Communicable Disease Newsletter Leprosy in the WHO South-East Asia Region: issues and challenges At the end of the year 2010, 11 Member countries of the WHO South-East Asia Region had achieved the global target for elimination of leprosy as a public health problem at national level. This means those countries successfully reduced their respective national annual prevalence rates to less than one case per 10 000 population. These achievements can be attributed to better understanding of pathophysiology and epidemiology of the disease, availability of effective multidrug therapy and, equally important, the commitment of national governments to attain elimination of leprosy as declared by the World Health Assembly resolution, WHA44.9 on Leprosy, in May 1991 and further reinforcement of the commitment through World Health Assembly resolution, WHA51.15 on Elimination of Leprosy as a public health problem, in May 1998. With simplification by WHO, leprosy diagnosis is most commonly
Volume 9 Issue 2 (2012)
Inside • Leprosy in the WHO South-East Asia Region: issues and challenges 1 • Azithromycin: a new tool for eliminating yaws from the South-East Asia Region 3 • Outbreaks and Public Health Emergencies — Hand Foot and Mouth Disease (HFMD) in Thailand-2012 4 • Progress Update — India makes tuberculosis a notifiable disease 5 — Artemisinin resistance containment in Myanmar 6 • NewsBytes • New publications 8 10
based on clinical signs and symptoms which are easy to observe and elicit by any health worker after a relatively short period of training. For the South-East Asia Region, it is imperative to note that: (i) at the end of 2010, 59% of registered prevalent cases and 68% of new cases globally were from the Region; (ii) 6 out of 17 countries in the world which registered more than 1000 new cases during 2010 were from the Region; (iii) some indicators for the programme (including registered prevalence, new case detection) show an increasing trend or have been static for at least the past three years from 2009 to 2011; (iv) there are persistently high numbers of child cases and disability grade 2 among new cases, which translate into ongoing active transmission and delayed detection of cases in the community at risk; and (v) despite the
• First person: How opioid substitution therapy saved my life 11 • Surveillance corner 12
Photo credit: WHO Timor-Leste
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advancement of scientific evidence, stigma and discrimination remain the major challenges. The increasing or static trends of prevalence rates and new case-detection rates could potentially be attributed to: (i) an increasing number of health workers (including health volunteers) trained in the diagnosis and treatment of leprosy; (ii) the expansion of programme coverage as a result of the integration of the programme into general health services and the strengthening of the health system itself; and (iii) increased awareness of the disease among the population and reduction of fear and stigma as a result of continuous campaigns. The Enhanced global strategy for further reducing the disease burden due to leprosy (plan period: 2011–2015) advocates as the global target, reduction of grade 2 disability among new cases by 35% (of the 2010 baseline) by the end of 2015. The use of grade 2 disability index in newly detected cases will enhance monitoring of both case detection (and early treatment) and of disability. The global strategy also recommends the use of innovative approaches to prevent late diagnosis and treatment. In order to better align with regional strategies for control of diseases and taking into consideration regional characteristics, WHO-SEARO incorporated the global strategy into the Regional strategic plan for integrated neglected tropical diseases control in South-East Asia Region 2012–2016. In the efforts to move forward the agenda for elimination at subnational levels in Member countries of the Region, and in order to make the prescribed strategies work, the following concerns might be considered. (1) Sustaining political and financial commitments There is not yet room for complacency as far as the leprosy programme is concerned despite the declaration of its elimination as a public health problem at national level. It does not in whatsoever way imply that we should now transfer all commitments towards other public health problems. It rather implies greater investments are required to eliminate the disease at subnational levels among those who suffer the most, i.e. hard to reach people, because of any of the barriers to accessibility of public health services. Non-endemic countries should expect unprecedented new cases owing to the long incubation period of leprosy, and therefore sustaining commitment to continuous vigilance is crucial, while endemic countries should strengthen and expand programme coverage in order to detect and treat cases as early as possible and to cut transmission. Much has already been done in this area of concern by different actors from different sectors but much more still needs to be done. Stigma and discrimination have become important human right issues. Not uncommon
