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Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region, Busan, Republic of Korea, 15-18 March 2006 : report

December 31, 2006 World Health Organization

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Report series number: RSI2006/GE/03(KOR)

REPORT ~FTH

TECHNICAL ADVISORY GROUP MEETING /TO STOP TB IN THE WESTERN PACIFIC REGION

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Busan, Republic of Korea 15-18 March 2006

WHO/WI'RO UBRARY

2 1 MIG 2009 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines November 2006

NOTE The views expressed in this report are those of the participants in the Fifth Technical Advisory Group Meeting to Stop TB in the Western 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 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific. which was held in Busan. Republic of Korea, from 15 to 18 March 2006.

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CONTENTS Acronyms ....................................................................................................................... iii Summary ........................................................................................................................ v Conclusions and recommendations of the TB Technical Advisory Group (TAG) ...................................................................... 1 Conclusions and recommendations of the regional Interagency Coordination Committee ............................................................................ 8 1 Introduction 1.1 Objectives .................................................................................................... 9 Organization .............................................................................................. 10 Opening ceremony .................................................................................... 10

1.2 1.3 2

Proceedings

2.1 2.2

TB Control in the Western Pacific Region: Current Situation and Future Perspectives ................................................. 13 Global TB Control: Current Situation and Future Perspectives ............................................................................. 14

2.2.1 2.2.2 2.3

Global Plan to Stop TB: 2006-2015 ............................................... 14 Global Strategies for TB-HIV and MDR-TB ..................................... 14

Modelling the impact of TB control strategies towards the 2010 targets in the Western Pacific Region ......................................... 16 The Strategic Plan to Stop TB in the Western Pacific 2006-2010 ............................................................. 17 Core indicators and targets of the Strategic Plan to Stop TB 2006-2010 ............................................................................... 18 Strategy to achieve core targets of the Strategic Plan to Stop TB 2006-2010 ............................................................................... 19

2.4 2.5 2.6

2.6.1 2.6.2 2.6.3 2.6.4

Strategy to achieve TB-HIV core target: Cambodia ...................... 20 Strategy to achieve TB-HIV core target: Malaysia ......................... 20 Strategy to achieve MDR-TB core target: China ........................... 21 Strategy to achieve MDR-TB core target: Republic of Korea .......................................................................... 21

2.6.5 2.6.6 2.7 2.8

Strategy to achieve PPM-DOTS core target: Japan ....................... 22 Strategy to achieve PPM-DOTS core target: Philippines ............... 22

Update on TB laboratory services .............................................................. 23 Country plans 2006-2010 ......................................................................... 24

IV iii;

2.8.1 2.8.2 2.8.3 2.8.4 2.8.5 2.8.6 2.8.7 2.9

China ............................................................................................. 24 Cambodia ..................................................................................... 25 Philippines ..................................................................................... 26 Viet Nam ....................................................................................... 27 Lao People's Democratic Republic ................................................. 28 Mongolia ...................................................................................... 29 Papua New Guinea ........................................................................ 29

Global Fund to fight AIDS, Tuberculosis, and Malaria ................................ 30

2.10 Monitoring and evaluation ........................................................................ 31 2.10.1 Measuring the progress towards 2010 targets ............................. 31

2.10.2 Report of the TB epidemiology workshop in Viet Nam ................. 33 2.11 Progress in countries with an intermediate burden of Tuberculosis ........................................................................................... 35 2.11.1 Hong Kong (China) ....................................................................... 35

2.11.2 Japan ............................................................................................ 36 2.11.3 Singapore ...................................................................................... 36 2.11.4 United States of America .............................................................. 36 2.11.5 International Standards for Tuberculosis Care ............................... 37 2.12 China: Progress towards 201 0 .................................................................. 37 2.13 Issues in other countries with a high burden of TB ................................... 39 2.14 Interagency Coordinating Committee session ........................................... 40

Annexes 1. Timetable ............................................................................................... 42 2. 3. 4. List of participants ................................................................................... 43 Opening remarks of the Regional Director ................................................... 53 Summaries: Five-year national plans of countries with high burden of TB ............................................................................ 56

ACRONYMS ACSM DOTS DRS DST EGA FDC GFATM HBC HIV ICC IBC ISTC MDG MDR-TB Advocacy, Communications and Social Mobilization Directly-observed treatment, short-course Drug resistance surveillance Drug sensitivity testing External quality assessment Fixed-dose combination Global Fund to fight AIDS, Malaria and Tuberculosis High TB burden countries Human Immunodeficiency Virus

Interagency Coordinating Committee Intermediate TB burden countries International Standards for Tuberculosis Care Millennium Development Goals Multidrug-resistant tuberculosis National Reference Laboratory National Tuberculosis control Programme Practical Approach to Lung Health Public-Private Mix DOTS Recording and Reporting system The Strategic Plan to Stop T8 in the Western Pacific 2006-2010 Technical Advisory Group Tuberculosis Tuberculosis and Human Immunodeficiency Virus co-infection World Health Organization Western Pacific Region

NRL NTP PAL PPM-DOTS

R&R Strategic Plan

TAG TB TB-HIV WHO WPR

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SUMMARY The tuberculosis (TB) Technical Advisory Group (TAG) was formed to monitor the progress and status ofthe Stop TB Special Project, which was established following the 1999 declaration of a "tuberculosis crisis" by the WHO Regional Committee for the Western Pacific. Four TAG meetings have been held so far. These meetings have provided important input in developing and implementing technically-sound plans for TB control, both at the regional and country levels. Significant progress has been made by the Stop TB Special Project. Early reports for 2005 suggest achievement of the interim targets set for 2005: region-wide directly-observed treatment, short-course (DOTS) coverage, 70% case detection and 85% success rate. The next step is to focus on the 2010 goal, decreasing by half the prevalence and mortality due to TB (relative to 2000). This step calls for strengthened and concerted effort not only to optimize the quality of DOTS and to improve access to services, but also to adequately respond to emerging threats such as multidrug-resistant tuberculosis (MDR-TB) and tuberculosis and human immunodeficiency virus co-infection (TB-HIV). The Strategic Plan to Stop TB in the Western Pacific, 2006-2010 (Strategic Plan) has been developed to guide countries in addressing the challenges and sustaining the momentum towards the 2010 Regional goal. All seven high-TB burden countries (HBC) in the Region have developed country-specific five-year plans in line with the Strategic Plan. The fifth TAG meeting, held in Busan, Republic of Korea from 15 to 18 March 2006, reviewed the progress of the Stop TB Special Project and allowed for discussion of issues and challenges regarding the 2010 Regional goal. TAG members reviewed the Strategic Plan and national plans for 2006-2010 and provided recommendations to WHO and its Member States. Sessions were held to discuss strategies to address emerging challenges and to achieve the core targets set for 2006-2010. TAG found the Strategic Plan as well as the country plans to be technically sound, and supported their implementation. A field trip was made to observe the internet-based Korean TB surveillance system. A separate session of the Regional Interagency Coordinating Committee (ICC) was convened to report progress and to further strengthen regional partnerships in support of sustainable TB control in the Region. The fifth TAG meeting was attended by a total of 76 participants, including eight TAG members; 22 National Tuberculosis Programme (NTP) Managers and staff from countries of the Region; 25 Representatives from international, governmental and non-governmental organizations (NGO); four resource persons and 17 WHO staff representing Headquarters, the Regional Office for the Western Pacific, and country offices. Dr Jaap Broekmans served as the Chair and Dr Sang Jae Kim as the Vice-chair for the meeting. Dr Donald Enarson and Dr Vicki Krause served as Rapporteurs.

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CONCLUSIONS AND KEY RECOMMENDATIONS OF THE TECHNICAL ADVISORY GROUP (TAG) GENERAL CONCLUSIONS: The Technical Advisory Group (TAG) congratulates Member States of the Western Pacific Region as the first Region to achieve the global targets of 85% treatment cure and 70% case detection for tuberculosis (TB) control. TAG notes with appreciation the remarkable efforts of Member States in reaching what seemed to be an almost unachievable target. Six high-TB burden countries (HBC), including Cambodia, China, the Lao People's Democratic Republic, Mongolia, the Philippines and Viet Nam, have all nearly reached or exceeded the targets. Without the tremendous work of health workers at all levels, this success could not have been achieved. TAG, while recognizing these major accomplishments, also notes the formidable challenges that lie ahead. To address these challenges, priorities must focus on the delivery of high quality tuberculosis services. TAG recognizes the substantial political commitment and leadership of the Regional Director, Dr Shigeru Omi. TAG specifically recognizes the superlative leadership, commitment and energy of the Regional Advisor, Dr Dong Il Ahn, and his team's efforts in achieving these targets.

TAG CONCLUSIONS AND RECOMMENDATIONS 1.1

STRATEGIC PLAN TO STOP TB IN THE WESTERN PACIFIC 2006-2010

CONCLUSIONS: The TAG recognizes the continuity, comprehensiveness, vision, and clarity of the Strategic Plan to Stop TB in the Western Pacific 2006-2010. This plan encompasses a significant expansion of the concept, building upon solid work from the previous five-year plan, and addressing the broader mandate posed by an emerging environment of challenges in access to care, HIV infection and expanding drug resistance. Extensive discussion led to several suggestions for refinement. TAG RECOMMENDS THAT THE REGIONAL OFFICE FOR THE WESTERN PACIFIC: 1. reword Objective 2 as follows: "To adapt DOTS to respond to TB-HIV and to build a comprehensive infrastructure to address MDR-TB"; 2. reword points under Objective 2 to: "..... at least 90% .... "; 3. reword section 2.2 b to: "at least 10% of failure cases ... "; 4. reorder Objectives 2 and 3 to reflect the logical sequence of work.

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1.2

STRATEGIES TO ACHIEVE CORE TARGETS

CONCLUSIONS: TA? concurs with the Regional office in outlining the important challenges facmg tuberculosis services in the Region. Furthermore, TAG confirms that these strategies are consistent with the newly-announced Global Plan to StO? T~ .. The~e strategies are formulated to address the major challenges: mamtammg hIgh quality tuberculosis services; ensuring equity of, and access to, tuberculosis services; and responding to multidrug-resistant tuberculosis (MDR-TB) and tuberculosis and human immunodeficiency virus co-infection (TB-HIV) TAG RECOMMENDS THAT COUNTRIES: 1. implement the five-year plans that they have developed in line with the Strategic Plan to reach the four core targets and further to contribute to reaching the 2010 impact targets, as well as the TB-related targets of the Millennium Development Goals (MDG).

1.2.1

MULTIDRUG-RESISTANT TUBERCULOSIS (MDR-TB)

CONCLUSIONS: TAG recognizes that multidrug-resistant tuberculosis (MDR-TB) is wellestablished in the Region, that the Region contains a substantial proportion of the global burden of MDR-TB, and that major challenges must be faced to address this problem. TAG RECOMMENDS THAT THE REGIONAL OFFICE FOR THE WESTERN PACIFIC: 1. place high priority on item 2.1 of the framework of the Strategic Plan 2006-2010, that surveys to assess the situation of multidrug-resistant tuberculosis be carried out without delay; 2. guide countries in elaborating a comprehensive plan, including occupational safety, for multidrug-resistant tuberculosis, with emphasis on China, where the greatest burden is estimated; and 3. engage the Green Light Committee in plans to develop regional capacity to address the problem of multidrug-resistant tuberculosis (including human resource development, and establishment of standards) by the end of 2006. This plan needs to explicitly identify resources required and how they will be obtained. TAG RECOMMENDS THAT COUNTRIES: 1. conduct national TB drug resistance surveys to establish a baseline and later to monitor the prevalence of MDR-TB; 2. develop training modules and guidelines, strengthen the laboratory network and build technical capacity to implement DOTS-Plus programmes; and

3 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region I

3. ensure the quality of management of MDR-TB, with particular attention to quality assurance of second-line anti-TB drugs.

1.2.2

TUBERCULOSIS AND HIV INFECTION

CONCLUSIONS: TAG recognizes the urgency and importance of action to address the negative impact of the rapidly expanding HN epidemic on the gains in tuberculosis control in the Region. TAG further notes significant progress in addressing this issue in Cambodia, whereas in other countries, these activities are lagging. TAG RECOMMENDS THAT THE REGIONAL OFFICE FOR THE WESTERN PACIFIC: 1. facilitate urgent implementation of the Framework to Address TB-HIV Co-infection in the Western Pacific Region. TAG RECOMMENDS THAT COUNTRIES: 1. develop, implement and scale-up TB-HIV collaborative activities through a country-specific framework to address TB-HN co-infection, in line with the regional framework.

1.2.3

SECTOR-WIDE ENGAGEMENT

CONCLUSIONS: TAG expressed its opinion that a broad set of activities is required to ensure equitable access to quality tuberculosis care for all persons with tuberculosis. Such activities include the engagement of all health care providers in practising high quality case management, either directly or through referral; the establishment of standards of care for all practitioners, particularly specialist physicians and university teachers; and the implementation of policies and strategies that improve access to, and equity of, care that prioritizes the poor and the marginalized. TAG RECOMMENDS THAT THE REGIONAL OFFICE FOR THE WESTERN PACIFIC: 1. promotes equitable access to quality TB care for all people with TB, particularly the poor and vulnerable populations of the Region. TAG RECOMMENDS THAT COUNTRIES: 1. fully realize their national plans 2006-2010 for Public-Private Mix DOTS (PPM-DOTS) and community involvement; 2. strategically and creatively use the International Standards for Tuberculosis Care (ISTC) to ensure comprehensive access to high quality care for tuberculosis, recognizing that policy for tuberculosis care is determined by the National Tuberculosis Programme (NTP);

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3. engage medical schools/universities in an exercise to evaluate and, if necessary, revise the curriculum of undergraduate, graduate and postgraduate training for tuberculosis to ensure that primary training is consistent with national policies; 4. initiate and / or expand services to marginalized population groups induding those in prisons and in rehabilitation centres; and 5. engage patients in promoting access to health services and knowledge of tuberculosis in the community.

1.2.4

ENGAGING REGIONAL RESOURCES AND EXPERTISE

CONCLUSIONS: TAG recognizes the tremendous breadth and depth of expertise and experience in the different areas of TB control in the Region. It further considers that this resource is not yet fully utilized and engaged. TAG RECOMMENDS THAT THE REGIONAL OFFICE FOR THE WESTERN PACIFIC: 1. in collaboration with Member States, engage the appropriate experience and expertise to facilitate exchange of knowledge and skills, and to support implementation of TB services; and 2. focus particularly on resources to address priority needs such as strengthening laboratory systems capacity and management of MDR-TB.

1.3

TB LABORATORY SERVICES

CONCLUSIONS: TAG has been apprised that the extent and quality oflaboratory services in the countries ofthe Region are insufficient for the basic needs of tuberculosis services and will be further stretched by the requirements of the new strategic plan for the Region. TAG appreciates the critical evaluation of the role and priority of laboratory services outlined by the informal regional consultation on laboratory services. Moreover, TAG recognizes that minimal requirements and relevant standards of biosafety to perform culture and drug sensitivity testing (DST) have not yet been fully defmed. TAG RECOMMENDS THAT THE REGIONAL OFFICE FOR THE WESTERN PACIFIC: 1. formulate essential requirements for TB laboratory services, with an emphasis on requirements in expanding culture and DST services, induding quality assurance and relevant standards of biosafety, according to level and type of activity; and 2. assist countries to prepare realistic budgets with costed items, for strengthening of TB laboratories to ensure that there will be no impediments.

TAG RECOMMENDS THAT COUNTRIES: 1. develop and implement a policy for the us.e and expansior: ?f culture facilities according to NTP requirements, WIthout compromIsmg smear microscopy services; 2. where cultures are routinely used in case management, recommend that laboratories directly report mycobacteriology results to the public health sector (in addition to the routine reporting of results to service providers); . 3. critically evaluate efficient means to diagnose sputum smear-negative pulmonary tuberculosis with specific reference to the role of cultures in this process; and 4. identify requirement, cost, and allocate funds for laboratory strengthening.

1.4

COUNTRY PLANS 2006-2010

CONCLUSIONS: TAG appreciates that national strategic plans follow the outline of the framework of the Strategic Plan to Stop TB in the Western Pacific 2006-2010. TAG believes that these plans (with minor adjustments) are technically sound. TAG recognizes that China will remain vital to achieving the goals and targets of the Strategic Plan and the Global Plan to Stop TB. Moreover, TAG is concerned by the constraints and resulting human suffering and unnecessary loss of life consequent upon the inability to move forward in tuberculosis control in Papua New Guinea. While Viet Nam was the first country to achieve the WHO interim targets, TAG views with great concern the fragility of financial support to the NTP. TAG also appreciates the progress made by countries with intermediate burden of TB and efforts being made to strengthen the dialogue between countries with intermediate and high burden of TB.

TAG RECOMMENDS THAT COUNTRIES: 1. consistently apply the 2010 targets of Western Pacific Region, endorsed by the Regional Committee in 2000, in the planning process; 2. while being cognizant of the framework of the Strategic Plan 2006-2010, clearly spell out the priorities for activities in their country plans; and 3. use the specific components of the global exercise on costing for the Global Plan to Stop TB that were undertaken to address country needs, to carefully revise their national plans to ensure that budgets are comprehensive and cover all requirements for activities. TAG RECOMMENDS THAT CHINA: 1. emphasize laboratory strengthening as a priority in their strategic development plan for the next few years; 2. prepare a strategic plan for tuberculosis services for the "floating population" (internal migrants), in collaboration with WHO, and

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engage in integrating plans for tuberculosis services with the d:veloping programme for rural medical cooperative scheme; 3. gIVen the success of the 2004 High Level Meeting in Xi-an and the impo~tance of China to the achievement ofthe regional goal, continue to reVIew progress of the NTP particularly in the high priority provinces of China, in collaboration with WHO, through a similar mechanism; and 4. outline a method of reporting that meaningfully shares successes and challenges within provinces in tuberculosis control with WHO and TAG.

TAG RECOMMENDS THAT PAPUA NEW GUINEA: 1. together with WHO and technical advisors, strengthen collaboration with major partners, in particular, Australia Agency for International Development (AusAID); 2. re-evaluate the priority given to tuberculosis within its national strategic plan for health services, recognizing the economic impact of tuberculosis, the high rate of disease in the country, the certainty that the problem will exponentially increase with the explosion of the HIV epidemic and that it will become unmanageable with the spread of drug resistance; and 3. engage assistance, with the help of Regional Office for the Western Pacific, in developing a proposal for funding for the upcoming round of applications to the Global Fund for AIDS, Tuberculosis and Malaria (GFATM). TAG RECOMMENDS THAT VIET NAM: 1. in collaboration with WHO and other Stop TB partners, identify the additional resources to prevent a disruption of care, with consequent negative impact on gains achieved; and 2. develop a competitive proposal for the next round of applications to the GFATM. TAG RECOMMENDS THAT INTERMEDIATE TB BURDEN COUNTRIES: 1. enhance political commitment to tuberculosis control; 2. develop common strategies for management of tuberculosis in migrant populations; and 3. pursue the goals of the Strategic Plan 2006-2010.

1 .5

MONITORING AND EVALUATION

CONCLUSIONS: TAG recognizes the crucial role of monitoring and evaluation in transparency and efficiency of programme implementation. TAG RECOMMENDS THAT THE REGIONAL OFFICE FOR THE WESTERN PACIFIC: 1. ensure, as a matter of priority, that baselines of all critical indicators

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(Le., indic ators relate d to preva lence , TB-H IV, MDR- TB and PPM-D OTS covera ge) are measu red (in additi on to being estima ted); engag e with global initiat ives to develo p direct , reliab le and valid measu remen ts for monit oring impac t of tuberc ulosis contro l, with an emph asis on tuber culos is morta lity, based on exper tise and exper iences in the Weste rn Pacific Regio n; carefu lly evalu ate propo sed chang es in the repor ting system to prese rve the cruci al role of the servic e provi der in using the inform ation to guide practi ce; outlin e metho ds for maint aining stand ards throu gh extern al qualit y assura nce (EQA) of data mana geme nt in survei llance system s of NTPs; and develo p a comp rehen sive monit oring and evalu ation frame work to guide count ries to overse e the progr ess of NTPs includ ing analy sis and use of data for progr amme impro vemen t.

TAG RECOMMENDS THAT COUNTRIES; 1. adapt and imple ment the new WHO record ing and report ing system to facilit ate report ing of the indica tors and target s for PPM-D OTS, TB-HIV and MDR-TB; and 2. develo p and imple ment guide lines for super vision of the NTP by differ ent level of staff, includ ing guida nce on the use of super visory report s.

1 .6

CROSS-CUTTING ISSUES

CONCLUSIONS: TAG recogn izes the impor tance of huma n resou rce capac ity in carryi ng out strate gic plans . The accur ate estim ation and mobil izatio n of suffic ient resou rces to imple ment the strate gic plan is crucia l. There fore, the capac ity to critica lly evalu ate local exper ience is vital for ensur ing efficie nt provis ion of servic es and adapt ation of polici es and strate gies. TAG RECOMMENDS THAT THE REGIONAL OFFICE FOR THE WESTERN PACIFIC: 1. engag e in furthe r streng thenin g of the huma n resou rce capac ity in the Regio n in order to imple ment the activi ties plann ed for 2006- 2010; 2. contin ue to play an instru menta l role in streng thenin g partne rships and mobil izing resou rces for TB contro l in the Regio n; and 3. provid e techni cal assist ance to count ries, where neede d, in prepa ring applic ations for the GFATM. TAG RECOMMENDS THAT COUNTRIES: 1. inclu de healt h syste ms stren gthen ing comp onen ts in their applic ations to the GFATM to ensur e the feasib ility and sustai nabili ty of the expan ded servic es propo sed; 2. under take ambit ious and comp rehen sive plann ing for resou rce mobil izatio n, takin g partic ular advan tage of the oppor tuniti es

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In th e W estern Paclhc Region

represented by the GFATM to minimize funding gaps in their strateoic plans; 1:>~ 3. in collaboration with W~O and partners, engage university faculty and members o~ professIOnal societies with programme personnel, to develop and implement research protocols on prioritized issues relevant to programme implementation (for example, evaluate current algorlthm.s for the diagnosis of smear-negative pulmonary tubercu?oslS and the role of culture in this process); 4. engage In a systematic approach to human resource strengthening ~~uding the development of a human resource development plan; 5. develop and implement budgeted workplans at the national and subnational levels.

CONCLUSIONS AND KEY RECOMMENDATIONS OF THE REGIONAL INTERAGENCY COORDINATING COMMITTEE (ICC) CONCLUSIONS: With the commitment and support from partners, increased funding was made available to implement activities of the Stop TB Special Project and to meet the 2005 targets for TB control. Without at least sustained funding for the next five years, it is unlikely that the Region will be able to implement the plans for 2006-2010. RECOMMENDATIONS TO THE REGIONAL OFFICE FOR THE WESTERN PACIFIC: 1. continue to facilitate collaboration among TB partners at all levels to strengthen partnerships for TB control in the Region; and 2. determine the cost and secure funding for technical assistance to countries to implement the Stop TB Special Project in 2006-2010. RECOMMENDATIONS TO COUNTRIES: 1. work locally with partners to mobilize resources to carry out activities of the five-year national plans; and 2. advocate with their respective governments to increase or to at least sustain current levels of funding for TB control activities.

II INTRODUCTION In September 1999, the WHO Regional Committee for the Western Pacific declared a "tuberculosis crisis" in the Region. As a result of this declaration and of the Committee's request, the Regional Director established the Stop TB Special Project and set the regional goal of reducing by half the prevalence and mortality due to tuberculosis by 2010. Subsequently, the TB TAG was formed as a means of monitoring progress and status of the project. Four TAG meetings have been held so far. These meetings have played a crucial role in the development and implementation of technically sound plans for TB control, both at the regional and country levels. The first phase of the five-year Stop TB Special Project concluded in 2005. Stronger political commitment and improved financing have contributed to extraordinary progress made during this period. Early reports indicate that the Region has achieved the TB control targets set for 2005: region-wide DOTS coverage, 70% case detection and 85% treatment success rate. The next step is to move from the 2005 interim targets to achieving the 2010 impact targets. This step will require sustaining and optimizing the quality of DOTS services, ensuring equitable access for all people with TB, and addressing emerging challenges like multidrug-resistant TB and TB-HIV co-infection. It is only through intensified efforts aimed at tackling these challenges that the 2010 Regional goal will be realized. In consultation with stakeholders, including Member States, the Strategic Plan to Stop TB in the Western Pacific 2006-2010 was drafted to address challenges for the next phase of the project. The Strategic Plan is in line with the Global Plan to Stop TB 2006-2015, aimed at meeting the TBrelated MDGs. All seven HBCs ofthe Region have developed country-specific five-year plans in tune with the Strategic Plan. The fifth TAG meeting held in Busan, Republic of Korea from 15 to 18 March 2006 reviewed the progress made during the first phase of the Special Project and discussed issues and challenges with regard to the Stop TB goal of2010. TAG members reviewed the Strategic Plan and national plans for 2006-2010 and provided recommendations to WHO and its Member States. Sessions were held to discuss strategies to address emerging challenges and to achieve the core targets set forth in the Strategic Plan. The regional ICC meeting convened on the second day of the meeting.

