WPRlRC55/SRl7 SUMMARY RECORD OF THE SEVENTH MEETING (Mandarin Hall, Shanghai International Convention Centre) Thursday, 16 September 2004 at 14:00 CHAIRPERSON: Mr Solomoni NAIVALU (Fiji)
CONTENTS page 1. HIV/AIDS ................................................................................................................ 2. Blood safety ........................................................................................................... 3. Tobacco control ...................................................................................................... 4. Tuberculosis ............................................................................................................ 5. Amendments to Articles 24 and 25 of the WHO Constitution .................. ...................... .................................................... 176 181 185 193 197
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REGIONAL COMMITTEE: FIFTY-FIFTH SESSION
1.
HIV/AIDS: Item 13 of the Agenda (Documents WPIVRC55/7 and WPRl5S/Il\l'.DOC. 2) (continued) Dr CABOTAJE (Philippines) agreed with previous speakers that there \'''is no room for
complacency, even if most of the countries in the Region had low prevalence rates
,I: HIV
infection.
Risk factors were widespread. She suggested therefore that use of the terms 'low' and 'slow' be abandoned. There was a real danger of infection spreading from high-risk groups to the general population; in the Philippines, workers returning from abroad might be such a source. Her country would complement its actions for high-risk populations with reinforced screening anti ,-,ounselling for sexually transmitted infections among pregnant women and mothers. She endorsed the proposed actions; however, she suggested that the words "community engagement" be added to Action 7. Dr LEE (Republic of Korea) said that the number of cases in her country was still low but was increasing rapidly. She supported the proposed actions. In order to decrease discrimination, her Government was establishing a legal and institutional framework and improving access to comprehensive treatment and care. All citizens with HIV/AIDS received antiretroviral treatment free of charge, with regular tests for immunity and viral load. The results of molecular epidemiological studies were particularly informative for surveillance systems and evidence-based strategies. Her Government promoted the use of condoms for both high-risk groups and the general public. Since 1993, it had supported the activities of nongovernmental organizations involvmg pecple living with HIV/AIDS. Counselling and information were increasingly being provided through the Internet. She looked forward to sharing her country's experiences with other Member States. Dr BOUPHA (Lao People's Democratic Republic) noted that his country was surrounded by others in which the prevalence of HIV I AIDS had reached very high rates, and preliminary information indicated that the disease was spreading rapidly among his people. The Ministry of Health, m close collaboration with WHO, Family Health International, the European Union and other donors, had conducted a first round of second-generation surveillance in 200 I, which had included ;nvestigations of sexual behaviour, seroprevalence and surveJllance of sexually transmitted infections. The country was found to have a low prevalence of HIV but a high prevalence of other sexually transmitted infections. A second round was to be conducted shortly, supported by Japanese funds through the Asian Development Bank. Marketing and use of condoms were expanding; however, knowledge about the diseases and their mode of transmission was still limited in the general population. Behavioural factors that affected the spread of infection should be investigated. For that purpose. operational research, additional resources, training of staff and community education would be required. The task ahead was immense, and his country looked to WHO to promote the necessary monitoring activities and
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provide technical and financial support for the control of HIV and other sexually transmitted infections. Dr KING (New Zealand) said that HIV/AIDS continued to be a major problem in Member States of the Region. By the end of June 2004, 819 people in New Zealand had been diagnosed with AIDS, and the cumulative rate at that time was 21.9 per 100 000 population. The most affected group (74% of the total) continued to be men who had sex with men, but the rate was increasing among heterosexuals. A health promotion approach was used, in close collaboration with civil society, with different organizations targeting different risk groups. Thus, the New Zealand AIDS Foundation worked with men who had sex with men, the Prostitutes Collective directed its efforts to prostitutes, the Family Planning Association addressed heterosexual men and women, and an organization helping drug users targeted that popUlation. A long-term public health programme was needed, with primary prevention at the centre and provision of condoms, as well as clean needles and syringes for drug users. People must be encouraged to use safer sex practices throughout their lives. Prevention, treatment, care and support systems would be effective only if they were accessible to people who needed them. In many countries, stigmatization was a significant barrier to uptake of health care. Delaying the introduction of prevention programmes increased the likelihood that the HIV/AIDS epidemic would grow exponentially, increasing the per capita cost of both prevention and treatment. Her Government supported the seven proposed actions, which she found sensible. She also supported the use of evidence-based treatment, the provision of antiretroviral therapy, the strengthening of surveillance systems and strengthened coordination of investment in disease prevention, as well as the enhancement of existing surveillance networks, building on capacity and investment in leadership in areas that allowed rapid detection and response to events that could be predicted from epidemiological studies. Since 2002, New Zealand had used an improved approach to HIV surveillance that involved regular use of results of tests for viral load. Used in combination with the results of antibody tests, they could provide a better picture of the magnitude and distribution of HIV infection. Her Government supported the "3 by 5" Initiative, but considered that a broad approach should be adopted, involving locally appropriate, targeted education and prevention, as well as increased availability of antiretroviral drugs. Many people appeared to believe that antiretroviral drugs provided a cure for AIDS and that they therefore did not need to change their risky behaviour; only education could change that perception. Her country supported the right of women everywhere to decide on their own sexuality, as that was crucial to controlling the epidemic. She suggested that proposed
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REGIONAL COMMITTEE: FIFTY-FIFTH SESSION
Action 5 be amended by addition of the words "and pursue policies and practices that promote human rights, equity and gender equality in access to prevention services, treatment and care." Dr KUARTEI (Palau) asked for greater attention to be paid to the Pacific islands within the
integrated, comprehensive national and regional prevention programme. Many cases of HIVI AIDS in his country were among people returning from more developed Pacific rim countries, and their condition was often not detected by the health system at entry. He therefore asked for enhancement of the regional surveillance system, ensuring that countries were alerted properly while respecting confidentiality. He also requested WHO support in developing human resources for prevention and treatment of HIV/AIDS. Prevention strategies should take into account the traditional leadership system of Palau. Lastly, he proposed that prevention of HIVI AIDS and other sexually transmitted infections should involve fathers, brothers and sons.
