(WP)CHD/ICP/TUB/OO l-E (WP)CHD/ICP/LEP/OO l-E Report series number: RS/94/GE/33(FIJ) Original: English
REPORT WHO/PLF/SPC WORKSHOP ON MANAGEMENT OF TUBERCULOSIS PROGRAMMES AND LEPROSY ELIMINATION IN THE PACIFIC
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC in collaboration with PACIFIC LEPROSY FOUNDATION and SOUTH PACIFIC COMMISSION Suva, Fiji 21 - 30 November 1994
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines August 1995 Wlh):\\P1U) LIIHlr\RV rfL\'\~~~ \. P;:~T.!<)r:';ES
17
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NOTE
The views expressed in this report are those of the parlIclpants in the WHO/PLF/SPC Workshop on Management of Tuberculosis Programmes and Leprosy Elimination in the Pacific and do not necessarily reflect the policies of the Organization.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the WHO/PLF/SPC Workshop on Management of Tuberculosis Programmes and Leprosy Elimination in the Pacific, which was held in Suva, Fiji, from 21 to 30 November 1994.
CONTENTS
SUMMARy .............................................................................................. . 1. 2.
1
INTRODUCTION................................................................................... PROCEEDINGS OF THE WORKSHOP.......................................................
2 2
2.1 2.2 2.3 2.4 2.5 2.6 3.
Opening ceremony................................................ ............ ............. Objectives....................................................................................... Participants. . . . . .. ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. ............................. Tuberculosis section..................................................................... Leprosy section ................... ............................. ....... ........................ Closing ceremony........................ .... ................. ................................
2 2 2 2 5 6 6
MAIN OUTCOME OF THE WORKSHOP ....................................................
3.1 Tuberculosis.................................................................................... 3.2 Leprosy.......................................................... ................
6 7
ANNEXES ANNEX 1 ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5 ANNEX 6 PROGRAMME OF ACTIVITIES............................................
9
FINAL LIST OF PARTICIPANTS .......................................... 13 GROUPING OF PARTICIPANTS ........................................... 19 FACILITATORS ................................................................. 21 INFORMATION SYSTEM FOR LEPROSy .............................. 23 GROUPING OF COUNTRIES ACCORDING TO EPIDEMIOLOGICAL STATUS .............................................. 25 SUMMARY OF LEPROSY SITUATION IN THE PACIFIC .................................................................... 29
ANNEX 7 -
Key words Tuberculosis - prevention and control I Leprosy - prevention and control I Programme management I Pacific Islands I Fiji
WHOIWPRO LmRARV MANILA. Pl:!l':';':'\ES
SUMMARY
The World Health Organization Regional Office for the Western Pacific together with the Pacific Leprosy Foundation (PLF) and the Soalh Pacific Conunission (SPC) organized a workshop on management of tuberculosis and elimination of leprosy in the Pacific for 28 participants from 19 Member States in Suva, Fiji, from 21 to 30 November 1994. The objectives of the workshop were: (1) (2) (3) (4) (5) to gain knowledge of effective methods of management of a national tuberculosis control progranune: to transfer the newly-acquired skills to upgrade the management of national tuberculosis progranunes; to review the leprosy situation in Pacific countries and areas; to identify activities which still require technical support in leprosy; and to plan a two-year strategy for intervention for tuberculosis and leprosy.
The tuberculosis section emphasized training trainers and progranune managers. The participants were exposed to the various methods of teaching and met a new facilitator for each new module on rotation. The methods included a combination of techniques, such as group discussions, exercises with individual feedback and a practical session represented by a field visit to the Tamavua Hospital. Special attention was given to supervisory activities, detection of sputum smear positive tuberculosis cases at district level. registration of cases, monitoring treatment and evaluation of treatment results. The questionnaire filled in by the participants at the end of the tuberculosis section of the workshop showed that the majority were satisfied with the course and its content. Many participants expressed a wish to re-orientate their national progranunes or parts thereof in accordance with the WHO guidelines. The leprosy section focused on country situation analysis and selection of activities to be implemented according to the situation. Each group represented countries with similar leprosy situations. Each one gave an outline of the main activities they needed to implement to reach the elimination goal or to monitor leprosy after its elimination as a public health problem.
