WPRlRC491SRJ4
SUMMARY RECORD OF THE FOURTH MEETING
WHO Conference Hall, Manila Tuesday, 15 September 1998 at 2 p.m. CHAIRPERSON: Dr Margaret CHAN (Hong Kong, China)
CONTENTS
I.
Programme budget (continued) .......................................................................... .
126 126
1.1 2.
Proposed programme budget: 2000-2001 (continued)
Annual report on sexually transmitted diseases, HIV infection and AIDS ...................................................................... . Expression of appreciation to Dr S.T. Han ........................................................... . Eradication of poliomyelitis in the Region: progress report ................................ .
129
3.
137 138
4.
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1.
PROGRAMME BUDGET: Item 9 of the Agenda (continued from the third meeting, section 1)
1.1
PROPOSED PROGRAMME BUDGET: 2000-2001 (continued): Item 9.2 ofthe Agenda (Document WPRJRC49/5) The REGIONAL DIRECTOR, referring to an earlier question on prior consultation regarding
the programme budget, said that some delegations had submitted written questions before the session, and others had requested informal consultation. He thought this was an acceptable way for the Organization to consult with Members. There was no formal system involving a committee, which might necessitate a more complicated procedure. On the question of the slightly increased allocation for the Regional Committee, he replied that normal minimal cost increases such as for air fares, had been included. He pointed out that the issue of country visits was tabled for discussion later in the week. Mr KANEKO (Japan) said that some areas had received reduced allocations in spite of their increased priority being recognized by the Director-General. He suggested that in order to avoid time-consuming discussion, a new mechanism might be envisaged whereby a certain percentage of the country budget, for example 10% or 20%, should be set aside for regional and global priorities. He suggested that information on objectives, targets and the regional situation might be clearer if the changes compared with past bienniums were illustrated with charts and tables where appropriate. Dr FERNANDEZ (Philippines), noting the difficulties resulting from economic recession, inflation and changing exchange rates, appreciated the flexibility the Regional Office had shown in making adjustments to the proposed budget and commended the multisectoral integrated approach. She expressed support for the maintenance, at least, of the proposed level of funding. She also supported the revision of allocations for communicable disease control according to the Director-General's announced intentions and for transparency. She suggested that each country should submit a financial utilization report, either quarterly or annually, using a common format.
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The REGIONAL DIRECTOR understood the representative of Japan to have made his proposal regarding the allocation of a percentage of the budget to priorities as relating to the country allocations. It might be more practicable if it were to apply to the intercountry progranunes. He considered that it would be preferable if such an initiative came from the Director-General. A proposal would be made to the task force. Mr KANEKO (Japan) asked whether a representative of Japan could attend the task force meeting. The REGIONAL DIRECTOR said that he was unaware of any plan to involve the Member States, but he would make a suggestion to this effect to the task force. The CHAIRPERSON invited specific comments on the proposed progranune budget, major heading by major heading.
1.
Governing bodies There were no comments.
2.
Health policy and management There were no comments.
3.
Health services development There were no comments.
4.
Promotion and protection of health Dr OTTO (Palau) expressed concern about the reduced allocation for environmental health in
view of the importance of environmental aspects of the Healthy Cities and Healthy Islands initiatives in the Pacific island countries. Dr WOONTON (Niue), referring to section 4.1 Reproductive, family and community health and population issues requested that men's health should be specifically included in family and community health in order to balance life expectancy between the sexes.
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She also suggested that in connection with section 4.3 Nutrition, food security and safety, the text on future nutrition policies should include tariffs or restrictions on certain imported food items, similar to those on tobacco and alcohol, in order to help discourage overnutrition. The DIRECTOR, PROGRAMME MANAGEMENT, responding to the representative of Palau, said that most of the reduction in allocations for programmes on environmental health in urban development had been made at the country level, with no provisions having been made for four countries in 2000-2001, whereas the allocation for intercountry programmes had been increased by 1.28%. The item should be considered in conjunction with item 4.4.3 of the proposed programme budget (Assessments of environmental health hazards), in which large reductions had been achieved at both intercountry and country level. Two countries discontinued their provision for this activity and two were proposing reduced collaboration. Environmental health nevertheless remained a priority in the Region. In response to the comments of the representative of Niue, he concurred that men's health was an important component of family health. With regard to the problem of restrictions on the import of foods that might be detrimental to health, WHO was expanding its negotiations with the World Trade Organization in order to develop a common policy.
5.
Integrated control of diseases There were no comments.
6.
Administrative services There were no comments.
Annexes Responding to a question from Ms DAVIDSON (Australia) with regard to Annex 1 of the proposed programme budget, the REGIONAL DIRECTOR said that the apparent decreases in the allocations for the least developed countries of the Region were due to the inclusion of reductions in allocations for WHO Representatives' offices.
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2.
