WPRlRC50/SRJ4
SUMMARY RECORD OF THE FOURTH MEETING Hyatt Regency Ballroom, Macao Wednesday, 15 September 1999 at 9 a,m. CHAIRPERSON: Dr Jose Alarcao TRONI (Macao)
CONTENTS
1. Annual report on sexually transmitted infections, HN infection and AIDS (continued) 2. Consideration of draft resolutions ................................................................................ 2.1 Reform in the Western Pacific Region .................................................................. 2.2 Proposed programme budget 2002-2003: country allocations ................................................................................................. 2.3 Eradication of poliomyelitis in the Region: progress report ,.... .................... ... .... ......... ....... ....... ............. ...................... ............. 3. Tuberculosis prevention and control ....................................................................... ,....
134
143 143 143 144 144
134
REGIONAL COMMITTEE: FIFTIETH SESSION
1.
ANNUAL REPORT ON SEXUALLY TRANSMITTED INFECTIONS, HIV INFECTION AND AIDS: Item 11 of the Agenda (Document WPRlRC50/7) (continued)
Dr SUN (China) noted that with the rapid spread of HIV I AIDS, collaboration between WHO and UNAIDS was very important. In order to prevent and control the disease, the link between AIDS and the use of injected drugs should be addressed. In the Region, 40% of HIV infections were associated with the use of injected drugs. Although antiretroviral treatment had proved very
effective, the high cost prevented its large-scale use. The problem of how to make it affordable posed a great challenge. In addition, further research was needed on emerging resistance to the treatment. He stressed that approaches to sexually transmitted infections (STIs) and HIV/AIDS should be interlinked to make the prevention and control of both diseases more effective.
Dr NOVOTNY (United States of America) remarked that, although the number of HIV infections might be stabilizing in some countries, he agreed with the Representative of China that the potential for an explosive HIV/AIDS epidemic was still present. It was important to address such issues as strengthening of primary and secondary prevention, which could be key in controlling the spread of the disease, particularly in countries without the resources for antiretroviral therapy. Behavioural and clinical surveillance should also be strengthened to better understand and monitor changes in patterns of HIV infections. Countries with increasing incidence should learn from the experience of others in the Region and strive to find a successful mix of methods appropriate to their own conditions. While development of therapies and research into a vaccine continued, the basic elements of prevention, such as education, voluntary testing and counselling, prevention of perinatal transmission, and political commitment should be emphasized. He encouraged the development of a regional strategic plan for prevention. Dr HONG SUN HUOT (Cambodia) described the HIV/AIDS situation in his country, where it was a priority health problem. The prevalence of HIV -positive cases among blood donors had increased from 0.1 % in 1991 when it was first detected, to 3.6% in 1997. In 1998, the prevalence of HIV-positive cases had been 3.75% among adults from 15 to 45 years, 2.6% among women of childbearing age, and from 30% to 60% among commercial sex workers. In the same year, figures had shown that there were approximately 16000 AIDS patients in the country. There was also concern about the increasing incidence of tuberculosis associated with AIDS. In 1993, a comprehensive
national plan for the prevention and control of AIDS and sexually transmitted infections had been developed and the National Policy on HIV I AIDS had been approved in 1995. The current focus was
SUMMARY RECORD OF THE FOURTH MEETING
135
on the introduction of the "100% condom use" programme among commercial sex workers and their clients. In spite of serious financial constraints, his country had continued to respond to the problem ofHNIAIDS and sexually transmitted infections, using a multi sectoral approach. Long-term impacts
of the epidemic, such as the problem of children orphaned as a result of their infected parents' deaths, were being addressed. An attempt was also being made to respond to social and economic conditions which increased the risk of infection for certain communities. addressed through collaboration with Thailand. Mr PEHIN ABDUL AZIZ (Brunei Darussalam) reported that the prevalence of HNIAIDS had stabilized in his country. The vast majority of reported cases involved foreign nationals, the chief mode of transmission being heterosexual. Key control and prevention measures were Cross-border issues were being
epidemiological surveillance, protection of the national blood supply, health education and awareness raising, religious approaches, and clinical management of and support to infected persons. Antiretroviral treatment was provided free of charge. Although STI prevention and care was important for reducing HN transmission, his country faced certain problems related to case management, including underreporting and lack of trained health workers. Steps were therefore being taken to improve case notification and to recruit trained doctors. Dr HUAN (Viet Nam) informed the Committee that the number of reported HN cases had
continued to rise each year in his country, over half being attributable to intravenous drug use. The number of AIDS cases and deaths had doubled since 1998, and transmission rates were increasing among commercial sex workers, pregnant women and military recruits. The number of STI cases was also rising rapidly and there was known to be considerable underreporting. Control and prevention measures were targeting high-risk groups, and included promotion of peer education, use of condoms and disposable syringes, and self-help groups. The community
