Seventh Stop TB Technical Advisory Group Meeting for the Western Pacific Region, Tagaytay City, Philippines, 26-28 July 2010 : report

WPR/2010/DCC/STB-E RS/2010/GE/39 (PHL) English only REPORT SEVENTH STOP TB TECHNICAL ADVISORY GROUP MEETING FOR THE WESTERN PACIFIC REGION Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Tagaytay City, Philippines 26–28 July 2010 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines September 2011 NOTE The views expressed in this report are those of the participants of the Seventh Technical Advisory Group Meeting and do not necessarily reflect the policies of the Organization. This report has been printed 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 Seventh Technical Advisory Group Meeting, which was held in Tagaytay City, Philippines from 26 to 28 July 2010. CONTENTS SUMMARY 1. INTRODUCTION ..................................................................................................1 1.1 Objectives .........................................................................................................2 1.2 Participants..................................................................................................................... 2 1.3 Agenda ........................................................................................................................... 3 2. PROCEEDINGS ....................................................................................................3 2.1 Introduction of the new Regional Strategy 2011-2015.............................................3 2.2 Objective 1: Presentation and discussion Promote universal and equitable access to quality TB diagnosis and treatment for all people......................................5 2.3 Objective 2: Strengthening TB laboratory capacity....................................................... 5 2.4 Objective 3: Scaling up the Programmatic Management of Drug-resistant TB ...........6 2.5 Objective 4: Expanding TB/HIV collaborative activities .........................................8 2.6 Objective 5: Strengthening TB programme management capacity supported by sustained political commitment and sufficient financing for TB control....................... 9 2.7 Cross-cutting issues .......................................................................................... 10 3. CONCLUSIONS AND RECOMMENDATIONS ...................................................13 3.1 Conclusions and recommendations by TAG members ................................................ 13 ANNEXES: Annex 1 - Timetable Annex 2 - List of participants Key words: Tuberculosis / Regional Strategy/ universal access / intensified case finding / MDR-TB / TB-HIV co-infection / infection control / laboratory / Programme Management / monitoring and evaluation / technical assistance / TB high-burden countries SUMMARY During the past 10 years, the Western Pacific Region has achieved and sustained the intermediate regional targets for tuberculosis (TB) control, namely, 70% case detection, 85% cure rate and 100% directly observed treatment, short-course (DOTS) coverage, with the Regional Strategic Plans to Stop TB in the Western Pacific 2000–2005 and 2006–2010. To meet the Millennium Development Goals and specific targets set by the Stop TB Partnership, a Regional Strategy to Stop TB in the Western Pacific 2011–2015 is being drafted. The Stop TB Technical Advisory Group (TAG) has provided invaluable assistance in guiding policy and strategy in the Region. The Seventh Technical Advisory Group Meeting was held to discuss and finalize the draft Regional Strategy to Stop TB in the Western Pacific 2011-2015. An Interagency Coordinating Committee (ICC) meeting was held during the TAG meeting to strengthen partnerships and increase commitments to meet the challenges of controlling TB in the Region. The objectives of the meeting were: (1) to assess TB burden in the Region and review the progress towards the 2010 Stop TB regional goals; (2) to make recommendations on how to promote early case detection, scale up the response to multidrug-resistant tuberculosis (MDR-TB) and TB-HIV co-infection, and strengthen laboratory capacity; (3) to produce the final draft of the Regional Strategic Plan to Stop TB in the Western Pacific, 2011–2015, for consideration by the Regional Committee in October 2010; and (4) to identify gaps in financial and technical support through the ICC and determine how to mobilize further commitments to address the gaps. The main conclusions of the meeting were as follows: (1) TAG strongly endorsed the Regional Strategy to Stop Tuberculosis in the Western Pacific Region (2011–2015), recognizing the importance of the five core objectives. Detailed recommendations on each objective can be found in Section 3. (2) TAG urged the WHO Regional Office for the Western Pacific to consider how best it can help them during the coming years and agreed to work with the Region to develop a comprehensive set of terms of reference, including rotation of members, which is strongly recommended. 