Dr RADFORD (United Kingdom of Great Britain and Northern Ireland) said that her country warmly supported the document. Member States had painted a varied picture of the HIV I AIDS situation in the Region; even a single case could have a devastating effect on a community, as had been described by the representative of Solomon Islands. Prevention was the only solution, as there was no cure. It was essential to raise the awareness of the entire population and to use evidence-based interventions directed to speCific target populations. It was important to acknowledge that risky behaviour existed: measures had to be identified to diminish its effect. Reduction of exposure to HIV had additIOnal health benefits, as it also reduced exposure to other blood borne viruses, such as hepatitis Band C. She suggested several areas in which the document could be strengthened. Mention s;,,)uld be made of the stigmatization of migrant and mobile populations, which included tourists. Those groups were especially vulnerable, and ways should be found to target them. She agreed with the representatives of New Zealand and the Philippines about the need to ensure gender equality and human rights. In the proposed actions, she considered that there should be mention of increased access to voluntary counselling and testing, and collaboration between the Western Pacific and the SouthEast Asia regions should be strengthened. Dr CUTTER (Singapore) said that, in the push for greater access to treatment, prevention programmes should not be neglected or the resources reduced. He agreed with the statement in the document that, unless the incidence of HIV was sharply reduced, HIV/AIDS treatment would not be able to keep pace with need. He also considered that communities should be helped to discuss the risk for HIV/AIDS more openly, as it was a problem for the population, not only the governments. People should realize that everyone was at risk.
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Ms ABEL (Vanuatu) said that her country supported the proposed actions. She asked for further technical support for promotion and implementation of the "3 by 5" Initiative, as Vanuatu's health system might have to be reviewed for appropriate implementation. While efforts were being made at country level to develop strategic HIV I AIDS plans, she called for better regional coordination of assistance from UNAIDS, WHO and the Secretariat for the Pacific Community. Such cooperation would enable small countries, like her own, to implement their plans within their limited resources. Mr EDWARDS (Marshall Islands) endorsed the report and stated that, although the prevalence of HIV infection in his country was low, many of the measures recommended by WHO and other partners had been taken to prevent the spread of the virus within the country and to other islands. The Marshall Islands had limited capacity for treatment and counselling, or for curative treatment of opportunistic infections. Surveillance and screening activities were rudimentary, but through health promotion programmes, efforts were being made to disseminate information on HIV/AIDS and other sexually transmitted infections to the general population. In spite of its limited capacity, the country continued to strengthen surveillance, collect data and ensure the supply and availability of condoms. Antiretroviral drugs could be made available to people living with HIV/AIDS through other sources of funding. He asked the Regional Office to initiate a pool of professional expertise that could be called upon for advice. Mr NETH (Federated States of Micronesia) said that small island nations like his own could easily be overlooked in the distribution of needed materials, such as antiretroviral drugs. He had therefore been pleased to note the commitment of the Global Fund to Fight AIDS, Tuberculosis and Malaria to finance provision of those drugs to the Pacific island countries. Dr SEKI (Global Fund to Fight AIDS, Tuberculosis and Malaria) noted that the Regional Director's report described the project financed by the Global Fund in detail, and he thanked Member States for their remarks concerning their collaboration with the Fund. He thanked the governments of countries in the Region, Australia, China, Japan, New Zealand, the Republic of Korea and Singapore, for their generous contributions to the Fund. The United States of America had also contributed, both financially and in leadership, and Canada, France and the United Kingdom of Great Britain and Northern Ireland were also major donors. WHO provided invaluable assistance to the Fund by contributing technical assistance and capacity-building throughout the grant process. The Regional Office had been exemplary in promoting collaboration between technical partners in ensuring effective use of the Global Fund. With regard to projects addressing all three diseases in the Region, 31 grants had been approved and 22 signed; for projects on HIV/AIDS, 12 grants had been approved and eight signed.
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Good progress had been made in the funded projects, with innovative approaches and real publicprivate partnerships. A number of challenges remained. For the Western Pacific Region, and Asia in general, containing localized epidemics to prevent generalized epidemics was a real issue, and the Global Fund had given substantial resources to support country efforts. Preparations were being made for the second round of grants under the guidance of the Board of the Fund, which would :lext meet in November 2004. Further collaboration and cooperation were needed for technical assistance in various domains. He noted that high quality proposals resulted in a higher success rate in the technical review panel, thus facilitating grant agreement and disbursement. A further challenge was to streamline and strategically differentiate means for procurement, monitoring, evaluation and financial management. More and closer cooperation with technical partners was needed in that respect. The main challenge in HIV/AIDS was implementing the "three ones" principle in practice, with better coordination among the various players. Harmonization among donors was a further challenge. The Global Fund remained committed to working hand-in-hand with Member States in the Western Pacific Region. At the invitation of the Chairperson, a representative of the International Council of Nurses made a statement to the Committee. The REGIONAL DIRECTOR, referring to the request for technical support from several Member States, assured them that efforts would be made to mobilize resources so that a permanent staff member could be assigned to WHO's office in Fiji. Suggestions from Member States
concerning a more long-term, comprehensive approach, including such issues as migration, mobile populations, gender issues, voluntary counselling and testing, and biregional collaboration, would be taken into consideration. The REGIONAL ADVISER SEXUALLY TRANSMITTED INFECTIONS, INCLUDING HIV/AIDS, referring to the "3 by 5" Initiative, said that, together with UNAIDS, an assessment would be carried out shortly in Papua New Guinea of the proposed project with the Asian Development Bank and the Ministry of Health. Regarding collaboration between the Western Pacific and the South-East Asian regions, it had already been under way for several years in such areas as epidemiology, promotion of condom use, preventive activities among drug users, and exchange of information.
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2.