1.1

Objectives

The objectives of the fifth TAG meeting were: (1) to review the progress towards the regional Stop TB targets of 2005; (2) to discuss issues and challenges with regard to the Stop TB goal of 2010; (3) to discuss and finalize the Strategic Plan to Stop TB in the Western Pacific 2006-2010;

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(4) to review, discuss and provide recommendations on the national plans 2006-2010 of the seven countries with a high burden of TB; and (5) to further strengthen the regional partnership through the ICC in support of sustainable TB control in the Region.

1.2

Organization

The meeting was attended by a total of 76 participants, including eight TAG members; 22 NTP managers and staff from countries of the Region; 25 Representatives from international, governmental and non-governmental organizations (NGO); four resource persons and 17 WHO staff representing Headquarters, the Regional Office for the Western Pacific, and country offices. Annex 1 shows the timetable of the meeting, Annex 2 contains the list of participants, and Annex 3 is the opening remarks of the Regional Director. Presentations from IBC on the progress in TB control, presentations from HBC on their five-year national plans, and summaries of the five-year national plans of HBC are in Annex 4, Annex 5 and Annex 6 respectively.

1 .3

Opening ceremony

Dr Shigeru Omi, WHO Regional Director for the Western Pacific, officially opened the fifth meeting of the TAG to Stop TB in the Western Pacific Region. He announced achievement of the 2005 Stop TB targets in the Region and congratulated all TB workers for accomplishing this milestone. Dr Omi attributed the success so far to three main factors: (1) sound technical guidance from TAG to facilitate effective implementation of regional and national five-year plans; (2) close monitoring of progress for initiating timely action as required; and (3) strong partnerships that have ensured availability of required resources. He cautioned that the 2005 targets are just halfway to the 2010 goal and stressed the need for renewed and strengthened efforts to sustain the achievements and address emerging challenges in order to make an impact on the TB epidemic. Appreciating the initiative to develop the Strategic Plan and national plans for 2006-2010, Dr Omi encouraged TAG members and countries in thorough deliberations to finalize the plans. He called for successful implementation of the plans in the coming years to meet the Regional goal and thereby contribute to the achievement of the MDG. He also acknowledged the progress made in TB control in countries and areas with an intermediate burden of TB. Dr Omi concluded by gratefully acknowledging the commitments made by TAG members, as well as all partners, towards fighting the tuberculosis problem in the Western Pacific Region. In his welcome address, Dr Jongku Lee, Director General, Ministry of Health and Welfare of the Republic of Korea lauded the role of WHO in declaring a TB crisis in 1999, and thereafter taking the necessary steps to control TB in

11 Fifth Technical AdvIsory Group Meeting to Stop TB in the Western Pacific Region

the Region. While joining the Regional Director in congratulating the Region for reaching the 2005 targets, he sought for strengthened efforts and collaboration to work towards the 2010 goals. Dr Lee related his experience with previous TAG meetings and shared the new initiatives undertaken in the Republic of Korea for TS control following the discussions therein. He committed the support of the Government of the Republic of Korea for TB control in the Asia Pacific Region to reach the 2010 targets. Mr Kwon Sang Lee, Vice-Mayor of Susan City, expressed his gratitude for holding the meeting in Susan, a city well known for hosting many important international events, including the recent APEC summit in 2005. He wished for a successful meeting that would come up with an effective plan to fight TB.

Dr Omi then appointed the office-bearers for the meeting. The following is a list of TAG members, indicating office-bearers for the meeting: Dr Jaap Broekmans (Chairperson) Dr Donald Enarson (Rapporteur) Dr Michael Iademarco Dr Sang Jae Kim (Vice-Chairperson) Dr Vicki Krause (Rapporteur) Dr Yin Li Dr Toru Mori Dr Shinichiro Noda

fI PROCEEDINGS 2.1 TB CONTROL IN THE WESTERN PACIFIC REGION: CURRENT SITUATION AND FUTURE PERSPECTIVES Dr Dong II Ahn, Regional Adviser for the Stop TB Unit of WHO Regional Office for the Western Pacific, presented the progress, achievements, and future perspectives of the Stop TB Special Project. Providing a background to the Stop TB Special Project in the Western Pacific Region, Dr Ahn referred to the declaration of a tuberculosis crisis in the Region by the Regional Committee in 1999. Subsequently, the Stop TB Special Project in the Western Pacific Region was established and the Regional Strategic Plan for 2000-2005 was developed with the goal of reducing the 2000 levels of TB prevalence and mortality to half by 2010. Intermediate targets were set to achieve the 2010 goal: region-wide DOTS coverage, 70% case detection rate and 85% cure rate of new smear-positive TB cases by 2005. Progress in Phase 1 (2000-2005): Achieving "70/85/100" targets

Significant progress has been made during the first five years of the Stop TB Special Project. In 2000, the case detection rate was only 37% and DOTS coverage was less than 70%. Preliminary data available for 2005 indicate that the Region has met the targets of 70% case detection, greater than 85% cure rate, and region-wide coverage with DOTS. Strong government commitment for TB control, sound technical advice from TAG, strong NTPs, strengthened partnerships and scale up of technical assistance from WHO made this success possible. Phase II (2006-2010): Reaching "50/50" targets During the second phase of the Stop TB Special Project, activities will be directed to achieve the 2010 goal of reducing by half the prevalence and mortality due to TB from the 2000 levels. The Strategic Plan to Stop TB in the Western Pacific 2006-2010 is a framework aimed at addressing the challenges and is to be used as a reference for national plans. Optimizing DOTS services; addressing MDR-TB and TB-HIV co-infection; involving all health providers in TB control; ensuring equitable access to TB services by the poor and vulnerable populations; and sustaining funding for TB control will be the major areas of work. Achieving the four core targets of the Strategic Plan related to case detection, DOTS-Plus, TB-HIV and PPM-DOTS will be essential to reaching the 2010 impact targets. Thus, in the coming five years, the Stop TB Special Project will move forward from having achieved the "70/85/100" intermediate targets to achieving the "50/50" impact targets.

Dr Ahn concluded by highlighting the expected outcomes of the Fifth TAG meeting: to discuss and finalize the Strategic Plan as well as the national plans of the seven high TB burden countries (HBC) for 2006-2010, and to strengthen partnerships among technical partners, countries and donors for TB control in the Region.

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2.2

GLOBAL TUBERCULOSIS CONTROL: CURRENT SITUATION AND FUTURE PERSPECTIVES

Two presentations were made during this session: the recently launched Global Plan to Stop TB for the period 2006-2015, and global strategies to address TB-HIV and MDR-TB.

2.2.1

Global Plan to Stop TB: 2006-2015

Dr Leopold Blanc, Coordinator of the Tuberculosis Strategy and Operations in WHO Headquarters, Geneva, provided an overview of the Global Plan to Stop TB. Worldwide, nine million cases of TB occur annually, one-third of them in the two most populous countries of India and China. Overall, the global incidence of TB continues to rise as a result of the growing HIV / AIDS epidemic in Africa. The Global Plan advocates implementation of the new Stop TB strategy over the next 10 years to reach the 2015 MDG. DOTS continues to be the primary component of the Stop TB strategy, with additional components necessary for TB control: managing MDR-TB and TB-HIV co-infection; contributing to health system strengthening; engaging all care providers; empowering patients and communities; and enabling and promoting research (diagnosis, treatment, vaccine, operational research). The five targets for global TB control are geared towards meeting the MDG goal of halting and beginning to reverse the incidence of TB. Thus the implementation (DOTS) targets relate to more than 70% case detection and at least 85% treatment success by 2005. The impact targets are to reduce the 1990 levels of TB prevalence and deaths to 50% by 2015. Dr Blanc discussed the possible impact of DOTS Expansion Working Group (DEWG) activities to the MDG. In addition its impact on TB-related MDG, DEWG activities such as PPM-DOTS, community DOTS, Practical Approach to Lung Health (PAL), and pro-poor approaches would have an impact on poverty-related MDG. The Global Plan projects the outcomes of planned improvements in case detection and treatment, and the technological developments that can be expected in the coming decade, which include better vaccines, new diagnostics and an improved drug regimen. According to the Plan, by 2015, prevalence and death rates are expected to be halved globally, except in Africa and in Eastern Europe. Total cost to implement the Global Plan is US$ 55 billion. With available funding of US$ 20 billion, the funding gap is US$ 35 billion.

2.2.2

Global Strategies for TB-HIV and MDR-TB

Dr Paul Nunn, Coordinator, TB-HIV and Drug Resistance, WHO Headquarters, Geneva, presented the problem ofTB-HIV co-infection

15 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

and MDR-TB, focusing on the global policy response, goals and strategies for addressing these problems. The estimated TB incidence was stable or falling in all WHO Regions except in Africa, due to the spread of HIV. Comparing treatment outcome by WHO Regions, poor treatment outcomes of TB patients are observed in Africa due to HIV, and in Europe due to MDR-TB. Addressing TB-HIV and MDR-TB is now a component of the WHO-recommended Stop TB Strategy to reach the 2015 MDG. During 2006-2015, the Global Plan aims to screen 210 million people attending HIV services for TB, and to test 27 million TB patients for HIV. It also plans to treat 780 000 patients for MDR-TB. The budget allocation for TB-HIV is US$ 6.7 billion and US$ 5.8 billion for MDR-TB. TB-HIV: Worldwide, approximately 13% of adult TB cases were HIV-positive in 2004. Highest TB rates per capita are found in Africa, linked to the HIV epidemic. The global policy for TB-HIV collaboration includes establishing mechanisms for collaboration between the national TB and AIDS programmes, activities to decrease the burden of TB in people living with HIV / AIDS, and activities to decrease the burden of HIV in tuberculosis patients. Publications to provide guidance on different aspects of TB-HIV policy are available. In terms of targets, the global TB-HIV goals for 2010 are to screen 22 million (98%) of people living with HIV / AIDS for TB, offer Isoniazid Preventive Therapy to 2.6 million (8%) people living with HIV / AIDS, provide HIV testing and counselling to 3.1 million (85%) TB patients, and start 300 000 (57%) TB patients on anti-retroviral treatment. MDR-TB: Two-thirds of the estimated global MDR-TB cases are in China, India and the Russian Federation. WHO Guidelines for the programmatic management of drug-resistant TB based on the DOTS framework has been published recently. Global goals for MDR-TB management are to treat 800 000 MDR-TB patients over the next 10 years at an estimated cost of US$ 6 billion (16% in the Western Pacific Region); to strengthen the business model of the Green Light Committee mechanism to support scaling up of DOTS-Plus; to increase the market of second-line TB drugs in quantity and quality; and to integrate management of MDR-TB into routine activities of TB control programmes. According to the Plan, by 2010, it is expected to conduct baseline drug resistance surveillance in 130 countries and assess trends in 65 countries; establish quality-assured culture and drug susceptibility testing in all countries with a national reference laboratory; treat 17% of all MDR-TB cases; provide technical assistance through Green Light Committee mechanisms in all Regions; and produce qualityassured second-line drugs in China, India, Russian Federation and South Africa. In conclusion, the Global Plan presents an opportunity to scale-up TB control and should not be missed. Successful implementation of the plan is likely to contribute to achievement of the TB-related MDG everywhere, except in Eastern Europe and in Africa.

16 'i'l

Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

2.3

MODELLING THE IMPACT OF TB CONTROL STRATEGIES TOWARDS THE 2010 TARGETS IN THE WESTERN PACIFIC REGION

Dr Philippe Glaziou, Medical Officer, Stop TB Unit, WHO Regional Office for the Western Pacific, presented the analytical model developed by the Region to guide strategic planning for the second phase of the Stop TB Special Project. A deterministic compartmental model was used to forecast the TB epidemic and to assess the impact of DOTS-Plus programmes in the Western Pacific Region. The following assumptions were made: (1) new pulmonary cases are infectious or non-infectious; (2) prior infection with Mycobacterium tuberculosis provides partial protection against re-infection; (3) case detection removes infectious cases from the prevalent pool; (4) untreated cases either die or self-cure; (5) the cure rate depends on whether the treatment regimen is DOTS or non-DOTS in drug-sensitive TB and on whether the treatment regimen is DOTS-Plus or not in MDR-TB; and (6) MDR-TB may be acquired through primary infection or through treatment failure. Scenarios for DOTS case detection rate and DOTS-Plus coverage were developed, with MDR identification and DOTS-Plus treatment reaching 10% and 26% coverage of MDR-TB cases by 2010 and 2015, respectively. The model shows a delayed impact of DOTS-Plus on the epidemic of MDR-TB. Most of the decline in MDR-TB prevalence is in relation to a rapid decline in the prevalence of TB (all forms) due to a rapidly-increasing case detection rate over the period 2000-2005. However, without DOTS-Plus implementation, the proportion of MDR-TB among prevalent TB cases would increase and stabilize at about 6%, and the decline in the overall prevalence of MDR-TB would gradually slow down and reach a plateau. Under DOTS-Plus expansion, a predicted 7969 and 42339 cumulative MDR-TB cases will be identified and treated with a DOTS-Plus regimen by 2010 and 2015, respectively. The following table shows the impact of an increased case detection rate of more than 80%, combined with an ambitious plan to implement DOTS-Plus programmes in the Region, on the regional targets for 2010:

I' j ;'

,'Ii

•CaS~,geter;:,tion'f,me ».70%~., , . no DOTS-pius . .. 57.1% Year reached: 2016 58.5% Year reached: 2018

Inqrllased ca~e; detefF~ion. tate and DOTS-Plus ' 47.4% Year reached: 2010 49.2% Year reached: 2010

Prevalence (2010/2000) Deaths (2010/2000)

17 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

DOTS-Plus will prevent 1179 cumulative incident MDR-TB cases by 2010, and 8215 cases by 2015. At that point in time, DOTS-Plus will prevent one incident MDR case for every five new MDR cases identified and treated under DOTS-Plus. Progressive DOTS-Plus implementation may prevent 2% cumulative incident MDR-TB cases by 2015 and 16% prevalent MDR-TB cases in 2015.

2.4

THE STRATEGIC PLAN TO STOP TB IN THE WESTERN PACIFIC 2006-2010

An overview of the Strategic Plan to Stop TB in the Western Pacific Region was presented by Dr Pieter van Maaren, Medical Officer, Stop TB Unit, WHO Regional Office for the Western Pacific. The modelling exercise referred to in Section 2.3 provides the context for the new plan. In order to reach the 2010 goal, case detection and cure rates beyond "70/85" would be needed, MDR-TB and TB-HIV addressed, and quality TB care made accessible to all persons with TB. The Strategic Plan for 2006-2010 was developed with a vision of eliminating TB as a public health problem. The goal of the plan is to reduce the prevalence and mortality due to TB by half by 2010 (relative to 2000), thereby contributing to the achievement of the overall MDG. The three objectives of the Strategic Plan are (1) to sustain and to optimize the quality of DOTS and go beyond the "70/85" targets; (2) to ensure equitable access to quality TB care for all people with TB; and (3) to adapt DOTS to respond to MDR-TB and TB-HIV. Four core targets to monitor progress towards meeting the objectives have been identified. Implementation of the Strategic Plan is expected to result in improved services through quality assured drugs, better diagnosis, and enhanced case management. The Plan also includes management of MDR-TB cases under DOTS-Plus projects, ensured access of TB patients to HIV / AIDS services including anti-retroviral treatment, and improved TB case management in non-NTP facilities through PPM-DOTS and adoption of the ISTC. The Cross-cutting components of the Strategic Plan are: to develop and implement a human resource development plan aimed at ensuring availability of trained staff; to sustain sufficient financing for TB control; to develop and implement evidence-based policy through operational research; and to enhance surveillance and monitoring and evaluation. The total investment required to implement planned TB control activities in the Region is estimated at US$ 2.2 billion over five years from 2006-2010. With the assumption that domestic financing will be unchanged until 2010 and that no major reduction in the budgets for already-approved Global Fund proposals will be made, the funding gap is estimated to be approximately US$ 637 million over five years.

18 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

2.5

CORE INDICATORS AND TARGETS OF THE STRATEGIC PLAN TO STOP TB IN THE WESTERN PACIFIC 2006-2010

Detailed discussion on the core indicators and targets of the Strategic Plan for 2006-2010 was held during this session. Dr Philippe Glaziou, Medical Officer, Stop TB Unit, WHO Regional Office for the Western Pacific introduced the agenda by way of a presentation. The core indicators for the Strategic Plan include case detection and cure rates, and indicators to assess progress in MDR-TB control, in TB-HIV collaborative activities and in PPM-DOTS implementation. The case detection rate remains a problematic indicator because its denominator - incidence - is particularly difficult to measure with precision. Current estimates of incidence lack precision in most countries. Estimates published by WHO are revised every year, and cannot be used at the subnational level. With regard to MDR-TB control, and in particular, DOTS-Plus implementation, the core target is the proportion of patients under quality-assured second-line drugs, out of all identified MDR-TB cases within DOTS-Plus programmes. The baseline is currently not measured, and is likely much lower than the target of 90%. A related expected result is that 10% of treatment failures (category 1 and 2) will have undergone DST. The TB-HIV core indicator is the proportion of cases under anti-retroviral treatment (ART) out of all eligible detected HIV-infected TB cases, with a target of 90%. Eligibility is currently not measured, and is not included in the revised WHO TB-information system. A proxy indicator was discussed, replacing the denominator with all identified TB-HIV cases. The baseline is currently unknown in most settings. The PPM-DOTS core indicator is the proportion of health facilities (public and private) providing DOTS, out of all health facilities involved in TB services, with a target of 90%. The baseline is currently unknown. Issues and challenges include: (1) All core indicators (a) Revised Recording and Reporting (R & R) system is not yet implemented. (2) MDR-TB (a) DOTS-Plus information systems are not standardized between project areas. (b) MDR-TB diagnosed and treated outside DOTS-Plus programmes. (c) Culture and DST: i. Performed as a money-generating activity in public health facilities with insufficient public funding. ii. Increasing purchasing power of patients may contribute to creation of services that do not meet the required standards

19 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

(3)

(4)

TB-HIV (a) No data on eligibility of TB-HIV cases for anti-retroviral treatment in the revised R & R. (b) Proxy for determining TB-HIV cases eligible for ART: all TB-HIV cases. Should the target remain 90%? PPM-DOTS (a) Determining criteria for defining a facility as a DOTS provider at the country level. (b) Determining the criteria for assessing facilities. (c) Denominator used (number of facilities involved in TB services) may vary over time

Core indicators for MDR-TB, TB-HIV and PPM-DOTS are included in the revised WHO TB information system, and countries are encouraged to adopt or to field-test them. Discussion • TAG members speculated that achieving the MDR-TB core target will not lead to addressing the magnitude of the MDR-TB problem. The suggestion was made to rapidly determine the actual size of the problem through baseline drug resistance surveys by drawing in expertise available in the Region and determining a target and strategy that will have an epidemiological impact on the MDR-TB prevalence. • The Regional Office of the Western Pacific was advised to take up the issue of approval for DOTS-Plus projects with the Green Light Committee to avoid delays in implementation should there be rapid expansion of DOTS-Plus. The Regional Office of the Western Pacific should also discuss options to ensure that projects meet the required standards in the event that countries decide to procure second-line drugs outside of the Green Light Committee mechanism. • Concern was expressed that DOTS-Plus activities in the Region are only planned with GFATM funding, which may not be sufficient to tackle the actual MDR-TB problem. Countries were advised to plan for scaling up DOTS-Plus activities beyond GFATM-funding. • TAG members agreed to use the proxy indicator for TB-HIV as an operational target for now. With experience and availability of better information on the difference between TB-HIV positive patients who need and do not need anti-retroviral treatment, the indicator may be revisited.

2.6.

STRATEGY TO ACHIEVE CORE TARGETS OF THE STRATEGIC PLAN TO STOP TB IN THE WESTERN PACIFIC 2006-2010

This session was held to discuss country-specific strategies to achieve the core targets of the Strategic Plan for 2006-2010. Six countries made presentations on the national strategy and described how the core targets apply in their settings.

20 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

2.6.1

Strategy to achieve TB-HIV core target: Cambodia

Cambodia has a generalized HIV epidemic with 1.9% of its adult population infected with HIV. TB is the most common opportunistic infection among people living with HIV / AIDS, accounting for approximately 40% of infections. Conversely, 10% of TB cases are HIV-positive and up to 37% of TB-HIV patients with a CD4 count of more than 200/mm 3 (and not on anti-retroviral treatment) die within two months of DOTS therapy. TB- HIV collaborative activities were initiated in 1999 when the first TB-HIV sub-committee was formed. Since then, a framework for collaboration has been developed, four TB-HIV pilot projects and a continuum of care project for people living with HIV / AIDS are being implemented, and two national surveys of HIV among TB patients has been carried out. Cross-referrals between the TB and AIDS programmes enables screening and diagnosis of TB among HIV / AIDS patients as well as enables HIV testing of TB patients, ensuring that patients enter the necessary care and support services. The R & R has been modified by NTP to capture data related to TB-HIV collaborative activities. Cambodia plans to test 80% of TB patients for HIV, screen 90% of newlydiagnosed HIV -positive individuals for TB and start 90% of eligible HIV-positive TB patients on anti-retroviral treatment. Strategies to achieve these goals include collaboration between the TB and HIV / AIDS programmes, including a joint action plan; expansion of continuum of care projects; and mobilization of resources from the GFATM. The challenge is the relatively low level of external resources and technical assistance available to the NTP for collaborative activities.

2.6.2

Strategy to achieve TB-HIV core target: Malaysia

Malaysia has a concentrated HIV epidemic, largely among injecting drug users. Since 2005, the Ministry of Health, along with NGOs, has embarked on harm reduction strategies, including a needle exchange programme and methadone replacement therapy. Much of the TB-HIV collaborative activities are related to screening for HIV and TB at prisons and rehabilitation centres. At TB treatment centres, TB cases are screened for HIV. Anti-retroviral treatment is available at subsidized rates and more health workers are being trained to administer both TB and anti-retroviral treatment therapy. Improved collaboration between HIV and TB programmes is needed and efforts are being made in that direction. Recent pUblicity regarding the unlikelihood of the country to achieve the TB and HIV-related MDG has led to a greater sense of urgency in adopting measures earlier deemed controversial by the top leadership.

21 Fifth Technical Advisory Group Meeting to Stop TB In

the Western Pacific Region

2.6.3

Strategy to achieve MDR-TB core target: China

The core indicator and target for MDR-TB in China is to provide, by 2010, treatment to 90% of MDR-TB patients identified in project areas. Strategies to achieve the core target on MDR-TB include developmen: of a framework and implementation plan; training of key staff; launchmg DOTS-Plus pilot projects using standardized treatment and management; and a gradual expansion of DOTS-Plus projects based on experiences from the pilot projects. General hospitals, specialized hospitals and some public health TB dispensaries already diagnose and treat MDR-TB. China plans to introduce management ofMDR-TB under the DOTS-Plus approach. Plans and guidelines for DOTS-Plus will be developed and implemented in two provinces with high rates of MDR-TB. This project will gradually expand by the fourth year to 31 DOTS-Plus sites in parts of six provinces with high MDR-TB rates. During 2006-2010, China plans to start more than 4500 cases of MDR-TB on treatment. DOTS-Plus sites will provide regular and accurate reporting based on WHO recommendations to measure and monitor the core indicator and target for MDR-TB. Support from GFATM Round 5 will be used for implementing DOTS-Plus activities.

2.6.4

Strategy to achieve MDR-TB core target: Republic of Korea

The incidence of initial MDR-TB in the Public Health Centres (PHC) has increased over the years to reach 2.7% in 2004. In Masan Hospital, a tertiary-level centre, initial MDR-TB increased from 2.4% in 1995 to 16.5% in 2002. The PHC manages only drug-sensitive TB cases and advises DST routinely for all culture positive cases. The Republic of Korea has a well-established private sector with the majority of TB cases seeking care initially from private doctors. Private clinics and hospitals manage both drug-sensitive and MDR-TB patients. However, culture and DST is performed by only seven laboratory units in the country. In the Republic of Korea, the core indicator for MDR-TB can be measured by performing DST for all culture-positive cases, by conducting nationwide inter-laboratory surveillance from all DST performing laboratories, and by developing a MDR-TB registration using an on-line data entry system. Some of the activities proposed to meet the MDR-TB core target include: providing the most appropriate treatment, including surgery where indicated; enhancing patients' compliance on treatment; tailoring the chemotherapy period where required; and developing international collaboration and training.

22 Fifth Technical AdvIsory Group Meeting to Stop TB in the Western Pacific Region

Discussion on MDR· TB

•

It was clarified that 2.7% of MDR-TB in PHC of the Republic of Korea could not .be taken as a representative estimate for the country, as PHC constJtutes only 20% of the TB centres in the country. The need to ensure quality of second-line drugs for MDR-TB was ex:p~essed. Paticipants from China informed the group that the MInIstry of Health is inviting WHO, Global Drug Facility, and the Green Light Committee for a meeting with China's pharmaceutical companies in order to promote compliance with good manufacturing practice requirements.