approach was being developed through clubs, counselling and small-group education in order to improve access to information. Public information was being stepped up through use of the media. With international support, antiretroviral therapy should shortly be available for pregnant women. Mr MARGHEM (France) observed that promotion of appropriate use not only of blood
products, but also of substitute products, was essential to blood safety. Further, self-transfusion,
136
REGIONAL COMMITTEE: FIFTIETH SESSION
which reduced the risk of contamination, was little used, even though it required only modest resources. WHO could be more active in that respect. Greater emphasis on blood safety would help control all diseases transmitted through blood use, and seemed preferable to a disease-specific approach. Stronger emphasis should be placed on case management, including the provision of psychosocial support to infected persons and their families. Associations and community groups made a considerable contribution to the social acceptance of people living with AIDS, and their work should be promoted. Cases should be managed first within existing health care structures. In view of the risk of recurring opportunistic diseases, networks should be set up to coordinate care and assure follow-up in the home, together with psychosocial support and supply of generic essential drugs to health services. With regard to access to antiretroviral therapies, France had been instrumental in establishing the International Therapeutic Solidarity Fund in order to reduce inequality in access to treatment. Aware of the difficulty of assuring access to such treatment in developing countries, France was providing support for the control of vertical transmission and the follow-up of such cases. He recommended that WHO should give more attention to case management of infected persons in the Region within the context of the International Fund for Therapeutic Solidarity Fund, in which all countries were welcome to participate. Dato' CHUA (Malaysia) was gratified to see that the number of HIV cases appeared to be stabilizing in several countries in the Region. Intravenous drug users accounted for the majority of cases in his country, and transmission among them continued to increase because of needle sharing and unprotected sex. Those in rehabilitation centres were not being discharged until they had been fully counselled. Cases were actively detected through screening of all blood donors, compulsory testing of drug users, and introduction of HIV testing in STI clinics. Extensive antenatal screening had recently been introduced in order to prevent vertical transmission and to provide data on the prevalance of HIV. Roughly 250 000 pregnant women had been tested on a voluntary basis. Results indicated that vertical transmission was very low, and that the AZT treatment provided free of charge to infected mothers had proved extremely effective in protecting their babies.
SUMMARY RECORD OF THE FOURTH MEETING
137
With regard to case reporting, he questioned the accuracy of the figures provided by some countries. Accuracy of the data depended on the extent of surveillance and active case detection. Although the estimates given in Table I of document WPRlRC50/7 were helpful in this regard, he asked to what extent those figures were accurate, acceptable, and fairly reflected AIDS incidence in each country of the Region. Discrimination against people living with HIV/AIDS and even opposition to the establishment of HIV clinics in certain areas were major problems in all countries of the Region and an obstacle to HIV control. Public education had not yet succeeded in overcoming the prejudice that infected persons had to face. Further study on stigmatization would help countries find ways to combat it. Mr WARAKOHIA (Solomon Islands) reported that although there were no HIV cases in his country, rising STI incidence, especially among young people, was a cause of concern. With the
support of the Macfarlane Burnet Centre for Medical Research, country assessment of HIV/AIDS was currently under way as a first step in preparing a comprehensive HIV/AIDS prevention and control strategy. Professor WHITWORTH (Australia) said that her country was keenly interested in the collective response to HIV/AIDS in the Region, and a considerable and growing portion of its overseas aid was donated to STI and HIV/AIDS prevention and control. Regional workshops had pointed to the need for more social and behavioural research to help target prevention measures at people most at risk. Australia had included such research in its national control strategies and would welcome the opportunity both to share its experience and to learn from similar projects in the Region. Noting the benefit that could be derived from genuine cooperation with other bodies active in HIV prevention and control, she called for closer collaboration between the Regional Office,
UNAIDS and other partners working at country and regional levels. In order to encourage such collaboration, she requested that details of specific activities involving collaboration between the Regional Office and UNAIDS, including identification of factors contributing to successful outcomes, should be included in the following year's report. Dr CHERN (Singapore) reported that the number of reported HIV infections in his country
was rising, although from a very low base, heterosexual contact
being the chief mode of
transmission. He agreed with previous speakers that cases could well be seriously underreported and shared the concern of Malaysia about the accuracy of the figures.