issues are those pertaining to colonies in which people affected by leprosy live for generations, and deprivation of public services for people affected by leprosy including health services and education. Reintegration into society and restoration of dignity and livelihoods of people affected by leprosy must be considered as the ultimate goals of the programme. (3) Strengthening health systems The integration of leprosy into the general health system has contributed tremendously to the leprosy elimination programme. Innovative managerial and programmatic issues need to be deployed into the system to bring greater benefit to the programme as well as other existing public health programmes at different levels within the system. Immunization programmes, in particular BCG coverage, contribute between 20 and 60% to the reduction of leprosy cases according to research; water supply, sanitation and hygiene are undoubtedly key public health interventions; and health promotion and education, again, crucial for prevention and control of diseases, are existing health programmes from which mutual benefits are evident. Better coordination and enhanced sharing of information and strategies could contribute much more. Leprosy programmes must go beyond the health sector to permeate deep into other sectors such as education, social-economy, industry and commerce, housing and rural development, to name a few. Active involvement of communities and families as well as people affected by the disease will boost the success of the programme. There is always a need to identify new strategies and technologies to achieve faster and further the programme’s goal. Effective investment in research and development will allow new interventions to become available in a timely manner. New and cost-effective public health interventions must be at the top-most priority. Strengthening of programme development and management at different levels requires equal investments, including data and information management so they can be used effectively as planning tools. Similarly, with contribution of different players in the programme, an innovative and enhanced coordination mechanism needs to be formulated and agreed upon by all.
(4) Multiprogramme and multisector approach
(5) Research and development
(6) Programme development and management
(2) Stigma and discrimination reduction
Dr Rui Paulo de Jesus Regional Adviser, Leprosy Unit
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Azithromycin: a new tool for eliminating yaws from the South-East Asia Region Yaws, a disease caused by bacteria (non-venereal spirochete treponema), remains one of the most neglected tropical diseases that affect the poorest and most vulnerable populations. WHO and UNICEF implemented the Global Treponema Control Programme (TCP) campaign from 1952 to 1964. It resulted in morbidity from the disease being reduced from 50 million to 2.5 million (95% decrease) in 46 countries, due to a single method: one dose injection of benzthine penicillin. Over the years, yaws disease control declined to be a priority but the disease continued to be reported from pockets in some countries. Currently, at least six countries in the world continue to report yaws cases. In the WHO South-East Asia Region, Indonesia and Timor-Leste remain endemic for yaws. However, India declared elimination of the disease after reaching zero cases by 2006 with single-dose injection benzthine penicillin intervention and public education for healthy behaviours (Figure 1). India is continuing serosurveys of children aged under five to verify transmission of the disease, so that it can declare the country free from yaws.
Figure 1: Yaws elimination in India: a success story.
Figure 2: Trend in reporting of new yaws cases in Indonesia.
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Cases Indonesia has a decentralized system of governance, and district governments are being advocated to mobilize resources and eliminate the disease by 2020. Since 2001, reporting of new cases increased from 2112 to 6631 in 2011 (Figure 2). Figure 3: Injection benzthine penicillin treatment – complete cure of yaws lesion.
Timor-Leste is also gradually initiating yaws elimination activities.
Azithromycin in yaws elimination Studies on oral intervention of a single dose of the drug azithromycin (2 gram) in Papua New Guinea and Ghana indicated that it is equally effective in yaws treatment as injected injection benzthine penicillin, which has been the standard treatment for yaws (Figures 3 and 4). Azithromycin is well tolerated, with minimum side-effects as seen in trachoma elimination programmes. Since oral azithromycin has operational advantages over injection of benzthine penicillin in yaws elimination, WHO held a meeting of experts in Morges, Switzerland in March 2012 to discuss recommending azithromycin for global eradication of yaws by 2020. The expert group recommended treatment of cases and total community at risk with azithromycin, with surveys to be conducted (WHO, 2012).
Figure 4: Azithromycin single dose treatment – complete cure of yaws lesion.