BLOOD SAFETY: Item 14 of the Agenda (Document WPR/RC55/8) The REGIONAL DIRECTOR explained that HlV/AIDS had put blood and blood product
safety on to the global public health agenda. However, there were many other important transfusiontransmissible infections, notably hepatitis Band C, and new pathogens that may threaten the blood supply. The ethical, social, legal, managerial and technical complexity of blood transfusion services required an integrated strategy. Laboratory screening on its own was not sufficient. First, governments should be committed to maintaining a safe supply of blood. A national organization needed to be given responsibility for developing a national blood programme. That organization should have appropriate leadership and be provided with adequate technical and financial support. Second, a pool of voluntary unpaid blood donors needed to be established. Low-risk populations should be targeted, and blood donors educated, counselled and monitored regularly. Third. donated blood should be regarded as a national resource that was provided voluntarily by healthy, socially committed individuals. Mechanisms needed to be established to ensure that that rare resource was appropriately and rationally used and was accessible to all patients who needed it. In the Western Pacific Region, WHO had worked closely with Member States to develop national blood transfusion services and to integrate them into national health care systems. The WHO distance learning programme on blood safety had been implemented in China and nine Pacific island countries. WHO's quality management programme had been introduced through a regional workshop and two regional training courses. WHO had worked closely with donor agencies and national health authorities to reorganize blood servIces in several developing countries III
the Region, with encouraging results. China and
Viet Nam, for example, had increased the resources they devoted to blood transfusion services and both countries had worked with WHO to reorganize them. However, there was no reason to be complacent. The Region was still facing great challenges, including a lack of blood donors. inadequate coverage of blood screening, poor quality control, inappropriate use of blood and bad organization. At the same time, the demands for blood and blood products transfusion were increasing, together with a public expectation of "zero-risk" blood. Much remained to be done. Blood safety was an important subject and the Regional Director knew that many Member States would have valuable contributions to make.
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Mr HWANG (Republic of Korea) suggested that the agenda for the tifty-sixth session of the Regional Committee should include an item on support for establishment of national mspection and accreditation systems for blood services and of a regional WHO collaborating centre to provide information on donor recruitment, selection, collection and retention. The Republic of Korea had initiated national blood services over 20 years ago and had abolished remunerated donations eight years ago. The blood donation ra~e
approached the level of
self-sufficiency. His country proffered its support to other countries intending to establish national blood services. After a recent incident in the Republic of Korea, in which the life of a woman with a rare blood type had been saved by a donation of compatible blood from the Japanese Red Cross. the authorities realized that closer international cooperation was essential to ensure an effective response to that type of emergency. He therefore proposed the establishment of a regional network that would enable countries to share information on rare blood types. Such a network would, not only help to improve blood transfusion services in the ReglOn, but could also promote cooperation in such areas as frequency surveys. establishment of rare-blood registries or the building up of rare-blood stocks. Dr YOSHIDA (Japan) supported the proposed actions. in partlcular. establishment of national
blood transfusion services based on voluntary blood donations and promotion of the rational use of blood and blood products. A new legislative framework for blood programmes had been enacted in Japan in July 2002. Guidelines on the safety of blood transfusion services had recently been published and collaboration had been enhanced between different departments of the Ministry of Health, Labour and Welfare involved in all aspects of blood donatlon and blood use. Inclusion of the Item on the agenda of the fifty-fifth session of the Regional CommIttee had provided Member States an opportumty to promote establishment of a safe and secure blood supply as a national priority. Dr HUI (Macao, China) endorsed the actions proposed for consideration of Member States. In Macao, the health authorities assured blood safety. A policy of voluntary. nonremunerated blood donation had been in force for ten years, and Macao was self-sufficient in blood and blood products, which were supplied free of charge. Screening of donatIOns and quality control was rigorous. In addition, public education was ongoing in order to improve donor management and retain donors. The authorities were currently training clinical staff in the proper use of blood and blood products and in that regard she requested WHO to provide blood-safety training and seminars.
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Dr RAHMAH (Brunei Darussalam) strongly supported WHO's efforts to promote blood safety III
the Region and fully endorsed the actions proposed in the document under review. In
Brunei Darussalam the Government-funded blood transfusion serYlces were provided through hospital-based blood banks. Donations were voluntary, nonremunerated and carefully screened. In order to improve services and quality management, Brunei Darussalam wished to take part in the WHO training courses on quality management. In view of the positive experience of the Pacific countries, WHO might wish to establish networks of course facilitators and participants for other Member States. She would welcome the provision of WHO's distance learning programme on blood safety to her country and others in the Region. Ms WARD (Australia) supported WHO's efforts to improve the quality, safety and supply of blood products manufactured from blood collected from voluntary, nonremunerated donors and to promote the appropriate use of blood. Australia had recently established a national blood authority in order to assure the provision of an adequate and safe blood supply. Although it had relied on
voluntary donations for the past 75 years, recent, more stringent donor selection and screening had reduced the number of volunteers. Attention to, and public recognition of, donors was therefore crucial in maintaining public support. A.voidance of unnecessary transfusion was a key element in reducing risk to patients and reducing wastage of a valuable resource. Australia and New Zealand had adopted the Council of Europe's standards for assessing their blood safety programmes. The two countries had agreed to establish a single regulatory authority to oversee the licensing of blood product manufacturing. Dr LEAF ASIA (Solomon Islands) observed that the issues set out in the document under review closely corresponded to the situation prevailing in his country. He supported the actions proposed, and requested WHO to pay special attention to blood safety in his country, particularly in view of the rising incidence ofHIV/AIDS. The main use of blood transfusion in his country was for obstetrical emergencies, where it was essential for saving lives. Solomon Islands continued to look to WHO for support in improving national blood services. Dr TENG (Malaysia) supported WHO's efforts to improve national blood transfusion services based on voluntary, nonremunerated donations, sound quality management, and the rational use of blood and blood products. Promoting donations and managing donors was crucial to such services.
In Malaysia, a successful entry point for recruitment had been higher education institutions. However, more needed to be done to retain new recruits.