2.6.5

Strategy to achieve PPM-DOTS core target: Japan

Involvement of the private sector in TB control dates back to the enactment of the tuberculosis prevention law in 1951, when the medical fee subsidy system for TB services was first introduced. Cost of TB services, whether in the public or private sectors, is subsidized for TB treatment, TB screening and for special programmes (including DOTS) in high-burden areas. Private clinics and hospitals notify TB cases to public health centres as mandated by the law and also to apply for medical SUbsidy for their patients. A TB advisory committee evaluates the validity of each application and administrative order, and monitors the treatment provided in public or private institutions. Thus, PPM-DOTS in Japan is closely linked with treatment monitoring and medical fee subsidy. Since 2000, Japan has been implementing its own version of DOTS with the aim of supporting smear-positive TB patients to complete treatment. At the time of discharge from hospital, three types of DOTS are considered, depending on the patients characteristics: (1) "Outpatient DOTS," wherein patients with a high risk for default receive daily treatment in the hospital; (2) "Home-visit DOTS" for patients requiring special care, for which treatment is given in the hospital once or twice a week; and (3) "Communication DOTS," for patients who are followed-up in the hospital once or twice a month. Each case is monitored and reviewed, and treatment outcomes of all TB patients are collected nationwide. According to a 2005 national survey, about 75-80% of health centres and hospitals providing TB care, either in the public or private sectors, follow this plan.

2.6.6

Strategy to achieve PPM-DOTS core target: Philippines

Following successful pilots, PPM-DOTS was officially adopted as a strategy to increase case detection and harmonize TB management among all health care providers. In March 2003 the Comprehensive and Unified Policy on TB management was declared and signed by major stakeholders both in the public and private sectors. National and Regional Coordinating Committees

23 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

composed of members from the public and private sectors have been established to provide oversight to PPM-DOTS activities in the country ..For the sustainability of PPM initiatives, the PhilHealth TB DOTS outpatlent benefit package was introduced to finance TB services. PPM-DOTS coverage is measured by calculating the proportion of private practitioners practising or referring patients to DOTS facilities against those who should have done so. So far, 72 PPM-DOTS units have been installed, representing an overall coverage of approximately 30%. To achieve the core target on PPM-DOTS, the NTP will expand PPM units to at least 216 by 2008; will ensure that all public hospitals are either DOTS or DOTS-referring facilities by the end of 2007; will increase DOTS certification and PhilHealth accreditation to at least 500 public DOTS facilities by the end of 2007; and will train at least 7000 private physicians (almost 100% of whom should be trained) as DOTS-referring physicians by the end of 2007.

2.7.

UPDATE ON TB LABORATORY SERVICES

Dr Kai Man Kam, Consultant, Public Health Laboratory Centre, Hong Kong (China), presented an overview on TB laboratory services in the Region and reported on the recommendations of an informal consultation meeting of laboratory experts in early 2006. The situation of TB laboratory services in the seven countries with a high burden of TB was reviewed. Although most countries have a functioning National Reference Laboratory (NRL), there were considerable variations in the different functions that are carried out. Most are already linked with NTP, as DOTS coverage had expanded to most of the population. A network of Supranational Reference Laboratories has also been offering assistance to NRLs in their development. Various EQA strategies have been developed at the country level or already at the initial stages of implementation. Culture abilities of TB laboratories showed considerable variation, and there is an urgent need for countries to strengthen their laboratory capacities, especially on human resources and training of staff. The informal laboratory consultation meeting recommended the following indications for use of culture and DST, in order of priority: (1) drug resistance surveys; (2) support to DOTS-Plus programmes; (3) diagnosis of smear-negative TB suspects as a final step in diagnostic algorithm; (4) quality-assessment of TB diagnostic committees' performance; and (5) other operational research. A stepwise approach should be adopted for establishing culture facilities. The prerequisites to culture expansion are: (1) documentation of ongoing proficiency and capacity to perform culture (first with solid media, then liquid media) and DST through the designated Supranational Reference Laboratories; (2) development of

24 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

technical. s~and.ards.for culture; (3) development of biosafety standards; (4) pa~tl~lpahon m laboratory networks in general laboratory accre~ltatlOn pr?g:-ammes; (5) links with partners with microbiology expertIse; (6) bUlldmg general laboratory capacity including laboratory management, training and information systems. Discussion • TAG members appreciated the rational recommendations of the laboratory meeting, reflecting the situation and requirements of the Region. • Concern was expressed that some countries are complying with biosafety level two requirements (instead of level three) for performing cultures because of the cost involved in upgrading from level two to three. Countries were advised to develop their own biosafety guidelines depending on their regulations. • It was suggested that a regional framework be developed for building up culture facilities considering the current and future requirements for drug resistance surveys and DOTS-Plus. In addition to the technical requirements, the framework would include a strategy for strengthening the laboratory network. • Drug resistance surveys have been conducted in five of the seven HBC. The Lao People's Democratic Republic and Papua New Guinea are planning to do so in the near future. Plans and funding for DOTS-Plus are already available in high MDR-TB countries of the Region-China and Mongolia will soon be implementing pilots and the Philippines is already expanding DOTS-Plus.

2.8.

COUNTRY PLANS 2006-2010

National TB programme managers of the seven high TB burden countries in the Region presented their five-year national plans for TB control. These presentations covered the progress of the NTP during 2006-2010 including achievements and challenges; and country plans for 2006-2010, including financial requirements and anticipated gaps. TAG noted that all country plans are technically sound and recommended their implementation.

2.8.1

China

Remarkable progress by the NTP in 2001-2005 has resulted in achievement of the 2005 TB control targets in the Region. Poor quality of DOTS in some areas due to too-rapid expansion, high rates of MDR-TB, a huge floating population, and insufficient human resource capacity are the major challenges for the coming years. For the period 2006-2010, the NTP plans to detect and treat two million infectious TB patients and to reduce prevalence and mortality rates of smearpositive TB to 50% by 2010 (relative to 1990). To sustain at least a 70% case detection rate, nationwide DOTS coverage will be maintained, using

25 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

the county as the implementing unit; the referral system between the NTP and general hospitals will be strengthened; and EQA will be fully implemented in all laboratories carrying out sputum microscopy. The NTP will ensure direct observation of treatment for smear-positive TB cases, expand the use of fixed-dose combination (FDC) TB drugs and improve the drug management system to maintain a cure rate of over 85%. To ensure equitable access, the plan intends to expand the TB control network to medical institutions and community health centres; implement hospital-based DOTS; strengthen health promotion activities; and integrate the floating population under the NTP. A national framework for tackling MDR-TB and TB-HIV will be developed, implemented as pilots, and gradually expanded. A human resource development plan will be drawn up and necessary training imparted. Government funding will continue to be the primary source for the NTP with supplemental funding from partners. The estimated cost for the Stop TB Plan 2006-2010 is US$ 955 million. There is an anticipated funding deficit of US$ 416 million. Discussion • The meeting was informed that drug resistance surveillance (DRS) data would be available for 13 of 31 provinces by mid 2006. (Nine have already been conducted, with an additional four planned.) In the coming years, a national DRS will be conducted and a national estimate is expected to be available by 2008. • China was advised to ensure a national network of quality-assured microscopy integrated with the NTP, concurrent with implementing/ expanding culture, and assigning a certain percentage of the NTP budget for laboratory strengthening. • Given the magnitude of the MDR-TB problem, it was suggested to expand DOTS-Plus services outside GFATM funded projects and to consider including all re-treatment cases and not just treatment failure cases for culture and DST. • To explore ways to address the floating population, ajoint consultation workshop may be organized with other WHO Regions facing a similar problem; experts on the issue will be invited to participate.

2.8.2 Cambodia The NTP of Cambodia has reached the WHO TB control targets set for 2005. Major challenges for the next five years are to address the high prevalence ofTB and TB-HIV co-infection (there was a 10% HIV prevalence among TB patients in 2005); improve human resource development and staff motivation; ensure quality and accessibility of services; expand community DOTS and PPM-DOTS; and address MDR-TB. The National Health Strategic Plan for 2006-2010 is based on seven national policy statements and has ten main outputs. In order to achieve the core target (beyond the 70% case detection rate), the NTP will strengthen DOTS

26 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

!III/iIliIj1lllllllli'llll-'i

at all levels; implement EQA for sputum microscopy; invest in Information, Education and Communication activities; expand community DOTS; and promote active case finding among high-risk groups. Strategies to strengthen TB-HIV collaboration are being jointly planned and implemented. To address MDR-TB, drug resistance survey will be conducted in 2006 and a DOTS-Plus project launched by 2007. Initiatives to expand PPM-DOTS are being explored in collaboration with partners. By 2010, 90% of the health centres will have implemented community DOTS, at least 50 operational districts will have implemented TB-HIV activities, and at least 80% of TB patients referred for HIV testing and at least 90% ofHIV+ve TB cases will be put on anti-retroviral treatment. The total estimated cost of the five-year plan is approximately US$ 36 million, excluding the cost of food assistance by the World Food Programme and technical assistance to the NTP. The breakdown of the expenditures is as follows: 22% for programme management, 15% for capital investment, 15% for capacity building, 15% for salaries, 13% for drugs, and 20% for community DOTS expansion. Discussion • Participants appreciated the positive approach and ambitious plan of the NTP despite the sub-optimal state of the general health care services, with many of its staff on salvage remuneration. The need for overall health system strengthening was emphasized. • The group was informed that through coordination with NGOs, the NTP managed to expand its services, particularly in areas where public health facilities are unavailable. However, this has been a costly exercise. • Difference in population estimates by the country and by the United Nations (as used by WHO) lead to inconsistent data. The country was advised to take up the matter to resolve this difference.

2.8.3

Philippines

Preliminary data of 2005 indicate that the country has been able to sustain the case detection and treatment success targets achieved in 2004. The major challenges for 2006-2010 are to sustain these achievements through quality DOTS service and strengthened engagement with the private sector; to ensure technical and managerial expertise of NTP health workers; to expand initiatives with regard to MDR-TB management and TB-HIV; and to strengthen implementation of sputum smear microscopy EQA and certification of DOTS facilities. The National Strategic Plan 2006-2010 addresses these challenges and is in line with the Strategic Plan to Stop TB in the Western Pacific 2006-2010. The plan provides strategies to reach the core targets, such as ensuring high political commitment; strengthening the technical and managerial capabilities of DOTS workers; enhancing the laboratory skills to maintain proficiency in delivering quality laboratory services; conducting monitoring and evaluation; strengthening PPM-DOTS collaboration; expediting a plan

27 Fifth Technical Advisory Group Meeting to Stop TS in the Western Pacific Region

for DOTS-Plus expansion; setting-up a TB-HIV coordinating committee and establishing TB-HIV surveillance; and scaling-up and enhancing PPM-DOTS. With the approval of GFATM Round 5 and the expectation that government support remains constant at the level of 53% to 60% of the total cost, financing for the NTP is adequately secured. There will be, however, a remaining financial gap of approximately 10%, which is still to be met from other sources. Discussion o The Chair noted that the National Strategic Plan for 2006-2010 has been clearly laid out. o It was noted that the mechanisms used to ensure quality of services in PPM-DOTS units include PhilHealth certification, systematic monitoring and evaluation by the PPM-DOTS committees, and periodic external evaluations. o Responding to a question, the presenter clarified that DOTS is already included in the curriculum of medical colleges. Efforts are being made to include it in the curriculum of para-medical courses as well.

2.8.4

Viet Nam

Viet Nam was the first high TB burden country to achieve the 2005 TB control targets. Major current challenges include the spread of HIV (4.8% HIV prevalence among TB patients), rapid urbanization and the private sector, reaching the poor and ethnic minorities, health sector reform, and MDR-TB (2.3% of new smear-positive TB). In the period 2006-2010, the NTP expects to treat 550 000 TB patients, establish culture services, introduce the PAL strategy and FDC tablets for a full oral regimen. The NTP plans to start the first national tuberculosis prevalence survey in 2006. The NTP plans further focuses on human resource development, management capacity strengthening, and Advocacy, Communication and Social Mobilization (ACSM) to sustain the DOTS strategy. The NTP plans to develop and implement PPM-DOTS in urban areas and implement the TB-HIV framework in high HIV-prevalent provinces. The mid-term plan provides for the introduction of DOTS-Plus and the treatment of 1500 MDR patients during the plan period. Special priority is given to access for diagnosis and treatment in 200 remote and mountainous districts, the development of community-based DOTS and improved access to TB care in penitentiary and re-education institutions (05-06 camps) and prisons in 16 provinces. The NTP identifies the following cross-cutting issues: sustainable TB control, human resource development, ACSM, adequate management capacity and health care system strengthening. The budget required for the period 2006-2010 amounts to US$ 49.3 million. After considering funds available from the Government of Viet Nam and

28 ~\l\.\\IIII\\IIII1l\\\IIII\;I~I\\I\\'\\I\I\W Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

GFATM, a budget gap of US$ 29 million exists. The NTP aims to mobilize resources to fill the gap by requesting additional support from GFATM and continued support from the Royal Netherlands Embassy, Hanoi. Discussion: • TAG noted with concern the uncertainty of funding for the NTP and observed that the present priority should be to secure adequate funding for implementation of the mid-term plan for 2006-2010. The plan to apply for additional support from GFATM Round 6 was strongly encouraged. A suggestion was made to focus on relevant TB-HIV activities in the • rehabilitation centres to screen and manage TB-HIV co-infection. • A workshop was held in Hanoi in 2005 to determine why TB incidence was not falling despite the good cure and detection rate. The report of the workshop is covered in Section 2.10.

2.8.5

The Lao People's Democratic Republic

The Lao People's Democratic Republic achieved full DOTS coverage and achieved the WHO "70/85" targets in 2005. Major challenges are to provide access to patients in remote districts; improve diagnosis of smear-negative and extra-pulmonary TB even at the province level; address TB-HIV co-infection and MDR issues; involve all health facilities including the private sector; and ensure managerial and financial support to plan, implement and monitor all activities. The TB country plan for 2006-2010 has been designed to address these challenges in line with the Global Plan and the Strategic Plan to Stop TB in the Western Pacific. Strategies to sustain and optimize the quality of DOTS include strengthening EQA implementation, ensuring uninterrupted supply of quality TB drugs, and improving diagnosis of smear-negative pulmonary TB suspects through referrals. To respond to TB-HIV, TB patients will be included as a testing group in sentinel surveillance conducted by the national AIDS programme, and will have access to HIV testing and a continuum of care services, including antiretroviral treatment where required. In the area of MDR-TB, culture facilities will be established in the national reference laboratory, drug resistance survey will be conducted, all treatment failure cases tested by culture and DST, and 90% ofMDR-TB cases treated with second-line anti-TB drugs. To ensure equitable access, identified poor districts and prisons will be prioritized; ACSM activities will be expanded; and direct observation of treatment will be decentralized to health centres or villages. The following cross-cutting issues will also have to be addressed: sufficient and skilled human resources; improved and maintained infrastructure and equipment; and adequate funding for implementation of the plan. The total cost for the Stop TB Plan in the Lao People's Democratic Republic for 2006-2010 is estimated at approximately US$ 10 million with a current estimated gap of appr.oximately US$ 4 million.

29 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Discussion • TAG advised the NTP to focus on optimizing DOTS. The situation of TB-HIV and MDR-TB should be assesses and activities planned and prioritized depending on the magnitude of the problem. • Most of the funding for the NTP was noted to be from external sources. The Lao People's Democratic Republic was encouraged to secure additional funding from its national budget.

2.8.6

Mongolia

Mongolia reached the three global TB control targets ahead of 2005. Major challenges for 2006-10 are: addressing poverty (70% of current TB cases fall below the poverty line); addressing the increasing migration of rural populations to urban areas; improving the quality of DOTS services for prisoners and the homeless; and addressing the shortage of human resources and funds for DOTS-Plus and TB-HIV activities. The Stop TB Plan 2006-2010 intends to increase the case detection rate beyond 70% by improving diagnosis of smear-negative TB patients. During this period, a national drug resistance survey will be conducted (2007); all treatment failure cases will be tested by DST; DOTS-Plus will be scaled up; and 90% of MDR-TB patients will be started on DOTS-Plus treatment. Seventy percent of TB patients will be tested for HIV and at least 80% of HIV-TB patients will be provided with anti-retroviral treatment. Pro-poor TB initiatives will focus on increasing case notification among underserved populations; improving the cure rate of TB cases among prisoners; and screening all migrants in Ulaanbaatar city for TB. A disease prevalence survey will be conducted before 2007-2008 and a national programme review carried out in 2008-2009. The budget required for the period 2006-2010 amounts to US$ 2.8 million. After considering funds available from the Government of Mongolia and GFATM, a budget gap of US$ 1 million exists.

2.8.7

Papua New Guinea

Papua New Guinea has been unable to reach the WHO targets set for 2005. According to provisional data for 2005, the country achieved 47% DOTS coverage, 20% case detection, and a cure rate of only 55%. The main reasons for the poor performance have been attributed to insufficient human resources and insufficient funding for the NTP. The major challenges for 2006-2010 include insufficient funding; emerging threats of HIV and MDR-TB; inequitable access to DOTS due to difficult terrain; the high cost of travel; and inadequate infrastructure and resources. The goal of the Country Strategic Plan for 2006-2010 is to reduce the prevalence and mortality due to TB by half by 2015 (relative to 1990), thereby contributing to the achievement of the TB-related target of the MDG. By ensuring funding, accessibility and quality of basic DOTS services, the country intends to achieve the "70/85/100" targets by 2010. From

30 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

2006-2010, prevalence of MDR-TB will be assessed through the drug resistance survey and TB-HIV collaborative activities will be scaled up. The total funding requirement for the next five years is US$ 12.3 million and the funding gap is US$ 11.5 million. The Government of Papua New Guinea is planning to fill this gap by submitting a proposal to the GFATM Round 6. Discussion • The inadequate level of political commitment for TB control and slow progress of the DOTS programme in Papua New Guinea was noted with concern. • It was regretted that the local staff sent for international training on TB were not retained at their jobs. The country was advised to address this issue for future training.

2.9

GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA

Dr Elmar Vinh-Thomas, Team Leader of East Asia and the Pacific of the Secretariat for the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) made a presentation on two main areas: (1) recent updates related to the GFATM; and (2) background of possible Round 6 call for proposals from GFATM. On recent updates, Dr Vinh-Thomas provided an overview on several milestones achieved by the Global Fund, including reaching disbursement ofUS$ 2 billion since the GFATM was established, with 350 grant agreements already signed with 131 countries globally. About 15% of the total funding is for activities to combat tuberculosis, and so far about 5 million additional cases have been treated through DOTS. He acknowledged the tremendous contribution of WHO and other technical partners in achieving these milestones. The second part of the presentation was to orient the meeting participants about the possible Round 6, which the GFATM 13th Board may launch this year. Preparations have been made by the GFATM Secretariat, including the redrafting of the proposal form and guidelines for Round 6. However, Dr Vinh-Thomas noted that the GFATM Board has yet to make a decision as to if and when Round 6 is to be launched. If Round 6 is launched in April 2006, proposals will have to be submitted by end of July 2006; the technical review panel (TRP) will thoroughly review and screen the proposals in August and September 2006; and the TRP will announce the approved proposals in November 2006. Finally, Dr Vinh-Thomas highlighted a number of important issues for Round 6, including the need for effective technical assistance for proposal writing, implementation and review, and the need to find entry points to country coordinating mechanism (CCMs) or principal recipients (PRs) in countries where the Stop TB Partnership is not currently involved.

31 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

2.10 MONITORING AND EVALUATION 2.10.1 Measuring progress towards the 2010 targets Dr Philippe Glaziou, Medical Officer, Stop TB Unit, WHO Regional Office for the Western Pacific, made a presentation on the regional progress towards the 2010 targets, methods of measurement, and the TB information system. The complex process of computation and annual reVISIOns of TB prevalence and mortality is centralized at WHO Headquarters in Geneva. Disease burden estimates are revised every year, including estimates for past years. The actual value to be reached for a 50% reduction target changes slightly every year. In some countries, estimates are unstable while in others-in particular when good quality prevalence surveys or good quality mortality statistics are availablethey do not change substantially. The following table shows the progress in prevalence and mortality in the context of the regional targets for 20 10:

Cambodia China Lao People's Democratic Republic Mongolia Philippines Papua New Guinea Viet Nam

-10% -18% -11 % -27% -16% -29% -8%

-10% -16% -10% -33% -17% -25% -6%

Surveillance activities will have to be strengthened. Countries need to build their capacity to carry out a systematic and extensive analysis of surveillance data. Methods for measurement of disease burden include prevalence surveys of disease, prevalence surveys of infection, and various indirect methods to estimate disease burden. Pros and cons of each method were reviewed and discussed. The advantage of measuring prevalence from population-based surveys is that it is an accurate measure of confirmed disease. It is useful when surveillance data is poor and it allows related investigations (e.g. of health systems). The disadvantage is that it is costly and logistically complex, may lack acceptability in affluent countries, and does not lead to an accurate measure of incidence.

32 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

Mortality remains difficult to estimate with precision due to the lack of quality vital registration systems. The following table shows the advantages and disadvantages of current methods to measure mortality:

~ Incidence X case fatality

;:;; i;~vantage. Ii:. Readily available Simple

Di.adv~tage.

Patient cohorts (Treatment outcomes)

• •

Not representative of all TB deaths Approximate at best Does not capture mortality from undiagnosed TB; Costly, not applicable in most HBC Not fully evaluated; Large sample size required

• Vital Registration Direct measure of trends Improve accuracy of cause of deaths statistics

• • •

Verbal Autopsy

The future of TB information systems may include case-based internetbased systems, such as those implemented in the Republic of Korea and in China. Such systems are more appropriate in countries with a good level of connectivity and infrastructure. The following table compares characteristics of the aggregated WHO information system and the casebased internet-based system in the Republic of Korea and in China:

Simple paper and pencil technology; readily available Aggregated data Accuracy checking limited Rigid format, long time period needed to update system

Internet-based Case-based database; any tabulated report possible Individual record checking by controller Flexible, can be updated in a very short time period

Further evaluations of the case-based systems will be carried out to document their advantages, shortcomings, and requirements. Future activities in the Region will include: (1) Standardization of prevalence survey methods, including socio-economic indicators; (2) Evaluation of case-based TB information systems; and (3) TB Epidemiology workshops at the country level.

33 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

2.10.2 Report of the TB epidemiology workshop in Viet Nam Dr Maarten Bosman, Medical Officer, Stop TB for Viet Nam, the Lao People's Democratic Republic and Cambodia, briefed the meeting on the results of a TB epidemiology workshop held in Hanoi in November 2005. Viet Nam introduced the DOTS strategy in 1989 and has achieved full DOTS coverage and the WHO targets for case detection and cure since 1997. According to the stipulation of Dr Karel Styblo, the founder of the DOTS strategy, the achievement of at least 70% case detection and 85% cure should have resulted in halving the incidence in 15 years. However, the notifications reported by the NTP remain at about 120/100000 popUlation for all forms of TB and 70 000/100 000 for new smear-positive TB from 1998-2004. So the core question is: "Why is TB incidence apparently not falling in Viet Nam, despite high rates of case detection and cure?" To address this question, the Ministry of Health organized an epidemiology workshop with participation from national and international experts. The workshop had the following objectives: to review, appraise and analyse data on the TB situation in Viet Nam; to agree on the validity of the surveillance data; to obtain consensus on the TB situation and its trends; to explain observed trends; and to propose interventions and further data collection (surveillance, epidemiological and operational research). The principal conclusions were that the rising TB incidence in young adults has offset the overall decline expected from strong programme performance; that HIV certainly plays a role, but may not be the only important factor; and that a significant proportion of HIV-positive TB patients are injectingdrug users. The conclusions were based on examination of three sets of data: the notification rates of new smear-positive cases reported during 1997-2004 by age and gender (N= 437 138); the results of 15 tuberculin surveys in school children in six provinces; and the results of treatment of new and previously-treated cases during 1997-2003 (N=378 262). The analysis of the notification rates stratified by age group and gender showed that there was a decrease in the annual percentage change in women in the 25-64 age group and in men in the 35-64 age group. However, in young males age 15-34 and young females age 15-24, the trend showed an increase in the annual percentage change. A small increase in the trend was also observed in the elderly (age 65 and over). These increases suggest that the lack of decline of the incidence is due to the fact that the decline observed in the middle-age groups is compensated in particular by the increase observed in the young males' group. With regard to the tuberculin survey results, it was concluded that there may be a decline in transmission of tuberculosis in Viet Nam. However, it was also said that the tuberculin data are in general difficult to

34 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

interpret. The analysis of the treatment results showed that during 19972003, the treatment success rate was consistently? 85%, in all provinces, and for all age and sex groups. The results of drug resistance surveys show low rates of drug resistance « 3% MDR in new smear-positive cases); it was also observed that MDR is not increasing in the north, central or southern areas. Finally, it was concluded that the TB programme creates about 300 new chronic cases annually (excluding the private sector). The workshop concluded that a convincing explanation for changes in TB incidence rates by age and sex is the rapid increase in HIV -positive TB patients in men and women 15-35 years old. It was also noted that in Ho Chi Minh City, the HIV prevalence in male TB cases (15-24) increased from 0% to 25-30% during 1998-2002; that HIV predominantly occurs in men (> 70% in 20-29 year olds); and that HIV in general has increased in the north, south and central areas. Due to the steep rise of HIV in Ho Chi Minh City, the notification rates of TB had increased, as did the case-fatality, mainly due to the high mortality in HIV-positive TB patients. Case-notifications among people living in 05-06 camps and youth centres have also increased steeply, from 2% per year in 2002 to as high as 6% per year in 2004. The workshop then discussed whether HIV can explain all TB increase in men and women 15-35 years old. Demography, migration, urbanization, crowding, and increased case-findings are possible contributing factors. These factors remain untested, and are unlikely to be sufficient explanation for the rapid nationwide TB increase in the 15-24 age groups. The workshop concluded that the nsmg incidence in young adults demands rapid action to fully understand the reasons for the increase, including the role of HIV; and prompt action is also needed to prevent further levels of HIV infection among injecting drug users and other groups at high risk. Collaboration between the TB and HIV programmes is essential to implement HIV testing for TB patients; to provide cotrimoxazole and isoniazid preventive therapy; to diagnose and treat TB among people living with HIV / AIDS; and to increase access to antiretroviral treatment. Finally, the workshop identified research areas needed for understanding the rising incidence, with the following order of priority: prevalence survey (s); the role of HIV and TB-HIV in rising incidence; the role of the diagnostic effort and rate of fall in incidence; the validation of surveillance data; and the role of incentives and response for targets. Other research areas identified include: health-seeking behaviour; the impact of the private sector; the impact of migration, urbanization, and crowding; the role of drug resistance; chronic TB; and DOTS-Plus and other epidemiological factors such as tobacco, chronic diseases, and the Beijing genotype.

