1. 1. We, the Ministers/Secretaries/Commissioner of Health and the Director-General of the World Health Organization, met in Berlin for the 4th Ministerial Forum of the Global Health Security Initiative. International collaboration continues to be important to protecting the public health security of our citizens and those of the international community. We discussed the challenges facing us, explored potential solutions and agreed on steps to further protect public health security globally.
   2. One challenge we face is ensuring timely and effective communications among our national governments in order to deal with public health crises such as an outbreak of smallpox. In September 2003, Canada coordinated Exercise Global Mercury – a smallpox outbreak simulation exercise to evaluate health communications among our governments, in response to the fictitious discovery of an outbreak of smallpox. This exercise tested international capacity for the rapid exchange of information, and provided insights into international communications that such a public health crisis can generate.We commend the effort of all member countries and organizations in making Exercise Global Mercury a success. This exercise was entirely successful in reaching its objectives. We have endorsed the final evaluation report on Exercise Global Mercury, and have asked our officials to undertake the necessary work from the lessons learned during this exercise in order to improve international communications capabilities of our public health professionals to deal with an actual public health emergency.
   3. We thanked the UK for leading the work on the risk incident scale. A preliminary assessment highlighted the need for the supporting material to be updated on an ongoing basis in accordance with developments in the evidence base. We endorsed progress made on developing a set of principles for risk management and communications in the event of a chemical, biological and radio-nuclear incident. We have asked our officials to further develop and refine their work and to bring forward a set of principles for our consideration at the 5th Ministerial meeting.
   4. From the outset of the Global Health Security Initiative we have attached considerable importance to strengthening our public health preparedness and response to a possible smallpox incident. We all have a stake in preventing the occurrence of such an incident, and in being fully prepared if the need arises. Since we last met in Mexico City in December 2002:
      • The United States and the World Health Organization (WHO) have completed a model train-the-trainers course on containing a smallpox outbreak. We agreed that the training materials for this course will be made available to the international community. To this end, we approved a distribution plan to be implemented without delay.
      • Italy has completed a report on strategies for isolation techniques for patients with smallpox and other highly contagious viral agents based on a meeting of experts, and we have decided that this report should be shared with other countries. We agreed to continue our collaboration in this area.
      • Our countries have successfully evaluated and shared information on the effectiveness of our respective smallpox detection assays at a smallpox practical laboratory workshop hosted by the United States. We are pleased to report that all countries performed to an acceptable standard. We agreed to continue our collaboration in this area.
      • We reaffirmed our commitment to strengthening the WHO smallpox vaccine reserve. The form of support for this global vaccine reserve is at the discretion of each member of the Global Health Security Initiative. Ongoing work on the logistical management of the reserve is underway in cooperation with WHO.
      • We have shared lessons learned from the experiences our countries have had with their smallpox vaccination programmes.
   5. We have consolidated our effort on smallpox and risk management and communications by forming a new Working Group on Risk Management and Coordination.
   6. Steps were taken to strengthen the coordination and collaboration among participating national high-level laboratories through the Global Health Security Action Group (GHSAG) Laboratory Network:
      • We approved the Terms of Reference for the GHSAG Laboratory Network.
      • We are addressing the challenges related to the issue of transporting diagnostic specimens and reference materials across international borders, and have agreed to work together to that end.
      • We welcomed the external quality assurance program developed by Germany for the Network.
      • We welcomed the smallpox laboratory training exercise developed by the US for the Network.
      • We shared lessons learned from our laboratory experiences with severe acute respiratory syndrome (SARS).
      • We recognize concerns surrounding biosafety and health security standards outside of GHSAG countries and support the need for evidence-based research to improve global standards in this area.
      • The UK will host an anthrax testing workshop in March 2004.
   7. We approved the generic criteria for priority chemicals, developed by the working group led by Japan, to improve preparedness for and response to chemical events. We anticipate proceeding to the next steps, such as identifying those chemicals for international collaboration, developing the inventory of scenarios and research, as well as a study on the feasibility of an international exercise.
   8. To underscore our commitment to improve public health security globally, we decided to undertake work in new areas concerning radio-nuclear threats, field epidemiology practices, and collaboration on research.
      • We endorsed the proposal from France to address radiological and nuclear threats to public health and health security.
      • We approved the initiative by Mexico to improve the field epidemiology response to a public health emergency of international concern.
      • Led by the European Commission, we will pursue better collaboration on research in order to, for example, facilitate the exchange of information, the identification of common interests and research gaps, and to consider opportunities for joint research.

We have called for concrete progress in these areas for our 5th Ministerial meeting.

1. Furthermore, we recognize that preparedness for and response to bioterrorism have much in common with preparedness for and response to naturally occurring global health threats such as pandemic influenza. Much work needs to be done to enhance preparedness by member countries and globally by addressing critical issues for an effective pandemic response. To this end we have agreed to the Terms of Reference for the Technical Working Group on Pandemic Influenza Preparedness. The Technical Working Group will focus on critical gaps related to the rapid development, evaluation and availability of pandemic influenza vaccines; and, the optimal use of antiviral drugs. This group will carry out its work in conjunction with the WHO and other appropriate international organizations.
2. While membership in the Global Health Security Initiative remains the same, we will initiate steps to more fully share with other countries appropriately designated information and outcomes from the Global Health Security Initiative, including the possibility of periodic information sessions determined by the World Health Organization at the World Health Assembly.
3. We have accepted the invitation of France to host the 5th Ministerial meeting in Paris in the autumn of 2004.

This statement was endorsed by:

• Mr. Ian C. Green, Deputy Minister of Health, Canada on behalf of the Honourable Anne A. McLellan, Minister of Health, Canada
• Mr. David Byrne, Commissioner of Health and Consumer Protection, European Union
• L’honorable Jean-François Mattéi, Ministre de la Santé, de la famille et des personnes handicapées, France
• The Honourable Ulla Schmidt, Federal Minister for Health, Germany
• Professor Girolamo Sirchia, Minister of Health, Italy (in absentia)
• Mr. Yoshiharu Otsuka, Vice-Minister of Health, Labour and Welfare, Japan, on behalf of The Honourable Chikara Sakaguchi, Minister for Health, Labour and Welfare, Japan
• The Honourable Julio Frenk, Minister of Health, Mexico
• The Rt. Honourable John Hutton, Minister of State for Health, United Kingdom
• The Honourable Tommy G. Thompson, Secretary of Health and Human Services, United States