Regional Response to Global Health Issues:
The involvement of regional organizations in the fight against infectious diseases in Asia and
Europe.
Vincent ROLLET, PhDWenzao Ursuline College of languages, Taiwan
French Center for Research on Contemporary China (CEFC)
APISA 5, 24-25 november 2011, Taichung, Taiwan
Outline
1. Progressive involvement of regional organizations
(RO) to fight infectious diseases in Asia and in
Europe. Political commitment of RO to combat ID Regional strategies Institutionalization of regional responses
2. Role of the regional responses
Prevention Control ( H1N1 2009) Research
3. Main challenges of these regional responses
Emergence and re-emergence of infectious diseases in Asia and Europe ASIA
> HIV • 5,23 million people were living with HIV/AIDS in Asia in 2010 (UNAIDS). • Low prevalence / large number of infected people (India: 0,1 % = 2,3
millions adults with HIV.• Progress in Cambodia, Myanmar and Thailand • No significant progress in Indonesia and Vietnam
>Tuberculosis• In 2008, the largest number of new TB cases occurred in South-East
Asia• 2350 deaths/day in Asia• Drug-resistant TB (India, China,..)
>Malaria• South-east Asia accounts for 15% (34 millions) of estimated cases worldwide
> Ancient diseases: leprosy, dengue, visceral leishmaniasis , lymphatic filariasis
> New and emerging diseases: SARS, avian influenza, Nipah virus disease,…
EUROPE
• Europe is far from being a fortress again infectious disease!
• Respiratory tract infections (influenza, tuberculosis,..), sexually-transmitted infections
(HIV, hepatitis B and C,…) , emerging and vector-borne diseases (malaria, plague,
chikungunya,..) and vaccine-preventable diseases (measles, rubella,..) still pose a great
challenge to the region.
• Each winter, hundreds of thousands of people in the EU become seriously ill and die as a result of seasonal influenza.
• Re-emergence of TB fuelled by the HIV epidemic
• HIV epidemic : main public health threats posed by communicable diseases in Europe.
Continuing transmission of HIV in many European countries.
• Avian influenza and other EID also a concern for Europe
Part 1
Progressive involvement of regional
organizations to fight infectious
diseases in Asia and Europe.
1. A clear political commitment
1980: 1st ASEAN Health ministers meetings (AHMM): “to strengthen
and coordinate regional collaboration in health among ASEAN
countries” notably in the domain of infectious diseases control.
1991: 4th AHMM: Framework for the exchange of health information in ASEAN with emphasis on AIDS
1992: 4th ASEAN Summit, coordinated effort to curb the spread of HIV/AIDS
2000: “Healthy ASEAN 2020”: HIV/AIDS, disease surveillance, TB,
malaria, polio: “ to accelerate the implementation of an existing
HIV/AIDS action program as well as to pursue efforts to
strengthen disease surveillance and control of TB, malaria and
polio”
2003: Special ASEAN Leaders meeting on SARS / First ASEAN+3
Health ministers’ Special Meeting on SARS
2004: ASEAN Strategic Framework on health and Development (2010-2015)
2006: H5N1
2007: MDG Goal 6 (HIV/AIDS, malaria and other diseases)
2010: 10th ASEAN AHMM: “to strengthen our political
commitment to intensify ASEAN cooperation in health
development and to mobilize resources at the national,
regional and international levels” notably in the domain of
infectious diseases.
1997: 9th APEC Ministerial Meeting: need for further collaboration in health among APEC economy members
1998: The Third APEC Ministers' Conference on Regional Science and Technology Cooperation: support for specific projects directed toward emerging infectious diseases (dengue) / better epidemiological communication
2000: APEC Leader Annual Summit: Commitment to fight HIV/AIDS and other infectious diseases
June 2003: 1st APEC Health ministers Summit: engagement to fight SARS
Oct. 2003: APEC leaders’ engagement to work to strengthen public health infrastructures to detect, respond to, and prevent bio-terrorism and naturally occurring disease outbreaks
2006:14th APEC Economic leaders ‘meeting; agreed to enhance cooperation within APEC on HIV/AIDS, Avian and Influenza Pandemics
2008 : 16th APEC Economic Leaders Meeting : “to strengthen the region's health systems and cooperation to prevent and control emerging infectious diseases
2009: 17th APEC Economic Leaders Meeting “to build up the ability of regional avian influenza and other potential emergency and sub-emergency disease such as HIV/AIDS and Tuberculosis
2010: 18th APEC Economic Leaders Meeting “ to improve the capacity of economies for responses
to infectious diseases, control of non-communicable diseases, and strengthening of health
systems”
Treaty on the functioning of the European Union (TFEU) formerly known as the Treaty of Rome
(1958); Article 168: “… coordination and cooperation to prevent major health threats
such as human diseases and to combat serious cross-border threats to health”
2002: 1st Programme of Community action in the field of public health (2003-2008): to promote and
improve health, prevent disease, and counter potential threats to health while fully
respecting the responsibilities of the Member States
2007: European Health Strategy (2008-2013): Commitment to combat HIV/AIDS reaffirmed /
engagement to cooperate at the regional level, where appropriate, to respond to influenza,
TB and malaria.