1. INTRODUCTION Following the declaration of a "tuberculosis crisis" by the Regional Committee for the Western Pacific Region in 1999, the Stop TB Special Project was established in 2000. During the past 10 years, the Region has achieved and sustained the intermediate regional targets of 70% case detection, 85% cure rate, and 100% directly observed treatment, short-course (DOTS) coverage with the five-year Regional Strategic Plans to Stop TB in the Western Pacific 2000–2005 and 2006–2010. To meet the Millennium Development Goals set for 2015, and specific targets of reducing by half the prevalence and mortality set by the Stop TB Partnership, a new five-year Regional Strategy to Stop TB in the Western Pacific 2011–2015 is being drafted. While maintaining high quality DOTS, countries will need to strengthen early case detection and universal access to quality TB services. Challenges posed by multidrug-resistant and extensively drug-resistant tuberculosis (MDR/XDR-TB) were raised in the Beijing Call for Action during a ministerial meeting in April 2009, followed by World Health Assembly resolution 62.15 on the MDR-TB response in May 2009. Scaling up the response to TB-HIV co-infection has also become crucial for TB control in the Region. The Stop TB Technical Advisory Group (TAG), established in 2000, has provided invaluable assistance in guiding policy and strategy in the Region. To date, six TAG meetings have been convened with nine TAG members including international TB experts, representatives of donor countries, and representatives of countries in the Region with high TB burden. 1.1 Objectives (1) To assess TB burden in the Region and review the progress towards the 2010 Stop TB regional goals. (2) To make recommendations on how to promote early case detection, scale up the response to MDR-TB and TB-HIV co-infection, and strengthen laboratory capacity. (3) To produce the final draft of the Regional Strategy to Stop TB in the Western Pacific 2011–2015 for consideration by the Regional Committee in October 2010. (4) To identify gaps in financial and technical support through the Interagency Coordinating Committee and determine how to mobilize further commitments to address the gaps. 1.2 Participants Thirty-six participants attended the meeting, including seven TAG members and 18 participants from the seven high-burden TB countries and Malaysia. Several experts from partner organizations (e.g. supranational reference laboratories, the Research Institute of Tuberculosis, Japan), with whom the Regional Office works closely, were also present, as well as WHO country officers from the seven countries with a high TB burden. The full list of participants can be found in Annex 2. - 2 - 1.3 Agenda The meeting agenda discussed the five objectives of the Regional Strategy in turn (Objective 1: Promoting universal and equitable access to quality TB diagnosis and treatment for all people; Objective 2: Strengthening TB laboratory capacity; Objective 3: Scaling up the Programmatic Management of Drug-resistant TB (PMDT); Objective 4: Expanding TB/HIV collaborative activities; and Objective 5: Strengthening TB programme management capacity supported by sustained political commitment and sufficient financing for TB control). WHO Regional Office staff delivered presentations on the objectives, highlighting the background and approach for each topic, as well as suggested targets and indicators, followed by presentations from "discussants" and in-depth discussions by TAG members and other participants. The agenda can be found in Annex 1. 2. PROCEEDINGS 2.1 Presentation of the Regional Strategy to Stop TB 2011–2015 (Agenda item 4) According to the latest WHO estimates, the Western Pacific Region is likely to achieve its goal of halving prevalence and mortality by 2010 relative to 2000 levels.1 This result will be due to the rapid expansion of DOTS while maintaining a high cure rate, thus reducing the number of prevalent cases from 3.5 million in 2000 to 2 million in 2008. During the same period, 10 million patients were diagnosed and an estimated 800 000 deaths were averted. Despite the progress made, the global and regional situations remain dire. Globally, a total of 9.4 million people are still suffering annually from TB, resulting in 1.3 million deaths. In the Western Pacific Region alone, there are approximately 1.9 million incident TB cases and 260 000 TB deaths annually. Cambodia, China, the Philippines and Viet Nam, four countries among 22 global high-burden countries, account for 93% of the regional case load. TB tends to be concentrated in high-risk and vulnerable populations, especially in countries where the socioeconomic discrepancies are widening. The situation is exacerbated by TB-HIV co-infection and the emergence and silent spread of drug-resistant TB, particularly MDR-TB. The overlap of both epidemics in certain vulnerable populations poses an important public health threat. In order to mitigate these threats, the Region must overcome a number of operational