mar 7.

Influenza A viruses have predominated through the season overall, making up 70.8% of those that have been typed, the CDC reported. But type B viruses have increased lately: of 1,102 lab-confirmed flu cases for the week, 580 (52.6%) were type B. Of 210 type B viruses that have been antigenically tested by the CDC this season, only 44 belonged to the Yamagata lineage targeted by the B strain in this year's vaccine. The other 166 isolates belonged to the Victoria lineage and are not related to the vaccine, the agency said. However, all the A/H1N1 and A/H3N2 isolates tested so far have been related to the corresponding strains in the vaccine.

Among type A viruses, H1N1 has been predominant this season. That pattern continued in the latest report, with 107 of 120 type A isolates that were subtyped identified as H1N1. Nearly all H1N1 isolates (98.9%) tested for drug resistance this season have been resistant to the antiviral oseltamivir (Tamiflu) but sensitive to zanamivir and to the adamantine drugs. In contrast, all A/H3N2 viruses have been susceptible to oseltamivir and zanamivir but resistant to the adamantanes. Type B viruses are also susceptible to oseltamivir and zanamivir, but the adamantanes are not effective against them.

Given the differences in drug sensitivity among the three types of flu, the growing proportion of B viruses "presents challenges for the selection of antiviral medications for the treatment and prophylaxis of influenza," the CDC report said. "Health care providers should be aware of the possibility of increased influenza B circulation in their area, and continue [to] test patients for influenza and consult local surveillance data when evaluating patients with acute respiratory infections during the influenza season." The CDC revised its recommendations on antiviral treatment for flu in December 2008, after discovering the high rate of oseltamivir resistance in H1N1 viruses.
(CIDRAP 3/23/09)


2. Updates
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP’s web site for information on fund management and administrative services and includes the website of the Central Fund for Influenza Action. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html The (interim) Influenza Virus Tracking System can be accessed at: www.who.int/fluvirus_tracker.
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
Epidemiological updates on the avian influenza outbreak in Hong Kong available at http://www.oie.int/wahis/public.php?page=single_report&pop=1&reportid=7609 and the outbreak in India at http://www.oie.int/wahis/public.php?page=single_report&pop=1&reportid=7606.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help hospital administrators and state and local health officials prepare for the next influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.pandemicflu.gov/. View archived Webcasts on influenza pandemic planning.
- CIDRAP: http://www.cidrap.umn.edu/ Find more than 150 peer-reviewed practices from 25 US states and 37 cities and counties aimed at furthering pandemic preparedness in public health and allied fields.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library’s Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Read about the latest news on H5N1 in wild birds and poultry.

Indonesia continues to report a high number of H5N1 high pathogenic avian influenza (HPAI) outbreaks in poultry from 2006-2008. HPAI remains endemic on Java, Sumatra, and Sulawesi islands with sporadic outbreaks reported from other areas. HPAI infection is considered to be established throughout most of Indonesia, although incidence varies widely. Only two of its 33 provinces have not experienced the occurrence of H5N1HPAI.

The high number of reported outbreaks monthly for Indonesia can be explained by the implementation of the "participatory disease surveillance and response" (PDSR) 1 program that targets village-type poultry production systems (both backyard and small-scale intensive) and has been very effective at detecting evidence of virus circulation in the village environment. The program is supported by FAO with USAID financial support.

Larger, less densely-populated provinces report HPAI outbreaks more infrequently than more densely populated provinces. It appears that H5N1 HPAI is more sporadic in the smaller, more dispersed poultry populations.

During February 2009, PDSR officers visited 1483 villages, of which 204 (13.8 percent) were infected. This was noticeably higher than the January 2009 infection rate of 8.5 percent. On the day of 28 Feb 2009, and in comparison with the situation on the day of 31 Jan 2009, an increased percentage of villages were classified as "infected" (HPAI compatible event supported by a positive antigen test result).