ANNUAL REPORT ON SEXUALLY TRANSMITTED DISEASES, HIV INFECTION AND AIDS: Item 10 of the Agenda (Document WPRlRC49/6) The REGIONAL DIRECTOR explained that in Australia and New Zealand, where there had
been intensive prevention programmes, incidence of HIV infection was continuing to decrease. Japan, the Philippines, the Republic of Korea and most of the islands of the Pacific were still not experiencing substantial increases in HIV infections and AIDS cases. However, epidemics were emerging or were already established in many other countries in the Region, such as Cambodia, China, Malaysia, Papua New Guinea, and Viet Nam. He said that WHO projected that these upward trends may continue in most of these countries. By 2000, the total number of HIV-infected individuals was expected to double, while the annual number of new cases of AIDS was expected to triple. WHO estimated that more than
35 million new cases of curable sexually transmitted diseases occurred in the Region each year. Chlamydial infections were reaching epidemic levels. Rates of STD infection as high as 40% had been found among some groups of commercial sex workers. The Regional Director said that the regional programme on AIDS and sexually transmitted diseases could be classified into four broad areas. First, WHO's main emphasis was on reinforcing the prevention and control of sexually transmitted diseases. This was done mainly through training for STD programme management and through the promotion of STD syndromic case management. Second, WHO supported activities which reinforced epidemiological surveillance of STDs and HIV/AIDS. Third, WHO focused on activities which targeted commercial sex workers. Specific
programmes, such as model clinics in the Philippines, promoted the delivery of health services and peer education activities. Fourth, WHO worked with Member States on the reinforcement of the safety of blood transfusion and blood products.
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The Regional Director said that the previous session of the Regional Conunittee had requested clarification on the methodologies used for STD and HIV/AIDS estimations and projections and an update on antiretroviral treatments.
In most instances, to estimate the prevalence of HlV infections, WHO applied specific infection rates from representative subgroups to similar, larger population groups. In countries experiencing an HlV epidemic, past and present incidence of AIDS was calculated using Epimodel, a relatively simple computer program developed by WHO. circumstances. "Back projection models" were also used in certain
STD estimates were based on reviews of the most recent available ad hoc STD
prevalence surveys documented in published scientific reports or collected through a review of reports that had been published in national and international scientific journals. Antiretroviral agents were now used in three circumstances: for the treatment of HlV and AIDS; after exposure to body fluids ofHIV-infected persons (or post-exposure prophylaxis); and for the prevention of HIV transmission from mother to child. The cost-effectiveness of antiretroviral
treatments needed to be compared with that of other HlV/AIDS interventions, such as education, controlling STDs, and ensuring a safe blood supply. The REGIONAL DIRECTOR urged Member States to pursue their efforts to control STDs, including HIV/AJDS, by providing more political support and by mobilizing additional resources. WHO would continue to collaborate closely with Member States, UNAIDS and all other partners involved to prevent and control the spread of STDs, including HIV/ AIDS, in the Region. Dr PAPPAS (United States of America) stressed the importance of dealing with HIV/ AIDS in the Region before it became an uncontrolled emergency, such as had occurred in Mrica. He concurred with the Regional Director that the currently low rates in Member States of the Western Pacific Region should not make them complacent. He strongly supported the approaches to monitoring that were described in document WPRlRC49/6, but advised that new approaches to prevention should be considered. Testing and counselling were being re-evaluated as means of prevention in light of the development of easier, cheaper testing and as complements to public education. Progranunes of testing and counselling in Australia, New Zealand and Thailand had allowed those countries to advance their fight against the epidemic. He welcomed the discussion of antiretroviral therapy in the document but noted that few countries could afford it. policy. The Regional Office should propose a strong prevention
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Dr BOUNGNONG BOUPHA (Lao People's Democratic Republic) said that because the prevalence of confinned cases of HlV/AIDS was still low in her country, few resources had been allocated to the programme. The actual number of cases was probably much higher, however. Better and more reliable infonnation on the prevalence and incidence of infection and on the pattern of dissemination was needed. That, however, would require large resources and increased technical
cooperation. Cultural difficulty in discussing sexuality and sexually transmitted diseases meant that little was· known about sexual behaviour and about use of health facilities for sexually transmitted infections. Her country was, however, surrounded by others in which HlV/AIDS was prevalent, and travel between countries was increasing. Measures that must be taken to prevent uncontrolled spread of the disease included allocation of the necessary financial and human resources, increased technical cooperation with WHO and exchanges of infonnation with other countries for surveillance, revision of the medical school curricula and expansion of education for the general public. hnproved prevention and treatment of sexually transmitted diseases would contribute to the prevention of HlV infection, and technical guidance had been provided by WHO in that area. She asked for further information about WHO's work with regard to gonococcal antibiotic resistance. For example, how was the problem monitored and what action was required to prevent increased resistance. Her country was concerned about the increasing costs of certain treatments and the reduced effects of certain drugs. Mr Wang-Kon MOON (Republic of Korea) noted that his Government had taken a leading role m controlling the spread of HIVIAIDS in the Region and would continue to support countries financially and technically. New computer programs were needed for effective surveillance in countries with low HIV prevalence. Surveillance programmes could be expanded to include studies of high-risk behaviour and the attitudes of young people to HIV. Before a nationwide programme for treatment of HlV was instituted, research should be conducted to detennine the duration of therapy, tolerance, resistance, side-effects, how infection with HIV was to be assessed and how partners were to be notified. WHO should make careful
recommendations on use of anti-HIV drugs. A programme for notification of partners would also be an effective way of reducing high-risk behaviour in countries with a low prevalence of HlV infection. Mrs HA (Viet Nam) reported that the HIV epidemic in her country was continuing. By
15 August 1998, a cumulative total of 9940 cases had been reported from 59 of the 61 provinces of the country. Of those, 65.5% had been attributed to use of injected drugs and 9.4% to sexual transmission.