challenges. First, the current level of case detection is insufficient to cut the chain of transmission. Second, there is insufficient laboratory capacity for early diagnosis of TB and for an effective response to MDR-TB and the TB-HIV co-infection. Third, the scale-up of the programmatic management of drug-resistant TB (PMDT) is hampered by shortages in the following: capacity to test for resistance; qualified human resources; effective links with private and hospital sectors; models of care that ensure adherence to long and complicated treatment regimens; quality-assured second-line drugs; and infection control. Fourth, progress has been slow in the implementation of TB-HIV collaborative activities. Lastly, current programme management capacity is often 1 It should be noted that the latest WHO estimates have large confidence intervals and should thus be interpreted with caution. The 2010 national prevalence survey in China, where approximately 70% of the regional TB burden is found, will provide important information to assess the real burden of disease. - 3 - insufficient for the acquisition and management of donor grants and the implementation and expansion of related, and often complicated, programme operations. The Regional Strategy to Stop Tuberculosis in the Western Pacific (2011–2015) builds upon the two previous regional strategic plans, but has been adapted to reflect these new and emerging challenges to TB control, as well as new evidence-based interventions and technologies. The purpose of the Strategy is to provide guidance to countries on the critical sets of interventions that are necessary to control TB in the Region with the following guiding principles: positioning the health systems strengthening agenda at the centre of the TB control strategy; considering the legal and ethical issues of TB care and promoting a human rights-based approach to TB policy developments; and valuing partnership, participation and social mobilization at all stages of TB programming. 2.2 Objective 1: Promoting universal and equitable access to quality TB diagnosis and treatment for all people (Agenda item 5) Dr Nobuyuki Nishikiori presented the first objective of the Regional Strategy with particular emphasis on the need for intensified case finding. New information on TB epidemiology in the Region revealed that significantly more TB cases are undetected, resulting in the ongoing spread of TB in communities even in those with an optimal DOTS programme setting. For example, prevalence survey data form Viet Nam and Cambodia suggested that a large fraction of TB cases are not fulfilling TB suspect criteria, defined as prolonged cough. Microscopy does not have sufficient diagnostic sensitivity—as high as 60% of active TB cases can be missed by microscopic diagnosis. The growing role of the private sector and the increasing diversity of patient health-seeking behaviour are other important challenges. In addition, as TB control progresses for segments of the general population, TB is concentrated increasingly in high-risk and vulnerable populations, including migrants, prisoners, the poor and the marginalized. Reaching out to the high-risk and vulnerable populations is, therefore, high on the agenda of TB control in the Region. There are a number of unexplored opportunities for increased case detection among groups of people at high risk of TB. For example, TB contact investigation could be more widely implemented. It is also known that diabetes is associated with both an increased risk of TB and poor treatment outcomes. Systematic TB screening among diabetic patients may contribute to early case detection and improve patient well-being. Other high-risk populations that deserve attention include health care workers, the elderly, migrants and people in congregated settings. The WHO Regional Office for the Western Pacific will increase its support in this area by developing a regional framework for TB high-risk and vulnerable populations. It also encourages the establishment and documentation of various innovative approaches for increasing case detection, including operational research projects. Discussant: Dr Donald Enarson, International Union Against Tuberculosis and Lung Disease Dr Donald Enarson highlighted the importance of focusing on all TB cases, especially those among high-risk groups. Intensified case finding should be enhanced, especially in children, and all cases should be reported by bacteriological category to facilitate analysis of data and trends in TB over time. Dr Enarson echoed Dr Nishikiori in saying that good quality, operational research is needed to diagnose and treat high-risk groups, which often have specific needs and require targeted TB control strategies. Furthermore, to ensure value for money, research is also important in terms of impact assessment and policy development. - 4 - Discussant: Dr Nguyen van Hung, Head of Department/Chief of National Reference Laboratory, National Lung Hospital, Viet Nam Dr Nguyen van Hung explained that increased case