35 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

2.11 PROGRESS IN COUNTRIES WITH AN INTERMEDIATE BURDEN OF TUBERCULOSIS (lBC) This session was held to discuss issues relevant to the intermediate burden countries (IBC): Brunei Darussalam, Hong Kong (China), Japan, Macao (China), Malaysia, the Republic of Korea, and Singapore. Dr Michael F. Iademarco, TAG member, chaired the session. Three IBC presented the progress in TB control since the 2002 TAG meeting, with a focus on specific issues. In addition, the United States of America's perspective on TB among migrant workers and foreign-born persons, and the ISTC, were presented.

2.11.1

Hong Kong (China)

In his presentation, Dr Cheuk Ming Tam, Consultant Chest Physician of the Department of Health, Hong Kong (China), noted an overall decreasing trend in TB notification in Hong Kong (China) over the past 50 years, until stagnating in the past 10-15 years. Some of the underlying causes were attributed to: ageing of the popUlation, ageing of the TB epidemic, and increased population movement, as well as a strengthened surveillance system. Findings of recent research studies support the hypothesis that the recent stagnant trend in TB notification probably results from a high prevalence of infection among older individuals, and a high risk of disease through reactivation, rather than from primary infection or exogenous re-infection. Thus, the DOTS strategy, which targets interruption of recent transmission, may have a smaller impact in Hong Kong (China) in the short-term than originally predicted. Since TB developing from endogenous reactivation of remote infection pro bably assumes a bigger role in the disease burden, the TB control strategy in Hong Kong (China) will put more emphasis on treatment of latent TB infection. A targeted approach is being adopted towards special highrisk groups. Dr Tam stated that the private sector in Hong Kong (China) notifies only approximately 3% of all TB cases. Data from TB laboratories of private hospitals are cross-matched with the TB notification registry to minimize potential under-notification. When a TB case is notified from the private sector, the health nurse of the Department of Health will liaise with the private doctor as well as with the patient to provide the necessary support, including health education, contact tracing, and monitoring of anti-TB treatment adherence. The public sector takes the leadership for TB control and sets the standard for TB care. An updated TB manual was published in 2006 to provide reference for medical professionals of both the public and private sectors.

36 1lD~,"'i&i'I,~M, .~ Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

2.11.2 Japan Dr Ai Sato, Technical Officer, Ministry of Health, Labour and Welfare, Japan, presented the TB strategy in Japan with a focus on ageing populations. Though an IBC, Japan has one of the highest TB incidences among industrialized countries. After a smooth and rapid decline in incidence levels from the 1950s to 1970s, the incidence rate slowed down after 1980, a scenario in line with the rapid ageing of the overall population due to lower birth rates and the prolongation of life expectancy in the years after the World War II. The proportion of TB patients aged 60 and above was only 18% in 1962, while it was 60% in 2003. This proportion is expected to remain the same for another couple of decades, followed by a gradual decrease with the passing of the cohorts, who are a significant proportion of the infected population. Ageing of TB patients means more TB patients with underlying medical complications, thus presenting diagnostic and management challenges. In many cases, coexisting complications mean poorer prognosis-barely over a 70% treatment success rate according to the nationwide surveillance on treatment outcome. Frequent lack of typical TB symptoms among elderly patients may also account for the poor prognosis and high proportion of early deaths, ever increasing since 1988. Progress since 2002 is best described in the example of Osaka City, where the Third TAG Meeting was held. Great improvement of TB control has been seen since that meeting, mainly due to the strong commitment of the local government and its vigorous promotion of DOTS.

2. 11 .3 Singapore The progress in TB control, with a focus on TB among migrant workers in Singapore, was discussed by Dr Khin Mar Kyi Win, Epidemiologist, Ministry of Health, Singapore. She outlined the milestones and achievements of the Singapore TB Elimination Programme, referred to as the STEP Programme, and discussed the process for granting work permits to foreign workers, who account for a significant proportion of TB cases (47% of new cases in 2005). The appeal system introduced in 2000 allows work permit holders diagnosed with active TB to appeal for conditional approval to continue work in the country, the decision of which is based on a successful treatment outcome. The number of approvals granted has increased from 15 in 2000 to 88 in 2004. Thus the policy in Singapore is to treat migrant workers with TB instead of to deport them.

2.11.4 United States of America Dr Michael Iademarco, from the U.S. Centers for Disease Control and Prevention and also a member of the TAG, shared the United States of America's perspective on tuberculosis among migrant workers and foreignborn persons. The number ofTB cases among US-born persons has declined over the years, whereas it has remained steady among the foreign-born. To prevent travel by infectious TB patients, panel physicians in overseas locations screen potential immigrants/refugees using a chest X-ray and acid-fast bacilli sputum smear. Within the country, services for evaluation

37 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

and treatment of TB is provided free of cost without regard to immigration status. Dr Iademarco discussed the high incidence of TB at the United States of America-Mexico border and the use ofbi-national health cards for TB patients which contains information on the patient's treatment status and provide toll free numbers for both countries. Other interventions include information exchange programmes with other countries; the use oflocal epidemiological profiles as the basis for screening and prevention programmes; customized patient education material; and close cooperation of the public health and immigration authorities.

2.11.5 International Standards for Tuberculosis Care (lSTC) Dr Paul Nunn, Coordinator, TB-HIV and Drug Resistance in WHO Headquarters, Geneva discussed the recently introduced ISTC. The ISTC is an internationally accepted level of care for all practitioners, private and public, who engage in managing patients with, or suspected of having, tuberculosis. The ISTC has been developed to ensure a minimum quality of care by all care providers, since TB is also managed by non-programme providers, especially those in the private sector, teaching hospitals, professional societies, training schools, and NGOs. The ISTC was welcomed as a document long overdue and the group welcomed the proposal to use it as a tool to guide activities ofthe professional societies; as the core of training for PPM-DOTS; as a focus for medical and nursing school curricula; and as a focus for advocacy.

2.12 CHINA: PROGRESS TOWARDS 2010 Country participants for the session were Dr Wan Liya, Dr Liu Jianjun, and Dr Wang Yan. Dr Yin Li, a member of the TAG, chaired the session. The group discussed the topics enumerated below: (1) Baseline of the 2010 goal to reduce TB prevalence and mortality by 50%: 1990 or 2000? (a) China is committed to achieving the MDG target for TB, which has the baseline year of 1990 and the target year of 2015. (b) China will also make an effort to achieve the Western Pacific Regional Committee target for TB, which has the baseline year of 2000 and the target year of 2010. (c) Chinese colleagues stated that it is not problematic for the baseline year to be reviewed and discussed at a technical level. It is possible to consider changing the baseline year from 1990 to 2000 after further discussion. (d) The importance of China to the achievement of the Western Pacific Region's target is clear to all those participating in the discussion. (e) TAG members expressed confidence in China's ability to deliver on the "50/50" targets regardless of the baseline year chosen.

38 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

(2)

Addressing MDR-TB in China: Options for prevention (a) Although the group fully endorsed the piloting and eventual expansion of DOTS-Plus in China, TAG members and other participants believe the priority must be the prevention of MDR-TB. (b) Improving the quality of DOTS should remain the priority for the NTP even as the country begins the DOTS-Plus pilot and capacity building for expansion of DOTS-Plus. Preventing emergence of MDR-TB is the priority. Treatment of MDR-TB is important from a humanitarian perspective but is unlikely to have a significant impact on the disease burden. (c) The group discussed the importance of strengthening the management of TB cases at the grassroots level to prevent the emergence of MDR-TB. There is an excellent opportunity to link TB control to the expansion of the Rural Cooperative Medical System and to the development of community health centres in urban areas over the next five years. (d) There is a need to involve TB hospitals in the NTP to ensure proper reporting, treatment and referral to the TB dispensaries after hospital discharge. This step could reduce the improper use of first and second-line TB drugs in many hospitals, thereby reducing the emergence of MDR-TB. This work has already started with a Ministry of Health document in 2005. Further work is needed in 2006. (e) Under the guidance of the State Council, the Ministry of Health is currently developing a set of laws on TB control specifying how TB should be diagnosed and treated. Whether these laws will take effect or not is uncertain. Nevertheless, TAG members strongly support this development. Information about TB law in other countries would be very useful to China. If available, the Ministry of Health would be interested in reviewing examples from other countries. (f) The development oflaws on TB control can be linked to the adoption of the ISTC developed at the global level. It would be useful for China to adopt relevant aspects of this standard. (g) There is a need to ensure the quality and uninterrupted supply of TB drugs. The recent procurement of TB drugs for smear-negative cases was decentralized to the 31 provinces because of regulations by the Ministry of Finance. Because capacity to procure drugs in the provinces is limited, there may be problems with drug quality, drug supply and higher drug cost. The Ministry of Health plans to further discuss this issue with the Ministry of Finance to see if drug procurement can be centralized. (h) There is a need for the NTP to gradually expand the use of FDC TB drugs. Ensuring the quality of FDC drugs should be a priority. (i) The group discussed the possibility of national regulations to restrict the sales of TB drugs. Although some provinces have implemented such regulations, it is not easy to implement such national regulations.

39 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

(j)

(k)

The current GFATM Round 5 proposal aims to treat approximately 4500 cases in the next five years. This is a small number of cases compared to the overall size of the problem. China will develop a plan by the end of 2006 to expand DOTS-Plus beyond the GFATM Round 5 project. Doing so will provide China with a roadmap for eventual expansion of DOTS-Plus. There is an urgency to prevent the further emergence of MDR-TB in China and to build the infrastructure (including pilot experience) for DOTS-Plus. Second-line TB drugs are being used throughout China, and resistance to these drugs is emerging. It would be useful for China to develop an overall plan to prevent and treat MDR-TB, outlining key steps that can be taken in a stepwise manner.

(3)

Opportunities for the TB programme to address health system issues, including health financing: (a) Some health system issues were discussed. (b) The participants congratulated China for an unprecedented level of political commitment. This commitment is evident in the naming of TB as one of the priority diseases to be controlled in the 11 th Five-year Plan for the country's development. Premier Wen Jiabao mentioned TB in his report to the National People's Congress last week. The Ministry of Health has also listed TB as a priority disease. The newly-established Disease Control Bureau will establish a separate TB division. (c) Central-level funding for TB may increase by 20% in 2006. (d) A key health system issue is inadequate human resource capacity. It is important to continue to strengthen human resource capacity for TB at all levels. Achieving the "50/50" targets will require a well-trained and motivated work force. A superlative work force is especially important at the central level.

2.13 ISSUES IN OTHER COUNTRIES WITH A HIGH BURDEN OF TB This session was held to discuss common issues relevant to HBC (other than China): Cambodia, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam. Dr Vicki Krause from the TAG chaired the session. There were three main issues discussed: (1) improving TB laboratory services; (2) engaging public general hospitals; (3) implementing TB-HIV surveillance. The discussion on improving laboratory issues referred to a previous presentation on a stepwise approach to building laboratory capacity. Each country outlined its challenges and plans with respect to improving TB laboratories in relation to the stepwise approach. Given that most countries are at the stage of implementing the quality assurance system based on the Regional Guidelines for Quality Assurance, the challenges

40 • •1111 ilfllUilUllII\lIIIllIIIIiIf. Fifth Technical Advisory Group Meeting to Stop TB In the Western Pacific Region

relate to further strengthening laboratory capacity by keeping staff motivated; sustaining training mechanisms; addressing limited geographic access to certain areas; and adapting to new challenges posed by health sector reform. In order to systematically address these challenges, Dr Mao Tan Eang suggested that developing a strategic plan for laboratories could be useful. Such a plan could prove relevant to other countries sharing common laboratory issues, e.g. the need to provide strategic direction on the use of culture and DST. Concerning general hospitals, most countries have concrete plans to engage the general hospitals for TB control. Some are being implemented as part of the conventional delivery of health services (i.e., Papua New Guinea); others are having difficulties (i.e., Mongolia) developing an effective involvement of the general hospitals. TB-HIV surveillance is an important issue for the six HBC, including those with low prevalent situations. Only Cambodia has a well-developed system for assessing the level of TB-HIV through a national seroprevalence survey conducted every two years. Other countries have yet to initiate joint surveillance for TB and HIV for assessing the problem beyond a limited area or pilot. However, all countries indicated that joint TB-HIV surveillance will be implemented as part of the plan to address TB-HIV issues.

2.14 INTERAGENCY COORDINATING COMMITTEE (ICC) SESSION Dr Pieter van Maaren opened the Interagency Coordinating Committee (ICC) session with a presentation on the overview of funding for the Stop TB Special Project in the Western Pacific Region, 1999 to 2005. At every TAG Meeting, a separate session is conducted by the ICC to provide a forum for discussing issues with donor agencies and other partners. This year, the ICC session provided an opportunity to present an overview of support from partners for the last five years, while looking ahead to the next five years. Donor support has been crucial to the success ofthe Stop TB Special Project. In the past five to six years, incremental increases in funding have been invaluable, allowing the WHO Regional Office for the Western Pacific, as the Secretariat of the Stop TB Special Project, to increase the human resource capacity from only two staff in 1999, to 16 staff. The Stop TB Special Project has several major donors, including the Government of Japan, United States Agency for International Development (USAID), the Canadian International Development Agency (CIDA) and AusAID. These donors contributed a total of US$ 20 million between 1999 and 2005, about 66% of the total funding of WHO Regional Office for the Western Pacific for the Stop TB Special Project. At the country level, GFATM has become the biggest source of funding

41 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

for TB, providing a total of 13 grants for TB in the Region in six HBC countries, including the Pacific islands and areas. The total amount of approved proposals from Rounds 1 to 5 is US$ 255 million, 62% of which is for China. Dr van Maaren also provided a report on how donor funds were used. About 60% of the funding received by the WHO Regional Office for the Western Pacific was allocated at the country level for country-specific activities. Funding support has been strategically shared among the major donors, with AusAlD and USAlD supplementing the WHO regular budget to fund key staff positions in the WHO Regional Office for the Western Pacific and in countries. CIDA provided significant funding to accelerate DOTS expansion and case detection in Cambodia and in China. The Government of Japan and USAID contributions provided most of the funding for WHO Regional Office for the Western Pacific activities, of which more than half were allocated to provide countries necessary technical assistance. Finally, Dr van Maaren outlined the needs of the Stop TB Special Project for the WHO Regional Office for the Western Pacific in the next several years. It is estimated that the WHO Regional Office for the Western Pacific will need between US$ 28 to 33 million over the next five years, an average of US$ 5.6 to US$ 6.6 million per year, an increase of 25% to 50%, compared to the average in the last five years. The increase in funds is needed to further strengthen the capacity of the WHO Regional Office for the Western Pacific, to provide more intensified technical assistance at the regional and country levels and to effectively coordinate the implementation and monitoring of the Strategic Plan for 2006-2010. Countries will be requiring more intensified support, particularly to address the more technically demanding challenges of MDR-TB, TB-HIV and DOTS quality improvement.

ANNEX 1

FIFTH STOP TB TECHNICAL ADVISORY GROUP MEETING FOR THE WESTERN PACIFIC REGION TIMETABLE 15 - 18 March 2006, Busan, Republic of Korea

;'t

'" -< m o

"'a. <

o o

-< G)

10:30

1, TB control in WPRO: Current situation and future

perspective 10:50 I 2. Global TB control; Current situation and future perspective

10:30 I 11:00 I 11:30

a. China b. Cambodia

;;: m ~ <0

12.lIiCs' c. Philippines • Issues

13. HaC. (3 gr<Jups)

11:20

I I

3. Modelling the impact of TB control strategies towards 2010 targets in WPR

related to migrants, ageing

Progress

" 'f} o

towards 2010 Other issues

--< OJ

population, 4. Regional Strategic Plan (RSP) 2006-2010 TB/HlV

11 :40

~ m 3 ru 'U

targets 6. Strategy to achieve core targets: a. TB/HIV (Cambodia and Malaysia) b. MDR-TB (China and Republic of Koreal

13:30 14:00 14:30

d. Viet Nam

13:30

14. Field ,(jsit: (4. groups)

e. Lao PDR f.

TB ina"nagement 'information system

0' " m '" 6' o

Mongolia FunctiQnil19 of P~C

14:00

14:45

16:00

c. PPM-DOTS (Japan and Philippines)

15:30 16:00 I 9.

g. Papua New Guinea

Meeting to discuss GFATM issues

ANNEX 2 LIST OF TECHNICAL ADVISORY GROUP MEMBERS, PARTICIPANTS, RESOURCE PERSONS, CONSULTANT, REPRESENTATIVES OF PARTNER AGENCIES, OBSERVERS AND SECRETARIAT

1. TECHNICAL ADVISORY GROUP MEMBERS Dr Jaap Broekmans, Director, KNCV TB Foundation (formerly KNCV), Riouwstraat 7, P.O. Box 146, 2501 CC The Hague, The Netherlands; Tel.: 31 (70) 416 7222/7245; Fax: 31 (70) 3584004; E-mail: broekmansj@kncvtbc.nl Dr Donald Enarson, Director, Scientific Activities, International Union Against Tuberculosis and Lung Diseases (The Union), 68, Boulevard Saint-Michel, 75006 Paris, France; Tel.: 33 1 44 320360; Fax: 33 1 43 299087 ; E-mail: denarson@iuatld.org Dr Michael lademarco, Associate Director for Science, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention, Mailstop E-10, 1600 Clifton Road, Atlanta, Georgia, United States of America; Tel. No.: 1 4046395336 (direct); 639 8120 (main); Fax No.: 1 4046398604; E-mail: mai9@cdc.gov Dr Sang-Jae Kim, Laboratory Consultant, International Union Against Tuberculosis and Lung Diseases (The Union). 101-703 Unjeongmaul, 621 Mabukri, Guseongup, Yonginsi, Kyeonggido 449-560, Republic of Korea; Tel.: 8231 2874301; Fax: 8231 3044301; E-mail: SJKim@iuatld.org Dr Yin Li, Director-General, Department of International Cooperation, Ministry of Health, No. 1 Xi Zhi Men Wai Nan Lu, Beijing 100044, China; Tel: (86-10) 6879 2039 ; Fax: (86-10) 6879 2279; E-mail: yinli@moh.gov.ch Dr Toru Mori, Director, Research Institute of Tuberculosis, Japan AntiTuberculosis Association, 3-1-24 Matsuyama, Kiyose-shi, Tokyo 204-8533, Japan; Tel.: 81 (424) 92-4767; Fax: 81 (424) 924600; E-mail: tmori@jata.or.jp Dr Vicki Krause, Director, Centre for Disease Control, NT Department of Health and Community Services, P.O. Box 40596, Casuarina, N.T. 0811, Australia; Tel.: 61 (0) 8-8922 8510; Fax: 61 (0) 8-8922 8310; E-mail: vicki.krause@nt.gov.au Dr Shinichiro Noda, Deputy Director for International Cooperation, International Affairs Division Minister's Secretariat, Ministry of Health, Labour and Welfare, 1-2-2, Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Japan; Phone: (81) 3 3595-2404 ; Fax: (81) 3 3502-6678; E-mail: noda-shinichirou@mhlw.go.jp

44 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

2. PARTICIPANTS BRUNEI DARUSSALAM Dr Hajah Salizawati Mohd Zainal, Senior Medical Officer, Ministry of Health, Commonwealth Drive, Bandar Seri Begawan BB3910 Tel.: (673) 2747587, Fax: (673) 223 0050 Email: sal@brunei.br Dr Mao Tan Eang, Director, National Center for TB and Leprosy Control (CENAT), Ministry of Health, Street 278-95, Boeung Keng Kang 2, Khan Chamkar Morn, Phnom Penh Tel: (855) 12916503, Fax: (855) 23 218090 E-mail: mao@online.com.kh Ph. Ton Chhavivann, Chief, Reference Laboratory, National Center for TB and Leprosy (CENA T), Ministry of Health, Street 278-95, Boeung Keng Kang 2, Khan Chamkar Morn, Phnom Penh Tel: (855) 12916503, Fax: (855) 23218090 E-mail: tsivanna@camnet.com.kh CHINA, PEOPLE'S REPUBLIC OF Dr Liu Jianjun, Director, National Center for TB Control and Prevention, No. 27 Nanwei Road, Xuanwu District, Beijing 100044 Tel.: (8610) 831 36116, Fax: (8610) 831 35306 E-mail: liujj@chinatb.org Dr Wan Liya, Consultant, Department of Disease Control, Ministry of Health, No.1, Xizhimenwai Nanlu, Beijing 100044, Tel.: (8610) 6879 2364, Fax: (8610) 6879 2279 E-mail: wanly@moh.gov.cn Ms Wang Van, Project Officer, Department of International Cooperation, Ministry of Health, No.1, Nanlu, Xizhimenwai Beijing 100044 Tel.: (8610) 6879 2390, Fax: (8610) 6879 2279 E-mail: wang_yan76@263.net HONG KONG, CHINA Dr Cheuk Ming Tam, Consultant Chest Physician, Department of Health, 21 IF Wu Chung House 213 Queen's Road East, Wanchai Tel.: (852) 2572 6023, Fax: (852) 28346627 E-mail: cm_tam@dh.gov.hk Dr Ai Sato, Technical Officer, Tuberculosis and Infectious Disease Control Division, Health Service Bureau, Ministry of Health, Labour and Welfare, 1-2-2, Kasumigaseki, Chiyoda-Ku, Tokyo 100-8916 Tel.: 81 335952257, Fax: 81 33581 6251 E-mail: satou-ai@mhlw.go.jp

CAMBODIA

JAPAN

45 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

LAO PEOPLE'S DEMOCRATIC REPUBLIC

Dr Phannasinh Sylavanh, Director, National Tuberculosis Centre, Ministry of Health, Dr Chanmy Sramany, Global Fund Unit, Vientiane Tel.: (856) 219078/020551 8676, Fax: (856) 452 855 E-mail: psylavanh-ntcplao@laopdr.com Dr Phommasack Bounlay, Deputy Director, Department of Hygiene and Prevention, Ministry of Health, Dongpalad Village, Chanthaboury District, Vientiane Tel. no.: (856) 21242980, Fax no.: (856) 212 42981 E-mail: bsack@laotel.com

MACAO, CHINA

Dr Chou Kuok Hei, Head, Tuberculosis Programme, Department of Health, Special Administrative Region (SAR), Macao Tel: (853) 532 196, Fax: 853 530 582 E-mail: ctb@ssm.gov.mo Dr Nirmal Singh a/I Sham Sher Singh, Deputy Director, (Communicable Disease Control), Disease Control Division, Ministry of Health, Malaysia, Level 3, Block E 10, Parcel E, Federal Government Administrative Centre, 62590 Putrajaya Tel.: 60388834411/4421, Fax: 603 8888 6270 E-mail: drnirmaI9_11@hotmail.com Dr Naranbat Nyamdavaa, Head, TB Department, National Center for Communicable Diseases (NCCD), NCCD Campus, Nam-Yan-Su Street, Ulaanbaatar 210648 Tel.: 976 11 450492, Fax: 976 11 450492 E-mail: ntpml@mongol.net Dr Khandaasuren Dovdon, TB Doctor, National Center for Communicable Diseases (NCCD), Nam-Yan-Su Street, Ulaanbaatar 210648 Tel.: 976 11 451169, Fax: 976 11 450492

MALAYSIA

MONGOLIA

PAPUA NEW GUINEA

Dr Paul Aia, National TB Programme Manage, Disease Control Branch, National Health Department, P.O. Box 807, Waigani, Port Moresby Tel.: (675) 301 3757, Fax: (675) 301 3604 E-mail: paul-aia@health.gov.pg Dr Jaime Lagahid, Director III, Center for Infectious Disease Office, National Center for Disease Prevention and Control, Department of Health, Sta. Cruz, Manila Telefax: (632) 711 6808 E-mail: drlagahid@yahoo.com