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Of the 1231 cases of AIDS, 664 had resulted in death. A sentinel surveillance system, established in 1994 in eight provinces and expanded to 20 provinces in 1996, had shown a decreasing trend in transmission due to intravenous drug use and an increasing trend of heterosexual transmission. A workshop had been held in Hanoi in August 1998, in which measures for further improving sentinel surveillance and methods for estimating and projecting the prevalence of HIV/AIDS had been discussed. The Institute ofVenero-dermatology had estimated that 25 000 to 50 000 new cases of sexually transmitted diseases occurred each year in Viet Nam, including gonorrhoea, syphilis, trichomoniasis and chlamydia. In 1997, 52 provinces had reported 71 000 cases of sexually transmitted disease. As most patients with such diseases were seen by private practitioners or treated themselves, however, that figure represented only about 10% of the true number. The system of surveillance in Viet Nam was not entirely satisfactory, and efforts were being made to strengthen it; a course in training managers of programmes on sexually transmitted diseases had been held in collaboration with WHO, with participants from Viet Nam and neighbouring countries. UNAIDS had included Viet Nam among four countries in which to implement their HIV Drug Access Initiative. A proposal for providing wider access to such drugs had been submitted to the Government of France, and it was hoped that with the assistance of that country and other partners antiviral bitherapy and tritherapy could be provided to 400 women for two years, during and after pregnancy. She looked forward to continued cooperation with WHO, UNAIDS and bilateral partners in efforts to control HIV and sexually transmitted infections and AIDS in Viet Nam. Professor WHITWORTH (Australia) emphasized the importance of annual reporting. Her
country had welcomed the increased allocation of regular resources to work on AIDS and sexually transmitted diseases in the 1998-1999 budget and was concerned to note the proposed 10% reduction in funding for the 2000-2001 biennium, particularly in view of the probable reduction in core funding of national AIDS programmes by UNAIDS. Collaboration between the Regional Office and UNAIDS in the collection and analysis of epidemiological data on HIV infection was valuable and could result in control of the epidemic within the Region. She asked that the next report provide further details of that collaboration, including identification of critical factors in achieving successful outcomes. She
welcomed the Director-General's proposal for a meeting with nongovernmental organizations since, in Australia's experience, such partnerships were invaluable in controlling the epidemic.
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Dr BABA (Japan) commended the leading role of WHO in controlling sexually transmitted diseases and HIV/AIDS. The latter had been successfully controlled in some countries of the Region, while in others the incidence had increased alanningly. She stressed the importance of surveillance and dissemination of data. STDIAIDS should be addressed not merely as a health issue but as a part of social development as a whole. In this respect, the proposed strengthening of programmes targeted to commercial sex workers and their clients was appropriate. Her country considered that HIV/AIDS was a priority for international collaboration. Within the 'global issues initiative on population and AIDS' , her country had allocated a total of US$ 3 billion over seven years, of which US$ 2.4 billion had already been contributed. Japan had also provided bilateral assistance and training to countries in the Region. It would continue to support the efforts of the Western Pacific Regional Office. Dr ABDUL LATIF (Brunei Darussalam) said that the number of HIV infections in his country was still increasing: as at 31 July 1998 there were 475 HIV infected people, 18 of them were
Bruneians; 457 were foreign nationals. Twelve of those infected had developed AIDS, and eight had died. Of those infected, 454 were male and 21 female. The majority (88%) were in the 20-39 age group at diagnosis. Heterosexual transmission accounted for 87% of the cases investigated. The
situation was causing grave concern, and showed the vulnerability of a small country with a large foreign population and well-travelled residents. The country remained committed to a strict
surveillance strategy and supported STD prevention and control as a means of preventing HIV infection. Dr TEMU (Papna New Guinea) welcomed the comparison of trends in the Western Pacific Region. The situation in Papua New Guinea was moving towards an epidemic, with high incidence of tuberculosis and sexually transmitted diseases. His Government had established a multisectoral
programme for control of HIV/AIDS and a strategic plan that was being implemented in 1998. He thanked the Regional Office, UNAIDS and AusAID for their support. Regional promotion of countrylevel progranune management, syndromic case management, the use of health services for the treatment of sexually transmitted diseases, and interventions focusing on commercial sex workers, were much appreciated. Alluding to the emergence of more bodies concerned with HIV/AIDS, the speaker
expressed the hope that WHO would reaffirm its leading role in epidemiology and monitoring of HIV/AIDS, as well as in prevention and control. He asked the Regional Director to continue to provide guidance and support for policy development, especially in the area of HIV and breast-feeding, and the matter of confidentiality. Further information on multidrug therapy would also be most welcome.