138
REGIONAL COMMITTEE: FIFTIETH SESSION
Continued vigilance was required to combat transmission of HIV through intravenous drug use and heterosexual contact in particular. The latter accounted for the rise in vertical transmission, and he urged Member States to strengthen HIV screening for pregnant women. Singapore was
offering HIV screening at a subsidized rate in all government clinics to encourage pregnant women to be tested. It had also set up anonymous test sites which could contribute to reducing transmission in countries where people feared discrimination. However, disclosure of certain information might be necessary in order to improve public health control of transmission. Singapore had therefore
amended its legislation to make provisions for disclosure to a spouse or partner of information relating to an infected person if there was a risk to public health or safety. It had also made it an offence to furnish false information to a blood bank in relation to the donation of blood or blood products. The coverage of the national medical savmg scheme had been extended to include all antiretroviral drugs registered in Singapore. However, the key to HIV control in his country was prevention through health education. Dr PRETRICK (Federated States of Micronesia) said that there were few cases of HIV
infection in his country, although the true extent of prevalence was not known. However, several factors might contribute to a rise in prevalence: a large young, sexually active, and mobile
popUlation; an increasing tourist trade; and high STI prevalence. The national HIV prevention and control plan, carried out in collaboration with UNAIDS and integrated in the existing primary health care delivery services, was geared to programme management, framing of HIV policy, public information, improved testing capacity, and condom distribution. Surveillance was an ongoing activity and over 5000 people had been tested in 1998, although up-to-date testing techniques were not yet available. Community-awareness actlvities were underway, including workshops, seminars and health education messages through the media. Technical support to strengthen HIV prevention and control would be welcome in such areas as quality assistance, surveillance test kits, condom procurement, policy development and staff training. Dr KIENENE (Kiribati) reported that his country had one of the highest HIV infection rates
in the Region, although the STI rate was relatively low. The focus of prevention and control had shifted from vertical programmes run by the Ministry of Health to a social approach involving the community and nongovernmental organizations.
