ICP/CDD/OOl
ENGLISH ONLY
;fSTERN PACIFIC ADVISORY COMMITTEE ON MEDICAL RESEARCH /
SUB-COMMITTEE ON DIARRHOEAL DISEASES FIFTH MEETING Convened by the
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 20 - 22 January 1986
Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines June 1986
NOTE
The views expressed in this report are those of the members of the Sub-~ommittee on. Diarrhoeal Diseases of the Western Pacific Advisory Comm1ttee on Med1cal Research and do not necessarily reflect the policies of the Organization.
"
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for the members of the Sub-Committee on Diarrhoeal Diseases of the Western Pacific Advisory Committee on Medical Research at its fifth meeting, held in Manila, Philippines, on 20-22 January 1986.
TABLE OF CONTENTS
1.
INTRODUCTION ....................................................................................................... ..
1
2. 3. 4.
DIARRHOEAL DISEASES IN THE WESTERN PACIFIC REGION •••••••••.•.••••• REPORT OF THE SIXTH MEETING OF THE TECHNICAL ADVISORY GROUP ON DIARRHOEAL DISEASE CONTROL (CDD) ••••••••.•••••••••••.•••• COUNTRY RESEARCH REPORTS •••••••••••••••••••••••••••••••••••••••••• 4 .. 1 4.2 4.3 4.4 4.5 4.6 4 .. 7 4.8
1 2 3 3 3 4
AUSTRALIA.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. JAPAN ••••••••••.••••••. ..••..•• ...................... •.•.••••• CHINA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MALAYSIA ••• '" '" ................... '" ••• '". '" •• '" ....................... '" PAPUA NEW GUINEA .................. '" '" '" ........... '" ................................. '" REPUBLIC OF KOREA ...... '" ........... '" ....................... '" ........ '".......
4 5
5 5 5
VIET NAM • '" ••• '" ... '" ....................... '" • • • • .. • • .. • • • . • • .. • • .. .. .. .. • .. • .. • .. .. VANUATU. '" ................ '" ••••••• '". '" •• '"
'".'O'O'O'O'O..................
5.
RESEARCH NEEDS ARISING FROM NATIONAL CDD PROGRAMMES ••••.••••••.••• 5.1 5.2 PHILIPPINES •• PAPUA NEW GUINEA •••••••••••••••••••• VIET NAM •••••••••• 'O •••••••.•••••• 'O........................... 'O'O ••••• ,. ,. •••••• ,. ••••••••••••••••••••••••• ,. ••••• 'O •••••• ,.
6 6 6 6
,..................
5.3
6. 7. 8. 9.
NEW PHILIPPINE PROJECTS .................... ........................ IMPLEMENTATION OF RECOMMENDATIONS OF THE FOURTH MEETING OF THE SUB-COMMITTEE ON DIARRHOEAL DISEASES ••••••••••••••••••••••• FUTURE DIRECTIONS FOR DIARRHOEAL RESEARCH IN THE REGION ••••••••••• RECOMMENDATIONS ANNEXES: ANNEX 1 - WELCOME ADDRESS BY THE REGIONAL DIRECTOR .••••••••••••••• ANNEX 2 - LIST OF MEMBERS AND SECRETARIAT
7 8 9 9
... ,. ......................... ,. ....... ,. .... ,. ....... .
13 15 19
.. ....... ............. . ,. ,.
ANNEX 3 - AGENDA 'O'O •• 'O.'O.'O ••.• 'O •.••. 'O •• 'O ••• 'O •• ,. •• 'O'O'O.'O'O.'O'O.'O'O.'O •• 'O.
ANNEX 4 - THE EXTENT OF DIARRHOEA PROBLEM IN THE WESTERN PACIFIC REGION •••••••••••••••••••••••••••••••••• ANNEX 5 - THE EXTENT OF THE DIARRHOEA PROBLEM IN THE WESTERN PACIFIC REGION: 1985 MORBIDITY, MORTALITY AND TREATMENT (MMT) SURVEYS IN SOME WESTERN PACIFIC REGION COUTRIES •••••••••••••••••
21
22
1.