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Ms ABEL (Vanuatu) said that no cases of HIV/AIDS had been reported in Vanuatu but that health workers were being trained in syndrornic management of cases. She thanked the secretariat of the Pacific Community, which had been working with WHO, UNAIDS and Pacific countries and territories to develop a prevention and control programme specific to the Pacific situation. It
encouraged nongovernmental organizations to work with governments. The Department of Health was being reorganized, and the national programme on HIV/AIDS now came under the family health programme, which included reproductive health, family planning and sexual health. All of this was designed to improve horizontal service delivery. Mr ROKOVADA (Fiji) said that his country had responded to the problem of HIVIAIDS and sexually transmitted diseases as long ago as 1988, with a programme based on the principles of primary health care which aimed to prevent the spread of HIV infection through the main routes of transmission. To this end it had trained health workers, and equipped health facilities for screening and disease surveillance. A public education campaign had been conducted.
An external review in
September 1993 had formed the basis for short-term (1994-1997) and medium-term (1998-2002) programming of activities. To date, there were 43 cases of HIV infection in Fiji, ten of which had developed into AIDS. The statistics did not include residents or nationals who had tested positive abroad and were being followed up by private physicians. OF these cases, 71% had involved heterosexual transmission and 18.4% homosexual; there had been one case of perinatal transmission and one involving contaminated blood. He asked for UNAIDS to estimate numbers of cases for the next ten years. No decision had yet been taken on the use of antiretroviral agents in Fiji, although because of cost antiretroviral agents did not seem feasible. The country concentrated instead on maintenance of good health and nutrition, and counselling. Since there had been only one case of perinatal transmission and malnutrition was a major threat, Fiji continued to advocate breast-feeding in all circumstances. However, the right of the mother to choose whether or not to breast-feed would be respected. Mr DAVIES (New Zealand) remarked on the worrying trends documented in the report, with a cumulative total of over 40 000 cases of AIDS by the end of 1997, and a prediction by the Regional Office of over 50 000 cases per annum by the end of the century. Since over 36% of cases were associated with the use of injected drugs, hepatitis C could well be a significant problem. He asked for the next report to include an analysis of hepatitis C prevalence among injecting drug users in the Region as well as recommended prevention and control strategies.
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He expressed condolences to the friends and colleagues of the late Jonathan Mann, who had made an invaluable contribution to the fight against AIDS and who had died shortly before the session. Dr LAUDON (France) noted that the document referred to considerable underreporting of HlV/AIDS and asked what technical support would be provided by the Western Pacific Region to remedy that problem. He asked also what kind of technical training and support WHO would provide to ensure .blood safety in countries that had no national policy for safe transfusion. Finally, he asked how WHO was collaborating with UNAIDS and what had been achieved since the previous session of the Regional Committee. Dr FERNANDEZ (Philippines) said that HlV transmission in the Philippines had been described as low and slow. Only 0.04% of the adult population was estimated to be infected. Most cases entailed heterosexual transmission and were men and in the 20-49 age group. The risk groups were male and female sex workers, male STD patients and injecting drug users. prevention programme had five components: The national
HIV surveillance, infonnation, education and
communication, laboratory services, clinical management and care, and programme management. The AIDS Prevention and Control Act of 1998 had further strengthened the national programme for prevention and control ofHlV/AIDS and STD. Dr LIU Guo-Bin (Macao) reported that the AIDS situation had been stable in the period from I January 1997 to 31 July 1998, with four cases of AIDS among 39 cases ofHlV infection (16 women and 23 men). Only five were permanent residents of Macao. The compulsory testing of foreigners coming to the country to work in various entertainment facilities had begun in 1992 and was now routine practice. Health education had increased awareness of how to control HlV and AIDS. Dr MAM BUN HENG (Cambodia) congratulated the Regional Office, which had been helping the country since 1991 to develop its programme for the control of sexually transmitted diseases including HlV/AIDS. A committee had been established at ministerial level, but the HlV/AIDS
remained an immense problem due to the speed of transmission. With the help of UNAIDS, UNICEF, the European Union, the World Bank and nongovernmental organizations improvement was expected. The speaker thanked the Regional Office for having been first on the scene to help in Cambodia. The DIRECTOR, PROGRAMME MANAGEMENT, voiced his satisfaction at the way in which the discussion focused on positive developments at country level. He remarked that the DirectorGeneral was to chair the UNAIDS Committee of Co-sponsoring Organizations from November 1998
