WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Fifty-second session Brunei Darussalam 10-14 September 2001 Provisional agenda item 16
WPR/RC52/10 27 July 2001 ORIGINAL: ENGLISH
PREVENTION AND CONTROL OF TUBERCULOSIS
Tuberculosis is the leading infectious killer of adults and youths in the Western Pacific Region, despite the existence of a highly cost-effective control strategy known as directly observed treatment, short-course (DOTS). In response to the threat posed by tuberculosis, in September 1999 the fiftieth session of the Regional Committee for the Western Pacific declared a “Tuberculosis crisis” in the Region and asked the Regional Director to make Stop TB a special project of the Western Pacific Region.1 The first meeting of the tuberculosis Technical Advisory Group (TAG), held in early 2000, established a regional target of a 50% reduction in tuberculosis prevalence and mortality by 2010. At its fifty-first session, the Regional Committee endorsed the Regional Strategic Plan to Stop TB in the Western Pacific as the framework for the Stop TB Special Project. 2 The second meeting of the TAG was held in June 2001, and reviewed five-year national Stop TB action plans, which include financial requirements, and national interagency coordinating committees (ICCs). This document describes the past year's developments, particularly the acceleration of DOTS expansion at the country level, for the information of the Regional Committee and for discussion at its fifty-second session. It identifies the issues that must be addressed to achieve the regional goal of halving tuberculosis prevalence and mortality by 2010. These include partnership development, securing regular drug supplies, strengthening human resource capacity for national Stop TB programmes, multidrug resistance, HIV/tuberculosis co-infection and poor quality surveillance.
1 2
Resolution WPR/RC50.R5. Resolution WPR/RC51.R4.
WPR/RC52/10 page 2
1. CURRENT SITUATION
1.1
Tuberculosis prevalence, DOTS implementation and economic impacts Fewer than half of the estimated 2 million cases of tuberculosis in the Region are reported
(823 421 cases were reported in 1999). For a more extensive discussion of the tuberculosis burden in the Region see The Work of WHO in the Western Pacific Region: 2000-2001 (pp 34-43). More than half of the Region's population has access to directly observed treatment, shortcourse (DOTS). However, there are significant constraints to further expansion of DOTS. These include financial shortfalls, technical limitations, and a shortage of skilled human resources. As tuberculosis affects the most economically productive age groups, the worsening burden of tuberculosis has a profound impact on national economies and human development in the Western Pacific Region. 1.2 Summary of the past year Five-year national Stop TB action plans (2001-2005), with supporting financial tables, have been drawn up in collaboration with WHO for each of the seven countries with a high burden of tuberculosis.3 These national action plans are based on the Regional Strategic Plan to Stop TB and were supported at the second meeting of the tuberculosis Technical Advisory Group ( TAG) in June 2001. The second TAG meeting also focused on country level partnerships and on moving the Stop TB Special Project into the implementation phase, particularly in the seven countries with a high burden of tuberculosis. Interagency coordinating committees (ICCs) have been strengthened at regional and country levels to coordinate financial support for Stop TB. The regional ICC coordinates mobilization of resources for the national action plans. Progress has been encouraging and contributions from partner agencies for regional Stop TB activities in 2001 have doubled compared with 2000. At the country level, China provides a good example of improved coordination. The Department for International Development of the United Kingdom (DFID), the Japan International Cooperation Agency (JICA),
3
Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines, Viet Nam.