2007: Bremen Declaration on Responsibility and Partnership in the fight against HIV/AIDS: to
strengthen responses to HIV/AIDS within the European Union / to provide the political
leadership to fight this pandemic
2. Regional strategies to respond to infectious diseases
1992: ASEAN Regional Program on HIV/AIDS Prevention and Control (1995-2000)
2002: 2nd ASEAN Regional Work Programme on HIV/AIDS (2002-2005): HIV surveillance; prevention programs; access to drugs,….
3rd ASEAN Work Programme on HIV and AIDS (2006-2010) : improving regional responses, HIV/AIDS and mobility, HIV and development,…
2005, ASEAN Regional Framework for the Control and Eradication of HPAI (2006-2008)
2007: ASEAN Avian Influenza Pandemic Preparedness Project
2008: ASEAN Regional Strategy for the Progressive Eradication of HPAI (2008-2010)
2004: ASEAN +3 EID program (funded by Australia)
4 priority areas:
1) ASEAN institutional strengthening for EID project management,
2) surveillance and response , 3) prevention and risk reduction and 4) enhancement of the regional pandemic response
mechanisms.
2005, the ASEAN Agreement on Disaster Management and Emergency Response
ASEAN Work Plan for multi-sectoral Pandemic Preparedness and Response.
2001: APEC Infectious Diseases Strategy
2006: APEC Strategy on Emerging Infectious diseases
prevention and control of EID into the overall planning of economic and social development
economies’ surveillance and response capacity on EID
collaboration in the prevention and control of EID
technical and scientific cooperation and assistance for prevention and control measures among
economies
2006: APEC Action Plan on the Prevention and Response to Avian and Influenza Pandemics
2007: APEC Functioning Economies in Time of Influenza Pandemic Guidelines
Guidelines for creating an enabling environment for Employers to
implement effective workplace practice for people living with HIV/AIDS
2003/ 2008: European Health Strategies
2005: Communication on Pandemic Influenza Preparedness
and Response Plan for the European Community
2007: Framework Action Plan to Fight Tuberculosis in the
European Union
2009: EU strategy on Pandemic influenza (H1N1)
2009: EU Strategy on HIV/AIDS (2009-2013)
3. Institutionalization of the regional responses
ASEAN Task Force on AIDS (ATFOA)
ASEAN Taskforce on Highly Pathogenic Avian Influenza (ASEAN HPAI Task Force)
ASEAN Technical Working group on pandemic preparedness and response (ATWGPPR)
ASEAN Secretariat Working group for One Health (ASEC One Health)
ASEAN Expert Group on Communicable Diseases (AEGCD)
1. Prevention : public health surveillance / preparedness
2. Control: Outbreak control / risk communication [ex: H1N1 (2009)]
3. Research
1. Prevention (Surveillance)
Nov. 2007, Ministries of Health of ASEAN+3 countries
agreed to share through a specialized webpage (ASEAN
EID Website), surveillance information about nine
infectious diseases as well as any public health
emergency of international concern (PHEIC).
In 2010, ASEAN+3 established a regional network of
laboratories, the ASEAN Laboratory Partnership (ALP),
enabling the surveillance of thirteen infectious
pathogens of particular concern in the region.
Training: To enhance surveillance capacities
(structures) and competencies (human resources)
In 1996, APEC developed the APEC Emerging Infections Network.
APEC EInet is an events-based surveillance mechanism (scans Internet and media continuously)
Link between commerce and health officials in A-P.
Training projects led by APEC economy
members: To strengthen surveillance
capacities and competencies
ECDC is responsible for the surveillance of
infectious diseases and shall maintain the databases
for epidemiological surveillance
Data collection based on case-reporting from the
Member States.
Routine surveillance of 46 diseases plus SARS, West
Nile Fever and Avian Influenza through the
European Surveillance System (TESSy)
Collection, validation, cleaning, analysis and
dissemination of data at the European level.
