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)

Health Task Force (HTF) >> Health Working Group (HWG)

European Centre for Disease Prevention and Control (ECDC)

EC Health Security Committee (HSC)

Part. 2

What role for regional

organizations in the fight

against infectious diseases?

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

Part. 3

Main Challenges

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

…

THANK YOUFor your attention !