PHILIPPINES

46 Fifth Technical Advisory Group Meeting to Stop TB In

the Western Pacific Region

Dr Rosalind Vianzon, Medical Specialist IV, Center for Infectious Disease Office, National Center for Disease Prevention and Control, Department of Health, Sta. Cruz, Manila Telefax: (632) 711 7808 E-mail: rgvianzon10@yahoo.com REPUBLIC OF KOREA Dr Hwa Hyun Kim, Director, Division of HIV, STI and TB Control, Korea Centre for Disease Control and Prevention, 5 Nokheon-Dong, Eunpyun-Gu, Seoul Tel.: 8223801442, Fax: 8223801418 E-mail: 2002k@paran.com Dr Seung-Kyu Park, Director, Chest Surgery and International TB Research Centre, and Director, National Masan TB Hospital 486 Gapo-Dong, Masan City 631-710, Seoul Tel.: 82 55 249 3781, Fax: 82 55 242 1135 E-mail: pulmol16@empal.com SINGAPORE Dr Khin Mar Kyi Win, Epidemiologist, Tuberculosis Control Unit, Ministry of Health, 142 Moulmein Road, Singapore 308087 Tel.: (65) 635 77402 /816 34933 E-mail: Kyi_Win_KHIN_MAR@ttsh.com.sg Dr Dinh Ngoc Sy, Director, National Hospital of TB and Lung Diseases, Manager of National TB Programme, Ministry of Health, 463 Hoang Hoa Tham, Badinh, Ha Noi Tel.: (844) 761 3728, Fax: (844) 832 6162 E-mail: ngocsy@bvlaobp.org Dr Bui Duc Duong, Vice Director, National Hospital of TB and Lung Diseases, Ministry of Health, 463 Hoang Hoa Tham Badinh, Ha Noi Tel.: (844) 832 6249 Fax: (844) 832 6162 Email: Bdduong@hn.vnn.vn

VIET NAM, SOCIALIST REPUBLIC OF

3. RESOURCE PERSONS Dr Nobukatsu Ishikawa, Vice Director, Research Institute of Tuberculosis, 3-1-24 Matsuyama, Kiyose, Tokyo 204-8533, Japan Tel.: 81424935605, Fax: 81424928258 E-mail: ishikawa@jata.or.jp Dr Kai Man Kam, Consultant, Public Health Laboratory Centre, Rm. 731, 7/F, 382 Nam Cheong Street, Shek Kip Mei, Kowloon, Hong Kong Tel.: 85223198303; 27761901, Fax: 85227761446 E-mail: kmkam@dh.gov.hk;kmkam@email.com

47 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Dr Woojin Lew, Visiting Researcher, Montreal Chest Institute, McGill University Health Centre 3650 St Urbain St. Room Kl.13, Montreal, Quebec, Canada H2X 2P4 Tel.: (1-514) 934 1934 ext. 32327), Fax: (1-514) 843 2083 E-mail: wjlew@hanmail.net

4. CONSULTANT Dr Jacques Sebert, 39 Square Michelet, 13009 Marseilles, France Telefax No. (33) 49171 4688, E-mail: jacques.sebert@free.fr

5. REPRESENTATIVES OF PARTNER AGENCIES AND OBSERVERS

DAMIEN FOUNDATION BELGIUM (DFB)

Mr Alex Jaucot, DFB Representative for South-East Asia, Beijing Representative's Office, Room 1502, Guangming Hotel, Liangmaqiao Road, Chaoyang District, Beijing 100016, China Tel.: 86108451 2250, Fax: 861064637144 E-mail: alex.jaucot@damien-bel.org.cn Dr Liu Zhentian, Medical Advisor for China, Damien Foundation Belgium, Room 1588, Guangming Hotel, Liangmaqiao Road, Chaoyang District, Beijing 100016, China Tel.: 861064678020, Fax: 86108451 2250 E-mail: liu.zhentian@damien-bel.org.cn

GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA (GFA TM)

Dr Elmar Vinh-Thomas, Team Leader, East Asia and the Pacific, GFATM. Chemin de Blandonnet 8, 1214 Vernier, Geneva, Switzerland Tel.: (41-22) 791 1722, Fax: (41-22) 791 1701 E-mail: elmar. vinh-thomas@theglobalfund.org

JAPAN ANTI-TUBERCULOSIS Dr Katsunori Osuga. Deputy Director, International ASSOCIATION (JATA) Programs, JAT A, 3-1-24 Matsuyama, Kiyose-shi, Tokyo 204-8533, Japan Tel.: (81) 424-93-5340, Fax: (81) 424-92-8258 E-mail: osuga@jata.or.jp JAPAN INTERNATIONAL COOPERATION AGENCY (JICA) Dr Mie Kasamatsu, Expert on TB Control, DOH-JICA Quality TB Control Programme Project, JICA Philippines, G/F National Tuberculosis Reference Laboratory, Research Institute for Tropical Medicine, Filinvest Corporate Avenue, Alabang, Muntinlupa City, Metro Manila, Philippines Telefax No. (632) 772-2063 E-mail: m8kasamatsu@jtw.zaq.ne.jp

48 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

MANAGEMENT SCIENCES FOR HEALTH (MSH)

Dr Olya Maria Duzey, Programme Manager for Asia and the Near East, Center for Pharmaceutical Management, Management Sciences for Health, 4301 N. Fairfax Dr., Suite 400, Arlington, Virginia 22203, United States of America Tel.: 1-703-248-1605, Fax: 1-703-524-7898 E-mail: oduzey@msh.org Dr Masaki Ota, Research Scientist, The First Division, Infectious Disease Surveillance Center, NIID, 1-23-1, Toyama, Shinjuku City, Tokyo 162-8640, Japan Tel.: (81) 5385 1111 ext. 2580, Fax: (81) 5385 1233 E-mail: otama@nih.go.jp Professor S.H. Lee, Vice-President of the Association and Chairman of Health Promotion Committee, 266 Queen's Road, East, Wanchai, Hong Kong Tel.: (852) 2572 3466, Fax: (852) 28340711 E-mail: antitb@ha.org.hk Dr Chantha Chak, Infectious Disease Team Leader, Office of Public Health, USAID Cambodia, Phnom Penh Tel.: (855) 23 216436, Fax: (855) 23 217 638 E-mail: cchak@usaid.gov

NATIONAL INSTITUTE OF INFECTIOUS DISEASE (NIID), JAPAN

THE HONG KONG TUBERCULOSIS, CHEST AND HEART DISEASES ASSOCIA TION

WORLD VISION INTERNA TIONAL

Dr Sri Chander, Regional Health Advisor, Asia Pacific Region, World Vision International, 10 Anson Road, #13-08 International Plaza, Singapore 079903 Tel.: (65)62211-040, Fax: (65) 62211390 E-mail: sri_ chander@wvi.org Dr Jong Koo Lee, Director General, Ministry of Health and Welfare, Seoul, Republic of Korea E-mail: jongku@mohw.go.kr Dr Sung Kyu Kim, Director, Korea National Tuberculosis Association, Dangsandong-6-ga, Yeoungdeungpo-gu, Seoul 121-150, Republic of Korea Email:skkimpul@yumc.yonsei.ac.kr Dr Duk Hyoung Lee, Director, Center for Communicable Disease Surveillance and Response, Korea Centers for Disease Control and Prevention, 5, Nokbun-Dong, Eunpyung-Gu, Seoul 122-701, Republic of Korea E-mail: leeduk0125@hanmail.net Dr Gill-Han Bai, Director, Korean Institute of Tuberculosis, 14 Woomyundong, Sochogu, Seoul 137-140, Republic of Korea Tel no.: 8225798822, Fax no.: 822 573 1914 Email: gbai@hotmail.com

DELEGATES FROM THE REPUBLIC OF KOREA (HOST COUNTRY)

49 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Dr Hee Jin Kim, Director, Department of Technical Cooperation, Korean Institute of Tuberculosis, 14 Woomyundong, Sochogu, Seoul 137-140, Republic of Korea Tel no.: 822 579 8822, Fax no.: 822 573 1914 Email: hatchingbird@yahoo.co.kr Ms Mi Kyuong Kang, Director, Department of International Cooperation, Korean Institute of Tuberculosis, 14 Woomyundong, Sochogu, Seoul 1 37 -140, Republic of Korea Tel no.: 8225744981. Fax no.: 822 9286 3810 Email: mikkang56@hanmail.net Dr Chul Hoon Jang, Director, Department of Bacteriology, Korean Institute of Tuberculosis 14 Woomyundong, Sochogu, Seoul 137-140 Republic of Korea Tel no.: 8225798822, Fax no.: 822 5731914 Email: CCHL@pusan.ac.kr Ms Bai Jeong Ym, Chief, Section of Epidemiological Research, Korean Institute of Tuberculosis 14 Woomyundong, Sochogu, Seoul 137-140 Republic of Korea Tel no.: 8225798822, Fax no.: 822 573 1914 Email: baijym@hanmail.net Dr Young Kil Park, Chief, Section of Molecular Biology Korean Institute of Tuberculosis, 14 Woomyundong, Sochogu, Seoul 137-140, Republic of Korea Tel no.: 8225798822, Fax no.: 822 5731914 Email: ypark7@empal.com Dr Sung Koo Han, Professor and Head, Department of Internal Medicine, Seoul National University College of medicine, Seoul National University Hospital, 28 Yeongon-dong, Jong-gu, Seoul 110-744, Republic of Korea E-mail: hansk@snu.ac.kr Dr Enhi Cho, Medical Officer, Busan Metropolitan Government, 5 Yeonsan-dong, Yeonje-gu Busan 611-735, Republic of Korea E-mail: cho6404@metro.busan.kr Dr Tae Sun Shim, Associate Professor, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-dong Songpa-gu, Seoul 138-736, Republic of Korea E-mail: Shimts@amc.seoul.kr

50 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Dr Sang-Nae Cho, Professor, Department of Microbiology, Yonsei University College of Medicine, 134 Shinchon-dong, Seoul 120-752 Republic of Korea E-mail: raycho@yumc.yonsei.ac.kr; raycho@yonsei.ac.kr Dr Sun Hee Lee, Professor, Pusan National University, Internal Medicine, Pusan National University Hospital, 1-10 Ami-Dong, Seo-Gu, Pusan 602-739 Republic of Korea Dr Dr Dong-Han-Lee, Korea Centers for Disease Control and Prevention, 5, Nokbun-Dong Eunpyung-Gu, Seoul 122-701, Republic of Korea

5. SECRETARIAT WHO WESTERN PACIFIC REGIONAL OFFICE (WHO/WPRO) Dr Shigeru Omi, Regional Director, WHO/WPRO, U.N. Avenue,1000 Manila, Philippines Tel.: (632) 528 9903, Fax: (632) 521 1036 E-mail: omis@wpro.who.int Dato' Dr Tee Ah Sian, Director, Combating Communicable Diseases, WHO/WPRO, U.N. Avenue, 1000 Manila, Philippines Tel.: (632) 528 9903, Fax: (632) 521 1036 E-mail: teeas@wpro.who.int Dr Dong II Ahn, (Responsible Officer), Regional Adviser, Stop TB and Leprosy Elimination, WHO/ WPRO, U.N. Avenue, 1000 Manila, Philippines Tel.: (632) 528 8904, Fax: (632) 521 1036 E-mail: ahnd@wpro.who.int Dr Pieter van Maaren, (Co-Responsible Officer), Medical Officer, Stop TB and Leprosy Elimination, WHO/WPRO, U.N. Avenue, 1000 Manila, Philippines Tel.: (632) 5289706, Fax: (632) 521 1036 E-mail: vanmaarenp@wpro.who.int Dr Philippe Glaziou, Medical Officer, Stop TB and Leprosy Elimination, WHO/WPRO, U.N. Avenue, 1000 Manila, Philippines Tel.: (632) 528 9708, Fax: (632) 521 1036 E-mail: glazioup@wpro.who.int Mr Bernard Tomas, Technical Officer, Stop TB and Leprosy Elimination, WHO/WPRO, U.N. Avenue, 1000 Manila, Philippines Tel.: (632) 528 9727, Fax: (632) 521 1036

51 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

E-mail: tomasb@wpro.who.int Dr Jamhoih Tonsing, Medical Officer, Stop TB and Leprosy Elimination, WHO/WPRO, U.N. Avenue, 1000 Manila, Philippines Tel.: (632) 5289720 Fax: (632) 521 1036 E-mail: tonsingj@wpro.who.int Dr Yao Hongyan, Medical Officer, Stop TB and Leprosy Elimination, WHO/WPRO, U.N. Avenue, 1000 Manila, Philippines Tel.: (632) 528-, Fax: (632) 521 1036 E-mail: yaoh@wpro.who.int

WHO/WPRO COUNTRY OFFICES

Dr Maarten Bosman, Medical Officer, Tuberculosis Office of the WHO Representative in Viet Nam, P.O. Box 52, Ha Noi, Viet Nam Tel.: (844) 943 3734 to 3746 Fax: (844) 943 3740 E-mail: bosmanm@vtn.wpro.who.int Dr Daniel Chin, Medical Officer, Tuberculosis, Office of the WHO Representative in China, 401, Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District, Beijing 100600, China Tel. No.: (8610) 6532 7189 Fax No.: (8610) 6532 2359 E-mail: chind@chn.wpro.who.int Dr Wang Lixia, Programme Assistant, Office of the WHO Representative in China, 401, Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District, Beijing 100600, China Tel. No.: (8610) 6532 7189 Fax No.: (8610) 6532 2359 E-mail: wangl@chn.wpro.who.int Dr Pratap Jayavanth, Medical Officer, Tuberculosis, Office of the WHO Representative in Cambodia, P.O. Box 1217, Sangkat Chaktomouk, Khan Daun Penh, Phnom Penh, Cambodia Tel. No.: (855) 23 216610 ext 205 Fax No.: (855) 23 216211 E-mail: jayavanthp@cam.wpro.who.int Dr Mauro Occhi, Medical Officer, Tuberculosis, Office of the WHO Representative in the South Pacific, Level 4. Provident Plaza One. Downtown Boulevard, 33 Ellery Street, P.O. Box 113, Suva, Fiji Tel. No.: (679) 3304600; 304631 Fax No.: (679) 3300462

52 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

E-mail: occhim@sp.wpro.who.int Dr Michael Voniatis, Medical Officer, Stop TB and Leprosy Elimination, Office of the WHO Representative in the Philippines, P.O. Box 2932, Manila, Philippines Tel. No.: (632) 5289767, Fax No.: (632) 7313914 E-mail: voniatism@phl.wpro.who.int Dr Rajendra Prasad Yadav, Medical Officer, Tuberculosis, Office of the WHO Representative in Papua New Guinea, 4th Floor, AOPI Centre, Waigani Drive, Papua New Guinea Tel. No.: (975) 325 7827, Fax No.: (975) 325 0568 E-mail: yadavr@png.wpro.who.int WHO HEADQUARTERS Dr Leopold Blanc, Coordinator, Tuberculosis Strategy and Operations, Stop TB Department, WHO Headquarters, Geneva, Switzerland Tel.: (41-22) 791 4266, Fax (41-22) 791 4268 E-mail: blancl@who.int Dr Paul Nunn, Coordinator, TB/HIV and Drug Resistance, Stop TB Department, WHO Headquarters, Geneva, Switzerland Tel.: (41-22) 791 2963, Fax (41-22) 791 4268 E-mail: nunnp@who.int

53 i$MIIllII~.! 11_:;

ANNEX 3 OPENING REMARKS OF THE REGIONAL DIRECTOR AT THE FIFTH TECHNICAL ADVISORY GROUP (TAG) MEETING 15-18 March 2006, Busan, Republic of Korea

DISTINGUISHED GUESTS, DR DAEKYE OH, DIRECTOR, KOREA CDC, DR JONGKU LEE, DIRECTOR GENERAL FOR HEALTH PROMOTION, MINISTRY OF HEALTH AND WELFARE MR.KWON SANG LEE, VICE-MAYOR OF BUSAN CITY, TAG MEMBERS, LADIES AND GENTLEMEN: I am very pleased to be the bearer of good news. From early reports we have received it seems clear that the Region has achieved its 2005 Stop TB targets, and we expect confirmation later this year. I congratulate each and every one of you for a job well done. As most of you know, TB holds special significance for me. When I became Regional Director of WHO in 1999, health ministers asked me to prioritize TB, which was killing 1000 people in our Region every day. Soon after, the Stop TB Special Project was established and regional TB control targets were set. I recall travelling from Noumea, New Caledonia, to Xian in China, and from New Delhi to Washington D.C. to advocate the Stop TB Project with governments and our partners. You will recall that in our first meeting in 2000, we set targets for the end of 2005 that included region-wide DOTS coverage, the detection of at least 70% of the estimated TB cases, and the cure of at least 85% of those detected. Reaching these targets was considered necessary in order to achieve the goal of reducing the burden and deaths due to TB by one half by 2010. At that time, the 2010 goal seemed rather ambitious. But with tremendous effort by all of you, we have taken the first hurdle, and we are meeting our 2005 targets. I would like to highlight three important factors that have made this possible. First, with guidance from TAG, our Region has worked with our Member States to develop technically sound, realistic and budgeted plans to address the TB problem. These plans laid out clear strategies for tackling the issues at hand. Secondly, strong partnerships at the regional and national levels ensured that necessary resources were made available, dramatically reducing the funding shortfall. Strong political commitment put TB control high on the agenda in all countries and areas in the Region, but particularly so in those with a high burden of TB.

54 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Thirdly, the progress and status ofTB control activities in countries and areas in the Region were closely monitored so that necessary actions could be taken in a timely manner. For example, during the fourth TAG meeting in 2003, countries and areas in our Region agreed to two-year acceleration plans to ensure that the 2005 targets would be met on time. But the 2005 targets take us just halfway to our goal. Renewed and strengthened efforts are necessary to make an impact on the TB epidemic. A doubling of the rate of decline in TB prevalence and mortality from the current 4% to 8% will be needed over the next five years. Let me highlight some of the formidable challenges ahead of us. The rapid DOTS expansion should not be at the expense of the quality of TB services. Countries and areas will need to address emerging threats that were not a significant issue before - TB-HIV co-infection and multidrug resistant TB. These are complex issues that are not as easy to deal with as ordinary TB and will require collaboration across programmes and sectors. The Stop TB Partnership recently launched the Global Plan to Stop TB 2006-2015, which projects the technical and financial needs to meet these challenges. In consultation with countries and areas, the Region has developed the second Regional Strategic Plan 2006-2010, in line with the Global Plan, to provide a framework for addressing the regional challenges. The seven countries with a high burden of TB have developed their own five-year national plans largely in tune with the regional plan. These plans will be discussed in depth today and tomorrow. I trust that the guidance from TAG will lead to final plans that, once fully implemented, will result in meeting the regional goal, thus contributing to achievement of Millennium Development Goal for TB. This meeting will also be an opportunity to assess the progress made in TB control in countries and areas with an intermediate burden of TB, including Japan, Hong Kong (China), the Republic of Korea and Singapore. We hope to learn from the experiences of these countries and areas in addressing issues like ageing, migrant workers and TB-HIV. I want to conclude by expressing my gratitude to the Ministry of Health and Welfare, Korea CDC, The Korea National TB Association, and the city of Busan for hosting this meeting. I would like to thank the TAG members for their invaluable support to TB control in our Region, and I look forward to hearing their recommendations. I would also like to thank our partners, including the Australian Agency for International Development; the Canadian International Development Agency; the Global Fund to fight AIDS, Tuberculosis and Malaria; the Government of Japan, the United States Agency for International Development; and our other partners, whose support has greatly facilitated the progress in TB control in the Region.

55 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

I wish every one a productive and successful meeting and hope that through this meeting, political commitment and partnership will be further strengthened at all levels to fight tuberculosis and poverty in the Western Pacific. Thank you

ANNEX 4 Summaries: Five-year national plans of countries with high burden of TB

CAMBODIA: SUMMARY PLAN 2006-10 PART I: PROGRESS DURING 2000-2005 TB BURDEN Cambodia is among the 22 countries in the world with a high burden of tuberculosis. According to estimates, TB has infected 64% of the total population "

1'2OOQ

...... ,.,. . :,.,.'aqM;: '. " •... ,,'y 11

!."

Population Incidence (all cases/100 000 pop/year) Incidence (new ss + /100 000 pop/year) Prevalence (all cases/100 000 pop) TB mortality (all cases/100 000 pop/year)

13 104000 530 234 789 105

13089000* 510

226 709

'Cambodia's Inter·Censal Population Report, Corresponding UN population estimate is 13 798 000 (2004)

TB CONTROL INFRASTRUCTURE The National Tuberculosis Control Program (NTP) operates under the responsibility of the National Centre for Tuberculosis and Leprosy Control (CENAT) and within the overall national health system of the Ministry of Health. Within the CENAT, there is the National TB Reference Laboratory (NRL) and the National TB Referral Hospital, one of the eight national hospitals in Cambodia. At the intermediate level or provincial level, there is the provincial TB supervisor who is responsible for program planning and management including training and supervision. At the operational district (OD) level, there is the district TB supervisor whose role is similar to the provincial TB supervisor. At the service provision level, there are TB units (consisting of a TB ward and a laboratory) and health centres. 142 TB units are in existence today, 70 at the referral hospitals (province or. district) and the remaining, at the former district hospitals (also known as health centres with beds). From 1999, TB control activities were started in health centres using ambulatory DOT approach. By the end of 2005, more than 750 health centres were implementing DOTS.

57 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

ACHIEVEMENTS: 2000-2005 Performance against 2005 regional targets.

The regional targets for TB control are to achieve 100% DOTS coverage, 70% case detection of new smear positive cases and 85% treatment success by 2005. In 1994, the NTP adopted the DOTS strategy and achieved 100% DOTS coverage in 2001. Since 1995, the NTP has attained and maintained a success rate of over 85%. Case detection rate has remained relatively low compared to the 70% target but is showing an increasing trend. Provisional data from quarterly DOTS reports suggest an increase in case detection to reach 67% in 2005. Performance of the NTP for the period 2000-2005 is shown in Figure 1. Figure 1. Progress in TB control: 2000-2005

• Provisional data from Q-DOTS reports

ISSUES AND CHALLENGES Quality of TB services Having achieved nation-wide coverage with DOTS, the challenge now is to ensure quality of services for TB. Particularly so, as the NTP is decentralising services for diagnosis through sputum collection and transportation, and utilising community volunteers for ambulatory treatment. Ensuring direct observation of treatment as per guidelines, and nation-wide implementation of external quality assurance for sputum microscopy will be crucial in the coming years. Ensuring equitable access In spite of the nation wide coverage through health facilities, access to the DOTS services is not available for several segments of the population,

58 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

including remote, poor and vulnerable populations. Mobilization of community support through the mechanism of partnership with Village Health Support Groups (DOTS supporters), private health providers, traditional healers, community leaders, monks, nuns and cured TB patients is one of the key strategies adopted to achieve this community DOTS approach since 2004. TB-HIV co-infection The nationwide HIV sero-prevalence survey conducted in 2003 showed that 11.8% of all TB cases were HIV positive. The estimated HIV prevalence in the adult population was 1.9% in 2004. In response to the high TB-HIV burden, a National Framework for TB-HIV collaborative activities has been endorsed, collaboration between NTP and National Centre for HlV, AIDS, Dermatology and Sexually Transmitted Diseases (NCHADS) strengthened. A TB/HIV coordinator has been nominated and TB-HIV activities started in four pilot ODs with other partners (CDC Atlanta, JICA, FHl and WHO). The "Continuum of Care" approach launched by the NCHADS, the "3x5" initiative and the new goal of "Universal access" will provide opportunities for TB patients co-infected with HIV to get access to Anti-Retroviral Therapy (ART). Human resource capacity A major challenge is the limited capacity of staff at all levels, especially capacity in planning, management and in the implementation of DOTS. Due to poor salary and lack of incentives, motivation of staff is often poor. Related to this are issues of delay in the detection ofTB cases, ensuring free of charge service, and irregularity of funding release

PART II: PLAN FOR 2006-2010 GOAL The main goal of the NTP is to contribute to improving the health of the Cambodian people in order to contribute to socio-economic development and poverty reduction in Cambodia by reducing the morbidity and the mortality rates due to tuberculosis as well as to contribute to attaining MDG goals.

OBJECTIVES AND CORE TARGETS FOR TB CONTROL: 2006-2010 Objective 1. The major medium-term objectives of the NTP are to ensure equity and access to quality TB services and to maintain a high cure rate of more than 85% and a high case detection rate of over 70% during the period from 2006 to 2010.

59 Fifth Technical Advisory Group Meeting to Stop TB in the Western PacifIc Region

Objective 2. The long-term objectives of NTP are to reduce the p~e,:,alence of TB and death due to the disease in order to contribute to attammg the MDG goals by 2015.

Core indicators and targets: 1. Case detection rate of 75% and cure rate of over 85% 2. 90% of health centres implement Community DOTS 3. At least 50 operational districts implement TB/HIV activities 4. 90% of TB patients referred for HIV testing 5. 95% of eligible HIV ITB patients receive ARV

MAIN STRATEGIES AND ACTIVITIES OF THE 5-YEAR PLAN The National Plan for 2006-2010 is based on the seven main policy statements of the National Health Policies & Strategies for TB Control in Cambodia (2006-10), updated from the previous one (2001-05), both developed through a working group, made up of CENAT & stakeholders. Main strategies and activities are summarized below.