INTRODUCTION
The Sub-Committee on the Control of Diarhoeal Diseases (CDD) of the Western Pacific Advisory Committee on Medical Research held its fifth meeting at the WHO Regional Office for the Western Pacific in Manila, Philippines, on 20-22 January 1986. The meeting was opened by Dr Y.H. Paik, acting on behalf of the Regional Director,'Dr Hiroshi Nakajima, whose welcoming address was read by Dr Paik (See Annex 1). Dr Kazumine Kobari was appointed Chairman and Dr Chev Kidson Rapporteur. The list of participants is attached as Annex 2. The Operational Officer, Dr A. C. Reyes, outlined the programme of work, which was accepted by the Sub-Committee. The programme is contained in Annex 3. The objectives of the fifth meeting of the Sub-Committee were the following: (1) (2) (3) (4) (5) to review recent developments in diarrhoeal disease research; to review the status of existing CDD research projects in the Region; to review implementation of the recommendations made by the Sub-Committee at its meeting in June 1984; to suggest future directions for diarrhoeal disease research; to consider new research proposals.
2.
DIARRHOEAL DISEASES IN THE WESTERN PACIFIC REGION
A review of activities in diarrhoeal diseases control in
countries/areas of the Region was presented by the Secretariat. Of eighteen priority countries/areas in the Region, fourteen have developed a national CDD plan of action and four are participating in some CDD activities. Seven of the programmes have already been reviewed in some degree. A comprehensive review took place in the Philippines in 1985 and one will occur in Viet Nam in 1986. In the case of smaller countries, CDD reviews are usually combined with expanded programme on immunization reviews for convenience.
Training is an important aspect;
more than 3700 persons have been
given training in programme management, clinical case management, oral
rehydration therapy, epidemiology, laboratory methods or environmental health.
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In the production of oral rehydration salts, only two countries (Philippines and Republic of Korea) are self-sufficient, while China, Viet Nam and Democratic Kampuchea are partly so. UNICEF is the principal external supplier of oral rehydration salts. While it is not economical for smaller countries to produce oral rehydration salts, there is a need for some larger countries to consider doing so. The extent of the diarrhoea problem in many countries in the Region has been identified in terms of total diarrhoea cases, diarrhoea deaths and the latter as a proportion of total deaths (see Annex 4). More detailed morbidity/mortality/treatment surveys data are available from some countries (Viet Nam, Philippines, Samoa: see Annex 5): the reasons for provincial variations appear to be related to socia-economic factors in Some cases. There is a need for successive year assessments to provide
longitudinal data. Projections have been made with respect to targets for 1989 with regard to the major aspects of the COD programme in the Region. During the discussion, members of the Sub-Committee raised questions concerning the effectiveness of ORS utilization and clinical training. It was especially noted that research development in countries in the Region had been sub-optimal in terms of the number and quality of research proposals submitted and that measures needed to be taken to improve this situation.
3.
REPORT OF THE SIXTH MEETING OF THE TECHNICAL ADVISORY GROUP ON DIARRHOEAL DISEASE CONTROL (COD)
Dr O. Mahalanabis highlighted the major points arising out of the sixth meeting of the Technical Advisory Group on Diarrhoeal Diseases Control in New Delhi in March 1985. Out of a total of 95 national COD programmes, 75 programmes are operational, 23 being implemented in 1984. Training programmes have involved 1468 persons from 37 countries. There is a need for more health education materials. In the area of research, 294 projects have been supported. With regard to implementation of national CDD programmes, few data exist on the home use of oral rehydration therapy. Emphasis has been placed on the development of technical guidelines for social marketing of ORS products. Efforts have been made to encourage greater coverage of COD information, particularly oral rehydration therapy, in the curricula of training institutions for medical, nursing and allied personnel. agency programmes.
There has
been an attempt to achieve greater integration of efforts of WHO and other With regard to research management and institutional development, there has been a reduced emphasis on etiological studies and an increased emphasis on other studies that will lead to more effective intervention measures. A shift in priorities has led to a revision of strategies, and a
- 3 -
restructuring of the committee system. will now cover the following areas;
The three scientific working groups
Immunology, microbiology and vaccine development Case management Epidemiology and disease prevention The addition of the third scientific working group should serve to stimulate operational research at the regional level. It was emphasized that there should be an expert group in each region, with responsibility for providing assessment of projects, site visits and other inputs needed for the stimulation and guidance of operational research in relation to national CDD programmes. A number of specific recommendations of the Technical Advisory Group on Diarrhoeal Diseases Control are intended to provide guidelines pertinent to the effective operation of regional expert groups (e.g. speed of response to project applications, development of centres/units, academic/operations linkages). In view of the difficulty in publishing much of the output of operational research studies in standard journals, a special effort will be made to provide a mechanism for this so that investigators in this area can be identified and encouraged.
4.