PDSR teams operate in 331/448 (74 percent) districts across 31/33 provinces including all known endemically infected areas. During the previous six months, PDSR officers visited 11 345 villages (20 percent) in the 331 districts under PDSR surveillance. An average of 6.4 percent of the villages visited during the previous six months was classified as infected at the time of visit. Cases over the last six months were concentrated in Yogyakarta, Banten and Lampung.
(ProMED 3/26/09)


3. Articles
A Unique Intervention to Increase the Influenza Vaccination Rate of Healthcare Workers at an Academic Medical Center
Kearney M et al. SHEA annual meeting. 20-22 Mar 2009. Presentation 380. Video available at http://www.youtube.com/watch?v=ruGgZbAVnko.

Background. Influenza vaccination is an effective means of preventing morbidity and mortality attributable to influenza in all populations. Vaccination of healthcare workers (HCWs) has been shown to decrease both absenteeism and transmission of infection to patients. However, we have been particularly challenged to improve vaccination rates in this population. For this reason, some have advocated mandatory vaccination of HCWs. We instituted an active declination policy and a mandatory education program for HCWs refusing influenza vaccine 2 yrs ago, but only achieved a moderate increase in rates. We attempted a unique intervention to increase vaccination rates this season.

Objective. To describe and assess a unique intervention to increase the influenza vaccination rate of HCWs.

Methods. The study was conducted at a 735 bed tertiary and quaternary care academic medical center. We wrote a song advocating the benefits of influenza vaccination. The song was recorded by Penn Yo, an undergraduate a capella group. We then filmed a video of hospital personnel lip syncing and performing the song. The video, titled “Baby Be Wise - Immunize”, was used to promote our vaccination campaign, is posted on our intranet, and is being broadcast on patient information channels in the hospital. The video can be viewed at http://www.youtube.com/watch?v=ruGgZbAVnko.

Results. Thus far, influenza vaccination rates are increased by approximately 40% compared to this time during our 2007 campaign.

Conclusions. Our “Baby Be Wise - Immunize” video engaged many members of the hospital community in a unique project. It effectively delivered important information about and helped dispel myths concerning influenza vaccination in a fun and enjoyable fashion. The project appears to have had a greater impact on vaccination rates than other interventions, such as active declination and mandatory education programs.


Factors Associated with Increased Healthcare Worker Influenza Vaccination Rates: Results of a National Survey of University Hospitals and Medical Centers
Talbot TR et al. SHEA annual meeting. 20-22 Mar 2009. Presentation 268.

Background. With increasing need to improve healthcare worker (HCW) influenza vaccination rates, identification of specific components of vaccination programs that lead to increased coverage is important.

Objective. To ascertain components of influenza vaccination programs associated with higher HCW vaccination rates among University HealthSystem Consortium hospitals.

Methods. Participating hospitals were surveyed regarding aspects of their institutional HCW influenza vaccination program for the 2007-08 influenza season. Topics assessed included hospital demographics, vaccination adherence, vaccine availability, use of declination statements, education methods, accountability, surveillance for healthcare-associated influenza, and monitoring and reporting of program data. Factors associated with higher vaccination rates were determined using t-test assuming unequal variances.

Results. Fifty hospitals representing 33 states and a total of 368,696 HCWs (mean: 7693, range 2,603-26,000) participated in the project. Programs differed widely in the definition of HCWs targeted by vaccination programs, as only 68% included physicians, 54% included volunteers, 46% included agency staff, and 34% included medical students. The mean vaccination rate for the season was 55.6% (range 25.6-80.6%). Programs with the following components had significantly higher vaccination rates than those without such tools: provision of vaccine on weekends (58.8% in those using tool vs. 43.9% in those without, p=0.01), utilization of train-the-trainer programs (59.5% vs. 46.5%, p=0.005), report of vaccination coverage rates to facility administrators (57.2% vs. 48.1%, p=0.04), report of coverage rates to the Board of Trustees (63.9% vs. 53.4%, p=0.01), sending employees a letter from hospital administration emphasizing the importance of vaccination (59.3% vs. 47%, p=0.01), and having any form of visible leadership support of the program (57.9% vs. 36.9%, p=0.01). Vaccination coverage was not significantly different between facilities that required a signed declination form for those refusing vaccination and those that did not (56.9% vs. 55.1%, p=0.68).