Enhance the DOTS strategy to provide quality services a) Improve quality assurance of TB microscopy and strengthen laboratory capacity in culture and DST at the central level and also, in Battambang and Kampong Cham provinces. Introduce Fixed-dose combination (FDC) of anti-TB drugs to increase patient compliance, reduce workload and improve drug management Explore the possibility of embarking on special approaches like Practical Approach to Lung Health (PAL) and TB and Tobacco. Strengthen the referral system from the community level to the hospital level and vice versa. Enhance and expand specific activities to deal with pulmonary TB smear negative, extra-pulmonary TB and TB in children through capacity building, provision of drugs and equipment, etc Promote case finding, including active case finding among selected groups such as TB contacts, people living with HIV I AIDS (PLHA), and targeted people in high prevalence areas I settings.

c) d) e)

Ensure equitable access to DOTS a) Ensure free of charge services for TB diagnosis and treatment in public health services by reinforcing the implementation of the policies and strategies, through dissemination workshops,

60 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

. , I

I '

issue of legislature papers like Prakas (declaration) or circulars, supporting logistics and incentives Expand community DOTS to the whole country based on the Community DOTS Guidelines, by involving more partners, especially NGOs and local partners, and community members like community leaders, village health support group members (VHSG), former TB patients, etc. Improve activities pertaining to sputum collection and transportation, in particular the quality of sputum samples and smear-making, as well as examination Seek additional resources to support activities related to TB screening, which include support for accessing service facilities, antibiotic therapy and X-ray examination as well as capacity building in related fields Explore possibilities to embark on an innovative approach for Pro-poor DOTS

, "

Address TB-HIV

The priority will be to build on the existing collaboration between CENAT and NCHADS and its partners, in the context of the national TB-HIV framework. The main strategy to achieve this will be the establishment of a strong referral/feedback mechanism between the TB and HIV / AIDS services a) To expand TB/HIV activities to the whole country in collaboration with NCHADS and other partners, in particular NGOs and local partners Strengthen collaboration between NTP and NAP at operational district level for referral of TB patients to VCT and relevant prevention, treatment (including ARV and care); and for referral of HIV positive persons for TB screening and relevant treatment. Determine the circumstances under which chemoprophylaxis will be provided to some target groups such as PLWHA Promote active case finding among people living with HIV / AIDS (PLHA) Repeat HIV sero-prevalence survey.

c) d) e) 4.

Expand PPM - DOTS

The proportion of TB cases treated in the private sector is unknown though studies indicate that many patients in cities approach private practitioners at first for their symptoms. In 2004, collaboration with selected private practitioners in the provincial towns was initiated. Activities planned include: a) Expand PPM DOTS in areas with strong presence of private sector in selected urban areas

61 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

b) c) d)

Publish PPMD guidelines and framework Organize workshops and training for private practitioners To further involve the NGO sector in implementing DOTS and other TB control activities like health education.

Advocacy and IEC a) b) Promote advocacy activities to keep TB control as high priority, including efforts for resource mobilization. Encourage the involvement of TB patients and former TB patients and community members, in TB control activities, which include activities for health education, case finding and DOT. Employ all appropriate means to improve information, education and communication (IEC) activities, including such strategies as mass media and interpersonal health education like peer group education, health education through health facility staff at schools, and communities.

Information system/Monitoring and evaluation a) Develop a more systematic database for recording and reporting system and promote the analysis, interpretation and use of TB health information. Develop tools for program M&E and supervision activities at all levels Enhance information technology (IT) including the use of appropriate database, electronic system, and GIS software for effective planning, monitoring and evaluation Publish quarterly reports/newsletters and six-monthly bulletins and disseminate information and statistics Conduct Joint TB programme review in 2006

b) c)

d) e)

Research a) b) Conduct Drug Resistance Survey in 2006 and National TB Prevalence Survey in 2010. Organize other studies such as the health-seeking behaviour of TB patients, impact ofTB on socio-economic development, TB and Tobacco, preventive therapy for HIV infected people, clinical studies, TB mortality survey, etc

Capacity building and HRD a) Study the TB health workforce situation and make future projection for the NTP taking into account all factors affecting both demand and supply sides Build staff capacity giving emphasis on continuing training according to identified needs; send key staff for training (including

62 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

c) d)

Master degree course), attending international conferences and study visits abroad etc Include the DOTS strategy in the curriculum of medical and nursing schools. Focus attention on staff motivation considering monetary and nonmonetary incentives like opportunity for individual capacity development, as well as appropriate working conditions.

MDR-TB

Drug resistance survey (DRS) conducted in 2000 showed no multi-drug resistance (MDR) among the new TB cases and less than 1 % among the retreated cases. However, a second DRS survey is planned in 2006 and there are plans to initiate DOTS Plus projects during 2006 -2007

PARTNERS NTP has developed and maintained long-lasting partnerships with various bilateral and multilateral organizations as well as with a growing number of non-governmental organizations in various fields of activities. Main partners in TB control include Centers for Disease Control and Prevention, USA (CDC), Canadian International Development Agency (CIDA), Global Fund for AIDS, TB and Malaria -Round Two, Govt. of Japan, Japan International Cooperation Agency (JICA), TBCTA, United States Agency for International Development (USAID), the World Bank, World Food Programme (WFP) and World Health Organization (WHO).

FINANCIAL SITUATION 2006-2010 Committed funds

Ministry of Health (MoH) provides domestic resources to the CENAT to cover the following: staff salaries, and partial administration costs, etc. The average amount earmarked for each year is between USD 600,000 to USD 700,000. The financial contributions and duration of external support are as follows: .Funding lIOurce. World Bank WHOICIDA/USAID JICA I

'.DuJQoO " 2003-2007 2004-2005 2004-2009 2004-2007 2004-2008 2006-2010

Total US$ 2.70m US$ 1.27m US$ 1.75m US$ 2.25m US$ 6.10m US$ 9.00m /

Govt. of Japan GFATM-R2 GFATM-R5

63 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Financial requirement and gap

An estimated budget of around US$36 million will be needed for the period from 2006 to 2010. This amount does not include financial requirement for technical assistance and food supply from the World Food Program. Financial requirement for food and other nutritional supplements is essential to improve compliance to treatment TB patients, who are often poor. It is estimated that about 20,000 tons of rice will be required for TB patients from 2006 to 2010. Expected major donors for the above financial requirement of the NTP are the Japanese Government through JICA in particular, WHO / CIDA, the World Bank, GFATM, USAID, US-CDC, apart from the government budget and other technical/financial partners. There is an uncertainty in terms of budget availability for the five-year period, since negotiations with some donor agencies are still under way. However, two scenarios can be presented. In the optimistic scenario, the financial gap will be about 19%, while a deficit of around 36% is predicted in the worst scenario.

64 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

CHINA: SUMMARY PLAN 2006-10 PART I: PROGRESS DURING 2000-2005 TB BURDEN China, with 17% of the global TB burden has the second highest number of TB cases in the world, next only to India. It also accounts for about 70% of the TB burden in the Western Pacific Region. 2000 Population Incidence (all cases/100 000 pop/year) Incidence (new ss + /100 000 pop/year) Prevalence (all cases/1 00 000 pop) TB mortality (all cases/1 00 000 pop/year) 1 275133000 105 47 271 20

2004

1 307989000 101 46 221 17

TB CONTROL INFRASTRUCTURE The State Council of China is ultimately responsible for the control of communicable diseases in China and has set the key national targets and plan for TB prevention and control. Under the overall guidance of the State Council, the Ministry of Health is responsible for setting all national policies and overseeing the implementation of the National TB Control Program (NTP). Actual implementation of the NTP at central level is carried out by the National Center for TB Control and Prevention of the Chinese Centers for Disease Control and Prevention (CDC), and a network of TB control institutions (mostly based in local CDC's) stretching from the provincial level down to the county level. TB suspects or cases can access free TB diagnosis and treatment at the local TB control institutions. However, most patients with TB symptoms initially seek care at the village clinic, township clinics or the general hospitals. In these facilities, care is provided on a feefor-service basis. Mter a patient is diagnosed with TB at the local TB control institution, the village doctor provides local supervision of treatment.

ACHIEVEMENTS: 2000-2005 Performance against 2005 regional targets.

The regional targets for TB control are to achieve 100% DOTS coverage, 70% case detection of new smear positive cases and 85% treatment success by 2005.

65 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

China has expanded DOTS coverage gradually to achieve 100% coverage in 2005. Case detection rate has increase significantly from a mere 31% in 2000 to more than 70% in 2005. Treatment success rate of over 85% has been sustained during the entire five-year period. Performance of the NTP for the period 2000-2005 is shown in Figure 1. Figure 1. Progress in TB control: 2000-2005

100%~-.~==~~~~;===~~==~.----

80% - t - - - - - - - -

coverage 79%

• Provisional data from Q-DOTS reports

ISSUES AND CHALLENGES Though China has achieved the 2005 TB control targets, it faces important challenges to its TB control programme. Quality of DOTS implementation As a result of rapid DOTS expansion in recent years, poor quality of DOTS exists in parts of the country. Treatment supervision and external quality assurance of sputum microscopy need strengthening. Insufficient human resources capacity to implement DOTS is a major challenge that has a direct bearing on the quality of services; this results in inadequate supervisory activities by staff. Multidrug - resistant TB (MDR-TBI According to WHO estimates, China has the largest MDR -TB epidemic in the world Approximately a quarter of the world's MDR-TB cases are in China. The WHO /IUATLD global TB drug-resistance surveillance (DRS) project showed that several of the world's MDR-TB "hotspots" are in China. Data from DRS surveys in 9 of China's 31 provinces have revealed alarming rates of MDR-TB in more than half of these provinces. In these provinces, the rate of MDR-TB in previously untreated cases ranged from 2% to 10%, substantially higher than the global average. What is

66 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

more worrisome is that MDR-TB rate is >7% among previously untreated TB cases in two provinces-Liaoning and Heilongjiang-that have implemented a successful DOTS program for nearly 10 years. This raises concern that implementing DOTS alone cannot control the serious MDRTB epidemic in China. TB-HIV co-infection

The emerging HIV I AIDS epidemic is another threat for TB control. Although considered a low HIV prevalence country, China already has many local areas with high prevalence of HIV I AIDS. Most experts believe the epidemic is moving from high-risk groups into the general population. If more is not done to halt this epidemic, a joint China-UN assessment report estimates the country could have 10 million PLWHA by 2010. The impact of the HIV I AIDS epidemic on the TB epidemic in China is unknown at this time. But since 45% of China's population is already infected with Mycobacterium tuberculosis, introduction of HIV into such a highly infected popUlation should increase the incidence and mortality of TB as well as the morbidity and morbidity of HIV I AIDS. In some high HIV prevalent areas, anecdotal reports suggest HIV-associated TB is already a serious problem. Migrant populations

The largest migration of people in China's history is happening now. Over 150 million people have relocated from poor rural areas to betteroff urban areas seeking better income and living conditions, According to governmental statistics, 70% of the migrants that move between provinces have relocated to 6 provinces in eastern China, In Beijing and Shanghai, 40% and 50% of the TB cases respectively are reported from the migrant popUlation. In Shenzhen, 80% ofTB cases are in the migrant population. In these cities and municipalities, the historical decline in TB notification has reversed in recent years because of the increase in TB cases among the migrant population. The high mobility of the population and discrimination faced at work if they are known to have TB, a low percentage of migrant TB suspects complete diagnostic evaluation (70% in one study) and an even lower percentage successfully treated (only 20% in Beijing and Shanghai).

GOAL Leadership is strengthened and effective measures are adopted, in an effort to ensure the completion of all task indicators contained in NTP, reduce tuberculosis (TB) cases and deaths, improve the healthy level of the whole population, and to promote the growth of society and economy in a coordinated way.

67 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

OBJECTIVES AND CORE TARGETS FOR TB CONTROL: 2006-2010 Objectives

In the period of2006-2010, two million infectious TB patients will be detected and treated; Smear positive TB prevalence and mortality rates are reduced by 50% by 2010 relative to 1990. Core indicators and targets:

1. 2. 3. 4. 5.

Case detection rate of new smear-positive TB patients will reach at least 70% or more; Cure rate of new smear-positive TB patients will be kept at least 85% or more; By 2010, 100% of the medical institutions will be involved in TB Control; By 20 lO, 90% of multi-drug resistant TB patients identified in project areas will receive treatment; By 2010, more than 80% of HIV-infected TB patients eligible for antiretroviral treatment in the project regions will receive this treatment; By 2010, more than 90% of the TB patients among the floating population in the project areas will receive treatment; By 2010, community awareness of TB will reach 80%.

6. 7.

MAIN ACTIONS AND MEASURES 1. Government commitment. The National Interagency Coordination Committee (ICC) to Stop TB, and leadership groups at all levels will take the lead on coordination, review the progress and put forward suggested recommendations. TB control budget from local governments should be integrated into the overall annual governmental budget. The government is responsible for funding the TB control programme based their commitments. All levels will develop a human resource development plan for TB. Various measures on TB case finding to be put into effect a) Medical institutions at all levels (including TB specialized hospitals, medical units of factory, mine and enterprise, and private clinics) will conform to the requirements set forth in regard to TB patient finding, reporting, internet based reporting and referral;

! ,

68 Western Pacific Region Fifth Technical Advisory Group Meeting to Stop T8 in the

tion In collab oratio n with educa tion depar tment s, health educa es, colleg o~ TB will be carrie d out in all unive rsities , junio r mIddl e and prima ry schoo ls; ble TB patie nts repor ted in the intern et-ba sed comm unica TB ~iseas~ repor ting syste m will be follow ed up by the ated evalu be will ts patien TB InstItu tIOns ; conta cts of infect ious for possib le TB diseas e; n Super vision and qualit y contr ol on TB sputu m exam inatio d; thene streng cente r in towns hip hospi tals will be Case- findin g activi ties will be carrie d out amon g key popul ations at risk for TB. Labor atory work to Enha nce the capac ity of the nation al TB refere nce labora tory nce guida ical techn e provid to carry out qualit y contro l activi ties, to the labs nation wide, and to carry out resea rch; ed TB Contr ol instit ution s at all levels will provid e qualit y assur tion menta imple the sputu m micro scopy servic es by intens ifying of extern al qualit y assur ance (EQA) system ; labs Biosa fety ofTB lab will be impro ved, work condi tions ofTB ed requir at all levels will be impro ved, and biosaf ety stand ards as by the State will be gradu ally impro ved; re of Acco rding to the need of work , isolat ion and cultu g will Myco bacte rium tuber culos is and drug susce ptibil ity testin be gradu ally expan ded.

d) e) 3. a)

ent Case mana geme nt. Enha nce the quali ty of patie nt's treatm timely mana geme nt throu gh direct obser vation of treatm ent and visory super out carry action to deal with adver se drug reacti on, d the visits to enhan ce super vised treatm ent for patien ts; and expan use of fixed- dose comb inatio n (FDC) TB drugs . ation Monit oring and evalu ation. One set of monit oring and evalu the e indic ators will be devel oped and optim ised. Fully utiliz and TBinform ation from comm unica ble disea ses repor ting system and NTP the of ess progr the ee specif ic repor ting system to overs be will gy odolo take appro priat e actio ns. Supe rvisio n meth d. thene stand ardize d and the qualit y of super vision will be streng NTP will Annu al summ ary, mid-t erm and final- term evalu ation of ize the organ will h Healt of be under taken . In 2010, the Minis try fifth nation al TB preva lence surve y. and drug Drug suppl y mana geme nt. Unde rtake prope r plann ing y as well suppl drug ted suppl y mana geme nt to ensur e unint errup . waste quent as preve nt occur rence of expire d drugs and conse

69 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Health promotion on TB control. The national health promotion strategy on TB Control will be implemented and multi-sectoral cooperation will be enhanced. The health promotion toolbox will be fully utilized and updated if necessary. Evaluation on the effect of TB health promotion activity and survey on "Knowledge, Attitude and Behavior" will be carried out in 2006 and 2009 respectively. Training. Training will be carried out according to the principle of cascade training; international exposure for staffs and visits of foreign experts will be facilitated; and standardized training materials will be developed based on actual needs. TB Control among special population, MDR-TB and TB/HIV coinfection a) In all provinces, special populations (floating population, incarcerated population, etc.) will be integrated in the local TB control programme to facilitate prompt detection and treatment; b) Framework and implementation plan on control of multi-drug resistant TB will be developed. Pilots will be launched for standardized treatment and management of multi-drug resistant TB and the programme gradually expanded. TB drug-resistance surveillance will be carried out; c) According to the framework of TB/HIV collaboration, implementation plans will be developed. A mechanism of coordination between TB control institution and AIDS prevention and control institutions will be set up. Surveillance of TB/HIV co-infection will be gradually implemented. And appropriate prevention, treatment and care will be provided to persons with TB/HIV co-infection.

10. International exchange and cooperation. Aid from international community will be actively sought; international best practices will be adopted; existing international cooperation projects will continue to be implemented effectively. 11. Operational research. Priority fields in operational research will be finalized; management of operational research strengthened; ethical committee established; and the results of operational research disseminated.

PARTNERS Main partners in TB control include Damien Foundation Belgium, Department of International Development (DFID) of the United Kingdom, GFATM, Government of Japan through the Japan International Cooperation Agency (JICA), the World Bank, the Canadian International Development Agency (through different partners) and WHO.

70 Fifth Technical Advisory Group Meeting to Stop TB In the Western Pacific Region

FINANCIAL SITUATION 2006-2010' Government funding will continue to be the primary source of funding for the NTP with supplemental funding from multiple channels. .'

2006 ,1 130.6 30.1 9.5 170.2 120.2 50.0

2007 H ·Ii

1 •• iii"

20Q8 ' .,

il~09,

2010

Total ,

Basic DOTS Increase case detection Others (MDR, HIVITS, migrants) Total funding requirement Resources available Gap

130.6 30.1 13.9 174.6 118.6 56.0

130.6 25.9 28.3 184.8 109.7 75.1

130.6 29.9 45.9 206.4 96.9 109.5

130.6 29.9 58.1 218.6 93.2 125.4

653.0 145.9 155.7 954.6 538.6 416.0

Funding availability and gap (%) 100% 80% 60%t-~~~--~<8t----

iii Funding Gap 18 Funds available

40% 20% +--l0=~1---

2006

2007

2008

2009

2010

, Referencel China's presentation on the Stop TB Plan 2006-2010 for 5th TAG meeting

71 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region , n 'j

LAO PDR: SUMMARY PLAN 2006-10 PART I: PROGRESS DURING 2000-2005 TB BURDEN Lao PDR is considered among the seven high TB burden countries in the Western Pacific Region. There are 17 provinces and 142 districts in the country . '

156 70 318 25

. " ,

\','

2000

,. ,

.2004,.. 5792000

Population Incidence (all cases/1 00 000 pop/year) Incidence (new ss + /1 00 000 pop/year) Prevalence (all cases/1 00 000 pop) TB mortality (all cases/100 000 pop/year)

5279000 162 73 357 28

TB CONTROL INFRASTRUCTURE The national Tuberculosis programme (NTP) is administratively placed under the Department of Hygiene and Prevention of the Ministry of Health. At the central level there is a Director, two Deputy Director, and eight national senior supervisors. At the service delivery level, the programme is integrated in the government health services in provincial and districts hospitals. In 160 health centres, the general health personnel are responsible for identifying tuberculosis suspects and referring these to the district or provincial hospital for diagnosis and take part in the treatment of tuberculosis patients. AIl provinces and districts hospital laboratories have one or two trained laboratory technician and perform quality assured microscopy with a good quality microscope and laboratory supplies. A National Reference Laboratory was built in 2005 and culture and drug sensitivity testing facilities are expected to be available by 2006 with technical support from Hongkong Supranational Reference Laboratory. Distribution of drugs from the central store to provinces and from provinces to districts is four times a year.

ACHIEVEMENTS: 2000 - 2005 Performance against 2005 regional targets.

The regional targets for TB control are to achieve 100% DOTS coverage, 70% case detection of new smear positive cases and 85% treatment success by 2005.

72 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

)

• ;

DOTS implementation started in 1995 and by end of 2005, all 142 districts of the country were providing DOTS services (100% DOTS population coverage). Access to DOTS is also available in 160 of the 703 functional health centres of the country. Detection of new smear positive cases increased from 40% in 2000 to 69% in 2005. Treatment success of new smear positive cases increased from 82% in 2000 to 86% in 2005. Thus Lao PDR achieved 100% DOTS coverage, 69% case detection and 86% success rate among new smear positive TB cases by end of 2005. Yearly progress for the period 2000-2005 and quarterly progress in detection of cases in 2005 are shown in the figures below. Figure 1. Progress in TB control: 2000-2005

" ;

" " I

100%.------------------------------80% t---'!~"""'-...

" I

--=

E:·:·:·:·:·:·:::jDOTS

r.nv,,,r:,,,,, 69%

* Provisional data from O-DOTS reports

Figure 2. Provisional data from the quarterly reports for 2005

DOTS detection rate: four quarters of 2005 80% 70% 60% 50% 40% 30%

.--+65%

...:1 5 %

T67%

~.68%

20% 2004

012005

202005

302005

402005

73 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

External quality assessment IEQA).

61 % of the TB laboratories are implementing EQA for sputum microscopy in 2005. The percentage of major error has dropped from an average of 27% in 2004 to 10% in 2005 (all year).

ISSUES AND CONSTRAINTS Access and human resources.

The mountainous geography ofthe Lao PDR and the low popUlation density in many areas increases the difficulty of communication, monitoring, and distribution of supplies and equipment. TB patients leaving in remote villages have often limited access to the district hospital due to distance and costs of transportation. Less support has been provided to TB staff in remote provinces and districts. In addition, there is a high turn-over of staff, particularly at the district level. Smear negative and extra-pulmonary TB patients.

75% of the cases notified by the programme are smear positive cases (2005) and less attention has been given to non-smear positive TB suspects till now especially in districts which have less resources for diagnosis - skilled manpower, non-availability of X-ray machine. Course for doctors on X-ray reading has started in 2004 with GF support TB-HIV.

Lao PDR is defined as low HIV / AIDS prevalence country (0.08% in adult popUlation in 2005). However the Medecins Sans Frontieres (MSF) supported continuum of care project in Savannakhet province hospital is treating 360 patients with ART (end 2005) and more than 20% of the TB patients registered in this hospital are co-infected with HIV-AIDS. There are plans to establish diagnosis and treatment facilities in Vientiane in 2006. Multi drug resistance has not yet but MDR is expected to be low considering the low proportion of failure of retreated cases « 1%). Involvement of the private sector in TB control activities is marginal at the moment but this situation could change with economic progress in Vientiane and large province capitals.

74 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

PART II: PLAN FOR 2006-2010 GOAL The overall goal of Lao PDR National TB Control Programme is to reduce TB morbidity and mortality by half by 2010.

OBJECTIVES AND CORE TARGETS FOR TB CONTROL: 2006-2010 The country plan for 2006-2010 refers to the Global and Regional Strategic Plan and constitutes a future implementation tool for TB control. The three main objectives are to:

Objective 1. Sustain and optimize the quality of DOTS and go beyond 70/ 85 targets Objective 2. Adapt DOTS to respond to MDR-TB and TB-HIV Objective 3. Ensure equitable access to quality TB cares for all people with TB Core indicators and targets linked to achieving the above objectives are: 1. Case detection rate beyond 70% and cure rate beyond 85% 2. To provide second line treatment to 90% of MDR TB cases identified by DST 3. To provide ART to more than 80% of eligible HIV+ TB patients 4. 90% of health facilities including private and general hospitals providing or referring to DOTS

ACTIVITIES AND OTHER TARGETS OF THE 5-YEAR PLAN To attain the slated objectives of the national TB control programme and achieve the targets set forth, Lao PDR will be undertaking the following activities in the next five years. 1.

Sustain and optimize the quality of DOTS and go beyond 70/85 targets by a) Ensuring quality of sputum microscopy through EQA implementation, training and retraining oflaboratory technicians, replacement of microscopes with GDF laboratory kits, and supervision to diagnostic laboratories. (Target: 90% of laboratory units implementing EQA have satisfactory performances) b) Development of culture and DST capacity in the TB reference laboratory from 2006

75 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Organizing a course on lung diseases and reading of X-rays for province doctors, and providing X-ray equipments and films where required Ensuring uninterrupted supply of quality TB drugs by maintaining adequate buffer stock (Target: 100% TB units receive uninterrupted supply of Q-TB drugs) Enhancing case management of for all registered TB case including smear negative and extra-pulmonary TB patients through referral for X-rays and other investigations (Target: 50% of smear negative TB suspects at district level are referred to the province hospital)

Adapt DOTS to respond to MDR-TB and TB-HIV by a) Developing capacity for culture and DST at the NRL to undertake drug resistance survey among new smear positive cases and failure of re-treatment cases (Target: DRS to evaluate % of MDR among new and retreated cases by category (relapse, returned after default, failure)) b) Establishing and scaling up DOTS Plus (Target: 10% of failure cases tested by DST and 90% of identified MDR-TB cases receive second line drugs) c) Conducting TB-HIV surveillance by including TB patients as a testing group in sentinel surveillance by National AIDS Programme (Target: Include TB patients as a testing group in sentinel surveillance by NAP) d) Ensuring access ofTB patients to HIV services including testing and ART (Target 1: Proportion of TB patients tested for HIV in setting where VCT are available (Cat 1: >60%, Cat II, > 70%). Target 2: 70% of newly HIV (+) patients tested for TB) Ensure equitable access to quality TB care for all people with TBby a) Improving case management ofTB by non-NTP facilities through training b) Translate and disseminate International Standards of TB care to medical students and health personnel c) Expanding implementation of the national ACS strategies to improve utilization of TB services (Target: Increasing number of districts implementing ACS) d) Establishing Community based DOTS in priority in 47 poor districts e) Expand DOTS in all prisons of Vientiane City Capital and provinces Cross cutting issues a) Ensuring availability of key TB control staff through ongoing training and retraining (90% of key positions filled with trained staff)

76 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

b) c) d)

Continue developing and maintain proper infrastructure and equipment Sufficient financing ensured through development of annual funding plan for NTP that incorporate all input and gap Develop evidence based policy and implementation strategy through operations research (PAL, information system, child TB, new diagnostic modalities) Enhance surveillance, monitoring and evaluation by conducting prevalence survey (2008), national programme review (2007 & 2009), and annual review of TB information system.