Since azithromycin is an expensive drug, WHO is making efforts to explore the possibility of free drug supplies from the pharmaceutical donors who are currently donating to the trachoma elimination programme. Dr C.R. Revankar Vector-Borne and Neglected Tropical Diseases, (VBN) unit Dr A.P. Dash Regional Adviser, (VBN) unit
Outbreaks and Public Health Emergencies Hand, foot and mouth disease (HFMD) in Thailand – 2012 In Thailand, HFMD cases have been reported by all hospitals and health centres in the public sector since 2001 and in late 2011 herpangina was also included in the surveillance system. Surveillance data of HFMD & fatal enteroviruses, Thailand, 2001-2012 During 2007–2011, annually 12 000–10 000 cases with two to six deaths were reported. From 1 January to 21 July 2012, a total of 18 974 cases (incidence 30 per 100 000 population) with two deaths were reported from all 77 provinces. The male-to-female ratio of HFMD/Herpangina situation, Thailand, 2012 compare to 2011
Source: Bureau of Epidemiology, Ministry of Public Health, Thailand.
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reported cases was 1.4: 1. The majority of cases (over 90%) were in children under 5 years, and 70% were in children under 2 years of age. Increased activity of HFMD in Thailand and in neighbouring countries led the national Government to intensify HFMD case detection and reporting, and strengthen outbreak investigation and control including regular cleaning of public places. At schools the measure implemented included
daily screening of children and consideration of temporary closure of affected school classrooms (for 5–7 days) if cases are found. The situation is being monitored closely. Dr Yogesh Chowdhry Disease Surveillance and Epidemiology Unit with contributions from Bureau of Epidemiology, Ministry of Public Health Thailand
Progress Update India makes tuberculosis a notifiable disease With a population of about 1230 million, India is the largest country in the WHO South-East Asia Region. It has the highest burden of tuberculosis (TB) in the world in terms of absolute numbers of incident cases that emerge each year, and it contributed to a quarter of the estimated global incident TB cases in 2010. Since its inception in 1997, the Revised National TB Control Programme (RNTCP) of India has initiated almost 14 million patients to treatment, saving more than 2.5 million lives. Since 2005, the programme has consistently achieved and exceeded the global target of 85% treatment success rate among new smear-positive cases, with 87% for the cohort of patients registered in 2009. The RNTCP is entering a new phase with the goal of universal access to TB care. This poses important challenges, such as early and complete diagnosis of all TB cases, including drug resistant cases, and ensuring quality care. This necessitates greater and fruitful engagement with the large private sector in the country. With continued efforts to have complete information on all TB cases through involvement of all health-care providers, including in the private sector, the government of India has recently taken a very important decision that is a milestone for TB: to make TB a notifiable disease. Every month, all healthcare providers have to notify every TB case to local authorities — the district health officer/chief medical officer of a district and municipal health officer of a municipal corporation/ municipality. The Government has clearly articulated that the reference to health-care providers will include clinical establishments run or managed by the Government (including local authorities), private or nongovernmental organization sectors and/or individual practitioners. The Indian Medical Association has also endorsed the move. Moreover, the Government of India has made provision for extra budgetary funds for TB. This will help in tackling the additional number of TB cases that will be reported due to mandatory notification.
A TB patient. © Gary Hampton/WHO-SEARO
Mandatory notification of all TB cases will help patients in accessing comprehensive care for TB. It will provide opportunities for the programme to ensure all patients get the right diagnosis, right treatment, contact tracing, chemoprophylaxis and facilitation for necessary social support. This will also help in proactive engagement with the private sector. Another important prospect is in estimating disease burden and trends more realistically, which is crucial for planning and implementation of the disease control programme. Dr A Sreenivasan WHO India Dr M Khurshid Alam Hyder Regional Adviser, Tuberculosis, WHO-SEARO Dr Rim Il-Kwang TB Unit, WHO-SEARO
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Artemisinin resistance containment in Myanmar Globally, the malaria burden has been reduced significantly in the past decade: death rates dropped by one -third in Africa, and by more than half in 35 of the 53 countries affected by malaria outside Africa. WHO estimates that in 2010 globally 216 million cases of malaria occurred (uncertainty range: 149 million to 274 million); and there were 655 000 deaths due to malaria (uncertainty range:537 000 to 907 000). In the South - East -Asia Region the estimated malaria incidence per 1000 population at risk was reduced by 27%, from 30 in 2000 to 22 in 2010, and the estimated malaria mortality rate per 100 000 population at risk was reduced by 29% from 4.2 in 2000 to 3.0 in 2010. A marked reduction of cases in Bhutan, DPR Korea, Indonesia, Nepal, Sri Lanka and Thailand was noted; these countries now aim to eliminate malaria as a long-term goal. Significant progress has also been achieved in Bangladesh, India, Myanmar and Timor-Leste. The Maldives has remained malaria-free since 1984. However, these gains can be reversed by the emergence of parasite resistance to artemisinin derivatives (the most successful drugs for malaria treatment) in the Greater Mekong Sub-region (GMS). As per WHO’s Global Plan on Artemisinin Resistance Containment (GPARC), the term ‘artemisinin resistance’ is a working definition used to refer to: an increase in parasite clearance time, as evidenced by 10% of cases with parasites detectable on day 3 after treatment with an artemisinin combination therapy (suspected resistance); or treatment failure after treatment with an oral artemisinin-based monotherapy with adequate antimalarial blood concentration, as evidenced by the persistence of parasites for seven days, or the presence of parasites at day 3 and recrudescence within 28/42 days (confirmed resistance).