Conclusions. Vaccination programs that emphasized accountability to the highest levels of the organization, provided weekend access to the vaccine, and utilized train-the-trainer programs had higher vaccination coverage. Programs that utilized declination statements did not have higher vaccination rates than those without such statements. Finally, the definition of “healthcare workers” targeted by the vaccination programs differed, and uniform definitions will be essential in the event of public reporting of vaccination rates.


Epidemiology of Acute Respiratory Illness (ARI) in Healthcare Workers (HCWs) During a Winter Season in Canada
Coleman BL et al. SHEA annual meeting. 20-22 Mar 2009. Presentation 270.

Background. Health Care Workers may be at higher risk of viral acute respiratory illness (ARI) than other adults because of occupational exposure. We performed surveillance for ARI in a cohort of health care workers during the 2007/8 winter season (Nov. 2007-May 2008) in Toronto, Canada.

Objective. To describe the experience of acute respiratory illness in health care workers during the winter season.

Methods. As part of a pilot study for a randomized control trial of vaccine versus seasonal antiviral prophylaxis, 56 adults were recruited in October, 2007: 12 received vaccine and 44 prophylaxis. Data on illness and exposure to ARI were collected weekly with diaries completed and NP swabs obtained for each ARI episode.

Results. 48/56 participants were health care workers, 48 in acute care hospitals. 34 (68%) were female; median age was 43 years (range 25-64). 20 worked in either the emergency department or intensive care unit. 20 (41%) had children <15 years at home; 23 (62%) regular contact with patients with ARI; 11 (22%) were smokers; 28 (57%) regularly took public transit. 37 (76%) reported receiving the influenza vaccine in 2006. Over 7 months of surveillance, 42 (87%) reported ³1 ARI. NP swabs were submitted for 44/64 (69%) ARI episodes, with viruses detected in 14 (32%): 5 influenza A, 2 influenza B, 3 human coronavirus, 3 respiratory syncytial virus, and 1 rhinovirus. Median symptom duration was 2 days (range 1-9) for episodes without NP, 4 days (range 1-15) if no virus detected, and 5 days (range 1-15) if virus positive (P=.006). An additional 7 influenza illnesses were detected by serology, 3 of which had no corresponding illness report. Health care workers worked on 85% of all days during which they were ill; 92% of health care workers worked on the first day of illness. Being a smoker was the only risk factor for symptomatic influenza (OR 6.0, P=.05).

Conclusions. During a season of suboptimal vaccine match, 29% of health care workers developed influenza. Virtually all health care workers worked during their acute illness.


4. Notifications
Feds issue pandemic guidance for cargo transport crews
In a move to protect cargo trucking crews—a critical part of the nation's infrastructure—during an influenza pandemic, the US Department of Health and Human Services (HHS) issued interim guidance on limiting exposure to a pandemic virus. The guidance primarily contains standard infection control practices, but touches on cargo work specifics such as avoiding face-to-face contacts during pick-ups and deliveries and encouraging employees to instead use text messaging and cell phones to communicate. The document also includes recommendations on disinfecting truck cabs and trailers.

Guidance available at http://pandemicflu.gov/health/cargo_trucking.html.


Influenza in the Asia-Pacific
The Lancet Conferences
Date: August 21-23, 2009
Location: Qingdao, China

The Lancet and The Lancet Infectious Diseases have joined forces to develop a conference that will enable leaders in their fields to present and discuss management of influenza with key health administrators, experts from the medical and scientific communities, and industry representatives. We hope the meeting will provide valuable insight into fundamental public health and operation strategies to bring about change within the Asia-Pacific.

Register now and take advantage of the early bird discount until May 31, 2009. To register, go to http://mail.elsevier-alerts.com/go.asp?/bELA001/qUQEAS8/x8BATS8


Conference: ICU Infection in an Era of Multi-Resistance
Dates: 4-6 Jun 2009
Location: Chicago, Illinois, USA
Venue: The Palmer House Hilton

Infectious diseases are the 2nd leading cause of death worldwide. In fact, many new and reemerging microbial threats, such as severe acute respiratory syndrome (SARS), avian influenza virus, and West Nile fever continually challenge intensive care providers.