SUMMARY RECORD OF THE FOURTH MEETING
139
Kiribati appreciated the support provided by WHO and other agencies such as the Pacific Community and the Australian Agency for International Development. WHO should take a leading role in such areas as law and ethics related to HNIAlDS, development of human resources for counselling, and policy issues. Those areas were essential elements in small countries with small populations, where confidentiality had to be maintained. Referring to clarification of the role and priorities of UNAlDS, he observed that the experience of Kiribati had indicated a loss of momentum in programme implementation since UNAIDS had assumed responsibility for supervising and coordinating AIDS control efforts. Ms EARP (New Zealand) noted that although rates of HNI AIDS infection had stabilized in certain countries, they were rising in others, and she urged WHO to maintain its support in those cases. The infection rates in her country were declining as a result of intense prevention and control efforts after AIDS had been declared a notifiable disease. A range of approaches which targeted specific communities or groups had proved effective in cases where appropriate messages could be communicated. Appropriate prevention strategies were essential, including such components as active surveillance methods, safe blood supply, integration of HNIAIDS prevention in STI programmes, encouragement of support groups of infected people, programmes targeted at sex workers and intravenous drug users, and promotion of behavioural change. WHO should continue to seek ways of improving access to antiretroviral treatment in order to prevent vertical transmission. She endorsed the comments of previous speakers regarding the need for improved liaison between the Regional Office and UNAIDS in order to improve the support UNAIDS provided in the Region. Dr TANGI (Tonga) expressed concern at the estimate that by 2000 there would be I million people infected with EN in the Region and agreed that a proactive approach to prevention and treatment was required. However, measures for young people, such as early provision of condoms, would need careful consideration. Regular use of condoms, as advocated for protection against HN infection, must be generating large profits for the manufacturers. He suggested that ways should be sought of channelling some of those profits back into the Region's prevention programmes. Dr TAMARUA (Cook Islands) commented that the report showed that sexually transmitted
and HN infections were still serious health problems in the Region. Although no cases of HN
140
REGIONAL COMMITTEE: FIFTIETH SESSION
infection had been reported in Cook Islands, the population was mobile and infected persons were known to travel in the country. A situational analysis of the national HIV/AIDS programme had been undertaken with the assistance of the Macfarlane Burnet Centre for Medical Research, Australia. It was encouraging to see from the report that public health measures and control strategies did indeed work. However, the cost of antiretroviral agents was a significant drawback for most countries of the Region. Primary prevention based on behavioural change in respect of sexual relationships was still the most cost-effective measure. Surveillance, prevention and control of STIs must be maintained, and collaboration between Member States was essential. Mr ROKOVADA (Fiji) said that collaboration to improve surveillance for STIs, HIV and AIDS, to improve programme management, to improve the use of STI syndromic case management, to further develop interventions focusing on commercial sex workers and their clients and to support the development of care for patients with AIDS and STIs was essential in view of the high rates of curable STIs in the Region. He welcomed the availability of short-term antiretroviral therapy to reduce mother-to-child transmission of HIV which should prove affordable. WHO should continue its monitoring activities and support for the public health components of STI prevention and control. He joined previous speakers in requesting information about the activities of the United Nations Theme Group on HIV/AIDS in the Pacific region. The Regional Director's interim report on budget performance for the 1998-1999 programme budget (document WPRlRC50/4) indicated that US$ 748 271 had been provided by UNAIDS for the biennium. He asked whether countries with limited transmission were entitled to a share of that allocation. Mr SHEM (Vanuatu) said that, although no cases of HIV infection or AIDS had been reported in his country, it maintained an awareness and surveillance programme targeting communities, groups at high risk and advocacy groups. Progress had been made in developing a national HIV/AIDS policy, collaboration with nongovernmental organizations, strengthening STI case management by health workers and developing ongoing public awareness programmes. Although the report before the Committee described programmes for integrating STI services with education for female sex workers, he considered that attention should also be paid to men and young people. Another target group in countries such as Vanuatu was fishermen who could be an important source of transmission. He thanked WHO, the Australian Government and the MaCfarlane Burnet Centre for their continuing support. Mr RETZLAFF (Samoa) reported that his research on legal strategies for combating HIVI AIDS had shown that the best generic legislation in the world was that of the Philippines. which
SUMMARY RECORD OF THE FOURTH MEETING
141
provided a holistic means of protecting the victims and preventing the spread of infection and disease. The existing legal approaches were to do nothing, as in most countries; to use coercion, as in Cuba; or to use a generic approach, as in the Philippines. Most countries used a piecemeal approach, amending existing legislation gradually. A document entitled AIDS and the law: does protection exist for AIDS victims?, which outlined his findings was available to interested representatives.