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1. INTRODUCTION
The training course "Managing Tuberculosis at District Level" comprises nine modules, each focusing on a specific task in management of tuberculosis at the district level. The course is aimed at district tuberculosis control officers, which is the level where the programme is fully implemented. This was the second course organized in the Region, focusing this time on the smaller Island countries of the South Pacific. The first course was held in Manila from 28 July to 4 August 1993 with participants from the highly-populated countries in the northern part of the Region. The purpose of the training course was mainly to provide knowledge and insights into the strategies of tuberculosis management according 10 the WHO framework. A world leprosy elimination plan had been set-up with the aim of decreasing leprosy prevalence to less than one case per 10000 population by the year 2000. Overall, as an average, the Western Pacific Region achieved the goal of elimination of leprosy in 1990. However, only 18 countries and areas had reached the elimination goal in 1993. Moreover, some countries in the Pacific still have high prevalence rates close to or above 10 cases per 10 000 population. The purpose of the workshop was to build a strategy for intervention according to the situation in each country.
2. PROCEEDINGS OF THE WORKSHOP
2. 1
Opening ceremony
The opening address was given by Mr A. Tudreu. the Permanent Secretary for Health and Social Welfare. Fiji. He was particularly concerned at the increase in tuberculosis incidence over the last few years and also the low detection rate in Fiji. He expressed a wish for strong action to be taken to control tuberculosis and for collaboration with other public health programmes. The workshop was opened by Dr Michael O'Leary on behalf of Dr S.K. Ahn, WHO Representative in the SOUlh Pacific. Dr O'Leary remarked in his opening speech that the leprosy and tuberculosis situations were very different. Elimination of leprosy as a public health problem by the year 2000 was a realistic issue in the Region with better management of programme and extensive use of Multidrug Therapy (MDT) in countries where the prevalence is still high. It is expected that 20 countries will have reached the target by 1995. In contrast, Dr O'Leary noticed the low priority given to tuberculosis control in the Region. There was a lack of funds for drugs and supplies. However, most important was the lack of knowledge on management of programmes both in leprosy and tuberculosis. This workshop was aimed at an improving programme management.
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2.2
Objectives The objectives of the workshop were:
(1) (2) (3) (4) (5)
to gain knowledge of effective methods of management of a national tuberculosis control programme; to transfer the newly-acquired skills to upgrade the management of national tuberculosis programmes; to review the leprosy situation in Pacific countries and areas; to identify activities which still require technical support in leprosy; and to plan a two-year strategy for intervention for tuberculosis and leprosy. The programme of activities is attached in Annex 1.
2.3
Participants
Twenty six participants from 18 countries attended the workshop (Annex 2). Only one participant (Mariana Islands) was unable to attend. In addition, seven resource persons, six observers and six members of the secretariat attended. The workshop languages were French and English. 2.4 2.4.1 Tuberculosis section Methodology
All facilitators had attended workshops in Geneva (1992 and 1994) to become acquainted with the training material. The participants were divided into four groups, three English-speaking groups comprising of eight to nine persons each and one French-speaking group of six persons. Participants from the same country were allocated to different groups (Annex 4). The facilitators rotated between the different groups (except the French group) on a daily basis (Annex 3). Each module was introduced by a facilitator, after which the participants were requested to read the related pages before going on to the exercises. Group discussions were held every day and at the end of each module. A field visit to the nearby Tamavua Hospital was induded in the agenda (Annex 1). 2.4.2 Course contents
The training material consisted of nine different modules each focusing on a specific task for management of tuberculosis at the district level (Annex 1). The modules were not uniform, but of varying difficulty. The time allowed for each module varied considerably. The module on 'Administering treatment' was the most difficult owing to its length and content.
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2.4.3
Practical training
In order to test the participants' understanding of the text, exercises followed each part of the text. The facilitators supervised and guided the participants in these exercises. Role-plays were incorporated to visualize and highlight situations that may be met as a district co-ordinator. One afternoon was spent on a field visit to the Tamavua Hospital, where the participants were shown the registry, patient files and follow-up activities. The laboratory at the PJ Twomey Hospital was also visited. A video tape on culture technique was shown. 2.4.4 Questionnaire A questionnaire was handed out to all participants with the following questions:
1. Based upon what you learned at this tuberculosis control workshop, which changes would you like to make to your tuberculosis control programme? Most countries wanted to adopt the WHO policy as a whole, some wanted to improve the treatment regimens, introduce supervised treatment and to reduce SCC from nine to six months. Evaluation of treatment outcome was also suggested.
2. HoI\' can these modules be incorporated into the training o/your tuberculosis control staff? The modules will be assessed for possible use and reference for training material. National workshops were proposed to take place within the coming year. Some participants requested that the diskettes with the course material should be made available.