COUNTRY RESEARCH REPORTS
4.1
Australia
Dr C. Birch reviewed recent rotavirus studies at Fairfield Hospital, Melbourne. This work is directed to the identification of rotavirus serotype. using polyclonal and monoclonal antibodies. Emphasis is on identifying protective epitopes of the virus usi~g a neutralization assay for characterizing relevant antibodies. The studies are being applied to epidemiological analysis of virus isolate patterns. Serotype prevalence changes in the community with time, consistent with serotype circulation in
the population. There is a need to develop an ELISA assay more suitable for direct fecal serotype identification. This type of study will provide background information for eventual vaccine trials. 4.2 Japan
Dr M. Ohashi presented data from an etiological survey of diarrhoeal diseases in Tokyo, and commented on the changing patterns of etiological agent prevalence since the early 1960s. While typhoid and dysentery have substantially decreased from 1950 to 1980, the morbidity rate due to food poisoning has remained the same these three decades. Salmonella typhimurium is the major responsible agent; there was an outbreak of botulism in 1984. Vibrio parahaemolyticus exhibits a seasonal pattern, related to the consumption of raw fish and the proliferation of the vibrio during the summer. A diarrhoea due to eating raw oysters appears to be associated with an as yet unclassified virus.
- 4 -
4.3
China
Dr Sima Huilan presented the results of a WHO sponsored multicentre study on the etiology of diarrhoea in the first three years of life in Shanghai, carried out at the Shanghai Epidemic Prevention Centre and the
Children's Hospital of Shanghai Medical College. This study involved 594 children with diarrhoea and 562 control children. Bacteria (Escherichia coli: [enteropathogenic E. coli (EPEC), enterotoxigenic E. coli (ETEC), enteroinvasive E. coli (ETEC~Salmonella, Shigella, Yersin~ enterocolitica,-~.~lera, ~. parahaemolyticlls, Aeromonas sp.,
Campylobacter jejuni), protozoa (Entamoeba histolytica, Giardia intestinales, Cryptosporidia) and virus (rotavirus, Norwalk agent, Corona virus-like particles, calicivirus, adenovirus, small round virus)
etiology were determined. A positive etiological agent was found in 72.9% of diarrhoeal children and in 21.9% of controls. Shigella was the major bacterial agent, but Campylobacter was a significant problem, as was rotavirus. Dr Duan Shu-cheng presented a summary of clinical observations on
studies carried out at the Shanghai Children's Hospital.
Parasitic
causation of acute diarrhoea was low in both urban and rural groups, the
entamoeba rates being the same in diarrhoeal children and healthy controls. Shigellosis in the first year of life appears to be more common than thirty years ago and is the most important bacterial cause of diarrhoea. Some rotavirus diarrhoea cases exhibit cardiac symptoms and
there may be associated hepatitis. 4.4 Malaysia Dr Lye Muon Sann presented outlines of some current research projects
in Malaysia. A study on the molecular epidemiology of rotavirus infections (Othman et al., University of Malaya) was concerned with serotype and analysis of the electrophoretic pattern of rotavirus isolatej from hospital-derived fecal samples taken from children with diarrhoea in Kuala Lumpur. This
study has somewhat similar objectives to the Australian study of Dr Birch. A study on the impact of water quality on water-borne disease incidence has been carried out in the Linggi River Basin. The area has been identified as one with rapid rural-to-urban developmental shifts. A study on the impact of diarrhoeal diseases on the nutritional status of children in the 0-4 years age group in six rural villages (Dr Lye et al., Institute for Medical Research) examined over 900 children over a 24-week period. The objective is to obtain information on the impact of diarrhoeal episodes on nutritional status.
A study on staphylococcus aureus enterotoxin production (Lim et al., Institute for Medical Research) is concerned with the differentiation of enterotoxigenic and nonenterotoxigenic strains.
- 5 -
4.5
Papua New Guinea
Dr P. Howard presented a proposal for extensive studies on diarrhoeal disease in Papua New Guinea, which will endeavour to provide data of practical value for the CDD programme in Papua New Guinea, where there is relatively little baseline information so far. These studies will seek to explain the apparent pattern of low endemicity with periodic outbreaks of diarrhoeal disease. To do so, they will encompass epidemiological, sociological and laboratory methodologies. In phase II, the studies will be concerned with preventive interventions. 4.6 Republic of Korea
Dr J.~. Kang reported data from a WHO-supported study which showed rotavirus to be the major causative agent of acute diarrhoea in a paediatric hospital population in Seoul. The seasonal pattern was thought to be unusual, with the major peak appearing in autumn (October-November) but not in winter. This differs from the seasonal patterns reported in Japan and other countries. Interest was expressed in future trials of rotavirus vaccines in view of the observed etiological problem. 4.7 Viet Nam Professor Dang Duc Trach reported on several ongoing and proposed studies.