HIV infection was a war in which the enemy was the virus. It was important to overcome prejudice in which the victim was looked upon as the enemy. The Honourable Justice Kirby of Australia had described a paradox in the fight against AIDS: as the most effective weapon was to change behaviour, it was essential not to alienate the victims but to take their interests into consideration. Experience in Samoa had shown that people with AIDS who were prepared to waive their rights to confidentiality and to speak about their experiences were highly effective advocates of behavioural change. He considered that there was a direct correlation between the prevalence of HIV/AIDS and the rights of women. Countries that respected the rights of women were able to control the epidemic more effectively than those where such rights were ignored. Positive changes were needed in customs, attitudes and lifestyles, backed by strong, effective leadership at the highest level. Huge resources were required to treat the opportunistic infections of people infected with HIV, which could quickly use up all the health resources of a country. Further burdens were the "brain drain to the grave", - the deaths of young people who had been educated at great expense - and the resources necessary for looking after the orphans of victims of AIDS. Mr UEDA (palau) reported that two cases of AIDS had been detected in his country, both of which had been imported and both of which had been fatal. After the second AIDS-related death, the family of the deceased had been counselled on the nature and process of the disease. In addition, radio broadcasts explaining that HIV/AIDS was sexually transmitted, much like other STIs, had allayed public fears. He agreed that HIV/AIDS should be tackled through an integrated STI
approach, and that the stigmatization attached to HIV/AIDS must be addressed. He acknowledged the assistance given to his country by the United States of America and the Secretariat of the Pacific Community among others. The REGIONAL DIRECTOR, replying to the points that had been raised, proposed that his next report on STIs, HIV infection and AIDS should include annexes describing collaboration between the Region and UNAIDS; the experiences of countries in the Region with regard to control of STIs, HIV infection and AIDS; and the legislative approach used in the Philippines, which might be used as a framework for further development in other countries.
142
REGIONAL COMMITTEE: FIFTIETH SESSION
A number of representatives had raised questions about the relationship between WHO and UNAIDS with regard to both funding and activities. Relations had initially been difficult, owing largely to lack of coordination; they had since improved, and the relative roles of the two organizations had been clarified. Thus, WHO focused on public health issues such as the STI
syndromic approach, epidemiological information, training, educating commercial sex workers and their clients through provision of condoms, and interventions for intravenous drug users. The other cosponsoring agencies, such as UNICEF and UNDP, also dealt with the areas in which they had the greatest strengths. Before the establishment of UNAIDS, WHO funds for HIV/AIDS programmes had been allocated directly to countries. Now, they were channelled through the United Nations Theme Groups on HIV/AIDS established in more than ten countries in the Region. Countries
received other allocations directly from the Regional Office and from bilateral funding agencies. The funds received from UNAIDS would be used as efficiently as possible in consultation with the countries. The REGIONAL ADVISER ON AIDS AND SEXUALLY TRANSMITTED INFECTIONS added that UNAIDS had provided US$ 2 million for HIVI AIDS activities in the Region for the biennium, through the Theme Groups. The Regional Office had mobilized additional funds, giving a total of US$ 7 million, two-thirds of which was allocated to country activities and one-third to intercountry activities. Of that amount, US$ 1.5 million had been provided by UNAIDS. Funding for HIV I AIDS in the Region had therefore returned to the level achieved prior to the establishment of UNAIDS. Further funding from bilateral agencies and other United Nations agencies had also
increased substantially in the past few years. In response to the representative of Malaysia, he said that the estimates and projections of the prevalences of HIV infection and AIDS were based on the results of workshops of experts organized in selected countries. Those data were revised continuously on the basis of country surveillance results. The estimates provided figures that were accurate enough to guide public health
interventions by indicating the magnitude of the problem and trends. The accuracy of the estimates depended on the accuracy of the epidemiological data collected in the countries. At the invitation of the CHAIRPERSON, the representative of Soroptimist International made a statement to the Committee.
SUMMARY RECORD OF THE FOURTH MEETING
143
2. 2.1
CONSIDERATION OF DRAFT RESOLUTIONS Reform in the Western Pacific Region (Document WPRlRC50/Conf. Paper No.1) Dr WOONTON (Niue), Rapporteur for the English language, proposed that operative
paragraph 4(4) be amended by changing the end of the phrase to read "a selected issue in part 2 of the report". Dr ROMUALDEZ (Philippines) added that the word "in" in that part of the phrase should be
changed to "as". Mr VILLAGOMEZ (United States of America) suggested that operative paragraph 4(3) be
strengthened by changing the phrase after the comma to "and that it includes a critical analysis and evaluation of WHO programmes with Member States in the Western Pacific Region." The CHAIRPERSON requested the Rapporteurs to prepare a revised version of the draft resolution reflecting the amendments proposed for consideration at a later meeting.