3. What extra assisTance would vou require from WHO, SPC and PLF to implement these changes? A large majority wanted to have comprehensive tuberculosis programme reviews carried out by WHO. Fiji asked for a tuberculin survey to be carried out to assess the annual risk of infection. Annual visits by WHO and SPC, national tuberculosis workshops, guidance on the quality control of drugs and procedures for drug procurement, help in preparing tuberculosis manuals, and funding for drugs and other supplies were also requested. The South Pacific Commission responded by offering support for technical assistance and operational research. Funding is possible for reviews and surveillance. The SPC would like to see integrated tuberculosis and leprosy programmes. The Pacific Leprosy Foundation is finding it difficult to expand into tuberculosis control. They are, however, supporting collaboration between tuberculosis and leprosy programmes through technical input from WHO consultants. Some countries in the Pacific have funds for tuberculosis provided through the War Memorial Anti-Tuberculosis Fund. 2.4.5 Course evaluation
An evaluation questionnaire was requested from all participants at the last session. The majority of participants found the workshop of great interest to their programmes.
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2.5 2.5.1
Leprosy section Presentations on leprosy elimination strategy
Dr S.K. Noordeen (Chief Leprosy Unit, WHO/Geneva) gave a presentation on Elimination of leprosy as a public heallh problem, progress and prospects. The author stressed the need for coordinated efforts by all interested parties to achieve the goal of eliminating leprosy in all countries. This goal was achievable with the powerful multidrug therapy, but intensified efforts should be made during the next five years. Dr Yo Yuasa from the Sasakawa Memorial Health Foundation, Tokyo, presented a paper on How can we accelerate progress towards elimination of leprosy? To make progress there was a need of fast, flexible and focused actions. Also the programmes needed to be effective, efficient and economic. However in order to achieve the goal, intensified actions may not be efficient in terms of manpower requirements and not economic in terms of costbenefit. Dr Leopold Blanc, Regional Adviser in Chronic Diseases, presented the Leprosy elimination plan for the Western Pacific Region. Although the elimination target had been achieved in 18 countries in the Region, some of the remaining ones still had a high prevalence rate and needed intensive efforts. The strategy was based on five main activities: extension of MDT in difficult-to-reach areas, special programmes for selected countries, improvement of management. monitoring and evaluation and planning of rehabilitation programmes. Dr Paul lakeman, Evaluation Unit, The Leprosy Mission (TLM) Singapore, presented a paper on Monitoring leprosy after elimination. He stressed the need for careful monitoring of trends and the need to use more refined indicators than simple prevalence. After presentations of technical papers, cosponsoring and invited organizations presented their role in leprosy elimination and in surveillance of communicable diseases. 2.5.2 Country presentation
Each country's participant had prepared a short presentation on the leprosy situation in his/her country. Because of the availability of records in Fiji, this country had prepared a comprehensive review of epidemiological aspects of the disease during the last ten years. A summary sheet has been prepared for each country and will be edited as a separate document. According to this presentation, all countries except three are able to provide information on disability and age among new cases. Information systems seem to be complicated and poorly efficient. 2.5.3 Group discussions Before group discussions, Dr Roland Farrugia, WHO consultant for the workshop, explained how to draft a plan of action for elimination of leprosy. Dr Blanc outlined the requirements for improving the recording reporting system for leprosy and proposed to use six essential indicators to monitor the disease (Annex 5). Countries and areas were divided in three groups according to their epidemiological status (Annex 6): Group 1: countries which have achieved the elimination target, Group 2: countries which are close to the target, and Group 3: countries which still have a serious leprosy problem. Each group elected a moderator and a rapporteur. The group reports (Annex 6) will serve as guidelines for the country plan of action.
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2.6
Closing ceremony
Dr S.K. Ahn. WHO Representative for the South Pacific, closed the workshop. He stressed the importance of the new management approach for tuberculosis progranunes and the necessity of having common definitions of patient categories to make progranune evaluation possible. He stressed also the necessity to supervise activities performed by health workers. On the leprosy aspect of the workshop, he recognized the importance of planning to achieve the target of elimination of leprosy as a public health problem, and the essential role played by the participants at the workshop. who will implement the programme. He noticed that this workshop was most welcome as it coincided with the 25th anniversary of the Twomey Memorial Hospital, where the workshop was held.