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for one year. She had announced that HIV/AIDS was a cabinet priority, and that WHO's global approach to AIDS and sexually transmitted diseases was being looked at afresh in the context of the cluster on Family and Health Services. In response to the representative of the United States of
America, he said that testing and counselling were to be evaluated in the coming year, so as to adapt successes to other countries and situations. The representative of the Lao People's Democratic
Republic had alluded to gonococcal antibiotic resistance. That was a very serious problem in the Region, due largely to inadequate or inappropriate antibiotic therapy, and to practices such as commercial sex workers giving clients antibiotics as prophylactic agents. WHO was encouraging all governments to monitor the sensitivity of antibiotics on a collective basis. The Gonococcal Antibiotic Sensitivity Progranune, established in the Region in 1991, had been producing data continuously since 1992, and its reports were published in the six-monthly newsletter on HIV/AIDS produced by the Regional Office. The representative of Australia had raised the issue of the reduction in the budget for 2000-200 I; the Regional Office was seeking extrabudgetary resources and cooperation with other agencies to remedy this situation. ill that context, it was reassuring to hear how Japan was looking at coordinating its contribution to UNAIDS, WHO and the Region. He pointed out that Japan was
funding one post for an epidemiologist and public health specialist to work at the Regional Office. He assured the representative of Papua New Guinea that the Regional Office would endeavour to comply with his request for support for policy development in the areas of breast-feeding by HIVpositive mothers and confidentiality. He welcomed the positive developments reported by the representative of Vanuatu concerning a coordinated approach to HIVIAIDS control in the Pacific island countries. That provided a good example of intercountry coordination. Referring to the request made by the representative of New Zealand for the Regional Office to provide an analysis of hepatitis C prevalence among intravenous drug users in its next report, he said that no data for the Region were at present available. However, the Regional Office would endeavour to provide some indication of the situation in its next report. He assured the representative of New Zealand that the deep regret of the Committee at the tragic death of Dr Jonathan Mann would be recorded in the final report of the session. The representative of France had raised the issue of extent of underreporting, especially in smaller countries. The Regional Office would seek ways of coordinating with such countries on that issue. France was funding a post for a specialist in blood safety in the Regional Office, in order to
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enhance blood safety in the Region. A major emphasis of WHO in that area was on the institution of non-remunerated blood donation, in order to obtain a supply of safer blood. Attention was also being paid to the proper management of blood services in order to improve cost-effectiveness and provide easier and cheaper access to blood transfusion. He assured the representative of France that
coordination with UNAIDS should improve as a result of the changes in WHO. Finally, he felt that the representative of Cambodia had summed up the views of the Committee in stressing the importance of multipartner support in the field of HlV/AIDS and sexually transmitted diseases. He thanked the representatives for their positive approach to discussion on the subject and for the pertinent suggestions they had made. The CHAIRPERSON requested the Rapporteurs to prepare an appropriate draft resolution for consideration at a later meeting.
3.
EXPRESSION OF APPRECIATION TO DR S.T. HAN Dr SHINOZAKI (Japan) proposed the adoption of the following draft resolution in recognition
of the outstanding contribution made by the Regional Director, Dr S.T. Han, to the improvement of health in the Western Pacific Region of WHO. The Regional Committee, Recognizing Dr S. T. Han's devotion to international health and the contribution he has made as Regional Director for the Western Pacific over the past 10 years;
I.
THANKS Dr S. T. Han for his dedicated leadership and invaluable contribution to health
development in the Western Pacific Region; 2. REQUESTS him to continue to contribute to health development in the Region in his personal
capacity; 3. DECIDES that in view of his immense contribution, he be made Regional Director Emeritus. The representatives of China, the Philippines, Kiribati, New Zealand, Fiji, the Lao People's Democratic Republic, Viet Nam, the Federated States of Micronesia, Niue, the Republic of Palau, the
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United States of America, Cambodia, Brunei Darussalam, Nauru, Australia, Tuvalu, France, the United Kingdom of Great Britain and Northern Ireland, Samoa, the Republic of Korea, Singapore, Hong Kong (China), Macao, Papua New Guinea, Mongolia and Vanuatu took the floor to express their wholehearted support for the draft resolution. Decision: The draft resolution was adopted by acclamation.
4.