A significant increase in parasite clearance time is considered as an early warning sign of artemisinin resistance and deserving of a response similar to that for confirmed resistance. Artemisinin resistance has been confirmed in the Thai–Cambodia border region and in Thai–Myanmar border region; and suspected in south-eastern Myanmar, in central Viet Nam and at the Myanmar–China border. Containment of artemisinin resistance in Thailand and Cambodia started in 2009 with a US$ 22.5 grant from the Bill and Melinda Gates Foundation through WHO; the grant ended in 2011. Currently support is being provided by the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM) and the United States Agency for International Development (USAID). Overall, the outcome was a marked reduction in the prevalence of Plasmodium falciparum but more needs to be done to eliminate it. In response to the threat of artemisinin resistance, the Strategic Framework for Artemisinin Resistance Containment in Myanmar (MARC) 2011–2012, was launched in April 2011 following intensive consultations with the Ministry of Health, NGOs, and development partners, and facilitated by WHO. The goals of MARC are: (1) to prevent or at minimum significantly delay the spread of artemisinin-resistant parasites within the country and beyond its borders, (2) to reduce transmission, morbidity and mortality of P. falciparum malaria, with priority to areas threatened by artemisinin resistance. There are seven objectives, with several key activities under each objective. The country is divided into three tiers: Tier 1 – Townships (21) with strong evidence of suspected resistance, widespread ecological and social risk factors and intensive population movement. Tier 2 – Townships (31) with unclear evidence of suspected resistance, near suspected resistance areas in Myanmar, Thailand, and China. Tier 3 – the rest of the Myanmar. Implementation of MARC started in July 2011 with support from donors such as the Three Diseases Fund, the Australian Agency for International Development (AusAID), the UK Department for International Development (DFID), USAID, the Japan International Cooperation Agency (JICA) and WHO. A meeting was held on 26–27 June 2012 in Nay Pyi Taw to review the accomplishments in Year 1, and identify challenges and the way forwards. Some key accomplishments of the first year of MARC are: (1) Scaling up of geographic and programmatic coverage as shown in Table 1.