The conference will:
- Discuss infectious disease guidelines for the control and/or prevention of infectious diseases;
- Develop methods/strategies for identifying patients with a potential risk for contracting antibiotic-resistant infections;
- Identify appropriate drug or drug/therapy combinations for combating antibiotic-resistant infections;
- Evaluate hospital and ICU team management strategies for superbugs and foreseeable antibiotic-resistant infections of the future.

Additional information and online registration available at http://www.sccm.org/Conferences/Topics/Summer_Conference/Pages/default.aspx.


NPHIC offers pandemic influenza resources online
NPHIC has assembled a wealth of helpful and sharable pandemic flu materials for local, state and federal communicators, and pandemic flu communication partners. Exchanging information and learning from each other’s efforts builds consistent, effective messages which are the keys to preparedness, and preparedness is our best weapon against pandemic flu.

Access the website at http://www.nphicpanflu.org/.


Conclusions from WHO’s regional workshop on research priorities in communicable diseases
The participants of the Regional Workshop on Research Priorities in Communicable Diseases organized by the WHO Regional Office for South-East Asia in New Delhi from 4-6 March 2009 recognized that the South-East Asia (SEA) Region is at high risk for new and emerging infectious diseases and has become a hotspot for many zoonoses, drug-resistant pathogens and vector-borne diseases. Better understanding of the epidemiology of and the broader social, economic, cultural, environmental, ecological and political dimensions are some of the challenges for today’s research in communicable diseases.

Research is essential for the development of new tools and interventions, and should be geared towards the development of evidence-based policies and interventions to increase efficiency and effectiveness of program development and management in disease promotion, prevention and control. Undoubtedly, the environmental, ecological, social, economic and cultural aspects in disease control require partnerships and networking with social scientists, environmentalists, health economists, both in developing research proposals and conducting research.

Member states should:
- Mandate the inclusion of an appropriate research agenda into national health policies and programmes.
- Allocate at least 5% of the budgets allocated to communicable disease programs for research.
- Establish a national data base of all on-going research relevant to the programme, including drug trials, development of vaccines and diagnostic tools and share this information both within the country and with other countries of the Region.
- Establish a mechanism such as a National commission on research to policy to interface between researchers and the policy makers/programme managers to facilitate the translation of research into policy and strategy.
- Set up a network of institutes engaging in research, such as national centres of excellence, academic institutions, and WHO Collaborating Centres to support research relevant to national programmes, facilitate close collaboration between researchers and programme managers and promote actionable research.
- Build/enhance institutional and individual capacity building for preparing quality research proposals and conducting research that can be applied for prevention and control of communicable diseases.
- Promote research that determines influence of environmental, ecological and social factors on epidemiology of communicable diseases.
- Utilize available financial resources e.g. GFATM to support research in country-specific context.
- Consider organizing similar workshops in member countries bringing together policy-makers, researchers, programme staff and other stakeholders to identify gaps and priority areas for research in countries.

WHO should:
- Discuss research as part of the agenda of the Regional Committee and Health Ministers’ meeting.
- Collaborate with Member countries in building research capacity at the national, institutional and individual levels, specifically in training researchers on research management, in engaging and applying research in disease control programmes and promoting actionable research.
- Collaborate with TDR and other partners on research relevant to programmes in the Region, including on emerging global issues, such as climate change and the current financial crisis.
- Assist with the design of operational research protocols and coordinate multi-centre studies to address programme challenges, in an effective manner.
- Facilitate networking of researchers and laboratories as was very effectively done during the SARS containment in Asia in 2003.
- Establish regional mechanisms to set research agendas, and develop standard research protocols related to specific issues which can be used or adapted by Member countries when needed including research on environmental and ecological paradigms of communicable diseases.
- Establish a specific programme on ARI/CDD research and control. This should be discussed at the Regional Committee Meeting.
- Facilitate sharing/ dissemination of research information among countries by various means including through a Public Health Journal of SEA Region.
- Review progress made on these recommendations after two years.