WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIOUE OCCIDENTAL
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ORGANISATION MQNDIALE , DE LA SANTE
REGIONAL COMMITTEE Thirty-first session Manila 9-15 September 1980 Provisional agenda item 24
WPR/RC31/24 30 June 1980 ORIGINAL: ENGLISH
PROGRAMME ON ACUTE RESPIRATORY INFECTIONS (ARI)
Document WPR/RC31/24 is presented to the Regional Committee in pursuance of Resolution WHA32.33, adopted by the Thirty-second World Health Assembly in 1979. Acute respiratory infections was the subject of the Technical Presentation during the thirtieth session of the WHO Regional Committee for the Western Pacific in October 1979. A short description of the regional medium-term programme enumerates the compelling reasons for formulation of a strategy for the control of acute respiratory infections; the principal objectives and targets; and the strategies and approaches planned to achieve the objectives and targets. The present situation and plans for the future are reviewed. Representatives are invited to comment and make suggestions for implementation of the programme.
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INTRODUCTION
1.1
Background
Acute respiratory infections was the subject of the Technical Presentation which took place during the thirtieth session of the WHO Regional Committee for the Western Pacific in October 1979. At the request of the Regional Committee, and after representatives of several Member States had expressed interest in the programme, the same subject was placed on the agenda of the present session in order to obtain guidance on future implementation of the WHO programme, which is one requiring the coordinated effort of a number of specialities. Resolution WHA32.33, adopted by the Thirty-second World Health Assembly in 1979, forms the policy basis of the global programme to which the regional programme described below will contribute. 1.2 The regional medium-term programme
The regional medium-term programme for acute respiratory infections is based on the Sixth General Programme of Work of the World Health Organization, covering the period 1978-1983. 1 It was developed mainly from materials received from Member States, though reports of WHO meetings and consultants and the experience of the Regional Adviseri~ Communicable Diseases have contributed. 1.2.1 Situational analysis 2
Statements by national authorities to the effect that communicable diseases are under control often exclude consideration of acute respiratory infections which, up to the present, have not been effectively controlled even under favourable economic conditions. Compelling reasons for WHO to evolve a worldwide strategy for the control of acute respiratory infections are: (1) (2) (3) the continuing massive morbidity attendant economic losses; fr~m
such diseases with
the very high premature mortality from pneumonia-influenza in many of the less developed countries; the need to determine the optimal usage of available vaccines;
IWHO Official Records, No. 233, 1976, Annex 7, page 93, specific objective 11.1.2. 2For an extensive analysis of the situation as it existed in 1979, see document WPR/RC30/TP/I.
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(4) the emerging resistance to antibiotics of many bacterial respiratory pathogens; (5) the prospect of further developments in the area of vaccines and anti-viral substances. A review of successful communicable disease control programmes, involving individual pathogenic agents, shows that success followed: (1) definition of the pathogen and its role in the disease; (2) an understanding of the ecology, method of transmission and mode of action of the pathogen; (3) interruption in the cycle of transmission at the point of maximal vulnerability with the simplest available technology. With acute respiratory infections, the problem is more complex, as many pathogenic agents are involved, each with different ecological needs, methods of identification and modes of action - often acting synergistically and in various combinations. Because of this, the control programmes that ultimately evolve are likely to differ from other communicable disease control programmes. With regard to influenza, the lack of a potent multi-antigenic vaccine, the comparatively high cost of available vaccines, the need for relatively advanced technology to identify the virus, and difficulties in the collection and distribution of information are the major problems. In the Western Pacific Region, activities in the field of acute respiratory infections intensified after a consultant visited Fiji, Papua New Guinea and Philippines from December 1977 to January 1978 to assess the problem and to make proposals for the development of a programme. After general review of those proposals by the third session of the Western Pacific Advisory Committee on Medical Research (WPACMR) , the Task Force on Communicable Diseases l met in September 1978 to discuss implementation details. In January 1979, a working group on acute respiratory infections met in Goroka, Papua New Guinea, to discuss surveillance methodology. Shortly afterwards ~'lrveil1ance activities commenced when, with WHO collaboration, an acute respiratory infection unit was established at the Institute of Medical Research. 1.2.2 Objectives and targets
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The objective of the programme is to establish a feasible scheme for the detection, treatment and prevention of acute respiratory infections and for the collection of valid information in countries or areas of the Western Pacific Region. Priority will rightly be given to the reduction of
lNow the Sub-Committee on Communicable Diseases.
