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 diseasesMost 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 movementRecognize 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

Dengue: Most important viral borne diseaseIn 2004: 78,690 cases (CFR- 1.2%)In 2007: 123,174 cases,1,251 deaths

Hepatitis B:10% of population are carriersModerate-to-high endemic (WHO)

Avian Influenza: 133 positive cases (CFR: 80%) - highest case number and fatality rate in the world

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 mortalityEstimation: 269 TB cases/100,000

Serotype Legend

4 13 2

42%

30%

8%

20%41%

32%

19%

8%

Makassar 2007-2008N = 111

Merauke 2001

Palembang 1998

Bandung 2002

Yogyakarta 1996

Jayapura 1994Jakarta 2004

Corwin 2001; Suwandono 2006; Porter 2005; Graham 1999; Richards 1997; Sukri 2003

Four antigenically distinct serotypes: infection with one serotype does not provide protection to the other three

DENV serotype distribution in Indonesia DENV serotype distribution in Indonesia –– showed diversity showed diversity

Management of Disease is not Simple, Need a Strong Disease Surveillance and Fundamental Research

National actions to promote capacity building

I. Maintain a safe, secure and sustainable capacityII. Best practices on biological safety and securityIII. Build and improve capacity to detect, diagnose

and track outbreaks of highly infectious diseasesIV. Build effective and sustainable partnership

between developed and developing countries

WHAT ARE WE FACING?Indonesia – A rapidly developing country with serious challenges in infectious disease

WHAT ACTIONS SHOULD BE TAKEN?

I. Laboratory capacity

Capacity, Quality and Safety

•Basic cell and molecular biology play an important role in building manpower and capacity in detection of diseases

• Laboratory services are essential to identify and confirm the causes of outbreaks

4 2

BSL3 facilities“ infectious disease outbreaks can be contained and suppressed through early detection, immediate response and cooperation and support at the national…level”

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 establishedRT - PCR assay for molecular identificationDNA Sequencing analysis also used for confirmationDetection of viral sequence changes will indicate possibility of outbreaks

Science and technology in health security –preparedness for pandemic

Risk AssessmentsMolecular 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

Message: Quality control and sustainability of the

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 MOH5 Microbiology Lab at Provincial School of Medicine3 MOH Hospital laboratories in large cities

34 District laboratories – lack of basic molecular biology

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)

110 Accredited Institutions of higher education – 69 Faculty Medicine (microbiology as one curricula)

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

• 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

Assistance and coordination in the case of alleged use of biological or toxin weapons – the need for international collaboration in building the national capacity

Conclusion – Improving National Capacity

Ensure the sustainability of maintenance and management – Continuous funding support, maximize existing resources and facilities to enhance effectiveness and efficienciesStrengthening and improving laboratory biosafety practices and biosecurity– long term commitmentEnsuring quality performance of laboratory –QA/QCExpand the use of safe and modern diagnostics – need to build national capacity in fundamental and translational research through joint activityRaise awareness of biologically threats globally - introduce Dual Use and Code of Conduct through academic curricula

Herawati Sudoyo MD, PhDEijkman Institute for Molecular Biology

Indonesian Academy of Sciences Indonesian Biorisk Association