The second programme report on the Tu-Liem study on the etiological structure of diarrhoeal disease with special reference to young age groups provides a complete summary of epidemiological and laboratory data. The mortality rate due to diarrhoeal disease decreased from 0.9 per 1000 in 1980 to 0.2 per 1000 in 1985. Rotavirus was the major etiological agent. Thirty diarrhoeal disease surveys have been performed in fourteen provinces covering 126 843 children under five years. The overall diarrhoea-associated mortality rate was 0.8 pet 1000, with 17.8% of all deaths being associated with diarrhoea. Thirty per ~ent of cases were treated with oral rehydration therapy. Ongoing and planned clinical studies are concerned with home-made oral rehydration therapy preparations, clinical management of rotavirus diarrhoea, shigellosis in malnourished children, and antisecretory traditional medicines.
Studies are planned in the area of environmental sanitation and on field trials related to vaccine development for shigellosis and eventually cholera.
4.8
Vanuatu
Dr Birch reported on a study of two villages (Mele, Maat) with different socia-economic backgrounds. Etiological analysis showed a very low association of diarrhoea with bacterial pathogens, possibly related to widespread breast-feeding and limited food storage.
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5.
RESEARCH NEEDS ARISING FROM NATIONAL CDD PROGRAMMES
The opportunity was taken of the presence of three Sub-Committee members associated with management of national CDD programmes to identify research needs related to these programmes. 5.1 Philippines
Ms Sullesta identified problems arising out of the comprehensive CDD programme review, including case management, effectiveness of herbal medicines, ORS supply, training. The review recommended that research be promoted in several areas; identification of suitable fluids and foods for use in the home to prevent dehydration; domestic and personal behaviour to prevent diarrhoea such as storage of water, food handling and hand washing;
identification of effective communication channels and techniques to promote awareness and acceptance of oral rehydration therapy and non-ORT strategies; extent of the problem caused by acute diarrhoeas in adults. It is proposed to consider the establishment of an interagency task force to formulate research problems concerned with the effects of water supply and sanitation on diarrhoeal disease. 5.2 Papua New Guinea
Dr Kame presented an overview of some of the problems in implementation of diarrhoeal disease control in Papua New Guinea. The national CDD policy is to distribute oral rehydration salts through health facilities only. There is a need to train more health workers in the use of oral rehydration salts as a means of therapy. There is a need for more comprehensive basic data on morbidity/mortality. The supply of oral rehydration salts is insufficient; there is sub-optimal awareness concerning oral rehydration therapy in the country and there are difficulties in oral rehydration salts distribution. Support for the CDD programme by provincial health staff and the community is inadequate, partly due to insufficient information availability. The reporting system needs improvement, while health education in this and other areas needs to be revived. There is no training centre for diarrhoeal diseases. In a positive view, there is close coordination between the CDD national programme and the research proposed by the Institute of Medical Research. 5.3 Viet Nam
Dr Dang Duc Trach outlined the history of the development of the national CDD programme in Viet Nam from 1982 to the present. There has been progressive recruitment of more provinces into the programme, so that by the end of 1986, it is expected that 30% of community health centres will be covered, with all forty provinces joining the programme by the end
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of 1986. Problems raised in the programme are concerned with tralnlng (low numbers of trainees, transportation and material costs), communication (hygiene instruction needed in primary school curricula), ORS logistics (increased local production, distribution), reporting system and coordination (COD/water supply/sanitation/nutrition/EPI).
6.
NEW PHILIPPINE PROJECTS
The opportunity was taken of the meeting in Manila for special presentations to be made of three new projects.
Dr Saniel and her collaborators presented a proposal for a multidisciplinary study on promotion of breast-feeding and improved weaning practices through health education: interventions for reducing diarrhoeal disease morbidity. This study is derived from a previous WHO-supported study on risk factors in a peri-urban region. The targets of this study are directed to the impact of breast-feeding promotion on diarrhoea morbidity. For this purpose, specific objectives have been formulated to allow appropriate data collection to test hypotheses concerning the likely effects of intervention. This will be a longitudinal study in three peri-urban barangays chosen by purposive sampling. Dr Santos-Ocampo and Dr Bravo presented a proposal to study improved ORS (super ORS) efficacy and safety in comparison with WHO-ORS-citrate. The super ORS is made by adding glycine and glycyl-glycine to the standard WHO-oRS-citrate formulation. A double blind study using at least 50 patients in each group will be conducted to determine the efficacy and safety of the improved ORS solution. Ms C. Verzosa presented a study on communications research on ORT product formulation, impact on acceptance, an~ use by mothers of children with diarrhoea. This project takes into account the need to consider optimal package labelling since education campaigns will not reach a sufficient number of the target population. The target group is those belonging to the low-income group. The objectives include the gathering of Qualitative information on mothers'/health workers' knowledge or experiences in the treatment of diarrhoea, identifying the perceived important factors among mothers and health workers that would affect their choice of a particular ORS product form, and determining mothers' and health workers' preferences for an ORS product form (preservation, taste, colour, clarity, wastage, availability, price).