PARTNERS Since 1995, the Damien Foundation Belgium has been supporting the requirement of drugs, laboratory supplies and operational costs of the NTP. WHO is continuously providing technical support, international training and coordination. From late 2003, Global Fund to Fight AIDS, TB and Malaria (GFATM) has become the major funding source. The NTP received $3.5 millions for GFATM round 2 (October 2003 to- September 2008) and $3.6 millions for GFATM round 4 (October 2005 to September 2010). The GFATM round two project entered phase II in October 2005 until September 2008. French Institute for Tropical Medecine (IFMT) has also been involved as sub contractor of the GFATM round 2 for training NTP staff in programme management at central, province and district levels.

FINANCIAL SITUATION 2006-2010 Till 2008, most of the budget requirement for regular activities is available. Financial gap exists for additional activities planned including culture, TBI HIV collaborative activities, and complementary funding fro prevalence survey. Significant financial gap is foreseen in 2009-2010 even for regular activities after end of support from GFATM round 2 and GDF. Application to GF round 6 is anticipated for filling the gap Table 1. Planned financial support and gap 2006-2010 lin US Dollars) II d I ,; "

• I,ii,

2006 I d

2001 I I n

1• • , I

11 d<W,;,

2901!f ••

2QOfJ ,

201Q ' i •

Total.' ii I i

GF2 (Phase II) GF4 (Phase I & II) GDF (TB drugs)

WHO Sub total Gap

TO::r:~~

,i •••

760907 703842 741 303 580366 658831 595460 150 000 150 000 150000 10 000 10000 10000 1444 208 1 560 134 1 516367 597729 826392 788568 2 3()4, 9~5. , 2041~,. 238!i~i;; ,1

862296

920828

10000 872296 961 554 833,f!50

10000 930828 930754 1861582

2206052 3617 781 450000 50000 6323833 4104 997 10428.830 " " > k

77 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Table 2: Financial gap by objectives 2006-2010 "',' ,P"

,;11

f:, aQ06:; ,; , 2e01' 193440 156190

200S 170315

,2009 . ," 153440

2Q~O';:

Total,' 826825

Obj.1. Sustain and optimize the quality of DOTS Obj 2. Adapt DOTS to resp-ond to MDR-TB and TB-HIV Obj 3. Ensure equitable access to quality TB care Transversal issues Administration 10% , ,

153440

49500

124000

71000

53000

105000

402500

3500

6500

1500

61500

134 500

470440 71688 I'

256700 54 339 'i'

508450 75127

606200 87414

TOTAL

78&568

597 729

126392

" "961':'554 '.

2367990 526200 373182 84 614 9311' 754'" , 4'104997

78 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

MONGOLIA: SUMMARY PLAN 2006-10 PART I: PROGRESS DURING 2000-2005 TB BURDEN Mongolia is one of the seven high TB burden countries in the Western Pacific Region. 2000 2533000 200 90 285 36

2004 2614000 192 86 209 24

Population Incidence (all casesl1 00 000 pop/year) Incidence (new ss + /1 00 000 pop/year) Prevalence (all cases/100 000 pop) TB mortality (all cases/100 000 pop/year)

TB CONTROL INFRASTRUCTURE' The TB Department of the National Centre for Communicable Diseases (NCCD), under the Ministry of Health, is responsible for the TB control programme in the country. The National TB Centre (NTC) conducts trainings; plans, procures and co-ordinates distribution of all necessary TB drugs and other logistics. The NTC reference laboratory is responsible for training, supervision and quality assurance of peripheral laboratories and performs sputum culture. Due to the great distances between health facilities and communities, most TB patients receive the first 2 months of treatment in hospital. In rural areas, Aimag TB centres have beds for TB patients while in Ulaanbaatar city, patients are referred to the TB hospital. The continuation phase is completed on an ambulatory basis. Each Aimag (provinces with 40,000-120,000 population) has a TB centre and the districts have TB dispensaries. Patients accessing care at the Soum level (population of 3000 on average) are referred to Aimag TB centres for sputum smear examination. Confirmed cases are hospitalised in the Aimag TB centre during the intensive phase of their treatment, and receive their treatment under supervision of the doctor at the Soum level during the continuous phase. In the prison hospital in Ulaanbaatar City, there are 100 beds for tuberculosis patients and a microscopy laboratory.

, 5·year plan of action for T6 control for 2000-2005; Ministry of Health, Mongolia

79 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

ACHIEVEMENTS: 2000-2005 Performance against 2005 regional targets

The regional targets for TB control are to achieve 100% DOTS coverage, 70% case detection of new smear positive cases and 85% treatment success by 2005. Mongolia achieved full DOTS coverage in 1999. Treatment success rate of 87% was maintained throughout 2000-2005. Case detection reached 73% in 2001. Thus, the country has achieved and maintained regional targets for TB control since the past five years. Performance of the NTP for the period 2000-2005 is shown below. Figure 1. Progress in TB control: 2000-2005 100% .-""".-----

1::::::::::::::::1 DOTS

"nvO:"::1'' ' 83%

* Provisional data from Q-DOTS reports

ISSUES AND CHALLENGES Vulnerable populations

According to Government health statistics, the proportion of population living below poverty line among TB patients was found to be 74%, compared to 36% in the general population. TB prevalence rate in prisoners was also found to be 30 times higher than in the general population (3.8%, compared to 0.13%). Moreover, the TB cure rate among prisoners was 65.3% compared to 83.3% among the general population. Other vulnerable groups identified include the homeless, unemployed and the urban poor.

MDR -TB Although the problem of MDR -TB has been known in Russia and China, the two neighboring countries of Mongolia, this problem has just been

80 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

identified and confirmed recently through international assistance in studying the drug sensitivity of TB stains isolated from treatment failure cases. MDR-TB is especially a problem among prisoners. MDR-TB was found to be 16 times higher among imprisoned patients compared to the general populations (16.1 %, compared to 1%)

PART II: PLAN FOR 2006-2010 VISION Achieve elimination of TB as a public health problem

GOAL To reduce prevalence and mortality by half by 2010 relative to 2000 contributing to the achievement of the overall Millennium Development Goals

OBJECTIVES AND CORE TARGETS FOR TB CONTROL: 2006-2010 Objective 1. To sustain and optimize the quality of DOTS and go beyond the "70/85" targets Objective 2 To adapt DOTS to respond to MDR-TB and TB-HIV Objective 3 To ensure equitable access to quality TB care for all people with TB. Objective 4 To enhance surveillance, and monitoring and evaluation Core indicators and targets: 1. Case detection rate beyond 70%, cure rate beyond 85%; 2. 90% DOTS plus treatment coverage of MDR-TB patients; 3. 100% ART coverage of HIV+TB patients; 4. 10% of cases notified under pro-poor TB initiatives (or a specific underserved population, e.g. migrant popUlation)

MAIN ACTIVITIES FOR 2006-2010 To attain the slated objectives of the national TB control programme and achieve the targets set forth, Mongolia will be undertaking the following activities in the next five years.

81 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region Ii d'

Case detection rate beyond 70%. cure rate beyond 85% a) In collaboration with non-government organizations, organize active case detection among high risk populations including prisoners (2005- 2010) b) Establish diagnosis and treatment centers in high TB prevalence remote areas - Khutul, Bagakhangai etc c) Develop guidelines for diagnosis and treatment of smear negative, extra-pulmonary and childhood TB (2007) d) Increase cure rate of TB cases among prisoners to 80% (20062010) e) Enhance information, education and communication activities to generate awareness in the general population (2006-2010) 90% DOTS plus treatment coverage of MDR-TB patients a) Conduct training on management of MDR-TB for TB specialists at the national level (2005-2007) b) Provide culture and DST services for all failure cases (2006-2010) c) Initiate and scale up DOTS-plus project nationwide (2006-2010) 100% ART coverage of HIV+TB patients a) Provide VCT services for 60% of TB patients (2006-2010) b) Provide ART for all TB-HIV patients (2006-2010) 10% of cases notified under pro-poor TB initiatives (or a specific underserved population. e.g. migrant population) a) Conduct X-ray active screening for 20% of migrant and vulnerable popUlation in Ulaanbaatar city (2006-2010) b) Improve TB screening among inmates at detention centers c) Develop TB management guideline for health workers at peripheral level (bagh, soum) d) Expand community involvement in TB care To a) b) c) d) e) enhance surveillance. and monitoring and evaluation Conduct TB prevalence survey (2007- 2009) Conduct TB epidemiology workshops (2006-2010) Review national TB programme implementation (2008, 2010) Carry out national TB drug resistance surveillance (2006-2007) Conduct annual review of the information system (2006-2010)

PARTNERS Since the 1960s, WHO has provided technical support for TB control in Mongolia. Besides WHO, the Japanese Anti-Tuberculosis Association (JATA) through Research Institute of Tuberculosis and IUATLD have been providing technical support to the NTP. Danish International Development Agency (DANIDA) has supported anti-TB drugs for the NTP. Open Society Foundation, an NGO has supported case finding in prisons and quality assurance of BCG vaccination.

an r

"I'll

'.'\111'

Fifth Technical Advisory Group Meeting to Stop T8

the Western Pacific Region

Since 2003, support for the NTP is largely from Round 1 and Round 4 of the Global Fund for AIDS, TB and Malaria (GFATM).

FINANCIAL SITUATION 2006-2010 Estimated costs and funding gap (in USD) for the Stop TB Plan 2006-2010 100% 80% 60% 40% 20% +--;...... I~--~

2006 000 1 010000

2007 500000 980000

2008 1 030000

2009 450000 740000

2010 000

83 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

PHILIPPINES: SUMMARY PLAN 2006-10 PART I: PROGRESS DURING 2000-2005 TB BURDEN Philippines is one of the seven high TB burden countries in the Western Pacific Region. It also ranks 9th on the list of the 22 high TB burden countries in the world.

2000 Population Incidence (all casesl1 00 000 pop/year) Incidence (new ss + 11 00 000 pop/year) Prevalence (all cases/100 000 pop) TB mortality (all cases/100 000 pop/year) 75653000 305 137 554 58

2004 81 617 000 293 132 463 48

TB CONTROL INFRASTRUCTURE At the central level, the National Tuberculosis Control Programme (NTP) functions under the National Centre for Diseases Prevention and Control (NCDPC) in the Department of Health (DOH). DOH is the policy-making body and provides standards and guidelines on TB control. It is responsible for supervision and monitoring of the DOTS strategy of the TB program through the NTP central office as well as through Centers of Development (DOH's regional offices). The Local Government Units health offices at the city and municipal levels implement the TB program. The NTP and the Centers of Development (CHD) through the regional TB coordinators provide them technical support. Laboratories with TB diagnostic capacity are available in each Municipality Health Centre, a site that serves a population of approximately 30,000 people. Funding for anti-TB drugs comes both from National and local government budgets. The central level has maintained responsibility for planning and procurement of anti-TB drugs, based on the needs assessments provided by regions.

ACHIEVEMENTS: 2000-2005 Performance against 2005 regional targets.

The regional targets for TB control are to achieve 100% DOTS coverage, 70% case detection of new smear positive cases and 85% treatment success by 2005.

84 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Yearly progress for the period 2000-2005 is shown in the Figure 1. Started in 1996, DOTS expanded gradually to reach 90% coverage in 2000 and nation wide coverage by the end of 2002. Detection of new smear positive cases showed an increasing trend to cross 70% in 2004, but declined to 68% in 2005. However, 2005 data must be viewed with the understanding that it is annualized from one quarterly report. Treatment success of over 85% has been sustained throughout this period. Figure 1. Progress in TB control: 2000-2005

* Provisional data from Q-DOTS reports

Public-Private Mix DOTS (PPMD) Strategy. It is estimated that one-third of TB patients seek treatment through the

private sector. Appropriately so, the Philippines has been one of the pioneers globally in piloting and expanding PPMD. With support from GFATM and USAID, a total of 64 PPMD Units are already operating in the country as of 2005. This Public-Private Mix DOTS scaling is already contributing to the case detection with good treatment outcomes and has engaged a large number of Private Physicians in DOTS (almost 3,000 trained). In areas of Metro Manila where PPMD units have been installed, it contributed up to a 16% increase in case detection in 2004. Similarly, in GFATM supported PPMD units covering a population of 2.9 million, PPMD units contributed to a 8% increase in case detection in the same year. TB Diagnostic Committees (TBDCs)

With the introduction of the DOTS strategy, the NTP established TBDCs to improve the diagnosis and management of smear negative TB cases and serve as a mechanism to engage Private Physicians in the NTP. There has been a significant expansion in the number of TBDCs particularly in the year 2004 as a result of the rapid expansion of the PPMD strategy. Currently,

85 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

74 TBDCs are established in the country representing approximately 40% of the total required for the programme. TBDC's have contributed to a significant decrease in over treatment of smear negative cases. External Quality Assurance IEQA)

With support from the Japan International Cooperation Agency (JICA) & Research Institute of Tuberculosis (RIT), the NTP is implementing EQA of sputum microscopy services. The National TB Reference Laboratory now serves as the primary laboratory overseeing the network of peripheral microscopy centers. At present, the NTP is expanding EQA to cover the remaining provinces/cities for a nationwide scope. Both public and private laboratories (PPMD laboratories) are to be catered by this strategy as part of their laboratory management. Childhood TB

The Childhood TB Task Force, a multi-sectoral body represented by various organizations formulated policies and technical guidelines for the management of childhood TB. Developed in the context of the DOTS strategy, they were tested in selected DOTS areas of the country. By way of these protocols, the NTP implementers in the field are now guided on how to manage children with TB in a more technical and feasible approach. Social Mobilization, Community Involvement

The NTP partnered has partnered with the World Vision Development Foundation, in implementing the "Kusog Baga Project." The DOTS strategy was expanded in the Project sites through community-based approach whereby Task Forces at the community level were organized. These groups have found their niche in the NTP mainly as Treatment Partners of TB patients, for referring TB suspects and as advocates of the Program. These groups or coalitions demonstrate how the NTP can broaden the base of community participation

ISSUES AND CONSTRAINTS MOR-TB and DOTS Plus

The first nation-wide drug resistance survey (2003-2004), showed a MDRTB prevalence of 4.5% in new smear positive cases. DOTS Plus programmes for the management of MDR-TB patients is yet to be implemented as a part of the national TB control programme. MDR-TB was addressed through the initiation of activities anchored in the context of public-private partnership. A GLC approved DOTS Plus project is being implemented by the Tropical Disease Foundation (TDF) , an NGO, in

86 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Manila since 1999. Efforts are being made to build on the existing system to mainstream DOTS Plus activities in realm of the NTP. As a preliminary step, the Lung Center of the Philippines, a public hospital, would serve as a satellite treatment center of TDF for its cohorts of MDR-TB cases. In the future, the government envisages spearheading the management of this emerging public health concern. Public-to-Pubic DOTS. Much of the achievements of PPMD have been in involving private physicians in DOTS. Enhancing the involvement of Government hospitals that are outside the NTP, and Medical Colleges in the country has great potential to improve TB control activities. A more comprehensive application of the DOTS strategy in hospitals is being disseminated, particularly to ensure that TB clients are not lost from the NTP system, even if they are initially managed at the hospitals, through a strong referral network. DOTS integration in the medical and paramedical training curricula is being advocated by the NTP in partnership with PhilTIPS and the Philippine Association of Medical Colleges

PART II: PLAN FOR 2006-2010 GOAL To reduce the prevalence and mortality by half by 2010 contributing to the achievement of the overall MDG

OBJECTIVES AND CORE TARGETS FOR TB CONTROL: 2006-2010 The three main objectives are to:

Objective 1. Optimize and sustain the quality of DOTS implementation Objective 2. Improve the detection of TB cases Objective 3. Adapt DOTS to respond to high-risks populations including MDR-TB and TB-HIV Core indicators and targets linked to achieving the above objectives are: 1) Success Rate of 85% or more 2) Case Detection Rate of 70% or more 3) DOTS-Plus support to at least 10% Failure Cases

ACTIVITIES OF THE 5- YEAR PLAN Priority of the NTP is to maintain and further improve on the performance to ensure quality of DOTS services. In collaboration with other key stakeholders, particularly the private sector, it is hoped that the goal of

87 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

reducing prevalence and mortality from this disease will be achieved. The NTP will embark on the following activities: 1.

Ensure the high political support for TB control as a priority of the national health plan and among the local government units (LGUs).

Continue to include the provision for first-line anti-TB drugs in the NTP budget of the national health plan and additional or supplemental funds to address the emerging threat of MDRTB. Advocate to the LGUs to firm up their local funds for drug augmentation and to mobilize additional resources for localized TB control operations. Provide necessary human resources for TB control at all levels in the context of the DOH's FOURmula One policies and that of devolution.

Improve the capabilities of DOTS workers, both public and private, to sustain quality implementation of DOTS services. a) b) Strengthen the capabilities of DOTS workers in all sectors concerned, cognizant to policy revisions/formulations of the NTP. Reinforce the technical and managerial capabilities of NTP Coordinators and DOTS unit managers to include data and logistics management and policy development Enhance the skills of NTP laboratory personnel for effective laboratory management including quality assurance. Provide technical assistance to key NTP Staff and to DOTS unit managers on relevant sustainability activities such as health financing and total quality management (TQM). Upgrade and formalize the inclusion of NTP-DOTS policies in the medical and paramedical training curricula. Support the active participation of local NTP-DOTS experts by ensuring the mainstay of NTP-DOTS topics in relevant health fora or conferences.

c) d)

e) f)

Strengthen the implementation of DOTS certification and accreditation. a) Promote certification and accreditation of DOTS facilities to ensure quality of services and avail of Phil Health Benefit Package. Fast track implementation of certification and accreditation through a joint process for both. Include the conduct of certification in the regular management activities of the CHDs. This should be jointly done with their PhilHealth counterpart who will undertake the accreditation process.

I J

88 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Maintain the support to key management functions, particularly monitoring and evaluation of NTP-DOTS implementation. a) Promote the use of the standard monitoring tool and augment financial support to peripheral levels to conduct of monitoring and evaluation. Conduct regular external evaluations with participation of both international and local key NTP partners.

Scale-up and enhance Public-Private Mix DOTS units in strategic sites. a) Strengthen the technical and managerial capabilities of the National and Regional Coordinating Committee on PPMD to optimize their functions. Identify potential sites for PPMD installation based on the set of criteria developed to optimise contribution from the private sector Conduct internal and external assessments of PPMD performance in a regular and timely schedule. Support the activities of PhilCAT in installation/enhancement of PPMD units Encourage and support experience sharing through field visits to other countries, presentations in international forum.

c) d) e)

Strengthen Public-to-Public collaborations between public hospitals and health centers to increase access to, and improve efficiency of, DOTS services. a) b) Solicit the support of hospital management, as DOTS referring facility or as DOTS service providing facility Provide training of necessary hospital staff and establish a focal site within the physical structure of the hospital for the delivery of DOTS services Develop procedural guidelines on ensuring the success of referrals from one facility to another.

Support the existing DOTS Plus initiatives and institutionalize these in the public sector. a) Develop policies, framework and plans for implementation and expansion of DOTS Plus implementation in the public health sector Develop training materials, and undertake training of NTP coordinators and implementers Advocate for additional support to effect the implementation in a wider coverage

b) c)

89 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

Strengthen the integration of TB and HIV in accordance to the country's disease scenario. The NTP recognizes this as a new activity and aims to establish a strong collaboration between these two related diseases in an epidemiologic scenario of high TB and low HIV prevalence. Thus, the NTP will look into the following:

a) b) c)

Set-up a coordinating committee, spearheaded by the DOH, to oversee the possibilities of convergence for the NTP and the NAP Formulate policies and guidelines that will link the activities of both programs pertinent to the management of TB-HIV Install a cross referral system to ensure the provision of necessary TB and HIV services Establish the surveillance of HIV in TB patients to determine prevalence and trends over time and to consider existing surveillance data

PARTNERS The Global Fund Round 2, amounting to $ 11.4 million is supporting the NTP since August 2003. The four implementers are: (1) NTP-DOH to strengthen quality DOTS; (2) World Vision Development Foundation, Inc. to raise demand for DOTS; (3) Philippine Coalition Against Tuberculosis (PhilCAT) to expand PPMD; and (4) Tropical Disease Foundation (TDF) to manage MDR-TB cases. Japan International Cooperation Agency (JICA) supports the Quality TB Control Project (QTCP), which is aimed at improving sputum smear microscopy services including external quality assurance (EQA). It also supported the first national drug resistance survey conducted in 2003-4. Funded by USAID, the Local Enhancement and Development Project (LEAD), focuses on strengthening local governance in rural poor areas. TB control is one of the components of the LEAD project. USAID is also supporting the Philippine Tuberculosis Initiatives for Private Sector (PhilTIPS) project, which has set up 20 PPMD units so far. Medicos del Mundo, an international NGO supported by the Spanish government, is supporting capacity building for laboratory personnel (including equipment) and supports two private sector DOTS facilities. WHO provides technical support in implementation of the national TB control programme. GDF provided drugs in 2003 for 3 years for use in PPMD facilities. GDF is also the procurement agency for first-line antiTB drugs for the regular programme.

90 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

FINANCIAL SITUATION 2006-2010 The financial requirements of the 5-year have been estimated on the previous years spending but also on the additional activities that have to be undertaken in order to achieve the 2010 goals. The five-year financial requirements, the donor support and the gaps are estimated in the table below. Table 1. Financial support and gap 2006-2010 IUS$)

...

.2006 11640000 4050 000 623000 3 150 000 19463000

2007 11 640000 9100000 100000 3150 000 23990000

2008 12660000 9500000 55000 3320000 25535000

2009 12660 000 9000000 0 1930000 23590000

. 2010

Govt. of Philippines GFATM Other grants/donors Financial Gap Total Requirements

13170000 9000000 55000 2130000 24335000

Figure 2. Financial gap for 2006-2010 in percentages

100% 80% 60% 40% 20% 0% 2006 2007 2008 2009 2010 DGap • Others Iii!IGFATM

o Govt.

91 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

PAPUA NEW GUINEA: SUMMARY PLAN 2006-10 PART I: PROGRESS DURING 2000-2005 TB BURDEN Among the 36 countries of the Western Pacific Region, Papua New Guinea ranks third in terms of estimated incidence rate and eight in terms of estimated number of incident cases. ,

d I, ,

2000 Population Incidence (all cases/100 000 pop/year) Incidence (new ss + 11 00 000 pop/year) Prevalence (all cases/100 000 pop) TB mortality (all cases/100 000 pop/year) 4809000 242 109 628 56

2004 5772000 233 104 448 42

TB CONTROL INFRASTRUCTURE Government and church providers jointly provide about 98% of the health services in the country. The church alone runs 46% of the health facilities, generally those that are located in the periphery. The Government funds salaries of church health workers. Almost all provinces have one provincial hospital each. These hospitals are under the direct control of the national government. In addition, bigger towns have urban clinics, while rural areas have rural health centers, sub-centers and aid-posts. The rural health facilities fell under the direct control of local level governments after the Organic Law was introduced in 1995. All provinces have Provincial Health Advisors who work under Provincial Administrators. Provincial Health Advisors are supported by the Provincial Disease Control Officers (PDCOs). Some districts have posts of District Disease Control Officers (DDCOs), who are directly accountable to District Health Administrators who, in turn, are under District Administrators.

92 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

ACHIEVEMENTS: 2000 - 2005 Performance against 2005 regional targets

The regional targets for TB control are to achieve 100% DOTS coverage, 70% case detection of new smear positive cases and 85% treatment success by 2005. In 1997, Papua New Guinea launched the DOTS Strategy. By 2005, the country achieved case detection and cure rates of only 18% and 49% respectively. The current DOTS coverage is difficult to measure. 38 (out of 87) districts had reported at least once under the DOTS Strategy. These districts constitute 47% of the country's population. However, not all health facilities of these districts submit reports while some facilities report erratically. Performance of the NTP for the period 2000-2005 is shown in Figure 1. Figure 1. Progress in TB control: 2000-2005

100%,------------------------------------------, 80%+-------------------------------------------~

* Provisional data from Q-OOTS reports

ISSUES AND CHALLENGES lack of political commitment and human resources

Unfortunately, TB program is not a tier-one priority (as per the "Health Sector Strategic Plan" of the government) although it kills more adults than any other infectious disease in the country. Neither did the recently published "Health Sector Strategic Plan of PNG (2006-2008)" include TB among the top health priorities of the government. This has serious implications on availability of resources and staffing and affects implementation of TB control activities.