Role in surveillance:
• Crucial role in the creation regional surveillance mechanisms to monitor the spread of several infectious diseases in their region.
• ASEAN and EU : updated and frequent coverage of 13 (ASEAN) and 49 infectious diseases
(EU) and a clear picture of their evolution at the regional level.
ECDC : analysis of the epidemiological situation and share scientific and valuable advices to
the governments of the EU countries to help them to make decisions
• Help to reinforce national compliance to the requirements of the International Health Regulations (IHR 2005)
• Enhance directly the global surveillance of infectious diseases as they support capacity
and competencies development of their members (Training, )
• Offer a privileged and a medium-size platform for sharing experience and best
practices related to disease surveillance through workshops on surveillance.
2. Prevention (Preparedness)
APEC/ASEAN/EU: Facilitators for sharing preparedness levels, experiences and
concerns :
Opportunity to share with other their level of preparedness in line with the regional preparedness strategies as well as best practices and concerns.
An important tool for the regional organization to improve regional preparedness as it allows comparison between members and then sometimes indirect pressure to the less prepared ones
Monitoring MS level of preparedness
Regional meetings, workshops, seminars or
videoconferences on preparedness
* APEC Workshop on Implementation of the APEC Action
Plan on Prevention and Response to Avian and Influenza
Pandemics (June 2007)
*ASEAN Regional Workshop on Multisectoral Coordination
in Pandemic Preparedness and Response (November 2007)
* Conference on Lessons learned from the influenza
pandemic A (H1N1)2009 in Europe” (July 2010) organized
by the EC and the Belgian presidency
ASEAN: a potential supplier of complementary emergency treatment and equipment to its MS.
Stock of medical supplies
Since 2007, ASEAN possess a stockpile of 500 000 courses of antivirals (Tamiflu and Relenza),
plus a large quantity of personal protective equipment (surgical mask, disposal gloves,
isolation suit and gown) provided by Japan and stockpiled in Singapore.
EU: Coordinator of national vaccination strategy plans
EC has helped EU countries to develop a EU Vaccination strategy
against pandemic H1N1 influenza :
Timing of vaccination campaigns,
Potential target groups and priority groups for vaccination
The level of immunization coverage
Encouraging good cooperation and communication between EU members
when they decide and implement their own vaccination strategy
EU / ASEAN: Facilitator for the access to and supply of vaccines in a region
EU Commission and the European Medicines Agency (EMA) have worked together to
speed up the marketing authorization procedure of vaccine once a pandemic is declared
European Commission proposed to set up a mechanism to help joint procurement of
vaccines for interested Member States
ASEAN member states recently, proposed to explore the feasibility of joint procurement
to secure the availability of drugs and pandemic influenza vaccines as well as to explore
mechanisms for joint production of the drugs and vaccines
Benefits: Lower price // save administrative cost // increase the total number of doses
rapidly available at the regional level
APEC/ASEAN/EU: Controllers of the level of preparedness of their ME/MS.
Simulation exercises• APEC Desk-top Pandemic Response Simulation Exercise (2006)• ASEAN Panstop 2007 / Panstop 2009• EU Common Ground Exercise on an Influenza Pandemic
Goal: to strengthen the effectiveness and the rapidity of the response to an epidemic
outbreak at the national, regional and global level.
!!! APEC gives the opportunity to Taiwan to test its preparedness
level against ID in coordination with other countries.
ASEAN/EU: Initiators of inter-regional prevention cooperation between Asia and
Europe.
• Joint Declaration of the ASEAN-EU Commemorative Summit (2007): ASEAN and the EU have
pledged to “strengthen their cooperation in public health to address the threats of emerging
infectious diseases”
Initiatives:
• Through Global initiatives: Global Avian and Human Influenza Facility (AHIF)
• Through WHO: Implementation of the National Strategic Plan for Avian Influenza (INSPAI)
• Direct EU technical and financial assistance to ASEAN countries: ex. Vietnam (H5N1)
• Under ASEF : ASEF Public Health Network, expert and scenario-building workshops between officials and professionals from Asia and Europe
3. Regional organizations & outbreak control:
The case of H1N1 (2009)
23 April 2009: US CDC confirmed seven cases of swine influenza A(H1N1) in humans (California and Texas).
23 April 2009 : Mexico reported 120 confirmed cases of respiratory illness due to influenza and 20 deaths.
11 June : WHO declares global swine flu pandemic
10 August: WHO declares the H1N1 influenza pandemic over:
More than 318,925 H1N1 cases including 3917 deaths had been reported
The EU as provider of coordination, scientific support and public health advice at the regional level.