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Table 1: Key Indicators: all implementing partners combined Tier 1 & Tier 2 (July 2011 – April 2012) 1. Number of people with confirmed P.f malaria treated with ACT + (PQ) 2. Number of people with confirmed P.v and other non – P.f malaria treated with CQ+PQ 3. Number of RDTs taken and read 4. Number of LLINs distributed 5. Number of volunteers trainxed and supported Overall MARC Achievements 10 months Tier 1 :42,103 Tier 2 :21,724 Tier 1: 26,333 Tier 2: 13,202 Tier 1: 219,690 Tier 2 : 85,605 Tier 1: 319,926 Tier 2: 32,827 Tier 1: 2,162 Tier 2, 1,545 Overall MARC targets (3DF) 12 months 105,283 of confirmed malaria treated with recommended ACT 55,472 of confirmed malaria treated with chloroquine 377,732 suspected malaria cases examined using RDTs 364,800 1,812 % Achievement 60.6%
71.3%
80.8% 96.7% 204.6%
(2) Preparatory activities for replacement of monotherapy with artemisinin combination therapy (ACT) in the private sector; distribution of ACT starts in August 2012. (3) Training of 3707 voluntary health workers in malaria detection and treatment, insecticide treatment of mosquito nets, distribution of long-lasting insecticide treated nets (LLINs) and health education. (4) Establishment of 10 screening points for malaria among migrants. (5) Procurement of equipment (MiniLab) and training of staff to monitor quality of malaria and other essential drugs in the market. (6) Mapping of migrant workers and study of their behaviour relevant to malaria. Over 81 900 LLINs for migrant workers were distributed at work sites through the national programme and the International Organization for Migration. (7) Advocacy at different levels: the private sector (e.g. plantation owners/managers) was engaged. (8) Improvement in data management; data by village are now available in some townships. Baseline surveys carried out in December 2011–January 2012 revealed the following: •• •• Very low prevalence of malaria in the areas surveyed, probably due to low transmission season. Over 97.4% households owned a bednet; 35% had insecticide treated bednets; and 11% had LLIN; 73.2% had 1 net for 2 people, 13.1% for ITN and 3.0% for LLIN. Time taken to seek treatment for any fever was within 24 hours for 66% of cases. Dipping bednets to coat them with insecticides, in Myanmar. © L Ortega/WHO Myanmar
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Pharmacies, retailers and itinerant vendors are the most important sources of artemisinin monotherapy (AMT); they are also the least likely to stock diagnostic tools and to know the national first-line treatment. Private clinics and health workers are a useful source of quality-assured ACT (and at low cost), but may still be stocking AMT. Blister cutting and partial dose provision is particularly common among pharmacies, retailers and itinerant vendors, where the median price of AMT is a likely key barrier to full course provision.
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Although the challenge is enormous, the initial important steps are being taken through MARC. The eventual success will depend on all stakeholders in development being engaged in the battle against artemisinin resistance in Myanmar. Dr Leonard Ortega Regional Adviser, Malaria Unit
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NewsBytes World TB Day 2012 World TB Day is a worldwide event to raise awareness about the state of tuberculosis, and different countries and regions choose locally relevant activities and messages to highlight this. It is a worldwide call for action as well as a means to mobilize political and social commitment at the national level. On 23 March 2012, The WHO Regional Office for SouthEast Asia held a commemorative function for World TB Day, using the theme “Let us unite to stop TB”, in line with the global theme of “Stop TB in my lifetime”. It called for greater partnerships with all sections of society to eliminate TB. On behalf of the WHO Regional Director for South-East Asia, Dr Samlee Plianbangchang, Dr Poonam Khetrapal Singh, Deputy Regional Director, delivered the opening message, highlighting partnerships, education and empowerment of the people in terms of primary health care as key to eliminating TB. She also emphasized that partnerships with NGOs, public and private hospitals and others since the 1990s had contributed to about a 25% increase in case notification and more than 90% of the treatment success rate. However, it was noted that tuberculosis is a disease of poverty and unless we reach the poorest of the poor, and focus on prevention and education, we cannot eliminate it. Dr Singh released the World TB Day kit, which included Tuberculosis in the South-East Asia Region – The Regional Report: 2012 and, a booklet on Success stories in tuberculosis from Member States of the WHO South-East Asia Region. A short film on TB was also shown. An online interactive activity for advocacy and awareness of TB was shared on the WHO-SEARO web site to provide the public with important and interesting information related to the disease.
Workshop on Laboratory Diagnosis of Emerging Infectious Diseases Outbreaks of emerging infectious diseases (EIDs) occur frequently in the WHO South-East Asia Region. Inability to diagnose such infections during the early phase delays the institution of containment measures and facilitates spread of the disease. Laboratory support is also essential to understand the epidemiology of these diseases. Accordingly, a Regional workshop was organized on “Laboratory Diagnosis of Emerging Infectious Diseases”, at the National Institute of Virology (NIV), Pune, on 28 May – 1 June 2012. NIV (a WHO collaborating centre on EIDs and Rregional reference laboratory for H5N1) had developed a curriculum and course material based on recommendations of the EID laboratory networking meeting held in August 2011. This was finalized, and a core team of EID trainers was built. The course included an overview of the role of the laboratory in diagnosis of EIDs of public health importance and in implementation of IHR (2005), quality systems in health laboratories, infrastructure required for laboratories to diagnose EIDs, biosafety and waste management, the role of laboratories in EID outbreak investigations, and on various tests including polymerase chain reaction (PCR). Laboratory “hands-on” sessions and demonstrations included the immunochromatography test, virus isolation using cell culture and egg inoculation techniques, identification of isolated viruses (cell culture and egg) and PCR.