ERADICATION OF POLIOMYELITIS IN THE REGION: PROGRESS REPORT: Item 11 of the Agenda (Documents WPRlRC4917 and WPRlRC49IlNF.DOC.lI) The DIRECTOR, PROGRAMME MANAGEMENT stated that the year that had passed since
the previous session of the Regional Committee was a landmark in the history of poliomyelitis eradication. It was the first year since records had been kept in which no new cases of poliomyelitis had been reported in the Western Pacific Region. That remarkable achievement was a credit to the many countries whose hard work had reduced the burden of poliomyelitis from 6000 cases in 1990 to zero in 1998 by carrying out nationwide immunization and surveillance activities for poliomyelitis eradication. It was also a credit to the many countries who had given technical and funding support in what had been a truly international effort. The last case of poliomyelitis in the Region had been a Cambodian girl aged 15 months who had had onset of illness on 19 March 1997. Since then, as of I July 1998, over 7000 acute flaccid paralysis (AFP) cases had been reported, of which 85% had had two stool samples taken within 14 days of onset. No wild poliovirns had been isolated from any of those cases. A total of 26 national innnunization days had been carried out in seven countries since 1992. In the last two years, efforts had been particularly intense. From November 1996 to April 1998,
Cambodia and Viet Nam had carried out eight rounds of supplementary innnunization with oral poliovirus vaccine in high-risk areas, notably around the waterways of the Mekong River and its delta where the last wild polioviruses had been found. There had been excellent cooperation on poliomyelitis eradication between countries in the Region and those in the South-East Asia Region. In many instances countries had arranged to
coordinate supplementary innnunization and share surveillance information with their neighbours.
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The process leading up to certifying the eradication of poliomyelitis in 2000 had been going on for two years and involved every country and area in the Region. At the third meeting of the Regional Certification Commission which had taken place in Brunei Darussalam from 4 to 5 August 1998, the eight countries that had been recently reporting poliomyelitis (Cambodia, China, the Lao People's Democratic Republic, Malaysia, Mongolia, Papua New Guinea, the Philippines and Viet Nam) had presented their plans of action for certification. In those plans, they had stated how they would
maintain AFP surveillance and supplementary immunization, and how they would respond rapidly to the possible importation of wild poliovirus from other regions. On behalf of the Regional Director, the Director, Progranune Management thanked all the partners whose support had made poliomyelitis eradication an international success. They were the Govermnents of Australia, Japan, the Republic of Korea and the United States of America, through the Centers for Disease Control and Prevention in Atlanta; the Agency for Cooperation and International Health; Rotary International; Rotary International Districts 2650 and 2640; and UNICEF. He also thanked the Govermnents of Canada, Finland, France, Italy, Malaysia and Sweden, who had supported the initiative in the past. He concluded by encouraging all countries to sustain their surveillance efforts so that regional certification of eradication could be achieved in 2000, and the ultimate goal of global certification could be reached. He explained that, after poliomyelitis had been eradicated, the laboratories of the world would be the OIily remaining source of wild poliovirus. It was essential that those laboratory stocks be contained. For that reason, WHO had developed a Regional Action Plan and Timetable for Safe
Handling and Maximum Laboratory Contaimnent of Wild Poliovirus and Potentially Infectious Materials. Dr LlU Peilong (China) expressed his delegation's appreciation of the progress report. He wished to add a few points and raise several questions. The danger of the importation of wild
poliovirus referred to in the report was a serious one, as borne out by the four imported cases reported by China in 1995 and 1996. High-quality surveillance in border areas was essential. The report also mentioned the difficulty of maintaining high immunization coverage in children. development of China, high population mobility added to that problem. In the final period of poliomyelitis eradication, vaccine-related cases would be a major issue. He understood that some developed countries were considering the use of inactivated vaccine to replace live vaccine. He asked whether WHO intended to promote a similar measure in developing countries. In the economic
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Finally, with the eradication of wild poliovirus, there was a danger of hybrid viruses emerging. He asked for WHO's views on whether a hybrid virus could cause transmission. Dr TEMU (Papua New Guinea) said he welcomed the achievements highlighted in the progress report and commended the leadership and successful country-level efforts of the Regional Director. However, he warned that his country's efforts to adhere to the certification requirements would be jeopardized unless the necessary resources were continuously available. His delegation wished to urge the Regional Director to continue his close collaboration with Member States to secure external funding and provide technical support. He expressed appreciation for the support provided by the Australian Government for the funding of national immunization days, and for the vaccines provided by the Government of Japan. His delegation was also grateful for the support received from UNICEF and UNFPA and for the technical support provided by the Regional Office. The importance of the collaboration of Member States in compiling an inventory of laboratories holding wild poliovirus could not be overemphasized. Mr TSUDA (Japan) expressed appreciation of the efforts made by Member States and WHO to eradicate poliomyelitis. He stressed the importance of maintaining a high level of surveillance and focusing on supplementary immunization in high-risk areas. Poliomyelitis eradication was a priority area for Japan's international cooperation, and his country had provided vaccines and cold chain equipment, assisted with surveillance and strengthened laboratory diagnosis not only in countries of the Western Pacific Region but also in the South-East Asian and African Regions. Japan had resolved to continue its cooperation with the Regional Office and its active support for the eradication programme. He asked for clarification of the relationship between the Regional Action Plan for Safe Handling and Maximum Laboratory Containment of Wild Polioviruses and Potentially Infectious Materials and the Global Action Plan. He stressed the importance of the strict containment of wild poliovirus, including stool samples containing the virus, not only in order to prevent the spread of the virus outside laboratories but also to prevent any contamination of virus isolates. He warned that wild poliovirus was also handled in
university research laboratories and in establishments manufacturing inactivated vaccines, where the pathogenicity of the virus was not always fully appreciated.