The EC provided coordination through the organization of daily audio-conferences which enable the participating Member States to share experiences and to learn from each other
Two main agreements reached by the EU Member States on travel and on school closure:
the Agreement on advice to persons planning to travel to or returning from affected areas (18 may 2009)
the Statements by the Health Security Committee and the Early Warning and Response System (EWRS) on school closures (13 August 2009).
> represent indeed the result of the EC efforts to coordinate and to harmonize the regional response in these two domains
EU acts also as a scientific and technical adviser through its ECDC which
provided risk assessment as well as scientific and technical support on
response to Member States
The H1N1 crisis in 2009 also revealed that in the future, the EU could play
an important role as supporter and coordinator of the efforts made by
Member States to create joint procurement of vaccines
ASEAN acting as provider of information, facilitator of communication and multiplier of external help for its region.
Provider of disease surveillance data, good practices,
laboratory-based surveillance information, activity updates,
capacity development resources and daily news flashes through
the EID website
Facilitator of the communication between the AMS through
its EID website, meeting and video conferences (Assessment
report > positive impression, useful, reduce the unknown).
Multiplier of external support to outbreak control :
ASEAN+3 Health Ministers Special meeting on Influenza A
(H1N1) (May 2009). Meeting between US CDC and AMS.
APEC as an H1N1 information supplier and supporter of the empowerment of business leaders in the region
APEC encouraged all its economies to work individually and
cooperatively to implement the APEC Action Plan on Prevention
and Response to Avian and Influenza Pandemic
Supplier of H1N1 epidemiological updates to all its economies through the APEC EiNet.
Empowered business leaders to make their decision during
the H1N1 crisis by offering them the possibility to receive tips
to improve their response and ability to cope with the influenza
virus after answering a series of questions through an online
checklist.
3. Research support Research in the EU: poorly financed (+/- 2% of GDP) and fragmented.
European Commission’s Framework Programmes (FP)
HIV/AIDS projects funded by the 1st Framework Program (1984-1988)
FP 5 (1998-2002) +/- 6 million euros spent on avian and pandemic influenza
FP6 (2003-2006)+ FP7 (2007-2013)
Since 2000, the EU has spent more than 100 million euros on influenza (54 projects)
F7: 55 million euros on ongoing research projects focusing on other
viral diseases such as hemorrhagic fever, Chikungunya, West Nile virus,
…
HIV/AIDS 214 million
euros on (57
projects)
Malaria 150 million euros
TB125
million euros
No such regional mechanism within ASEAN and APEC.
BUT ASEAN and APEC MS/ME joint EU FP research projects on ID.
Ex:
• Taiwan and China : SARS Control project led by
the University Medical Center Rotterdam in 2005
• Vietnam, Cambodia and China, partners to a
project on innovative diagnostic tools and
therapeutic approaches for dengue disease led
by the Institut Pasteur
1. Implementation challenges
a. Disparity in the level of development of the national preparedness plans
ASEAN: Thai-plan retained the format of a
strategic framework rather than an
operational guide
EU: still serious gaps in the plan .Persistence
disparities in the level of preparation of
MS notably between “old” and “new” EU
MS.Source: E. Morris, S. Schneider, Pandemic Emergency Preparedness in the European Union (2009) presented at the 2010 International Disaster and Risk Conference, Davos
b. Difference in the levels of national surveillance of infectious diseases EU
Influenza surveillance: Not entirely comparable between countries.
Variability in the data (size and representativeness of the sentinel networks,
accuracy of the estimation,…)
Differences between countries in the rigor and resources devoted to
collecting and validating this data TB, STI,…
ASEAN and APEC:
Despite progress made in dengue surveillance in Asia, many challenges
remain: standardization of classification of dengue, limited resources
and infrastructure for surveillance and control, quality of diagnostics,
…
No obligation to report infectious diseases to a regional surveillance
system
2. Resources challenge Financial resources devoted by regional
organizations to infectious diseases regional projects are quite limited or strongly rest on outside donors.
APEC: small-budget projects or financed by one country
ASEAN: Mainly financed by non-regional actors (Australia, US,…) Political commitment not synonymous of financial
commitment for regional initiatives ASEAN MS have preference for bilateral cooperation
Human resources
Only five people currently take care of the ASEAN EID website management while EC and its ECDC relies on much larger team.
3. Other challenges Regional risk communication challenge
EU Risk Communication (H1N1): a complete failure
Regional coordination challenge
Not an easy task notably during health crisis
Affected by political, ethnic and religious tensions between and within countries
…