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With the support of the World Bank, a national blood centre had recently 1:leen established. which had contributed greatly to improving the national blood transfusion senice, in particular through better quality management and appropriate use of blood and blood products. Malaysia endorsed the lines of action proposed and requested that particular at'ention be paid to the training of adequate numbers of health personnel in order to ensure the sustainability and quality of blood transfusion services. Mrs ELV ANDER (United States of America) stressed that blood supply was important to global health, especially given the rise of bloodborne diseases like HIV I AIDS, and that it was important to secure political and social commitment at the highest levels to assure national blood transfusion systems based on voluntary donations. Further, sufficient financial and human resources were needed to ensure a safe and effective system, and in that regard she suggested that Member States might explore voluntary organizations and private-sector entities for support. The United States of America endorsed the establishment of national quality-control systems and reiterated that a combination of public- and private-sector regulation was an effective way to guarantee an adequate and safe blood supply. Physicians needed training to avoid unnecessary use of blood and blood products. Her country was pleased to have been able to provide technical support on issues related to blood safety in the Region through its Global AIDS Program. Ms ARTHUR (France) reported that French-speaking areas of the Pacific had always given priority to blood safety within the framework of voluntary donations organized by the public health authorities. The blood transfusion centres in New Caledonia and French Polynesia rigorously
complied with all relevant quality standards and the procedures determined by the Ministry of Health that covered all aspects of blood transfusion services. She supported the actions proposed by WHO, which were adapted to the situation of countries in the Region. Nonetheless, they would require the provision of appropriate information to both donors and users in order to assure the proper use of products. They also implied the mobilization of considerable resources; in that regard, low-income countries might need to secure partnerships with wealthier ones. The blood transfusion services of New Caledonia and French Polynesia might take part in assuring blood safety in the Region by making available technicians to help in structuring such services in other Member States. Dr YI (China) said that China was committed to improving standards for blood safety. A law
regulating blood donation practices had been passed in 1998; 100% screening of donated blood had been achieved. Voluntary nonremunerated blood donations had increased from 22% of total blood
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donations in 1998 to 85% in 2003; further support was needed for the establishment of an external quality assessment scheme. Institutional planning, quality management training and national
accreditation of blood donation facilities had begun in 2001, with support from WHO. Support was needed to upgrade technology for screening and testing of blood and to develop guidelines for the safe use of blood and blood products in remote areas. She requested WHO to facilitate regional exchange of information on the formulation of national policies on blood safety and to follow up the provision of support for the external quality assessment scheme that had been committed by WHO Headquarters in 2002. The REGIONAL DIRECTOR, responding on the need for a registry for rare blood types, said that there was no WHO collaborating centre designated for that area; he gave an assurance that it would be considered. The DIRECTOR, HEALTH SECTOR DEVELOPMENT, said that promoting quality management practice for blood transfusion services at regional and national levels had been the focus of the safe blood transfusion programme. Regional workshops in quality management training had been conducted in the last two years; the third workshop had been planned. He appreciated technical and financial support from Singapore and provision of expert services from Australia, Hong Kong (China) and Malaysia. He assured the representative from Brunei Darussalam that the country would be invited to the training workshop and that the possibility of making the distance learning programme on safe blood transfusion available to Brunei Darussalam would be considered. The first distance learning course had been delivered to eight Pacific island countries through the Pacific Open Learning Health Net facilities; a second course had been planned. A subregional intercountry external quality assessment scheme for blood transfusion services had been established for Pacific island countries. He encouraged China and Viet Nam to set up national external quality assessment
schemes; he assured the representative from China that WHO would provide the necessary technical support. Dr TANGI (Tonga) suggested that, related to the topic of blood safety, which they had been
discussing, it might be a good time for the Committee to improve the circulation of their own blood. He then led the meeting in some simple tai chi exercises. 3. TOBACCO CONTROL: Item 16 of the Agenda (Document WPRlRC55110) The REGIONAL DIRECTOR said that the devastation caused by the tobacco epidemic - the world's single largest preventable cause of premature death and disability was unfortunately
becoming all too familiar. Tobacco caused 3000 deaths in the Region every day, and almost 5 million annual deaths globally, a figure that would double by the year 2030 if nothing was done.
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In the previous year, the Regional Committee had encouraged Member States to sign and ratify
the WHO Framework Convention on Tobacco Control as soon as possible, and to integrate its provisions into national tobacco control efforts. Today, the Region was at an extraordinary moment in the history of public health. Because Member States had heard and heeded the call to action, the Convention was on the verge of becoming international law, forever changing the response to the global tobacco epidemic. The Western Pacific was the only WHO region where all Member States had signed the Convention. The Region was also leading the race to ratification: 10 Western Pacific Member States had ratified the Convention, representing 34% of the total of29 countries that had ratified. The power of the Convention process had also contributed to important progress in tobacco control over the past year: Many countries had strengthened controls on tobacco advertising and promotion, instituted smoke-free policies, improved health warnings on tobacco products, and increased prices on tobacco products. But that was just the beginning. The Convention was the foundation and now the hard work had begun. For the Western Pacific Region, the next steps were outlined m the 2005-2009 regional action plan for the Tobacco Free Initiative, which built on previous plans and laid out an ambitious agenda for tobacco control that went beyond the Convention. Today that plan was presented to the fifty-fifth session of the Regional Committee for discussion and endorsement. He assured the Committee that WHO would provide Member States with the strongest possible support necessary to implement both the Convention and the regional action plan. Dr FUKCDA (Japan) commended the WHO Regional Office for the advancements made in tobacco control. Japan had signed the Framework Convention on Tobacco Control in March 2004 and had ratified it in June 2004. Once the Convention entered into force, Japan was ready to
coordinate with all related ministries to enhance tobacco control Japan was against the new specific fund mechanism. He urged WHO to continue its efforts to promote understanding of the underlying principles of the Convention so that it could go into full effect. Dr SHAPlE (Malaysia) praised those Member States that had ratified the WHO Framework Convention on Tobacco Control. Malaysia was concluding the internal process for its ratification. One key factor in the attainment of targets in public health was successful tobacco control; he supported the regional action plan for the Tobacco Free Initiative for 2005-2009. The Ministry of Health of Malaysia had taken steps to strengthen national capacity to implement a comprehensive
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tobacco
control
strategy
In
partnership
with
other
government
agencies,
universities,
nongovernmental organizations and the private sector.
To ensure its sustainability, the national In August 2004,
secretariat on the Convention had been set up within the Ministry of Health.