World Health Assembly Highlights: IHR (2005) and Pandemic Influenza Preparedness Framework (PIP) Implementation of the International Health Regulations (2005), and the Pandemic Influenza Preparednesss framework, were both reviewed during the Sixty-fifth World Health Assembly, held in Geneva, Switzerland, on 21–26 May 2012. The annual report on the imple mentation of the International Health Regulations (2005) was presented during the World Health Assembly, and globally, information collected using available tools showed that fair progress had been made in 2011 in core capacities such as surveillance, response, laboratory and zoonotic events. However, capacities need to be developed in human resources, and for preparedness for chemical and radiological events. Most countries are also likely to request a two-
Deputy Regional Director, Dr Poonam Khetrapal Singh, releasing “Tuberculosis in the SouthEast Asia Region – The Regional Report: 2012”.
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year extension to the deadline (June 2012) for establishing core capacities under IHR. A draft resolution proposed by the Secretariat (Add65/17 add2) urges Member States to, among others, ensure identification of remaining gaps and take necessary implementation steps for strengthening core capacities; and strengthen active collaboration among Member States, WHO and other relevant organization for full implementation of IHR (2005). It also urged the DirectorGeneral to build and strengthen WHO’s capacities to fulfill its role under IHR (2005). The Pandemic Influenza Preparedness (PIP) framework was acknowledged as crucial for global health security. However, WHO was urged to be flexible, as delegates considered industry and partners to play important roles in developing mass vaccines to counter outbreaks. Delegates proposed that 70% of the partnership contribution resources be used for preparedness and 30% for response. For PIP to be fully implemented, delegates also stressed the need for greater human and financial resources to support WHO capacity and leadership.
chronic hepatitis B infection and 30 million people with chronic hepatitis C infection in the Region. In May 2010, the World Health Assembly adopted a resolution (WHA63.18) that called for comprehensive prevention and control strategies for viral hepatitis. In particular, the Assembly requested WHO to develop, in collaboration with Member States, necessary measures, guidelines, strategies, time-bound goals and tools for the surveillance, prevention and control of viral hepatitis. In view of this, WHO South-East Asia Regional Office organized two informal consultations (in June 2010 and April 2012) on viral hepatitis to: (i) review the current status of disease burden, and prevention and control activities; (ii) identify priorities for research, policy, and action; and (iii) to develop a strategy for improved prevention and control of viral hepatitis, in the South-East Asia Region. A workshop to finalize the Regional Strategy for the Prevention and Control of Viral Hepatitis was therefore held from 11 to 13 July 2012 in New Delhi, India. Representatives of 10 Member States, WHO staff from headquarters and the Region, NGOs and eminent persons in this field participated. On behalf of the Regional Director, South-East Asia, Dr Samlee Plianbangchang, the Deputy Regional Director, Dr Poonam Khetrapal Singh, read out the opening remarks. The remarks highlighted that: “Viral hepatitis must be given greater priority in terms of both resources and effort in all Member States of the South-East Asia Region. Good surveillance is essential. Infant immunization coverage for hepatitis B must reach levels greater than 95%. It should be
Workshop on the Regional Strategy for the Prevention and Control of Viral Hepatitis Viral hepatitis, caused by infection with one of the hepatitis viruses, is a major public health problem worldwide, and particularly so in the WHO South-East Asia Region. WHO estimates that more than 5 million people in the Region will die from the consequences of viral hepatitis in the next 10 years. There are an estimated 100 million people living with
The opening session of the workshop on Regional Strategy for the Prevention and Control of Hepatitis.