2.2
Proposed programme budget 2002-2003: country allocations (Document WPRlRC50/Conf. Paper No.2) In response to a query from Mr LID Peilong (China) regarding operative paragraph 3, the
REGIONAL DIRECTOR said that there was no statement in the policy organs of the Organization regarding responsibility for deciding on country allocations. Recent practice had been that the
governing bodies decided on the regional allocation, and the Regional Director decided on the country allocations. In attempting to ensure that the Organization was one entity, the DirectorGeneral would take the opinions of the Regional Committees into account in making a decision for WHO as a whole. That approach was reflected in the fourth preambular paragraph and operative paragraph 3. In 1998, the Regional Committee had mandated the Regional Director to draw up criteria for deciding on country allocations, which had been discussed by the Committee at its current session. He undertook to convey the opinions of the Committee to the Director-General at the meeting with the six Regional Directors that would be held in tandem with a retreat of Executive Board members in October 1999. Dr ROMUALDEZ (Philippines) shared the concern of the representative of China and
therefore proposed that the fourth preambular paragraph 4 be amended to reflect that concern by the
144
REGIONAL COMMITTEE: FIFTIETH SESSION
addition of the words "which takes into account regional differences in the health needs of different countries" at the end ofthe paragraph. Decision: The draft resolution, as amended, was adopted (see resolution WPRlRC50.RI).
2.3
Eradication of poliomyelitis in the Region: progress report (Document WPRlRC50IConf. Paper No.3) Mr LnJ Peilong (China) questioned the last clause in operative paragraph 3(2), which
suggested that external support for surveillance and supplementary immunization might cease once global certification had been achieved. The REGIONAL DIRECTOR said that it was difficult to gain a clear idea of the extent to which external support would be necessary or available after eradication but, if smallpox eradication was anything to go by, surveillance would be continued, but supplementary immunization may no longer be necessary. As long as stocks of virus were kept in laboratories outbreaks were still
possible. He proposed that, in order to meet the concerns expressed, the words "and beyond, if necessary" should be added to the end of the resolution. Decision: The draft resolution, as amended, was adopted (see resolution WPRlRC50.R2).
3.
TUBERCULOSIS PREVENTION AND CONTROL: Item 12 of the Agenda (Document WPRlRC50/8 Rev.l) The REGIONAL DIRECTOR, introducing the item at the invitation of the CHAIRPERSON,
recalled that earlier in the session he had said that it was unacceptable that the Region should be entering the new millennium with rising levels of tuberculosis. When he had consulted with the Member States of the Region after his nomination, virtually all, developed and developing, had voiced their concern about the disease. He pointed out that directly-observed treatment, short course (DOTS) was already an effective weapon with which to fight tuberculosis. With the political will, the number of cases in the Region could be halved within ten years, as indicated in Figure 6 of his report.