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In the opinion of his delegation, the present status of wild poliovirus containment in the Western Pacific Region was not satisfactory, as some national laboratories were unable to handle the virus adequately. The National Institute of Infectious Diseases in Japan had been requested to ensure the containment of the relevant materials. The subject was due to be discussed in more detail at a meeting in Geneva in October 1998. Dr DURHAM (New Zealand) said that the programme had reached a critical point. She noted the spectacular success of immunization days in countries where conditions were immeasurably more difficult and involving populations immensely larger than hers. She applauded the annual report's
systematic approach, exemplified by Table 3 of the report. She requested information on the financial and human resources required to carry out the Regional Action Plan and Timetable for Safe Handling and Maximum Laboratory Containment of Wild Polioviruses and Potentially Infectious Materials. Would funding be from the regular budget or would it be extrabudgetary? If extrabudgetary, had funds been secured? What action should countries take to secure the laboratory containment of wild
poliovirus in the next 12 months? What were the training needs? How would the implementation of the plan be monitored? What action was envisaged if the results were variable or poor? Dr PAPPAS (United States of America) said that as verification of eradication proceeded, the capacity-building element of the programme should be documented and evaluated as a part of costlbenefit analysis with a view to subsequent campaigns against other diseases. He urged close attention to interregional control and to the need for donors to close the "funding gap" ofUS$150 million for the global programme. Dr T AITAI (Kiribati) associated himself with the call for continued close cooperation and financing and technical support to ensure the maintenance of measures for immunization, surveillance and containment until global certification of eradication was achieved. Dr ROKOVADA (Fiji) said that in Fiji routine vaccination coverage with oral poliovirus vaccine (OPV) for 1997 had been over 90%, a figure that was likely to be improved upon as subdivisions completed their reports. A national survey of all vaccinations would be carried out in 1999. No supplementary campaign was envisaged as the disease was not endemic in Fiji.
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Since 1997, the Government had been responsible for procurement of all vaccines in the EPI programme. Furthermore, since 1995 immunization against Haemophilus injluenzae type B (HIB) was included, because HIB meningitis was a killer of infants in Fiji. Active hospital surveillance for poliomyelitis had started in 1997, when four cases of acute flaccid paralysis had been recorded. As good surveillance was reckoned to detect one such case per 100 000 population, six or seven a year could be expected. Professor WHITWORTH (Australia), noting the importance of sustained surveillance, commended WHO's efforts to coordinate activities between countries from different regions, particularly those involving China and Myanmar. She shared Japan's concern about containment of wild poliovirus. Mrs HA (Viet Nam) expressed her country's commitment to the eradication goal and endorsed the report. Viet Nam had maintained full immunization coverage for more than 90% of children under one year of age. From 1993 it had held national immunization days, vaccinating over 99% of children under five years with two doses of oral poliovirus vaccine. High-risk response vaccination had been implemented since 1997 in Southern and Central Provinces, reaching 60 districts in 1998, with so far no reported case of wild poliovirus infection. strengthening of surveillance. High coverage must be maintained, with further
Efforts were continuing in Viet Nam to strengthen local vaccine
production and to achieve self sufficiency. She acknowledged Japan's assistance in this regard and looked forward to continued cooperation to strengthen production. Dr OITO (Palau) said that the programme promised to be one of WHO's success stories and thanked the Governments of the United States of America and Japan and WHO and UNICEF for their support to Palau, where the immunization rate was over 95% for children under two years of age. Dr BOUNGNONG BOUPHA (Lao People's Democratic Republic) emphasized the difficulty of ensuring wide immunization coverage in countries where communications were difficult. In her country 85% of the population lived in rural areas. Yet with WHO's support and the dedication of national authorities and programme managers, immunization had increased from 40% in 1992 to 70% in 1997. The last case attributable to wild poliovirus had been reported in July 1996 in Sekong province, where two rounds of high-risk response immunization had been carried out in 1997. Since 1994, national immunization days had reached every village. Supplementary immunization had reached
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95%-99% of villages and 80% to 91 % of children up to five years of age. Good surveillance for acute flaccid paralysis had been extended to the whole country. Dr ABEL (Vanuatu) reported that in her country immunization coverage with oral poliovaccine was over 90%. Acute flaccid paralysis surveillance had been a pennanent feature of the EPI A national survey to detemrine coverage for all vaccine-
programme since its establishment.