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mandatory for all blood and blood products to be screened for hepatitis B and C. The quality of hepatitis testing in public and private laboratories must be monitored. Finally, there should be widespread public awareness campaigns, targeted at health and social workers as well as the general public, to increase awareness about the risk of viral hepatitis.” The Regional Strategy for the Prevention and Control of Viral Hepatitis focuses on six key areas: •• •• •• •• •• •• policy, planning and resource mobilization surveillance research prevention and control education medical care and treatment.
WHO’s role in supporting Member countries in areas related to the Global Fund In the past 10 years, the Global Fund to Fight AIDS, tuberculosis and malaria has played a significant role in scaling up interventions, enhancing coverage and access for prevention and treatment for the three diseases, and has made a significant contribution to progress in achieving the Millennium Development Goals for HIV , TB and malaria in South-East Asia. WHO’s role has been defined technical support, and in some countries, logistics and supplies. However, the Global Fund has recently undergone changes and reforms. In light of these, a two day Regional meeting on “the Role of WHO in supporting the Member States in areas related to the Global Fund” was organized in SEARO, New Delhi, 16–17 July 2012. The meeting was attended by WHO Representatives and Global Fund Focal Points in WHO country offices. The general objective was “to support SouthEast Asia Region Member countries in sustaining achievements and expansion of necessary interventions in prevention and control of HIV/AIDS, TB and malaria programmes supported by the GFATM.”
These Regional frameworks are aligned with the four strategic axes of the WHO’s global comprehensive approach in the prevention and control of viral hepatitis: partnership, mobilization and communication; data for policy and action; prevention of transmission; and screening, care and treatment.
New publications Seasonal communicable diseases: an information booklet, 2012 edition An information booklet
Seasonal Communicable Diseases
The best way to keep communicable diseases at bay is to increase awareness about them and know how to prevent them. The 2012 edition of Seasonal Communicable Diseases: an information booklet provides useful information on key communicable diseases in South-East Asia, as well as tips on what people can do to protect themself.
Quality assurance in bacteriology and immunology – third edition There is an increasing dependence on clinical and public health laboratories for better patient management and also for preventing the spread of emerging pathogens. With rapid and significant growth of laboratories at all levels of health care, it has become mandatory to check results to make them reliable and cost-effective, as well as comparable with those obtained by international laboratories. These guidelines dwell upon the basic concepts of quality assurance in microbiology and also describe essential practices and steps of ensuring quality in various activities that a microbiology laboratory is expected to undertake in its support of primary healthcare system in a biosafe environment and in accordance with the International Standards Organization (ISO).
SEARO Regional Publication No. 47
Quality Assurance in Bacteriology and Immunology Third Edition
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First person How opioid substitution therapy saved my life My name is Jimmy Dorabjee but my preferred name would be “Lucky”, because that’s what I am. I have used drugs for 40 years, and injected for most of them. But I have not been infected with HIV or hepatitis B or C. Today the UN estimates there are 4.5 million people who inject drugs in Asia and overall one in six who inject drugs are living with HIV . I was born in 1948 to a middle class family in Bombay (now Mumbai). There used to be a time when I misused drugs; lost control, lost jobs, lost love, lost my family. Indeed I lost everything I ever had before I came to terms with myself: that I am a drug user but I am a human being, with dignity and pride in myself and a lot to offer the world. All through my life I only received the message that if you use drugs, you are a pariah, a useless human being, and are unworthy of trust, love or respect. So what changed in my life that I no longer had the desire to use heroin? Most important was the fact that I had access to and began to use buprenorphine, which is used as an opioid substitution therapy (OST). Without the protecting and reinforcing effects of buprenorphine, I probably would still be there, out on the streets hustling and scouring heroin. Or I may have become HIV infected or just died. In the early 1990s I moved to New Delhi and joined the Jimmy Dorabjee at a training programme on opioid substitution therapy. NGO SHARAN. In 1993 the NGO began providing services with a harm reduction philosophy, including the provision of buprenorphine as a pilot programme. This became India’s first hard reduction service. Despite strong evidence of various benefits of OST, including reduced illicit opiate use and reduced risk of HIV , only around 2% of people in South-East Asia have access to OST. Today, I am seen as an expert in drug treatment and on issues of HIV and drug users, in India and throughout Asia. I am a researcher, trainer, consultant, and a specialist – in short, a worthwhile human being. But I still use buprenorphine and I lead a very “normal” life. My life is going well and I have a wonderful family and work that I love. – As told to Gary Reid, HIV/AIDS Unit Jimmy was a Founding Member and former Chairman, of the Asian Harm Reduction Network, the Principal Fellow of Harm Reduction at the Burnet Institute Centre for International Health, Melbourne, Australia. Today he is a member of UN Regional Task Force on Injecting Drug Use and HIV/AIDS in Asia and the Pacific, Core Member with Reference Group to the United Nations on HIV and Injecting Drug Use, and Chairperson of the Asian Network of People Who Use Drugs.