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7.
IMPLEMENTATION OF RECOMMENDATIONS OF THE FOURTH MEETING OF THE WPACMR SUB-COMMITTEE ON DIARRHOEAL DISEASES
The recommendations and the action taken on the recommendations are as follows: (1) Recommendation: More efforts should be made to involve behavioural scientists in operational research programmes involving social and behavioural practices. Action taken: Behavioural scientists have been involved in CDD operational research being planned or implemented in the Philippines. A partial list of behavioural scientists has been prepared. (2) Recommendation: Epidemiologists should be involved in the planning and monitoring particularly of field research. Training in epidemiology should be encouraged. Action taken: The lack of trained epidemiologists not only in the field of diarrhoeal diseases control but in general epidemiology as well, continues to be a major problem. The lack of a career structure in epidemiology is a constraint. Fellowships for training in epidemiology are available upon request. It is, however, noteworthy that most of the research protocols submitted appear to have been reviewed by epidemiologists. (3) Recommendation: Avenues should be explored to increase the information flow to CDD investigators in the Region. Action taken: There has been an improvement in information flow on diarrhoeal diseases control to CDD investigators in the Region. Appropriate mailing lists have been prepared for the important publications. The problem however of where to get essential CDD references or research findings at country levels remains.
(4)
Recommendation: New approaches should be explored to promote intervention related research. Action taken: Researchers in the Region were reminded that the Region's research priority lies in the field of operational research. Three CDD programme directors were invited to the Sub-Commitee meeting to present operational problems which could be solved by research.
(5)
Recommendation: Members of the Sub-Committee should be sent copies of research proposals for their review. Action taken: Members of the Sub-Committee have been requested from time to time to serve as reviewers of research proposals submitted in the Region and their willingness to do so is much appreciated.
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8.
FUTURE DIRECTIONS FOR DIARRHOEAL RESEARCH IN THE REGION
The Sub-Committee considered the broad guidelines for future research contained in the report of the sixth meeting of the Technical Advisory Group on Diarrhoeal Diseases Control (WHO/CDD/8S.l2) and the Guidelines for management of research activities (CDD/RES/8l.3 Rev.l(198S) as the basis for future research activities in the Region. The special role of the new global Scientific Working Group on Epidemiology and Disease Prevention in helping to stimulate regional operations research was noted. The terms of reference for regional scientific working groups were noted: (1) problem-oriented research; (2) descriptive/exploratory research related to national COD programmes. The issue of how to stimulate operational research in the Region was discussed, with special reference to
using national programme reviews as a means of generating research problems. Members of the Sub-Committee mentioned a number of new projects for which proposals are being considered or developed. These include studies on new rotaviruses, rapid tests for application to cholera epidemiological assessment, rotavirus serotyping in relation to vaccine trials, descriptive epidemiology of typhoid, the role of hygiene in shigellosis and longitudinal studies on cholera epidemiology. The special need to initiate studies relating to water supply and waste disposal was noted. Also stressed was the need for expert assistance in developing operational research protocols in relation to priorities identified in each country.
9.
RECOMMENDATIONS
1.
The Sub-Committee endorses the views expressed in section 1.2.1 of the . Guidelines for management of research activities (CDD/RES/8l.3 Rev. 1.1985) that the Region should be concerned mainly with: (a) Problem-oriented research: This seeks to solve specific problems in national COD programmes as identified by national COD programme managers or comprehensive programme reviews - for example, a lack of ORS packets or failure to use them in certain communities, or an inadequate use of sanitary facilities. This type of research seeks answers to specific issues that are important for the programme and should be initiated with a minimum of delay. It usually does not require an extensive literature search.
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(b)
Descriptive or explanatory research related to the goals of national COD programmes: Although pertinent to the implementation of national COD programmes, this research is not directly related to specific COD programme problems and does not involve an operational test of solutions, or focus on problems requiring an immediate solution. On the other hand, it may require special skills in a particular discipline - e.g. social science, epidemiology. An example of such research is: what are the prevailing beliefs and practices in a country concerning the recognition, treatment, and prevention of diarrhoea?