3. MAIN OUTCOME OF THE WORKSHOP
3.1 3.1.1
Tuberculosis Classification of tllberculosis
Tuberculosis patients can now be classified in a more convenient way according to their bacteriological status and the outcome of treatment. 3.1.2 Treatment regimens
For e.ach of the patient categories, there is a specific treatment regimen using at least four drugs including rifampicin and isoniazid during the initial intensive phase. A treatment regimen for relapse and failure cases is also planned with a second line of drugs. 3.1.3 Sputum smear microscopy
The new approach emphasizes sputum smear microscopy as the main tool of diagnosis. The rational is that priority is given to detection and cure of new cases of sputum smear positive tuberculosis thus reducing transmission in the community. 3.1.4 Supervision
Supervision of health care staff and laboratory technicians as well as patients can be planned as systematic and regular activities. 3. 1. 5 Reporting
Through the registration and reporting system, it will be possible to calculate the cure rate of new cases of sputum smear positive tuberculosis. This will also be an indicator on the programme control efforts (cohort analysis). Countries will first introduce the new management approach in limited areas and then expand it progressivelY but quickly to the whole country.
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3.2
Leprosy
The group discussions defined critical activities that will be undertaken by each country according to their leprosy situation. A clear strategy for each group of countries was defined and will be used by countries as guidelines for their plan of action (Annex 6): Group 1 Critical activities are: treatment of MB patients cured by Dapsone monotherapy, integration of leprosy detection and care in the general health care system through a referral system, monitoring the disease with more refined indicators, and maintaining keeping awareness of the health workers. Group 2 Critical activities are: improvement of treatment delivery, better implementation of treatment in difficult-to-reach areas, monitoring according to six essential indicators, and training the relevant health workers and educating the public. Group 3: Critical activities are: improvement of the treatment coverage, improvement of case-finding, implementing a simple and reliable method for monitoring, and training health workers and educating the public. Each country will draw up a plan of action according to the appropriate strategies.
- 9 AlIlIIEX 1
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANT~
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R£GIONAl DU PACIFIQUE OCCIDENTAL
WHO/PLF/SPC WORKSHOP ON MANAGEMENT OF TUBERCULOSIS PROGRAMMES AND LEPROSY ELIMINATION IN THE PACIFIC Suva, Fiji 21-30 November 1994
WPRlTUB/LEP/CHD(3)/94.IA 19 SEPTEMBER 1994
ORIGINAL: ENGLISH
PROGRAMME OF ACTIVITIES
Monday. 21 November 08.00-09.00 09.00-09.30 09.30-10.00 10.00-10.30 10.30-11.00 11.00-12.00 12.00-14.00 14.00-15.30 15.30-15.45 15.45-16.45 Tuesday, 22 November 08.00-09.45 09.45-10.00 10.00-12.00 12.00-14.00 a.m. Administering treatment (continued) COFFEE BREAK Administering treatment (continued) LUNCH BREAK p.m. a.m. Registration Opening ceremony COFFEE BREAK Introduction 10 the workshop methodology Managing tuberculosis at district level Administering treatment LUNCH BREAK Administering treatment (continued) COFFEE BREAK Administering treatment (continued)
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WPRfTUBILEPICHD(3)194.IA Page 2
Tuesday, 22 November 14.00-15.30 15.30-15.45 15.45-17.00 Wednesday, 23 November 08.00-09.45 09.45-10.00 10.00-12.00 12.00-14.00 14.00-15.30 15.30-15.45 15.45-17.00 Thursday, 24 November 08.00-09.45 09.45-10.00 10.00-12.00 12.00-14.00 14.00-15.30 15.30-15.45 15.45-17 .00 Friday, 2S November 08.00-09.45 09.45-10.00 10.00-12.00 a.m. Maintaining regular drug supplies COFFEE BREAK Maintaining regular drug supplies (continued) p.m. a.m. Quarterly reporting on case-finding COFFEE BREAK Quarterly reporting on case-finding (continued) LUNCH BREAK Quarterly reporting on treatment results COFFEE BREAK Quarterly reporting on treatment results (continued) p.m. a.m. Monitoring treaunen! COFFEE BREAK Monitoring treatment (continued) LUNCH BREAK Registering cases COFFEE BREAK Registering cases (continued) p.m. Ensuring identification of tuberculosis suspects COFFEE BREAK Ensuring identification (continued)
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WPRfTUB/LEP/CHD(3)/94.1A
Page 3
Friday, 2S November 12.00-14.00 14.00 p.m. LUNCH BREAK Field visit
Saturday, 26 November 08.00-10.00 10.00-10.15 10.15-12.00 12.00-12.45 12.45-13.00 a.m. Supporting laboratory services COFFEE BREAK Conducting supervisory visits Introduction to plan of action Evaluation questionnaire FREE DAY
Sunday, 27 November Monday, 28 November 09.00-09.15 09.15-09.45 09.45-10.15 a.m.