preventable diseases would be conducted in October 1998. Dr PRETRICK (Federated States of Micronesia) said that although his country had been free of poliomyelitis for at least 25 years, a vigorous immunization programme had been carried out. In 1997, the level of coverage among children under two years of age was as high as 94%. All students had to complete vaccination before attending courses. Acute flaccid paralysis surveillance had started in January 1998, with monthly reports from hospitals. He thanked partner agencies for their support. Dr SAIMY (Malaysia) said that the last case in Malaysia had been reported in 1992 and the country was about to declare itself free of poliomyelitis. However, active surveillance and wide immunization coverage continued, especially in view of the large migrant population. Dr FERNANDEZ (Philippines), recognizing the major achievement of governments, paid tribute to the thousands of health workers involved in the Expanded Programme on Immunization and in national immunization days. In 1997, the Philippines had reported no cases for the first time. Routine oral polio vaccine immunization and NIDs had been carried out from 1993. Close surveillance for acute flaccid paralysis had been carried out since 1992. Dr GERMAIN (France) wished to be associated with the commendations of other delegations; the positive results of the programme must be consolidated and vigilance redoubled until eradication was achieved. He supported China's proposal for the surveillance of all cases of acute flaccid paralysis. Vaccination must continue in high-risk areas in order to prevent the possible reintroduction of wild poliovirus. The DIRECTOR, PROGRAMME MANAGEMENT, said that most of the coordination with other regions to date had concerned China and Myanmar. Since 1996, three meetings had been held
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under the auspices of WHO on policies and strategies to ensure eradication of poliomyelitis in border areas. Interregional meetings had been held on communicable diseases control and prevention, one in 1996 in New Delhi, a second in Beijing in October 1997 and a third was planned in Thailand in November 1998. Poliomyelitis eradication was a major item of each meeting. Ways were being
sought to establish closer contact with countries in other regions neighbouring on the Western Pacific, namely the Eastern Mediterranean and the European Regions. The representatives of Papua New Guinea, Japan, New Zealand and Australia had raised the very important question of safe handling and maximum laboratory containment of wild poliovirus and potentially infectious materials. This issue had been brought to the attention of the Regional Committee at the specific request of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific at its meeting in Brunei Darussalam in August 1998. As the representative of Japan had mentioned, this issue not only affected laboratories dealing with wild poliovirus investigation but also those producing poliomyelitis vaccines. A lot of political will would be required of countries with large networks of laboratories in order to institute effective containment. He drew attention to the activities proposed to be undertaken by Member States during the next 12 months; namely, the
establishment of an inventory of laboratories holding wild poliovirus, infectious or potentially infectious materials; the formulation of measures to ensure that the laboratories that were handling and storing such materials were doing so at the biosafety level - 2 (BSL-21P0lio) or above; and the preparation of maximum containment measures (BSL-4) for all remaining materials. Unless this important issue was dealt with, the danger of wild poliovirus starting to circulate again would be ever-present. The REGIONAL ADVISER, EXPANDED PROGRAMME ON IMMUNIZATION explained that plans were being developed to ensure elimination of wild poliovirus throughout the world after eradication had been declared. The first step would be to make an inventory of potentially infectious materials still stored in teaching, research and diagnostic laboratories. For instance, such materials might remain from a survey conducted 10 or 20 years previously. The vast majority of those materials would be destroyed; the few wild polioviruses that would be required for research or reference would eventually be sent to designated laboratories that had the capacity to handle them safely. In the
Western Pacific Region, with the agreement of the Government of Japan, the National Institute for Infectious Diseases in Tokyo had been so designated. The resources required for adequate containment could largely be provided from those available for surveillance in recently endemic countries. The actions taken in each country should be monitored by the national certification committees and by the Regional Certification Commission.
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In response to the representative of China, he said that maintaining high coverage in high-risk areas, particularly for mobile populations, was very important. People who moved to seek employment in cities might have poor access to health services. WHO had been working with countries, including China, to develop plans of action to ensure immunization of all children, regardless of whether they were permanent or temporary residents. Considerable progress had been made in China. Vaccine-associated paralytic poliomyelitis became a greater issue as wild poliovirus disappeared. Oral vaccine was recommended by WHO as the vaccine of choice for poliomyelitis
eradication. It was very effective and cheap and had been the only vaccine used in most countries that had been recently endemic. Countries that wished to introduce intravenous poliomyelitis vaccine should bear in mind that it was perhaps seven times more expensive than the oral vaccine and an additional injection was required. WHO did not consider use of intravenous vaccine necessary in recently
endemic countries and did not recommend it for eradication or certification of eradication of poliomyelitis. The possibility of the emergence of a hybrid virus had been considered. At a recent meeting in Geneva, it had been concluded that that was not a major risk, although research on the issue would continue. Recently endemic countries were concerned about having adequate resources to ensure regional and global certification. Adequate resources were available from the many partners and agencies for vaccine for 1998, but there might be some shortfall from 1999 onwards of vaccine and funding for surveillance and laboratory costs. Continued support was being sought from the partner agencies. However, no country need fear that, because poliomyelitis had not been reported for 18 months, activities or support would cease. It should be borne in mind that it was as expensive to maintain surveillance in the absence of poliomyelitis as in its presence: reporting had to be maintained at the same level. The Chairperson thanked all the speakers and requested the Rapporteurs to prepare an appropriate draft resolution for consideration at a later meeting.
The meeting rose at 5.15 p.m.