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mortality in children. Although by implication this points to the developing countries, discussions have also repeatedly centred on the importance of reducing morbidity, which constitutes an easily demonstrable burden for industrialized countries. The targets are: (1) to establish acute respiratory infection units to monitor, investigate and control acute respiratory infections in defined populations in five countries of the Western Pacific Region by 1983; to reduce mortality from acute respiratory infections in children under five years of age by 50% between 1982 and 2000 in every country or area of the Region.
(2)
Specific targets for the reduction of morbidity await the development of reliable tools. 1.2.3 Strategies and approaches
Because of lack of information on acute respiratory infections in the community, the programme places emphasis on the strengthening of surveillance and the testing of intervention methods. Agreement has to be reached on terminology and criteria for the diagnosis of various acute respiratory infection syndromes. A network of units is envisaged, to cover the whole Region, which will monitor, investigate and control acute respiratory infections in defined populations, using standardized descriptive and technical methodology. As indicated above, the target is to create five such units by 1983. Programme activities should be concentrated in countries such as Papua New Guinea and the Philippines, where respiratory infections rank very high as reported causes of death. Although data may not be readily available, other developing countries in the Region are also known to have a high mortality rate. A rational basis for the management and ~untrol of acute respiratory infections needs to be established, including evaluation of the effects of vaccines where appropriate. Other approaches to establishing a comprehensive programme include: development of a standardized data recording and reporting system; a regional advisory panel which would meet biennially; a prototype acute respiratory infection unit; and committees to coordinate national control activities. 2. PRESENT SITUATION AND ACTION TAKEN
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Since early 1979, an acute respiratory infection unit has been in operation at the Institute of Medical Research, Goroka, Papua New Guinea with WHO collaboration. A national committee on acute respiratory infections has been created in the Philippines and a rural and an urban
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area have been designated where acute respiratory infection unit activities will be undertaken. In Malaysia, there is a plan to develop activities at the Institute for Medical Research. The Institute will take part, with centres in Nairobi and Rio de Janeiro, in a global collaborative study on simple and rapid diagnosis of viral diseases. It is hoped that other governments will consider the establishment of acute respiratory infection units. It is known that the Department of Community Medicine, Adelaide, Australia is carrying out work which fits in with the concept and . endeavours will be made to compile an inventory of such work in the Region. 3. PLANS FOR THE FUTURE
Although WHO's acute respiratory infections programme in its present form is still relatively young, the Western Pacific Region is already deeply involved in activities for its development. It is hoped that, before the end of 1983, at least six countries or areas of the Region will have been able to formulate and develop national programmes and that national seminars, which will include field training, will have been held in each one. A regional seminar on standardized methodology will be organized for participants in the programme and a working group of experts will meet to make recommendations on clinical management. While priority must be given to reducing the unnecessarily high mortality rate in infants and children in developing countries, there is also a need to investigate ways to reduce morbidity, which remains a major public health problem in developing and developed countries alike. The establishment of community based acute respiratory infection units in as many countries or areas as is feasible will accelerate the process of creating a reliable data base and designing and testing control strategies. The importance of paediatricians in developing the programme is fully realized and efforts will be made to keep them informed and involved in exchanges of ideas. In 1982 or 1983 a cost-effectiveness study will be undertaken. Countries or areas that have so far indicated their interest in collaborating in some facets of the programme include American Samoa, China, Cook Islands, Fiji, Guam, Hong Kong, Kiribati, Malaysia, Papua New Guinea, Philippines, Tonga and Trust Territory of the Pacific Islands. Significant support has been provided, through the Voluntary Fund for Health Promotion, by the Government of Australia and the Japan Shipbuilding Industry Foundation. Since regular budget funds are limited, further contributions from extrabudgetary resources will be indispensable for development of the programme.
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