Introduction to the leprosy workshop - Dr L. Blanc Progress towards elimination of leprosy - Dr S.K. Noordeen How can we accelerate progress towards elimination of leprosy?
- Dr Y. Yuasa
10.15-10.30 10.30-11.00 11.00-11.30 11.30-12.00 12.00-14.00 14.00-14.30 14.30-15.00 15.00-15.30 p.m.
COFFEE BREAK Regional elimination plan for Western Pacific Region - Dr L. Blanc Monitoring leprosy in the post-elimination era - Dr P. Jakeman Cohort study of leprosy in Fiji - Dr E. DaulakolDr K. Jesudasan LUNCH BREAK The role of Pacific Leprosy Foundation in elimination of leprosy The role of Sasakawa Memorial Health Foundation in elimination of leprosy The role of South Pacific Commission in regional disease surveillance in the South Pacific
15.30-16.00
COFFEE BREAK
- 12 WPRlTUB/LEP/CHD(3)/94.1A Page 4 Monday. 28 November 16.00-16.15 16.15-17.00 Tuesday. 29 November 09.00-10.15 a.m. Country presentation: French Polynesia, Guam, Kiribati, Mariana Islands, Marshall Islands 10.15-10.30 10.30-12.00 COFFEE BREAK Country presentation: Federated States of Micronesia, Nauru, New Caledonia, Palau, Papua New Guinea, Samoa 12.00-14.00 14.00-15.30 p.m. LUNCH BREAK Country presentation: Solomon Islands, Tonga, Tuvalu, Vanuatu, Wallis and Futuna 15.30-16.00 16.00-17.00 Wednesday. 30 November 09.00-12.00 a.m. Group discussions: Group l. Group 2. Group 3. Accelerating progress towards elimination - Country plan of action Monitoring and evaluating elimination progress - Country plan of action New approaches and strategies closer to the elimination goal - Country plan of action COFFEE BREAK Presentation of a draft plan of action for elimination of leprosy Introduction to country presentations - Dr R. Farrugia Country presentation: American Samoa, Cook Islands, Fiji
12.00-14.00 14.00-16.00 16.00 p.m.
LUNCH BREAK Group reports Closing ceremony
ANIlEX 2
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL
WHO/PLF/SPC WORKSHOP ON MANAGEMENT OF
TUBERCULOSIS PROGRAMMES AND LEPROSY ELIMINATION IN THE PACIFIC Suva, Fiji 21-30 November 1994
WPRlTUB/LEP/CHD(3)/94/IB/2 21 November 1994 ORIGINAL: ENGLISH
INFORMATION BULLETIN NO.2 FINAL LIST OF PARTICIPANTS, RESOURCE PERSONS, OBSERVERS AND SECRETARIAT
1. PARTICIPANTS
AMERICAN SAMOA
Ms Alofa Filoialii Department of Health Services Pago-pago Tutuila Dr Tamarua Teariki Director of Clinical Services Ministry of Health Rarotonga Dr Esaroma Daulako Medical Superintendent PJ Twomey Memorial Hospital Suva Dr Wiliame Bera Kaitani Med ica1 Superintendent Tamavua Hospital Suva Dr Amn P. Kumar Senior Medical Officer (TB) Tamavua Hospital Suva
COOK ISLANDS
FIJI
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WPRlTUB/LEP/CHD(3)/94/ffi/2 page 2 FIJI (cont.) Dr Benjamin Lomaloma TB Control Officer, Western Division Lautoka Hospital Suva FRENCH POLYNESIA Dr Philippe Glaziou * Institut Territorial de Recherches MedicaIes Louis Malarde Papeete Dr Cecilia T. Arciaga Communicable Disease Control Coordinator III Bureau of Communicable Disease Control Department of Public Health and Social Services Agana Mr Kiteon Kabure Leprosy/Tuberculosis Control Officer Tungaru Central Hospital Ministry of Health, Family Planning and Social Welfare Tarawa Dr Kennar Briand Director of Public Health Ministry of Health and Enviromnent Majuro Mrs Lerina Nena TB & HD Program Manager Department of Health Services Pohnpei96941 Mr Ben Jesse Health Services Specialist Department of Health Services Pohnpei 96941 NAURU Dr Godfrey Waidubu Senior Medical Officer Reoublic of Nauru Dr Jean-Paul Grangeon Medecin Inspecteur Territorial de la Sante Adjoint, Direction Territoriale des Affaires Sanitaires et Socia1es Noumea Dr Fran~oise Droetto Chef du Centre Medical Polyvalent Noumea
GUAM
KIRIBATI
MARSHALL ISLANDS, REPUBLIC OF THE
MICRONESIA, FEDERATED STATES OF
NEW CALEDONIA
*ror leprosy portion (28-30 November- 1994)