WPR/RC52/10 page 3
the World Bank (WB) and WHO are all working closely together to expand and sustain DOTS in China. The national ICC is an important part of that process. Given the critical importance of strong political commitment to achieving a reduction in the tuberculosis burden, the Regional Office invited medical parliamentarians from the Region to a meeting in Manila in April 2001, to discuss issues related to tuberculosis and health development. A major outcome of the meeting was a “Call for Action”, urging parliamentarians throughout the Region to act as a “Voice of the Poor” by supporting tuberculosis control. Since the establishment of the Stop TB Special Project in September 1999, WHO's human resources devoted to expanding DOTS at the country level have been strengthened at regional and country levels. In Viet Nam, international training courses were organized in collaboration with the International Union Against Tuberculosis and Lung Diseases (IUATLD). The courses included managerial skills for DOTS expansion at the country level. To mark World TB Day, more than 7000 copies of the regional Stop TB advocacy kit were produced and distributed to all countries and areas, the media, and partner organizations.
2. ISSUES
2.1
Accelerating DOTS expansion The foundations of Stop TB were laid during its first year and the special project has now
moved into the implementation phase. To meet the regional targets for 2005 of 100% DOTS coverage, 70% case detection (among infectious cases) and an 85% treatment success rate, Stop TB will work with countries to accelerate DOTS expansion by developing partnerships, securing regular drug supplies, and building capacity, particularly in the area of human resources. Effective national ICCs, working closely with the regional ICC, will be needed to make up the financial shortfall for regionwide DOTS expansion. However, few of the seven countries of the Region with a high burden of tuberculosis have developed a national ICC.
WPR/RC52/10 page 4
To ensure the sustainability of drug supplies, it is crucial that national tuberculosis programmes secure uninterrupted supplies through either national or bilateral sources. However, adequate financing mechanisms to ensure a regular supply of anti-tuberculosis drugs are not in place in most highly endemic countries in the Region. A secure supply of drugs for all infectious patients is needed. Effective DOTS expansion in each country also depends on the presence of adequate human resources. Establishment of a strong national Stop TB team at the central level is essential, yet some countries have not yet established such a capacity. 2.2 Challenges Pockets of drug resistance are beginning to spread in some countries and multidrug resistance is posing an increasing threat. Immediate action needs to be taken to stop drug-resistant tuberculosis by improving cure rates and expanding the DOTS strategy. Although regional HIV/tuberculosis co-infection rates are still low, some countries have reported an increase in co-infection. In Phnom Penh, Cambodia, 1999 survey data indicated that approximately 14% of tuberculosis patients were HIV-positive (a slight decrease from 1997). The incidence of HIV/tuberculosis co-infection is expected to rise in several countries over the next few years and coordination between HIV and tuberculosis control needs to be strengthened. The overall goal of Stop TB is to halve the prevalence and mortality of tuberculosis by 2010. However, national prevalence data are unavailable from some countries in the Region, making it difficult to monitor progress towards this goal. In addition, vital registration data are unavailable or unreliable in many countries and areas.
3. ACTIONS PROPOSED
The following actions by Member States are proposed for consideration by the Regional Committee. 1. Strengthen political commitment to accelerate DOTS expansion and to facilitate implementation of five-year national Stop TB action plans.
WPR/RC52/10 page 5
2.
In countries and areas that have not already done so, form national ICCs to improve links to sources of financial support and other resources and to strengthen partnerships for DOTS expansion.
3.
Involve Ministries of Finance in order to ensure adequate funding for the procurement of tuberculosis drugs.
4.
Strengthen human resources for tuberculosis control at the country level. Sufficient numbers of staff, especially at the central level, need to be assigned to the national tuberculosis programme (NTP) and training needs to be conducted at all levels.
5.
Strengthen drug resistance surveillance. The first step towards combating multidrug resistant tuberculosis should be proper implementation of DOTS, which will help to prevent the emergence of drug resistance.
6.
Implement the WHO/UNAIDS joint strategy on HIV/tuberculosis co-infection as appropriate for each country. The WHO/UNAIDS joint strategy provides a coordinated approach for HIV and tuberculosis control programmes and enables an integrated approach to be employed for control and surveillance of the two diseases.
7.
In order to monitor the epidemic and the effectiveness of national tuberculosis programmes, strengthen surveillance through prevalence surveys and improvements to the quality of vital registration data.