SUMMARY RECORD OF THE FOURTH MEETING
145
WHO had declared tuberculosis to be a global emergency in 1993 and in 1998 the Organization had launched the global Stop TB initiative. The problem was particularly severe in the Western Pacific Region, which was home to approximately 29% of global tuberculosis cases, more than any other region apart from the South-East Asia Region. It was estimated that there were almost 2 million new cases of tuberculosis in the Region every year, only 43% of which were notified. WHO also estimated that about 355000 people in the Region had died from tuberculosis in 1998. Not only was that a personal tragedy for the victims and their families, it also had profound implications for national economies, because the disease was particularly prevalent in the 15 to 54 age group, the most productive segment of the population. The problem was growing; the regional notification rate for infectious cases had increased from 18 per 100000 in 1994 to 23 in 1998, a 28% increase. One reason for this was the increasing gap between rich and poor in some countries. The burden of the disease was much heavier in poor populations than in more affluent ones. If an infected breadwinner of a family was not properly diagnosed and treated, he or she could lose, on average, a full year of work. If the breadwinner died, an entire family could be pushed over the brink into poverty. He pointed out that the WHO-recommended DOTS strategy cured mne out of ten tuberculosis patients. It was also one of the least expensive health interventions in low- and middleincome countries. The price of the drugs to treat one patient for six months ranged from US$ 20 to US$ 30. If DOTS was implemented regionwide, tens of thousands of people every year would be spared from unnecessary suffering and death. DOTS implementation in the Region had started in the early 1990s. Coverage had steadily increased and, by the end of 1998, 46% of notified patients in the Region had been receiving the treatment. However, almost 60% ofthe estimated cases remained undetected, so that only 20% of the total estimated cases in the Region were currently benefiting from DOTS. Tuberculosis was often seen as an unchangeable fact of life, so insufficient attention had been paid to its control in the majority of the countries where the disease was most prevalent. Moreover, resources for tuberculosis control had been reduced at both institutional and community levels. As a consequence, many health systems were not adequately equipped to deliver appropriate tuberculosis care. The development of a good DOTS programme could both benefit from and contribute to improvements to health systems.
146
REGIONAL COMMITTEE: FIFTIETH SESSION
To make real progress against tuberculosis in the Region a special effort was needed. He therefore proposed that tuberculosis should become a special project of WHO in the Region, with an increased allocation of resources. A Stop TB external advisory group would be created in order to involve international experts in the Stop TB project, and a special effort would be made to ensure that DOTS was established regionwide by 2005. He urged all Member States to give the highest priority to tuberculosis control, using the DOTS strategy within the framework of health sector development. He was confident that, working together, Member States and WHO would succeed in halving the number of tuberculosis cases in the Region in ten years. Dr GALSIM (Philippines), conunending the report, said that it was clear that the war against tuberculosis was far from over. That was the case in his country, which was one of22 accounting for 80% of the global burden, and he welcomed and strongly supported the Regional Director's proposal for a special project. The Philippines was conunitted to 100% DOTS coverage by 2001, and
tuberculosis control was a priority in its health sector reform agenda, the budgetary provision having been doubled for 2000. The national health insurance progranune covered DOTS for outpatients; a "TB Alert" had been launched to encourage those with symptoms to report for treatment; and 25 organizations had signed a memorandum of understanding in support of DOTS. Continued national and international collaboration was crucial for the provision of improved laboratory services to ensure case-finding and reliable drug supplies. WHO's cooperation was needed in advocacy and training and to provide leadership. Dr Joon Sang LEE (Republic of Korea) conunended WHO's efforts to extend DOTS in the Region with the support of the World Bank and nongovernmental organizations. He asked the Regional Director why tuberculosis control was to be a special project and how that had been decided. Dr TEMU (Papua New Guinea) also conunended the efforts of the Regional Office and Member States, but expressed concern at the slow progress in introducing DOTS in his country, which suffered under the constraints listed in section 5 of the report. The health system was weak and lacked qualified staff, the drug supply was unreliable, the terrain difficult and financial resources short. Convinced of the effectiveness of DOTS, his country sought support for tuberculosis control together with measures against HNIAIDS. With a multi sectoral approach, Papua New Guinea hoped to develop a sustainable delivery system and achieve full DOTS coverage by 2005.