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WPRlTUB/LEP/CHD(3)/94/IB/2 page 3 PAPUA NEW GUINEA Dr Abert Solomon Specialist Medical Officer (Leprosy) Depanment of Health Boroko. N.C.D. Dr Caleb Oao Chief of Public Health and Preventive Services Ministry of Health
PALAU
K2.!:!!r SAMOA Dr Sio Ainuu Head of Medical Unit National Hospital Apia Dr Obed Alemaena Physician Central Hospital Honiara Mr Ken Konare Chief Programme Officer Tuberculosis and Leprosy Programme Ministry of Health and Medical Services Honiara TONGA Dr Taniela Lutui Ministry of Health Nuku'alofa Dr Tiliga Pulusi Tuvalu Ministry of Health, Sports, and Human Resources Development Vaiaku Funafuti Mr Jean-Claude Barako Tuberculosis/Leprosy Officer Northern District Hospital Lauganville Santo Mr Georges Boule National TB/LEP Control Officer c/o Coordinator of Preventive Programs Depanment of Health Port Vila Mr Russell Tamata National TB/LEP Control Officer c/o Coordinator of Preventive Programs Department of Health Port Vila
SOLOMON ISLANDS
TUVALU
VANUATU
WPRlTUB/LEP/CHD(3)/94/1B/2 page 4
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WALLIS AND FUTUNA
Dr Christian Tosi Medecin chef. Service de lutte contre les grandes endemies H6pital de SIA Mata Utu
2. RESOURCE PERSONS
Dr Roland Farrugia Medical Officer P.O. Box 1164 Crows Nest Sydney. NSW 2065 Australia Dr Philippe Glaziou •• Institut Malarde BP 30, Papeete French Polynesia Dr Paul Jakeman Head of Evaluation Unit The Leprosy Mission Katong P.O. Box 149 Singapore 9143 Republic of Singapore Dr Michael Levy Medical Advisor AIDSllnfectious Diseases Branch New South Wales Health Department Locked Mail Bag 961 North Sydney. NSW 2059 Australia Dr Yo Yuasa Executive and Medical Director Sasakawa Memorial Health Foundation 3-12-12 Mita, Minato-ku Tokyo 108 Japan Dr Godfried Gerrits WHO Consultant on leprosy/tuberculosis Port Vila Vanuatu Dr Kumar Jesudasan WHO Consultant on leprosy/tuberculosis Suva Fiji
..... ror tubercuIosll ponton (21·26 No"ember 1994)
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WPRlTUB/LEP/CHD(3)/94/IB/2
page 5
3. OBSERVERS
Dr Brian McMahon Chainnan Pacific Leprosy Foundation Christchurch New Zealand Mr Michael Gousmett General Manager Pacific Leprosy Foundation Christchurch New Zealand Mrs Rosemarie O. Keighley Development Officer Pacific Leprosy Foundation Christchurch New Zealand Dr Meciusela Tuicakau Senior Medical Officer PJ Twomey Memorial Hospital Suva Fiji Dr Sakiusa Mainaliwalala Principal Medical Officer Lautoka Hospital Lautoka Fiji Dr Inoke Buadromo Principal Medical officer (Outpatient) Tamavua Hospital Tarnavua Fiji
WPRlTUB/LEP/CHD(3)/94/IB/2 page 6
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4. SECRETARIAT
Dr Jan Andersson Tuberculosis programme WHO Regional Office for the Western Pacific Manila Philippines Dr U.opold Blanc (Operational officer) Regional Adviser in Chronic Diseases WHO Regional Office for the Western Pacific Manila Philippines Dr S.K. Noordeen Chief, Leprosy Unit WHO Headquarters Geneva Switzerland Dr Richard O'Brien Medical Officer Tuberculosis Unit WHO Headquarters Geneva Switzerland Dr Michael O'leary Epidemiologist Intercountry project on health situation trend assessment WHO Representative Office in the South Pacific Suva Fiji Dr ¥van Souares Epidemiologist South Pacific Commission Noumea CEDEX New Caledonia
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ANNEX 3
GROUPING OF PARTICIPANTS
American Samoa Dr Tamarua Teariki Cook blands Dr Dauloko Fiji Dr Maioaliwalala Fiji Dr Cecilia Arciaga Guam Mr Kiteon Kabure Kiribati Dr Kennar Briand MarshaU blands Mr. Lerina Nena
Fiji Dr Tuicakau Fiji Dr Andre Mark Durand Mariana bland. Dr SioAinuu Samoa MrBen Jesse Micronesia Dr Abert Solomon Papua New Guinea Dr Obed Alemae". Solomon bland. Dr Godfried Gerrit.