One of the best ways to identify such problems is to conduct comprehensive programme reviews during which operational research problems are identified. A meeting should then be convened with national enD programme managers and local researchers, with consultants to be provided if requested, to prepare the necessary protocols for study. Guidelines for formulating such protocols should be developed with the help of the appropriate experts. Protocols should then be submitted to the Regional Office for possible funding or else research groups could be commissioned to undertake the studies needed. Countries should be encouraged to conduct comprehensive reviews. 2. (a) Efforts to strengthen epidemiological expertise in diarrhoeal disease control should be continued through fellowships or the convening of special training courses in diarrhoeal disease epidemiology. The workshop or training course should preferably be held in countries of the Region where ongoing operational research or other COD activity is being carried out. (b) Recognizing the shortage of general epidemiological expertise in many countries in the Region, the Sub-Committee recommends that the relevant secretariat within the Regional Office for the Western Pacific, in conjunction with individual countrtes, should draw up specific requirements for training in epidemiology and statistics for Member States. This should encompass all levels of training in order to develop an appropriate infrastructure of epidemiological expertise. Attention should be paid to both long-term development and short-term projects to meet the specific requirements of the COO programme. (c) Health administrations should be encouraged to create appropriate career structures for epidemiologists. 3. Efforts should be continued to identify and compile a list of social scientists, health economists and other experts in operational research, who can collaborate in the conduct of research or assist researchers with advice on aspects such as cost-effective and cost-benefit estimates. This list should be circulated to members of the Sub-Committee, to Member States and to relevant institutions and investigators.
11/12
4.
The Sub-Committee recommends that an appropriate mechanism should be developed to facilitate the carrying out of the following functions designated by the Technical Advisory Group on Diarrhoeal Diseases Control for regional scientific working groups: (a) (b) (c) designating areas of needed research and preparation of a research plan based upon a review of existing knowledge; identifying scientists and institutions with the ability to formulate and carry out research projects; reviewing the relevance, scientific quality,'feasibility and budgets of all research proposals submitted to the programme and, based on this review, determining financial support; monitoring and evaluating the technical and scientific progress of each research project supported and recommending its continuation, revision or termination.
(d)
5.
It is recommended that WHO should continue to collaborate with institutions in developing countries in conducting research on diarrhoeal diseases at the level of laboratory investigation and field studies. This might best be approached by the recruitment of appropriate experts on a short-term basis who would collaborate under the conditions existing locally in connection with a specific project.
13
ANNEX 1
WELCOME ADDRESS BY THE REGIONAL DIRECTOR OF THE WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC TO THE 5TH SESSION OF WPACHR SUB-COMMITTEE ON DIARRHOEAL DISEASES
1 have great pleasure in welcoming all of you to this meeting of the Sub-Committee on Diarrhoeal Diseases of the Western Pacific Advisory Committee on Medical Research. The Sub-Committee was first convened in April 1980 and the fact that this is its fifth meeting reflects the importance attached by WHO to the problem of diarrhoeal diseases in the Region. Evidently, considering the heterogenecity of the Region, the diarrhoeal disease problem varies considerably in magnitude and severity from one country to another. The problem is the most serious in developing Member States, where it may be one of the leading causes of morbidity and mortality, especially in infants. In addition, acute diarrhoea is a major contributor to malnutrition. The objective of the control programme is to reduce mortality and morbidity due to acute diarrhoeal diseases and its associated ill effects, particularly malnutrition in children under 5 years of age. The main approaches used to implement the programme include: (1) the reduction of diarrhoeal mortality through early treatment with oral rehydration therapy, accompanied by education of the mothers on appropriate feeding of children during diarrhoea and in convalescence; The reduction of diarrhoeal morbidity through the implementation of preventive measures such as promotion of breast-feeding, safe weaning practices, good domestic and personal hygiene and improvement in basic sanitation; surveillance and control of diarrhoeal disease epidemics; training of health personnel in various aspects of diarrhoeal diseases control; research including basic and health operational research For
(2)
(3) (4) (5)
The important role that health systems research plays in the diarrhoeal disease control programme cannot be overemphasized.
example, while the use of oral rehydration therapy is considered to be safe and effective, its acceptance and application in the field, not to mention its delivery in a systematic way to the end-users are important problems. Consideration must also be given to such aspects as promotion of breast-feeding, proper weaning practices, good domestic and personal
hygiene, feeding during and after the diarrhoeal episodes, the preparation of effective home-made dehydration solutions, and so on.
14
Annex 1
There is also a need for basic research on the epidemiology, pathogenesis and control, particularly of drug-resistant agents, development of new vaccines, formulation of new intervention measures, etc.