Malaysia had hosted the first consultation on the impact of the ASEAN Free Trade Area on the tobacco trade and well-being of the ASEAN population; officials representing the public health, trade, taxation and finance sectors in 10 ASEAN member countries had attended. He gave an assurance that public welfare would take precedence over economic gains from the tobacco trade in Malaysia. Dr RAHMAH (Brunei Darussalam) supported the regional action plan for the Tobacco Free
Initiative for 2005-2009. She affirmed her country's highest level of political commitment to tobacco control to protect the well-being of the population. Brunei Darussalam had ratified the Convention in June 2004. A religious ruling C1atwa") declaring tobacco prohibited for Muslims ("haram") had been issued in July 2004 by the State Mufti; that had been a significant step in tobacco control in a country with an 80% Muslim population. The high-level interministerial committee for the implementation of the prohibition of smoking and tobacco had been established in January 2004, with the Permanent Secretary of the Office of the Prime Minister as chairman. To coordinate intersectoral cooperation, the Government was developing national policy and legislation in accord with the Framework Convention on Tobacco Control. Appropriate taxation measures and tobacco cessation programmes were being considered. To address challenges in implementing the provisions of the Convention at national and regional levels, WHO support would be needed, especially in the areas of advocacy, capacity-building, sustainability of tobacco control programmes, and transnational border control. Ms HALBERT (Australia) supported the proposed budget and regional action plan for the Tobacco Free Initiative for 2005-2009. She recognized the challenges posed by the high rate of male smokers and increasing rate of female smokers in Australia. She noted the importance of taking steps to discourage future generations from smoking, and protecting children from second-hand smoke. She commended all the Member States of the Western Pacific Region for signing the Convention and said she looked forward to participating in the conference of parties. Australia was among the 10 Member States in the Region that had ratified the Convention and was fully committed to tobacco control. A new national tobacco control strategy was being developed; a set of clinical guidelines for smoking cessation had been developed and distributed in cooperation with the Division of General Practice. She welcomed opportunities to work with other Member States in developing initiatives for regional capacity-building; among the projects under consideration were the development of an interactive training website and CD-ROM, and the organization of a meeting with regional representatives and prominent personalities to promote tobacco control among indigenous
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REGIONAL COMMITTEE: FIFTY -FIFTH SESSION
populations.
To persuade people to quit smoking, the Government had ordered graphic health
warnings on cigarette packets and removal of sales tax on nicotine replacement therc,-y· She noted that the meeting of the intergovernmental working group on the Convention in Geneva in January 2005 would be a good opportunity to discuss regional initiatives.
Dr LI (China) expressed support for the proposed regional action plan for the Tobacco Free Initiative, 2005-2009. The fact that all Member States of the Region had signed tae Framework Convention on Tobacco Control and that 10 Member States had already proceeded to ratification showed that the Region had made substantial progress in tobacco control, laying a solid foundation for future work. China was committed to tobacco control and had instituted a number of practical measures, including the establishment of an intersectoral coordinatIOn agency, preparations for ratification of the Framework Convention, action to ensure a tobacco-free Olympic Games in 2008, and the reform of relevant regulations and legislation in line with tobacco control goals. A tax had been imposed on farmers who grew tobacco. Further, tobacco product manufacturers were strictly controlled; their number had been reduced from 184 to 84, and the establishment of new enterprises was discouraged. However, Chma still accounted for one-third of the world's production and consumption of tobacco products. Tobacco control would not be easy therefore and would need to proceed gradually. He expressed appreciation for the support received from WHO and Member States in that area and hoped that it would continue. Mr KIRATA (Kiribati) endorsed the proposed regional action plan. Kiribati haJ high rates of smoking, and rates in young people were on the increase. The habit had been imported some 100 years earlier when European traders had brought tobacco to the country and it had become a part of traditional gatherings and rituals. The Convention, signed by Kiribati in April 2004, marked a
significant milestone in the history of tobacco control at the global and national levels and would provide countries with guidelines for implementing tobacco control measures. Kiribati was currently formulating legislation to support implementation of the Convention as a necessary step prior to ratification. The first draft had been approved and would be presented to Parliament in
November 2004. Ms LEE (Republic of Korea) endorsed the proposed regional action plan, which she believed should reduce tobacco consumption significantly in the Region. The Republic of Korea had already raised the price of cigarettes seven times since 1994, but only by small amounts. It would impose significant further rises in 2004 and 2005, which would amount to a price increase of 5_'%. The plan had initially generated considerable political resistance on economic and electoral grounds, but agreement to the proposal was now increasing. The additional tax income generated would support the health promotion fimd, a national fund for the promotion of public health and im;,rovement of
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access to health care among low-income families. Experience had shown that strong political will and close coordination between government bodies was needed to sustain the long-term efforts needed to control tobacco use. The Republic of Korea hoped to ratify the Convention during 2005. Dr TSANG (Hong Kong, China) said that the Convention was a major achievement. As a
signatory to the Convention, Hong Kong was highly committed to tobacco control and had already succeeded in reducing smoking levels from 23% in 1982 to 14% in 2003. It reaffirmed its
commitment to institute rigorous antitobacco measures, working under the guidance of the provisions of the Convention. Action would include the imposition of high taxes on tobacco products, and the banning of tobacco advertising, smoking in public places and the sale of tobacco products from vending machines. Dr T ANGI (Tonga) said that Tonga, which had always given strong support to tobacco control
initiatives, endorsed the proposed regional action plan. It had signed the Convention and hoped to proceed to ratification in the next month. Tonga's approach was to integrate tobacco control The national advisory committee on
measures with noncommunicable disease activities.