Fiji Dr Lomaloma Fiji Dr Caleb Otto Palau
New Caledonia
-
Dr Fr..coise Droello New Caledoni. MrBaroko
Vanuatu Dr Boule VaDuatu Dr Christi.. Tosi WaDi. And Futuna Dr Souare. Secretariat
-
Mr Ken Konare Solomon bland. Dr Taoiela Lutui Tonga Dr Tiliga Pulusi Tuvalu MrTamata Vanultu Dr McMahon Observer MrGousmett
-
Micronesia Dr Godfrey Waidubu
Resource Person Dr Kumar Jesndasan
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ANNEX 4
FACILITATORS
...
."
.
"MONDA'\' ." , . GROUP I
.
TUl:SDAY
... .
WEDNFSDAY
'I'B'ORSDAY
FRIDAY ....
SA11l1IDAY .
Dr Jan Ander!Oson
Dr Michael Levy
Dr Richard O'Brien
Dr Jan Andersson
Mr Michael Levy
Dr Richard O'Brien
GROUPU
Dr Michael Levy
Dr Richard O'Brien
Dr Jan Andersson
Dr Michael Levy
Dr Richard O'Brien
Dr Jan Andersson
GROupm
Dr Richard O'Brien
Dr Jan Andersson
Dr Michael Levy
Dr Richard O'Brien
Dr Jan Andersson
Dr Michael Levy
Dr Philippe Glaziou
Dr Roland Farrugia Dr Philippe Glaziou
Dr Philippe Glaziou Dr Roland Farrugia
Dr Roland Farrugia
Dr Philippe Glaziou Dr Roland Flnugia
Dr Roland Farrugia Dr Philippe Glaziou
GROUPlV
Dr Roland Farrugia
Dr Philippe GI,zion
INFORMATION SYSTEM FOR LEPROSY 6 ESSENTIALS INDICATORS 1 PREVALENCE RATE 2 DETECTION RATE 3 PERCENTAGE OF PATIENTS WI TH DISABILITIES AMONG NEW CASES 4 PERCENTAGE OF PATIENTS < 15 YEARS OLD 5 PERCENTAGE OF NE W CASES REGULAR 6 PERCENTAGE OF PATIENTS WH O COMPLETED ADEQUATE TREATMENT N ...,
I
~ ~ VI
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ANNEX 6
GROUPING OF COUNTRIES ACCORDING TO EPIDEMIOLOGICAL STATUS
GROUP 1: COUNTRIES IN THE POST-ELIMINATION ERA (Cook Islands, Fiji, French Polynesia, New Caledonia, Samoa, Tonga, Wallis and Futuna) Main problems identified: (I) a pool of old cases treated with DDS will present a relapse in the future. (2) health workers forget about the disease as it dies out. (3) referral system will tend to be inefficient with time. 1. Management of old DDS cases 1.1 Need to identify all old cases, potential source of infection. I. 2 Clinical assessment, screening time table and technical standards to be used. 1.3 All inactive old MB cases and cases in whom misclassification of the disease is suspected should be retreated: -The group felt that the two-year MB-MDT regimen is not a practical recommendation, use of a short course regimen such as RMP + OFLO for one month, or a six-month MB-MDT regiment would be easier to implement, but not recommended. 1.4 Creation of a master register 1.5 Need to prepare a comprehensive budget: (a) resources to be allocated in manpower, drugs, procedures, training.