Unfortunately, the lack of research activities, particularly in areas where diarrhoeal diseases are a major problem, continues to be a weakness in the Region's diarrhoeal disease control programme. This is one of the reasons this meeting has been convened. Rrief1y, the objectives of the meeting are.
(1) (2) (3) (4) (5)
to review recent developments in diarrhoeal disease research; to review the status of existing COO research projects in the Region; to review implementation of the recommendations of the June 1984 meeting of the Sub-Committee; To suggest future directions for diarrhoeal disease research; To consider new research proposals.
As suggested during the fourth meeting in June 1984, COO programme managers have been invited to attend this meeting in order to ensure that due priority is given to health systems research-oriented projects, the results of which can be immediately applied in the field. Let me in closing, express the hope that your deliberations will be most stimulating and fruitful and that you will have a very pleasant stay in Manila.
15
ANNEX 2
LIST OF MEMBERS AND SECRETARIAT 1.
MEMBERS
Dr Christopher Birch Gastroenteritis Laboratory Fairfield Hospital Yarra Bend Road Fairfield, Victoria 3078 Australia Dr Chev Kidson Queensland Institute of Medical Research Bramston Terrace Herston Brisbane Australia 400 Dr Duan Shu-cheng Children's Hospital Shanghai First Medical College Foong Lin Chiao Shangha i 200032 China Dr Sima HuUan Deputy Chief Shanghai Hygiene and Anti-epidemic Center 280 Changsu Road Shanghai China Dr Kazumine Kobari University Hospital Faculty of Medicine University of the Ryukyus 207 Nishihara Okinawa 903-01 Japan Dr Makoto Ohashi Department of Microbiology Tokyo Metropolitan Research Laboratory of Public Health Shinjuku-ku Tokyo 160 Japan
16
Annex 2
Dr Lye Munn Sann Epidemiological Division Institute for Medical Research Ja1an Pahang Kuala Lumpur Malaysia Dr Mediadora Sanie1 Chief, C1i~ica1 Research Service Research Institute of Tropical Medicine A1abang, Muntin1upa Metro Manila Philippines Ms E. Suiles ta Public Health Nurse Bureau of Quarantine Ministry of Health Manila Philippines Dr Peter Howard Institute of Medical Research P.O. Box 60 Goroka, E.H.P. Papua New Guinea Dr Philip Kame M.D., Division of Disease Control National Ministry of Health Port Moresby Papua New Guinea Dr J.D. Kang Dongsan Sacred Health Hospital Ha11ym Medical Co11ete Chungryangri-dong Dongdaemun-ku Seoul Republic of Korea Professor Dang Due Trach Chairman National CDD Programme National Institute of Hygiene and Epidemiology 1 Yers in Street Hanoi Viet Nam
17/18
Annex 2
2.
SECRETARIAT
Dr Takusei Umenai Director, Disease Prevention and Control WHO Western Pacific Regional Office Manila Dr Arturo C. Reyes Acting Regional Adviser Communicable Diseases WHO Western Pacific Regional Office Manila Dr Agostino Borra Associate Expert Intercountry EPI/CDD Programme WHO Western Pacific Region Manila Dr Harkishan Mehta ICP HST Team Leader c/o WRC's Office ~, Fiji Dr Dilip Mahalanabis Medical Officer Diarrhoeal Diseases Control WHO Headquarters Geneva
Switzerland
19
ANNEX 3
AGENDA
Monday, 20 January 1986 0800 - 0830 0830 - 0900 0900 - 0930 0930 - 1000 1000 - 1015 1015 - 1045 1045 - 1145 Registration Opening address by the Regional Director Self-introduction and selection of Chairman and Rapporteur Group photo and coffee/tea break Plan of work and announcements Diarrhoeal diseases in the Western Pacific Region Report on the 6th Meeting of the Technical Advisory Group of the Diarrhoeal Disease Control Programme (TAG), New Delhi, 1985 Presentations: Recent developments in diarrhoeal disease research in the Region (Australia) Lunch break Continue presentation of recent developments in diarrhoeal disease research in the Region (China and Japan) Coffee break Continue presentation of recent developments 1n diarrhoeal disease research in the Region