noncommunicable diseases had four working committees dealing, respectively, with diet, physical activity, tobacco use and alcohol use. He hoped to use the lessons learned from his visit to VicHealth in Melbourne, Australia, to provide some funding from a proposed increase in taxation on tobacco products to encourage the members of those committees, who were largely volunteers from nongovernmental organizations in health and other relevant sectors. Dr CABOTAJE (Philippines) expressed strong support for the proposed regional action plan. The instrument for ratification of the Framework Convention had been forwarded for approval to the Office of the Philippine President and to the Committee on Foreign Relations, and the interagency committee on the Convention would follow up the ratification process. With technical support from WHO, new legislation on tobacco regulation had been passed in 2003. Other ongoing initiatives
concerned smoke-free schools, participation in the campaign for a smoke-free South-East Asia Games in 2005, and efforts to tackle the lack of availability of nicotine-replacement therapy in support of smoking cessation. Mrs LE THI THU HA (Viet Nam) said that Viet Nam had signed the Convention in September 2003. It had recently submitted the instrument of ratification to the President's Oftlce for approval and hoped to be among the first 40 countries to complete ratification. It had also
successfully implemented a smoke-free policy at the twenty-second South-East Asia Games and the second ASEAN Para Games, both of which it had hosted in December 2003, and was currently conducting two large-scale second-hand-smoking prevention projects. Viet Nam endorsed the
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REGIONAL COMMITTEE: FIFTY-FIFTH SESSION
proposed regional action plan and would collaborate closely with WHO and other partners to ensure its implementation. Dr SELUKA (Tuvalu) commended Member States on achieving regionwide signature of the
Convention. Tuvalu would continue to develop appropriate policies and legislation through a national task force comprising various stakeholders from governmental and nongovernmental organizations. Communities in Tuvalu had expressed a commitment to implement the Convention, having recognized the long-term benefits to health, especially for future generations. proposed regional action plan. Dr BINGWOR (Fiji) commended the Regional Director on his informative presentation and
He supported the
endorsed the proposed regional action plan.
With respect to the plan's fivt objectives, FijI had
achieved objective I, and was in a position to achieve objective 2. Two posts were dedicated to tobacco control and enforcement, using national legislation and the Convention as the basis for their work, and a specific budget allocation had been made for tobacco control. The national tobacco control action plan and policies were being revised. Objectives 3-5 remamed a challenge, however, and their achievement would require regional collaboration. She expressed appreciation for the
workshop organized, with WHO support, to assist the Pacific island countries in the Convention signing and ratification process, and welcomed the news that all countries in the Region had signed. Fiji had succeeded in staging a smoke-free South Pacific Games in 2003, and had taken the opportunity provided by the Games to conduct health promotion activities on tobacco control. as well as public awareness on HIV/AIDS and other sexually transmitted infections. Findings of recent
research on the disease burden associated with tobacco use in Fiji, undertaken in partnership with WHO and the Secretariat of the Pacific Community, would be made available by the end of the year. She expressed appreciation to WHO for the presentation to Fiji of the 2004 Wo:-!d No Tobacco Day award, which would encourage the country to continue its tobacco control efforts. Ms ARTHUR (France) said that France had been committed to tobacco control since the enactment of legislation on control of tobacco use and alcoholism m 1991. It had signed the
Convention in June 2003 and hoped to proceed to ratification in the near future. It also welcomed the progress made in ratification and application of the Convention by the Member States of the Region and endorsed WHO's view that tobacco control measures must be placed on a sound financial footing to ensure long-term sustainability. Tobacco use claimed the lives of 11% of the population of New Caledonia every year. Measures to reduce that toll had included a smoke-free schools initiative. There were plans to introduce a ban on tobacco advertising. significantly raise taxes on tobacco products. support smoking
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cessation programmes and conduct information campaigns. The proposed programmes were in line with the activities envisaged in the proposed regional action plan. Mr EDWARDS (Marshall Islands), endorsing the proposed regional action plan, said that the
Marshall Islands had signed the Convention in 2003 and that a resolution to ratify the convention was currently before Parliament. Legislation to ban smoking in public places had been introduced in 1986 and the law rlllated to sale of tobacco to minors had been amended in 1993 to require annual compliance and inspection reports to the Ministry of Health. Despite those efforts, tobacco
consumption remained a challenge, with increasing numbers of women and schoolchildren taking up smoking because of peer pressure, ready availability of tobacco products and limited understanding of the adverse effects. Moreover, rates of morbidity and mortality related to tobacco use continued to rise, especially in older and underprivileged groups. The Ministry of Health was collaborating with the Ministry of Education to include information on tobacco in the school curriculum. He requested WHO to establish a clearinghouse in the Pacific for information on tobacco control, similar to that in Penang, Malaysia. Dr KUARTEI (Palau) expressed support for the proposed regional action plan. He urged WHO to pay greater attention to research on the chewing of tobacco which, in combination with chewing of betel nut, was the main type of tobacco consumption in Palau. He joined the representative of Tonga in calling for the integration of tobacco control activities with those for control of noncommunicable diseases. in particular cancer, oral health and maternal and child health programmes. Dr POIMATAGI (Niue) commended those Member States in the Region that had signed and ratified the Convention. Niue had signed in June 2004 and hoped to consider ratification in due course. A two-stage study on tobacco consumption in Niue had been conducted with WHO support. The second phase, in October 2003, had culminated in the development of a smoke-free policy. Endorsement of the policy by the Government and the development of appropriate legislation had regrettably been delayed, however, because of the impact of cyclone Heta. He endorsed the proposed regional action plan. Dr MATHESON (New Zealand) said that the Convention provided a global template for the minimum standards for best practice in tobacco control. Ensuring its ratification and entry into force was the first and critical step for Member States. New Zealand had signed the Convention in June 2003 and had proceeded to ratification in January 2004. The country's current focus was the revision of regulations to ensure compliance with the provisions of the Convention concerning the packaging and labelling of tobacco products. He supported the proposed regional action plan, which would be
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crucial in guiding Member States towards effective implementation of the Convention at the national and regional levels. Mrs BLACKWOOD (United States of America) noted that the Secretary of Health and Human Services of her country had signed the Convention in May 2004 on behalf of the United States of America, because the treaty provided a strong framework for tobacco control. The United States of America would remain committed to working with partners on tobacco prevntion; its participation with 164 other countries in the Global Youth Tobacco Survey was one instance of that. While the United States of America supported the regional action plan, she proposed two textual changes in order to protect the sovereign right of countries to decide whether or not to ratifY.