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Surveillance corner Avian influenza in the South-East Asia Region: Jan–Jun 2012 Outbreaks of highly pathogenic avian influenza (HPAI) were reported among poultry and wild birds in Bangladesh, Bhutan, India, Indonesia, Myanmar and Nepal in the first half of 2012. Avian influenza in poultry is deeply entrenched in Bangladesh and Indonesia whereas occasional outbreaks are reported in other countries. A “stamping out” policy has been adapted for containment of poultry HPAI outbreaks in all countries. As of 7 July 2012, The SEA Region has reported 222 cases of influenza A (H5N1) with 174 deaths since 2004. Table 1: Country-wise distribution of human cases of avian influenza, 2004–2012 Country Bangladesh Indonesia Myanmar Thailand Total 2004 0 0 0 17(12) 17(12) 2005 0 20(13) 0 5(2) 25(15) 2006 0 55(45) 0 3(3) 58(48) 2007 0 42(37) 1 0 43(37) 2008 1 24(20) 0 0 25(20) 2009 0 21(19) 0 0 21(19) 2010 0 9(7) 0 0 9(7) 2011 2(0) 12(10) 0 0 14(10) 2012 3(0) 6(6) 0 0 9(6) Total 6(0) 190(158) 1(0) 25(17) 221(174)
Indonesia has reported 190 human cases of influenza A (H5N1) with 158 deaths since July 2005. The number of reported human cases has been progressively decreasing, the fatality rate in humans remains still high, i.e. 83%. Avian influenza remains a public health threat and all countries have established a functional surveillance and response mechanism through intersectoral collaboration. H5N1 virus infections in humans remain rare despite frequent and widespread contact with infected poultry and contaminated environments. Joint risk assessments are crucial to reduce public health risks from avian influenza.
Figure 5: Annual number of cases of human infection with avian influenza in the South-East Asia Region. 60 50 40 30 20 10 0 Cases Deaths
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The emergence and circulation of different zoonotic Year influenza viruses in animals and possible coinfection of human and animal influenza viruses in the human population are a matter of public health concern. Influenza data must be linked in time and space to be useful for assessment of public health risks from animal influenza viruses. Therefore the Food and Agricultural Organization of the United Nations (FAO), the World Organisation for Animal Heath (OIE) and WHO are working together to establish a functional four-way linking project in Bangladesh and Indonesia.
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2012
Editor: Dr Rajesh Bhatia Editorial support: Dr Supriya Bezbaruah and Ms Greaney Jennie Design, pre-press support and layout: TPD
© World Health Organization 2012. All rights reserved. For complimentary copies, write to Communicable Disease Newsletter, Department of Communicable Diseases World Health Organization, Regional Office for South-East Asia, World Health House, IP Estate, New Delhi 110002, India Tel : +91-11-23370804, Fax :+91-11-23378412, email: cdsnewsletter@searo.who.int Communicable Disease Newsletter is a communication of the Department of Communicable Diseases, WHO/SEARO. The designations employed and the presentation of the material in this publication do not imply the expression of an opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The material used in this communication may not always reflect WHO policy. Reproduction of material from Communicable Disease Newsletter, in part or in whole, is encouraged, as long as credits and acknowledgements are given. Online version of CDS Newsletter : http://www.searo.who.int/LinkFiles/CDS_News_letter_vol-9_issue-2.pdf