Need for a set of standard procedures and recommendations to help countries develop a plan of action within a specified time frame. 2, Need 2.1 2.2 2.3 Referral system to maintain a referral system with a leprosy expert. Somebody should be identified as the country leprosy expert Leprosy activities could be integrated into dermatological services One or several international referral centres should be identified: - for smear readings - for quality assessment - for referral of patients from small countries, if needed - for training of health workers
3, Keeping awareness 3.1 Elimination should be reached throughout the country 3.2 Then sustained control activities should be eliminated 3.3 Leprosy week: health education involving the media, training using short seminars. active case-finding in high endemic pockets, investigation of local epidemics. - Role of school surveys - Responsibility of the actual programme managers to avoid complacency. All participants recognized the need for a draft plan of action to be prepared, to use the knowledge and help improve the leprosy situation in each country.
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Annex 6
GROUP 2: COUNTRIES CLOSE TO THE ELIMINATION TARGET (American Samoa, Guam, Nauru, Solomon Islands, Tuvalu, Vanuatu)
1.
Delivery of treatment (a) (b) Availability of Blister Packs. Maintain a buffer supply to ensure continuity of medications.
2.
Monitoring of treatment (a) Establish an "Inter Island Monitoring System" to ensure appropriate and continuity of treatment. (b) If applicable to introduce a Record System that has the capability of providing information as shown and shared by WHO.
3.
Training (a) (b) (c) (d) Maintain awareness amongst the public health clinic staff: "Think leprosy" Maintain technical expertise in the diagnosis and treatment of leprosy. To include NGOs in the planning and training. Public awareness training Levels to be trained: I. Physicians
2. 3. 4. 5. 6.
Programme Managers Nurses Primary Health Care Workers Laboratory Personnel Health Educators
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Annex 6
GROUP 3: COUNTRIES WHERE LEPROSY IS STILL A PUBLIC HEALTH PROBLEM (Kiribati, Federated States of Micronesia, Marshall Island, Palau, Papua New Guinea) The group reviewed the current situation of each country, e.g. prevalence rate and detection rate. All countries in the group had a prevalence rate higher than 3.5 per 10 000 population (from 3.7 to 25 per 10 000) and a detection rate which varies from 0.5 to 7 per 10 000 population. The group considered three main topics: 1. How to reduce the prevalence rate 2. Case finding 3. Monitoring 1.
How to reduce the prevalence rate Cleaning registers:
(a)
This activity is essential to discharge all patients who died, completed their treatment, moved, etc. All patients known to be alive should be traced and reassessed for their clinical status. (b) Achieving 100% MDT coverage and 100% completion rate:
To achieve these targets, policies for drug supply and distribution and for case holding should be reviewed and revised if needed. Where the health service cannot delivery the treatment, alternate solutions should be found using other service or community participation. 2. Case finding
(a) Active case finding proved to be not very cost effective in particular the general population surveyor school survey. (b) Sensitization of the population using media or posters, etc. is needed to improve early detection of cases. (c) Raising awareness of health workers for leprosy diagnosis when doing routine screening for MCH or school and doing outpatient clinic. 3, Monitoring
The central registry should be encouraged where the population is small and number of cases limited. The frequency of reporting peripheral information to the central level depends on the organization of the programme and the needs. Minimal useful and accurate information should replace many lengthy and most of the time unnecessary information.
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ANNEX 7
SUMMARY OF LEPROSY SITUATION IN THE PACIFIC
Country I. American Samoa Cook Islands Fiji French Polynesia Guam Kiribati Mariana Islands Marshall Islands Micronesia Nauru New Caledonia Papua New Guinea Palau Samoa Solomon Islands Tonga Tuvalu Vanuatu Wallis & Futuna
Population
No. of Cases
Prevalence rate per to ()()()
No. of new ~
Detection rate per to ()()()
40 ()()() 20 ()()() 740 ()()() 190 ()()() 144 ()()() 76000 50000 54000 103000 9000 180500 3 823 ()()() 13000 185 000 355500 98 ()()() 9000 161 ()()() 20000
20 0 42 to 24 41 9 8 286 8 35 3799 12 14 59 1 1 16 0
5 0 0.55 0.5 1.67 5.4 1.80 1.48 27.7 8.8 1.9 9.9 9.2 0.76 1.7 0.1 1.1
4 0 7 7 4 17 4 8 Ito 3 to 519 4 5 8 0
1 0 0.1 0.36 0.27 2.2 0.8 1.48 to.6 3 0.55 1.3 3.08 0.27 0.22 0 1.1
2. 3. 4. 5. 6. 7. 8. 9. to. 11 12. 13. 14. 15. 16. 17. 18. 19.
1.0 0
29 0
1.8 0