In numbered paragraph I of the "Introduction" to the regional action plan. 2005-2009 (p. 8 of the English text), replace "ensuring the timely ratification ... " with "attaining timely ratification ... ". Rephrase Objective 1 (p. II of the English text), to read: "By 2009, attain ratification of the WHO Framework Convention on Tobacco Control in all Western Pacific Region Member States". Mr SAMO (Federated States of Micronesia) voiced his country's support for the regional action plan. Micronesia had signed, and expected to ratifY, the Convention. The Government was well aware of the burden of tobacco, and there was no longer any need to demonstrate its lil effects. H1S country was a consumer, not a producer of tobacco, which was smoked and chewed in the Federated States of Micronesia. Like the representative of Palau, he called for research on the effects of chewing tobacco. Dr TANGI (Tonga) asked the representative of the United States of America to repeat the proposed textual amendments. After a brief discussion in which the Regional Director intervened, it was agreed that, since the document was produced by and for the Western Pacific Region, insertion of the words "Western Pacific Region" was unnecessary. Objective I should therefore read: "By 2009, attain ratJfication of the WHO Framework Convention on Tobacco Control in all Member States". The REGIONAL DIRECTOR thanked Member States for their commitment to tobacco control; he cited the way in which the Pacific island countries had joined forces during negotiations. Examples of leadership in the Region included Malaysia, which had taken the lead in discussions on tobacco and trade, and New Zealand, which had become one of the few smoke-free countries in the world; he was very proud of those and other achievements of Member States of the Region. The REGIONAL COORDINATOR, TOBACCO FREE INITIATIVE, responded to questions from Tonga, Samoa and Fiji about health promotion foundations. He observed that effective tobacco control had to be integrated with other health programmes, and needed to be financially self-
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sufficient.
That could be achieved through regular budgets
Or
by means of health promotion
foundations through increased taxes. Such foundations, funded by tobacco taxes, could also be used to fund other public health measures. Funding support from the Centers for Disease Control (United States of America), Japan and New Zealand was much appreciated. He thanked China, Fiji, the Philippines, and Viet Nam for their work on tobacco-free sports, an activity that changed perceptions and reduced the social acceptability of smoking. In response to the request from the Marshall Islands on a clearinghouse, a global infonnation system for tobacco control was to go on line shortly, and there would be an attempt to do something specifically for Pacific island countries. Replying to Palau, he noted that the regional action plan included research on chewing tobacco, which would be pursued. 4. TUBERCULOSIS: Item 18 of the Agenda (Document WPRJRC55112) The REGIONAL DIRECTOR explained that, when he became Regional Director in 1999, he had consulted widely with ministers from all the countries in the Western Pacific Region. Almost without exception, they had asked WHO to prioritize tuberculosis (TB), because it had been causing such devastation in the Region. The Regional Committee had confirmed that sense of urgency when it had declared a "tuberculosis crisis" in the Western Pacific Region in 1999. He had immediately established Stop TB as a "special project" of the Regional Office and had committed both human and financial resources to relieving the Region of the tremendous burden imposed by the disease. In the five years since the Regional Committee's declaration, tremendous progress had been made towards the Region's targets of 100% coverage with directly observed treatment, short-course, or DOTS; a 70% case detection rate; and an 85% treatment success rate by the end of 2005. In fact, the Western Pacific had been the first WHO region to achieve a treatment success rate of 85%, and with DOTS coverage currently at around 80%, he was confident that the Region would be able to reach 100% coverage before the end of2005. Low case detection rates remained a serious concern, although evidence was emerging that the efforts of Member States to address that problem were now paying off. The paper noted that the regional case detection rate in 2002 was 40%. He was pleased to inform the Committee that, since that paper had been prepared, WHO had consolidated preliminary data for 2003. Those data revealed that the rate had increased to around 50%, largely due to the great efforts that had been made in China. Nevertheless, the Region was still a long way from the case detection target of 70% by 2005. The key prerequisite for increasing case detection was the availability of DOTS services of high quality. It was essential that WHO and its Member States take urgent action to accelerate their efforts to detect and treat more patients, not only by expanding DOTS, but also by increasing the involvement of the private sector and intensifYing TB case finding among people living with HIV.
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Otherwise they risked, not only missing the 2005 target, but also the 2015 Millenni'lm Development Goal of halting and starting to reverse the incidence of TB. HIV -related TB remained a serious threat to WHO's work to reduce the burden of TB in the Region. Around 30% of deaths of AIDS patients were due to TB, and the mortality rate among TB patients coinfected with HIV was around ten times higher than among TB patients not infected with HIV. He strongly encouraged all Member States to strengthen TB-HIV surveillance and to enhance collaboration between TB and HIV programmes to ensure timely detection and proper treatment ofTB patients who were coinfected with HIV. Only 15 months remained until the end of 2005. He urged all countries, particularly those with low DOTS coverage and case detection rates, to make the greatest possible efforts during those 15 months so that the Region could meet the 2005 target of 70% case detection. If Member States met the goals that they had set, they would save thousands of lives every year in the Regior:. The REGIONAL ADVISER FOR STOP TB AND LEPROSY ELIMINATION said that the number of countries offering DOTS had expanded from only 17 in 1999 to 34 in 2003. The percentage of the population with access to DOTS had risen to 87% in 2003. However, even if one took the 2003 figure, case detection in the Region as a whole remained low at 5 I %, far from the 70% target. Some countries were on target, but China, the Lao People·s Democratic Republic and Viet Nam might need to step up their efforts. The prevalence ofHIV among tuberculosis patients had risen rapidly, and was particularly serious in Cambodia, Malaysia and Viet 1"am. The funding gap in the Region had fallen from 40% in 2001 to 5% in 2004; some US$ 650 million had been needed over five years in order to expand DOTS throughout the seven countries with a high tuberculosis burden. Thanks were due to the work of Member States and to funding from the World Bank and the Global Fund, the Department for International Development of the United Kingdom (DFlD), the Government of Japan, the Australian Agency for International Development (AusAID) and the United States Agency for International Development (USAID). If the Region succeeded in attaining 100% DOTS coverage and 70% case detection by 2005, then prevalence could be halved by 20 I 0 and the MiJlennium Development Goal could be achieved in 2015. However, in order to do so, the 2005 target would have to be reached. Mr YOSHIDA (Japan) said that tuberculosis remained a major public health concern in the Region, and he supported the priority given to it in the Regional Office. His country agreed with the use of the gradual approach, which improved case detection rates in areas in which DOTS had been introduced successfully. His Government understood the wish to reach the 2005 target date, but the Regional case detection rate had been only 40% in 2002, significantly below the target of 70%. He asked the Regional Director whether he thought the target would be attained.