93 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

The ratio of health personnel to population is very low in the country, for all categories. For instance, there are only 3 medical officers and 42 nursing officers per 100,000 persons, which are the lowest among all Pacific countries. The NTP Unit has one Technical Officer, who acts as the National Program Manager (TB) with no secretarial assistant or other support staff. Unlike other programs, only three provinces have government Provincial TB Coordinators and the posts of District Disease Control Officers (DDCOs) is often vacant or filled temporarily. Supervision and monitoring National oversight of provinces and districts is very limited. Main reasons include limited capacity of the program units due to under-staffing and inadequate funds/vehicles for travel. The Organic Law (1995) has exacerbated existing problems with supervision. Provincial Health Advisors have lost most of their authority to monitor and supervise district health workers. The law has transferred these functions to district and local level governments (LLGs). The transfer of senior officers from rural health centers to provincial hospitals and withdrawal of vehicles for supervision by provincial governments have made outreach services (including supervision) almost defunct. TB-HIV: the dual epidemic The HIV epidemic has reached a generalized stage in Papua New Guinea. Sero-surveillance surveys among women attending antenatal clinics in 4 major health facilities (in Port Moresby, Goroka, Lae and Daru) showed that the prevalence rate of HIV ranged from 0.7-2.5% (2003). Data from sentinel surveillance centers at 3 major health facilities (in Port Moresby, Goroka and Lae) showed that 12-19% of the TB cases were HIV positive (2003), which is considerably high. A meeting of all major stakeholders was held in August 2005 to discuss a collaborative approach to address the emerging challenge of TB-HIV coinfection. A National policy for TB-HIV collaborative activities has been drafted. Multi-drug resistant TB (MDR-TB) No studies have been conducted to assess the level of drug resistance in the community. Anecdotally, data for the year 2005 from Queensland TB Center (Australia) reveals that 6 out of 24 TB cases (25%), who reported at the Center for TB diagnosis from Torres Strait Islands, had multi-drug resistant TB. (The Torres Strait Islands of Australia share an international border with PNG). Moreover, the cure rates have been very low in the country for several years and hence it is likely that incidence of MDR-TB may be rising.

94 Fifth Technical AdvIsory Group Meeting to Stop T8 in the Western Pacific Region

Some of the provincial hospitals have been treating patients with secondline drugs, but these treatments have been empirical rather than based on laboratory diagnosis ofMDR-TB. The Central Public Health Laboratory has re-started culture services recently. However, it would be able to introduce quality-assured drug sensitivity testing (DST) services only after it is able to strengthen quality-assured sputum microscopy services in the country.

PART II: PLAN FOR 2006-2010 VISION The National Government's vision is a TB-free nation by 2050, i.e. to achieve elimination of TB as a public health problem in the country.

GOAL The goal of the Country Strategic Plan is to reduce the prevalence and death rates by half by 2015 (relative to the 1990 level), contributing to the achievement of the TB target of the UN Millennium Development Goals of "having halted and begun to reverse the incidence rate".

OBJECTIVES AND CORE TARGETS FOR TB CONTROL: 2006-2010 To achieve the goal, the following two objectives are planned: Objective 1: To achieve the "70/85/ 100" targets by 2010 or earlier Objective 2: To respond to the challenges posed by the emerging threats of MDR-TB and TB-HIV

Core indicators and targets: 1. To detect at least 70% of people with infectious TB by 2010 or earlier 2. To cure at least 85% of those diagnosed by 2010 or earlier 3. To achieve a population coverage of 100% with the DOTS Strategy by 2010 or earlier 4. Assess the MDR-TB situation by 2009 5. At least 30% of TB cases with HIV receive ART 6. At least 80% of HIV cases with TB receive treatment under DOTS

95 Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

STRATEGIES AND MAIN ACTIVITIES FOR 2006-2010 The Country Plan represents a massive intensification of efforts over the next 5 years and consists of a phased expansion of DOTS over a period of 3 years (as a package approach). In addition to the classical components of DOTS, the package approach would include scale up of initiatives such as community-based DOTS, introduction and scale up ofTB/HIV collaborative activities and, assessment of the MDR-TB situation in the country. The expected results can be achieved by implementing strategies described below. 1.

Country capacity for good quality DOTS implementation assured by implementing the following strategies a) Providing access to sputum microscopy services by strengthening/ establishing 121 laboratories (one for every 50,000 population). Non-sputum microscopy health centres would be provided with funds for sputum collection and transport to the nearest sputum microscopy centres on a fortnightly basis. b) Ensuring access to DOTS by scaling up the community-based DOTS initiative. This initiative would involve sensitizing community leaders and influencers like councillors, pastors and tribal chieftains to assist their local health facilities in providing DOT to patients, taking patient retrieval actions, providing social support to the patients and referring TB suspects for early diagnosis. c) Implementing the External Quality Assessment (EQA) protocol for ensuring good quality sputum microscopy services in collaboration with the Supranational Reference Laboratory (SNRL) at Brisbane d) Strengthening supervisory support to the provinces and districts for ensuring good quality DOTS program. The Government is now strengthening the NTP Unit with 14 health personnel for the national as well as regional levels. While advocacy with Provincial Govts to post TB Coordinators will continue, contractual Provincial TB Consultants will be hired as an interim measure for supervision, coordination and monitoring the program at provincial and district levels. The National and Regional Officers and Consultants would, in turn, provide guidance and support to these Provincial Consultants by visiting them on a periodic basis. e) Training of key staff. At least 80% of the existing supervisors, clinical officers and sputum microscopists would be trained over the next 3 years. In addition, at least 50% of the community health workers and aid-post workers would be trained Uninterrupted supply of quality-assured TB drugs at all DOTS units would be ensured by procuring drugs from the Global Drug Facility

96 Fifth Technical Advisory Group Meeting to Stop TB In the Western Pacific Region

(GDF), and through the introduction of Fixed Dose Combination (FDC) drugs 3. With technical assistance from the SNRL at Brisbane, it is expected to conduct drug resistance survey (DRS) in two provinces, viz., Morobe and National capital district in 2009. This will entail building technical capacity of the Central Public Health Laboratory (CPHL) for mycobacterial culture and drug susceptibility testing services. TB- HIV collaborative activities set out in the Country Policy on TB/HIV Collaboration will be implemented, namely: a) Establish mechanism for collaboration by setting up National TB/HIV Coordinating Committee, conducting surveillance of HIV prevalence among TB patients (at least 20% of the districts by 2010), and joint TB / HIV planning, monitoring and evaluation b) Decrease the burden of TB in people living with HIV / AIDS (PLWHA) through intensified case-finding among PLWHA, INH preventive therapy and by ensuring tuberculosis infection control in health care and congregate settings c) Decrease the burden of HIV in tuberculosis patients by providing HIV Counselling and testing (on a voluntary basis); HIV / AIDS prevention, care and support including introduction of cotrimoxazole preventive therapy and antiretroviral therapy

Key cross-cutting issues and strategies a) Country-driven advocacy, communications and social mobilization strategies including effective advocacy at all levels, development of advocacy packages, use of mass media, cured TB patients etc will be undertaken Monitoring and evaluation mechanisms will be enhanced through annual national level review meetings, program evaluation surveys and, publication of annual progress reports. Measurement of impact (e.g. TB prevalence surveys, household health surveys, modelling and analysis of routine data) would be used from 2011, after basic DOTS services become available across the country. Adequate technical assistance and cooperation from Development Partners like the WHO and AusAID will continue to be required to support implementation of the Stop TB Strategy. In addition, periodic external technical assistance would be sought for special needs (e.g. Annual Program Evaluation, External Laboratory Quality Assurance, Drug Resistance Survey, TB-HIV Collaborative Activities, and Procurement and Supply Management).

97 Fifth Technical AdvisQry Group Meeting to Stop TB in the Western Pacific Region

Strengthening health systems. The Government and its collaborators will engage further with others to identify bottlenecks and support system-wide actions to improve stewardship and management, financing, human resource development, service delivery and structures, and community engagement. At the time of writing this Plan, the Disease Control Branch of NDOH (which includes the NTP Unit) is being restructured in an effort to strengthen health systems. Addressing TB and poverty by ensuring that the poor and the marginalized populations receive special attention for TB control. This would include the provision of free quality TB care, promotion of better access through optimal decentralization of services, involvement of former TB patients and TB support groups to advocate for patient-friendly services and encouragement of community participation for DOTS. Addressing TB in children by promoting the care of children with TB as part of routine TB activities. The NTP will explicitly address issues related to diagnosis, treatment, and drug formulations for children with TB. NTP will improve registration of children with TB, reporting of their treatment outcomes, and use this information to ensure that all children with TB receive a high standard of care.

PARTNERS' The major funding partners for the health sector in Paua New Guinea include Australian Agency for International Development (AusAID), New Zealand Agency for International Development (NZAID), Asian Development Bank (ADB) and the World Health Organisation (WHO). All partners pool funds to the Health Sector Improvement Program (HSIP), which then release funds to various programmes including the National TB Control Programme

FINANCIAL SITUATION 2006-2010 Table 1 gives a summary of funding needs of the program for the next 5 years. The total cost of US$ 12.31 million represents a sixteen-fold increase in annual investment for TB control compared with the funding available currently through the Health Sector Improvement Program (HSIP). The estimated budget for 2006-2010, shown here, includes the costs of proposed TB-specific activities but excludes the costs of existing government staff and infrastructure. It also excludes general investments required in health systems that are not TB-specific and activities that relate to the health sector as a whole. , Reference: GFA TM Round 5 Proposal

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Table 1. Funding requirements for 2006-2010 ,

, ., ,

Financial

. Activity

support required lin US Dollars) ,

2006 239046

2007: 304929

2008·' 393710

'2009 426519

2010 459329

Total

Human Resources (recruited through WHO) Infrastructure and equipments Trainings and review meetings Planning, administration, quality assurance and social mobilization Drugs, laboratory supplies and printed materials ,. lotaf

1823533

92690 362404 543145

92690 368268 883905

48276 513570 1 367938

2483 314319 1 333342

2483 62566 1 293111

238621 1 621 125 5421441

1121 359

467787

572 937

522792

3207667

2358644

'21~7

579

2896431

2599456

2340'280:

12312390

Funding gap

As summarized in the table above, the total cost of the Plan for the next 5 years is US$ 12.31 million. Presently, the NTP Unit receives only about US$ 0.15 million from HSIP every year. Thus, the estimated funding gap is US$ 11.56 million for the next 5 years. Hence, the National Government and its Development Partners must fulfil their commitment towards the country by mobilizing funds to fill the funding gap for the critical period of 2006-2010, immediately.

99 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

)

I ,

VIET NAM: SUMMARY PLAN 2006-10 PART I: PROGRESS DURING 2000-2005 TB BURDEN1 Vietnam is one of the seven countries with a high burden of TB in the Western Pacific region. It also ranks 13th on the list of the 22 high TB burden countries in the world.

2000 Population Incidence (all cases/100 000 pop/year) Incidence (new ss + 11 00 000 pop/year) Prevalence (all cases/100 000 pop) TB mortality (all cases/100 000 pop/year) 78137000 183 82 251 24

2004 83 123000 176 79 232 22

TB CONTROL INFRASTRUCTURE The Director of the National Hospital of Tuberculosis and Respiratory Diseases (NHTRD) in Hanoi is responsible for the National Tuberculosis Program. Because of geography and transportation, Pham Ngoc Thach Hospital (in Ho Chi Minh City) is responsible to supervise TB activities for 22 southern provinces. Both hospitals are responsible for the overall implementation of the NTP in the provinces including training, drug distribution and supervision. They also act as reference laboratories and are responsible for the quality control of the laboratories at the peripheral levels. Provincial TB centres and Tuberculosis Units are responsible for implementation of the tuberculosis program in the provinces and districts respectively. The provincial tuberculosis coordinator gives close guidance to the districts, supervises training activities, data collecting and the distribution and proper use of drugs. The tuberculosis district unit is responsible for confirmation of the diagnosis by microscopy, initiation of the ambulatory treatment at communes near the patient's home, and supervision of the conduct of the NTP in the communes. At the commune level, a general staff is responsible for communicable diseases including tuberculosis. Health workers are responsible for community health care including TB and in the villages. The commune and , Global TB Control, WHO Report 2006 (in press)

100 i~ Fifth Technical Advisory Group Meeting to Stop TB in the Western Pacific Region

village levels identify and refer TB suspects to the districts and provide ambulatory treatment for TB.

ACHIEVEMENTS: 2000 - 2005 Performance against 2005 regional targets.

The regional targets for TB control are to achieve 100% DOTS coverage, 70% case detection of new smear positive cases and 85% treatment success by 2005. Vietnam was the first high TB burden countries to achieve the TB control targets. The NTP of Vietnam introduced DOTS in 1985 and achieved 100% DOTS coverage and the WHO targets for case detection and treatment success since 1997. Performance of the NTP for the period 2000-2005 is shown in Figure 1. Figure 1. Progress in TB control: 2000-2005

* Provisional data from Q-DOTS reports

High political commitment. TB is a priority not only at the national level, but as well at the provincial and district levels. TB control committees exist at the local level and provide financial and staffing support to TB control efforts. TB control is generally seen as a public health problem and a development issue linked to poverty reduction. Strong programme leadership and guidelines. One of the main reason for NTP's success can be attributed to the strong leadership in implementing the DOTS strategy at the grass root level,

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following a well designed DOTS implementation plan with clear standardised policies supported by appropriate guidelines on all operational issues. Well-developed network for services. Another achievement of the NTP is the establishment of a TB control network with trained staffs at all levels _ central provincial, district, commune and villages. Each of the commune health posts (CHP) serves on average a population of some 5 to 8,000 people enabling most patients to attend CHP's for DOT on ambulatory basis.

ISSUES AND CONSTRAINTS Emerging HIV epidemic The impact of the NTP is mitigated by the rapid spread of HIV in Vietnam since the early nineties. AIDS sentinel data show that 4.8% of TB patients were HIV positive in 2004. More than 10 provinces had greater than 5% prevalence of HIV among TB patients. It likely that in the near future the number of tuberculosis cases will increase in association with a further spread of the HIV epidemic, since a high proportion of the adult population has been infected with M. tuberculosis in the past. Thus far in Vietnam, no national strategy for TB/HIV has been adopted to address the needs of PLWHA and HIV-positive TB patients, though local collaboration between the NTP and the AIDS program exists in some provinces.

MDR-TB Preliminary results from the second national tuberculosis drug resistance survey (2001-2002) show that 2.3% of new cases patients had MDR TB, as compared to 2.3% the 1996 national DRS. Any resistance in previously untreated cases declined from 32.5% in 1996 to 29.0% in 2001-2002. While the prevalence of primary MDR TB in Vietnam is still considered acceptably low, nevertheless each year some 300 to 350 chronic cases, identified as failure cases from the retreatment regimen occur within the country. As yet the NTP has no treatment available for these cases.

Limited or restrained access to DOTS The 2003 joint evaluation of the NTP identified distances, language, belonging to an ethnic minOrity (14% of the popUlation) and stigma as factors related to poverty and access to DOTS. Out-of-pocket expenditure for transport and purchase of needles and syringes for streptomycin injections was identified as a barrier for poor patients. Other vulnerable groups identified by the team are prisoners, persons detained in rehabilitation centres and HIV-positive people.

102 _lIIllii9;!i#~di,· Fifth Technical Advisory Group Meeting to Stop T6 in the Western Pacific Region

Sustained financing At the start of the 2006-201O-development plan, full funding is not ~t all secured. Current stocks and quantities of first line TB drugs that WIll be purchased by the MOH during 2006 will last to October 2007. Due to lack of funding the implementation of DOTS plus has been postponed.

PART II: PLAN FOR 2006-2010 GOAL The goals of the NTP of Vietnam are to reduce tuberculosis morbidity, mortality and transmission, and related psychosocial suffering and to prevent development of drug resistance in order to contribute to the comprehensive poverty reduction and growth strategy of Vietnam.

OBJECTIVES AND CORE TARGETS FOR TB CONTROL: 2006-2010 The main aim of the NTP development plan 2006--2010 is to implement the expanded DOTS framework. The plan has 6 objectives:

Objective 1 To ensure provision of high quality DOTS services at all levels of health service delivery Objective 2 Increased access to and use of health service of ethnic minority groups and the poor Objective 3 To develop and implement Public-Private mix DOTS in urban areas of 12 big provinces/cities Objective 4 Implementation of framework to address TB-HIV co-infection Objective 5 Development and provision of diagnosis and treatment for patients with MDR TB Objective 6 Increased access to TB diagnosis and treatment for people in penitentiary and re-education institutions (05-06 camps) in 16 provinces Core indicators and targets: 1. New smear positive case detection of over 70% and treatment success of over 85% 2. 95% of district laboratories have zero errors found by EQA 3. 100% of eligible districts/communes contract mass organizations and implement Community TB care (CTBC) 4. 50% of private health care providers registered for NTP collaboration in the 12 identified provinces

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100% of TB patients receive VCT services in routine care in the eight provlllces 6. 100% of known HIV+ve TB patients receive CPT 7. By 2010, NTP has capacity to diagnose and treat 550 MDR-TB patients per year 8. Treatment success of 70% among registered MDR-TB patients 9. Decrease the prevalence of MDR-TB in new sputum smear positive patients (Baseline 2.3%, 1996-97 survey) 10. All 16 identified provinces have accessible and good quality TB care for prison and social re-education populations

MAIN ACTIVITIES OF THE 5-YEAR PLAN 1.

Ensure provision of high quality DOTS services at all levels of health service delivery Main activities planned for improvement of the existing DOTS services to meet the objective above include: a) Early case detection and diagnosis by implementing the Practical Approach for Lung health strategy to improve TB detection and developing new strategies for diagnosis of sputum smear negative pulmonary TB and extra pulmonary TB cases and TB in children. Strengthen and develop quality assured laboratory services by implementing External Quality Assessment (EQA) for microscopy and upgrading provincial laboratories to perform culture (64 labs by 2010). Provide quality treatment of cases by introducing Fixed Dose Combinations and intensifying direct observation of drug intake during full course of all re-treatment cases and patients treated with MDR TB. Implementation of a fully oral 8 months Cat 1 regimen (2EHRZ/ 6EH) from 2008 onwards allowing for community based DOT Strengthen monitoring and evaluation by implementing an electronic reporting and recording system; use of GIS for monitoring epidemiological trends and operational indicators; design and implement a Management Information System on finance, manpower, and activities for all levels Scale up surveillance and research by establishing a research committee and strengthening research capacity. Carry out epidemiological research and operational research projects on emerging topics Develop and implement a comprehensive strategy for Advocacy, communication and social mobilization. Monitor and evaluate activities. Review human resources capacity and develop/revise job descriptions for staff to correspond with current policies and

d) e)

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recommendations for TB control. Training and re-training as required. Strengthen management capacity of the NTP by developing a regional network.

Increased access to and use of health services by ethnic minority groups and the poor Expansion of existing efforts to strengthen PHC services in 200 remote districts, including DOTS services, to ensure that poor TB patients have access to existing mechanisms like the health care fund for the poor and degrees 135 and 139. Specific activities are to: a) Continue to implement the "strengthening basic health care network and TB activities project" in remote and mountainous areas. Promote the use of health insurance license for the poor and national budget for the poor for out pocket expenditure (further examinations, foods and transport) for urban and rural poor TB patients Collaborate with mass organizations (women union, farmers union,) to help TB poor patients. Develop community DOT (Community TB care - CTBC) through implementation of sputum collection-referring system; collaboration with village health workers, mass organizations and private sector for referrals in remote and mountainous communes. Evaluate existing incentive system for health workers, develop socioeconomic and gender indicators for monitoring and analysis and carry out operational research.

c) d)

Develop and implement Public - Private Mix DOTS in urban areas of 12 provinces/cities The plan aims to establish focal groups and coordinating committees for PPMD in 7 provinces in 2006, 23 in 2007 and the remaining provinces during the rest of the plan period. The total number of patients expected to benefit is 2,000 to 5,000 per year depending on the expansion of the project. Specific activities include: a) Establish advisory board, assess national PPM - DOTS situation develop national strategies and operational guidelines for PPM DOTS Human resources development through training of NTP and private sector, establishment of PPM focal groups at provincial and district levels. Advocacy, communication and social mobilization for PPMD by mobilizing relevant health care providers, and informing community about TB, DOTS, and PPM - DOTS. Maintain and strengthen the relationship between the NTP and

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private sector through quarterly meetings, feed-back results of detection and treatment outcome to private sector partner and provide updated information quarterly Monitor and evaluate PPM - DOTS project at provincial level and undertake operational research projects

Implement the framework to address TB- HIV co-infections The Plan is to implement the framework to address TB IHIV co-infection, as formulated by WPRO. Coordinating committees will be created at district level initially in the most affected provinces, but in principal countrywide at the end of the plan period. It is planned to offer routine VCT to all TB patients in high HIV prevalence provinces. With scaling up of ARV, HIV positive TB patients will have increased access to HAART. Activities include: a) b) Surveillance of HIV prevalence among TB patients; joint planning, monitoring and evaluation for HIV ITB activities Epidemiological surveillance I research through data collection from routine care in 10 and periodic survey in 5 high HIV prevalence provinces, observational study of morbidity and mortality of HIVinfected TB patients (3 years) and validation of diagnostic algorithms Decrease the burden of HIV in TB patients by referral to VCT, HIV prevention method, ensuring HIV I AIDS care and support including ARV Decrease the burden of tuberculosis in people living with HIV I AIDS through intensified TB case finding, introduction of INH preventive therapy.

Development and provision of diagnosis and treatment for patients with MDR-TB The NTP will start DOTS plus in 5 provinces initially. In total 1,500 MDR patients will be enrolled on standardized second line treatment. Patients will be hospitalized during the first month and treated ambulatory at commune level during the 17 months continuation phase. Following activities will be undertaken: a) Build the physical and technical laboratory capacity to do quality assured culture and DST for diagnosis and follow up treatment of MDR TB (in four laboratories) Build the physical, technical, and human resource capacity to treat MDR TB patients (in five provinces) Ensure uninterrupted supply of quality first and second line TB drugs to the MDR treatment sites and other necessary supplies (for 1500 patients) Assess the trend of the prevalence of MDR TB through periodic drug resistance surveys and annual analysis of routine DST data

b) c)

106 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

e) f) g)

Development materials for MDR TB management, IEC strategy. Program management, supervision, monitoring and evaluation, development. Evaluate yield, outcomes and cost-effectiveness of using rapid diagnostic test for rifampicin resistance under routine program conditions. Evaluate clinical outcomes of MDR-TB treatment program Mobilise external technical assistance for DOTS-Plus implementation.

Increased access to TB diagnosis and treatment for people in penitentiary and re-education institutions (05-06 camps) in 16 provinces The project will initially target 16 provinces and be implemented in close collaboration with the Ministry of Police, the Ministry of Labor, Invalids and Social Affairs (MOLISA) and the National AIDS Program. a) b) Establishment of joint Council for TB control in penitentiary and social re-education institutions and joint situational assessment. Development and adoption of joint strategic approach including development of manuals appropriate to prison and 05/06 institutions (on screening, diagnosis, treatment, laboratory services, treatment, social support etc.) Develop appropriate ACS strategy for prisoners / inmates / camp inhabitants, family members and guards to encourage referral and self-reporting of suspects. Establishment and training of volunteer monitoring committee(s) for each province, including people from mass organizations, ex prisoners / ex 05-06 camp inhabitants, legal people, health people, teachers etc. for: Access to services for TB/HIV co-infection including VCT services, CPT, access to ART, treatment of opportunistic infections, TB screening among HIV positives and IPT Supervision, Monitoring and evaluation by volunteer monitoring committee, Co-coordinating councils and NTP Surveillance and research including drug resistance survey, prevalence of TB, case notification and results of treatment, longitudinal study on TB for persons in 05/06 camps

PARTNERS The development plan for 2001-2005 was supported by the World Bank, the Royal Netherlands Embassy, Global Fund for TB, AIDS, and Malaria (GFATM) Round one, and the Government of Vietnam. KNCV TB foundation, Medical Committee Netherlands Vietnam, and the World Health Organization (WHO), provide technical support to the National TB Programme

107 Fifth Technical Advisory Group Meeting to Stop T8 in the Western Pacific Region

FINANCIAL SITUATION 2006-2010 The total amount of funding to implement the plan is about 38.4 million Euros. This does not include 23 million Euros for salaries paid by the Government of Vietnam .. The Ministry of Health will provide 10 million Euros for incentives, supervision and supplies (increasing 15% compared with that in the period of 2001-2005). 5.8 million Euro (7.5 million USD) will be available through phase 2 of round one of the GFATM. The gap, which is about 22.6 million Euros, needs to be mobilized. Table 1. Budget requirement for the NTP in the period 2006-1010 (EURO)

• ~~ ,; . :CoMPon~ Obi. 1 Obi. 2 Obi. 3 Obi. 4 Obi. 5 Obi. 6 To ensure provision of high quality DOTS services at all levels of health service delivery Increased access to and use of health service of ethnic minority group and the poor To develop and implement public-private mix DOTS Implementing the framework to address TB-HIV co-infections Development and provision of diagnosis and treatment for patients with MDR TB Increased access to TB diagnosis and treatment for people in penitentiary and re-education institutions (05--06 camps) in 16 provinces

29926499 1 376810 259275 1754680 4567925 535430

Assuming approved funding for phase 2 ofGFATM round 1, Government of Vietnam and possibly from the Royal Netherlands Embassy, a funding gap of 15 million Euros still remain.

Key facts

Organisation World Health Organization (WHO)

Document type Technical Documents

Adoption date December 31, 2006

Source World Health Organization