1145 - 1215
1215 - 1330 1330 1500
1500 - 1515 1515 1700
(Malaysia, Papua New Guinea and Republic of Korea) Tuesday, 21 January 1986 0815 - 0830 0830 0930 Meeting of Secretariat Review of diarrhoeal disease research projects in the Region (Australia, China and Vanuatu) Coffee break Continue review of diarrhoeal disease research
0930 - 1000 1000 1030
projects in the Region (Viet Nam)
20
Annex 3
1030 - 1200
Presentations:
Problems in the implementation
of diarrhoeal disease programmes (Papua New Guinea, Philippines, Viet Nam) 1200 - 1300 1300 - 1500 1500-1530 1530-1700 Wednesday, 22 January 1986 0830 - 0930 Review of the implementation of recommendations
Lunch break Continue review of diarrhoeal disease research
projects in the Region Coffee break Continue review of diarrhoeal disease research
projects in the Region
of the June 1984 meeting of the WPACMR Sub-Committee on Diarrhoeal Diseases 0930 - 1000 Coffee break Future directions for diarrhoeal disease research in the Region
1000 - 1030 1030 - 1130 1130 - 1215 1215 - 1300 1300 - 1500 1500
Priorities in diarrhoeal disease research Discussions Consideration of new research proposals
Lunch break Conclusions and recommendations
Closing ceremony
TABLE 4 THE EXTENT OF THE DIARRHOEA PROBLEM IN THE WESTERN PACIFIC REGION (MANAGEMENT INfORMATION SYSTEM DATA - 1985) Country/ Area Cook Islands Fiji Guam PNG Total Population 17 754 690 922 114 919 3 300 000 0-4 years
Total Reported Diarrhoea Cases 834 (all ages) 8 512 (0-4) 208 (0-4) 65 564 (all ages)
Rate (%) 47.0 91.4 15.4 19.9
Total Reported Diarrhoea Deaths 0 17 2 (0-4) 220 (all ages) 152 (0-4)
Rate (%)
Total Reported Deaths All Causes 115 3 562 37 4 940 2 369 100 946 12 101
Remarks 1984 1984 1983 1983 1983 1982 1985 (1st 6 mos) N
2 216 93 143 13 549 499 400
0 0.03 0.20 0.07 0.30 1.42 0.04
Philippines Viet Nam
53 170 000
7 557 500
540 064 (0-4) 664 565 (all ages)
71.5 11.2
10 760 (0-4) 2 154 (all ages)
-N N
59 092 000 10 046 000
Solomon Is. Tuvalu W. Samoa Vanuatu
267 265 7 271 160 000 127 800
52 303 129 22 866 23 577
7 559 (all ages) 467 (0-4) 45 732 (0-4) 7 347 (0-4) 13 000 (all ages)
28.3 3620.2 2 000 311.6 101. 7 N/A
0 0 8 (0-4) 16 (all ages)
0 0 N/A 0.34 0.13
58 63 440 173
1983 1984 1984 1984 1984
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Z
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THE EXTENT OF THE DIARRHOEA PROBLEM IN THE WESTERN PACIFIC REGION: 1985 MORBIDITY, MORTALITY AND TREATMENT (MMT) SURVEYS IN SOME WPR COUNTRIES/AREAS
Country/ Area VTN 1)
Localities Surveyed Huong Phu Huong Dien Phan Tiet Da Nang Dien Ban An Nhon 7l Uong Bi 8) Nam Dinh 2) 3) 4) 5) 6) 1) La Union 2) Boho1 3) Bukidnon 4) Metro MIa.
Urban Rural Rural Rural Urban Urban Rural Rural Rural Urban Rural Rural Rural Urban Rural Urban Rural
Month
Proportion DiarDiarrhoea of Deaths rhoea All Causes Associated w/ Associated Episodes/ Sample Mortality Rate Mortality Rate Diarrhoea Per Cent Child/year Size Per 1000 Per 1000 11 11 5 10 2 2 4 2 3 3 3 12 905 682 609 396 734 791 416 700 768 659 704 504 5.82 6.04 5.03 1.09 1.40 4.40 4.50 4.95 15.90 18.20 43.60 4.50 8.00 12.90 18.40 0.36 0.51 0.35 0.96 N/A 0.60 0.67 N/A 3.00 4.60 18.30 1.62 2.90 1.20 5.10 6.15 8.45 6.20 51.00 N/A 13.60 15.00 N/A 18.03 25.00 42.01 36.00 36.40 9.50 27.90 1.02 2.48 2.50 1. 70 3.70 1. 79 2.70 2.90 2.30 2.90 3.20 2.50 2.03 1.60 2.70
ORS Used Proportion 0* 25.2 11.85 0* 0* 0* 1.09 49.39 44.00 30.00 27.00 15.95 60.00 28.00 26.00 ~ z
January June
July April May March June July January January January December August December December
N
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PHL
W.SMA 1) W. Samoa LAOS Vient iane Prefecture 2) Champasak Province 1)
2 749 10 565 10 708
*Base1ine data before the starting of the programme.
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