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Surveillance for multidrug-resistant tuberculosis and coinfection with tuberculosis bacillus and HN was essential in order to follow the trends of the emerging threat closely. Prompt, adequate
measures had to be taken in such cases. Japan had helped to increase human resource capacity in developing countries by holding international training courses at the Research Institute of Tuberculosis in his country over the past 40 years. Japan would continue to develop human resources with WHO and other Member States. Measures against tuberculosis were a high priority in Japan. The existing legislation had been revised in June 2004, and new guidelines for tuberculosis control were being prepared. The guidelines would include promotion of the Japanese version of DOTS, which offered comprehensive patient support by telephone and consultations. Regarding funding, Japan had supported the activities of the Regional Office and would continue to fight tuberculosis in cooperation with WHO. Dr CABOTAJE (Philippines) said that her Government accorded high priority to control of
tuberculosis. It worked with both the public and private sectors to implement a unified control policy. Her country expected to achieve the target of 70% case detection rate by 2005 through cooperation between public and private sectors and expansion of DOTS to vulnerable groups and high-risk populations. Systems had been set up to assure the quality of DOTS and a treatment success rate of 88% had been maintained. Through a coordination mechanism in the Department of Health, a number of partners had planned their various forms of assistance in order to complement or enhance national efforts. DOTSrelated activities were being sustained in part by a benefits package for tuberculosis patients introduced by an insurance corporation. Her Government much appreciated the technical support provided by its partners in a number of areas related to tuberculosis control. Dr YU (China) expressed appreciation for the detailed information provided to Member States by the Secretariat, and agreed with the proposals for tuberculosis control. He explained that, at a special meeting on tuberculosis, Vice-Premier Wu Yi had identified those measures in the national plan relevant to the attainment of global objectives. The Government had promulgated a series of policies and control measures, investing more in interhospital cooperation, screening in village clinical facilities and tracking tuberculosis patients. It had intensified monitoring of tuberculosis patients, paying particular attention to high-risk areas. A multilevel training approach was used to improve the confidence of staff. DOTS coverage was 85% at the end of 2003, and in June 2004 it had reached 93%. The detection rate was 45% in 2003 and would reach 60% by the end of 2004.
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In the past few years, China had been working with WHO on tuberculosis control, and was committed to achieving the target of the National Tuberculosis Prevention Programme and the WHO target for 2005. However, there was still a long way to go, and cooperation and support from partners were needed. He proposed, in the first place, detection, treatment and management of multidrugresistant tuberculosis, an activity which would call for more support from Member States. Next would be work on tuberculosis and HIV coinfection. Surveillance and treatment of tuberculosis in HIV patients was very complex, as was treatment of AIDS patients with demonstrated tuberculosis symptoms. He therefore called on WHO to provide more human resources training and opportunities for intercountry exchanges.
Dr PARK (Republic of Korea) said that in the public sector the five key elements of DOTS recommended by WHO had been implemented by the Republic of Korea. The public sector treated 40.5% of tuberculosis patients with DOTS, and the cure rate had reached its target of 85%. The detection of new smear-positive cases was still 62.3% of estimated incidence, due to the low rate in the private sector. The prevalence of active tuberculosis, based on chest X-rays, was 0.38% and the annual risk of infection was 0.25% in 2004. The incidence of new smear-positive tuberculosis was 22.9 per 100000 population and was set to fall below 10 per 100000 by 2010. Current mortality was 6.6 per 100000 population. but the aim was to reduce it to less than 3 per 100000. The case detection rate should be improved by government enhancement of cooperation with private organizations such as the Korean Institute for Tuberculosis, a \VHO collaborating centre for reference laboratories that examined more than half the microbiological samples in the country. The Government was also collaborating with WHO on international education programmes. According to a survey conducted in 2000, multidrug-resistant tuberculosis accounted for 2.2% of cases, and more recent data would be reported by the end of2004. New antituberculosis drugs were being considered.
Dr CHOU (Macao, China) said that Macao provided free tuberculosis prevention, diagnosis and treatment; DOTS had been available in all health facilities in the public sector since 1997, with 100% coverage. All tuberculosis cases were treated with WHO standard regimens, which could be modified in the light of drug susceptibility to avoid multi drug resistance. The Government provided an uninterrupted supply of quality-controlled drugs. A multidisciplinary team of medical doctors and social workers had been set up to provide health education, monitor treatment, trace defaulters and arrange welfare benefits for patients to enable them to complete the course. The default rate had thus fallen from 10% to 2%-3% in recent years.
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5.
AMENDMENTS TO ARTICLES 24 AND 25 OF THE WHO CONSTITUTION (Document WPRlRC55IINF.DOC.3) The REGIONAL DIRECTOR drew attention to document WPRlRC55/INF.DOC.3, and
explained that, at the previous day's informal consultative meeting of representatives, a strong consensus had emerged that the Western Pacific deserved one additional seat on the WHO Executive Board. However, because the composition of the Executive Board was a constitutional matter, Member States had to ratify the change. Several years earlier, the World Health Assembly had approved an increase in the number of members from the Western Pacific to five; however the amendments had not yet received the requisite number of ratifications to enter into force. All Member States of the Western Pacific Region had ratified, but a further 18 ratifications from elsewhere were needed. The information document listed the countries that had not yet ratified, by region. He asked each Member State to consider the list and note whether there were any countries on it that it might be able to influence. It had to be borne in mind that the relevant authority was not the Health Ministry but the Ministry of Foreign Affairs, or even the Prime Minister's office. He asked Member States for their active cooperation in that collaborative endeavour. The meeting rose at 17:28.