SUMMARY RECORD OF THE FOURTH MEETING
147
He inquired about the cost-effectiveness of DOTS and its current costs and benefits compared with the short-course chemotherapy of the 1980s. He also requested additional information on "best practices" for the Region in integrated HIV/AIDS and tuberculosis control, and suggested that research on sustainable cost-effective implementation in the affected countries be provided for in the budgets for the next three bienniums, together with measures to mobilize external funds. He further recommended that HIVI AIDS and tuberculosis be declared as regional emergencies and that a commitment be made to give them priority in those budget periods. Mr LIU Peilong (China) said that the report contained an excellent analysis of the epidemiological situation and some striking figures, in particular referring to the preponderance of cases in the Western Pacific Region (29%) and of deaths in China, where with improved reporting China's regional share of mortality in the Region was revealed to be about 70%. DOTS coverage in the Region, had increased from 30% in 1996 to 46% in 1998, largely due to increased coverage in China, China fully supported the regional efforts for control and the Regional Director's proposal that tuberculosis should be a special project. In China, control was becoming a national priority, and DOTS had been implemented in several provinces since 1993 with the support of the World Bank. The outstanding results showing that it was the right strategy, necessitating and contributing to improvements in the health care delivery system. The greatest difficulties were financial. China appeared in the first group of countries in Annex 3 to the report, those with a high burden of tuberculosis and low implementation of DOTS, and the "financial constraints" were rightly mentioned. Large-scale financing would have to be guaranteed if the programme was to succeed and if the targets given in Table I were to be considered realistically attainable. In 2000 the Chinese Ministry of Health was launching the Fourth Tuberculosis
Epidemiological Survey and convening a high-level workshop on control in an attempt to win political support for sustainable efforts. However, owing to the magnitude of the problem, national efforts were insufficient, and he appealed to WHO to support China to persuade decision-makers of the magnitude and urgency of the problem, to mobilize the international community to provide financial aid to China, and to enhance technical cooperation for laboratory services and training of staff.
148
REGIONAL COMMITTEE: FIFTIETH SESSION
Referring again to Table 1, he observed that some of the targets were too high to be realizable for China by 2005. Dr SHINOZAKI (Japan) said that the number of tuberculosis cases in his country had fallen steadily every year for some 40 years until 1997, when there had been a surprising increase with reports of nosocomial and group infections and drug resistance, necessitating revision of the strategy. The Minister of Health had declared an emergency in July 1999, and many national NGOs had joined in measures to combat the disease. The low implementation of DOTS in some countries of the Region might be due to the lack of availability of drugs free of charge, which together with the need for patient registers, should be made the subject of measures to ensure political commitment. Japan had contributed to training programmes and technical support through the Tuberculosis Research Institute in Tokyo. The country was classified in Group 5 with Australia and New Zealand in Annex 3 to the report but he felt that, with a prevalence rate of over 30 cases per 100 000 population, it should rather be among countries with a "middle burden". The importance of collaboration with countries with a high or similar burden was recognized, and he proposed that a mechanism be set up for exchange of experience in tackling drug resistance and group infection, in promotion of DOTS and in provision of anti-tuberculosis drugs. Japan thus pledged both technical and financial support to the Regional Office and countries of the Region. He stressed the importance it attached to wide DOTS coverage, human resources development and improvement of laboratory services. Understanding conditions in "middle-burden" countries was vital. Japan fully supported the Regional Director's proposal for tuberculosis to be a special project. Dr MARGHEM (France) expressed full support for WHO's efforts to control tuberculosis. The resurgence of the disease called for the mobilization of all countries of the Region. While recognizmg the progress achieved with DOTS, he inquired whether only those countries applying all five components of the strategy were considered to be implementing it.
SUMMARY RECORD OF THE FOURTH MEETING
149
In addition to DOTS, he felt that supplementary measures were necessary. In particular,
weaknesses in the organization of health services, poor observance oftreatInent regimens and followup, irregular drug supply and the failure to integrate all such activities in primary health care would limit the effectiveness of DOTS and endanger tuberculosis control. He also stressed the importance
of research on foci of infection however costly, if transmission was to be interrupted, not forgetting the social causes of the disease and the need to improve hygiene and reduce poverty. To that end, multisectoral action and economic development were the key to prevention of tuberculosis, the reappearance of which bore witness to new poverty in some "developed" countries where tuberculosis was not merely a result of co-infection with HIV. In countries where this co-infection occurs, WHO should promote an integrated tuberculosis/AIDS strategy similar to that being implemented in other regions.
The meeting rose at 12:30 p.m.