detection is of major importance for Viet Nam and that targeted active case finding has been implemented for people living with HIV/AIDS (PLWHA), prisoners and contacts. Viet Nam is taking part in the joint WHO/Canadian International Development Agency (CIDA) project to intensify early case detection of sputum smear-positive cases. The Chairperson of the meeting, Dr Jaap Broekmans, summarized the discussion on Objective 1. Overall, Objective 1 was strongly endorsed by the TAG members. Active case finding and contact tracing should be intensified and laboratories should be strengthened. The screening of health care workers was stressed by many participants as an important activity. Operational research should focus on how to effectively reach the various high-risk groups, as well as on issues such as patient/doctor delay in order to analyse how to improve health-seeking behaviour. Dr Broekmans concluded that, before using it as an indicator, the patient diagnostic rate (PDR) needs to be further assessed and clarified. It may prove useful as a tool for programme “self-assessment” and to further identify high-risk groups after using the onion model. Finally he pointed out that there was wide support for the WHO Regional Office to develop guidelines on intensified case finding, risk group management, risk factors and contact tracing as proposed by Dr Catharina van Weezenbeek. China mentioned that more attention should be given to vulnerable populations (e.g. migrants) and that TB/HIV testing will be implemented all over China. 2.3 Objective 2: Strengthening TB laboratory capacity (Agenda item 9) Globally, TB control is facing diagnostic gaps, although new technologies are currently emerging. In recent years, WHO has endorsed diagnostic policies for TB, including commercial liquid culture and drug susceptibility testing (DST) (2007), molecular line probe assay for MDR-TB detection (2008), and LED microscopes and non-commercial DST (2009). For the rapid detection of TB and rifampicin resistance, the automated nucleic acid amplification test (GeneXpert) is expected to be endorsed by WHO in 2010. These recent and new diagnostics aim to achieve early diagnosis and care for TB, smear-negative TB, and rapid MDR/XDR-TB detection. The rational diagnostic policy should be country-specific and based on TB burden and risk groups. For example, rapid molecular DST is needed in high MDR-TB settings, whereas culture and rapid DST is required in high HIV settings. Integrating and sharing new tools in tiered laboratory systems will increase cost-effectiveness. As the world gradually moves towards universal access for TB diagnosis and treatment, including HIV-associated TB and drug-resistant TB, laboratory scale-up becomes crucial. The scale-up so far has been limited due to weak health systems, inadequate human resources, insufficient programmatic and managerial capacity, inadequate infrastructure, and most prominently, lack of recognition of the importance of laboratory capacity in many countries. The Global Laboratory Initiative, established by WHO Headquarters, recommends a step-wise approach to tackle these challenges: (1) preparation of laboratories in terms of policies, infrastructure, biosafety and staff training; (2) introduction of new technologies (policy adjustment and procurement of instruments); and (3) impact assessment. Following the global direction of laboratory strengthening, the Regional Strategy will assist member countries in country-specific TB laboratory strengthening, including the introduction of new diagnostic technologies and capacity-building. - 5 - Discussant:Dr Yamuna Mundade, WHO Medical Officer, Papua New Guinea The new definition for a tuberculosis case requires culture testing or one of the new molecular techniques, which has increased the burden for TB diagnosis in many countries with limited resources. Laboratory capacity must urgently be scaled up using a step-wise approach. The core elements for a laboratory scale-up plan were presented as: policy framework for the implementation of new TB diagnostics, laboratory infrastructure, supply and equipment management, specimen transportation mechanism, data management system, a quality assurance system, and human resource development. First, it must be determined which TB cases should be subject to culture testing. The risk groups include Category 2 failures, all failures, all Category 2 cases, and all TB cases. Countries can begin their assessment of culture needs from notification and Drug Resistance Survey (DRS) data. Diagnostic strategies also need to be assessed—whether solid or liquid culture should be used, and whether other molecular methods such as line probe assays and Microscopic Observation Drug Susceptibility (MODS) can be used. To assess feasibility, the number of tests required needs to be estimated. Other influencing variables for culture testing decision-making include the quality of the culture laboratory and patients that require follow-up. Sputum processing should not be considered a rate-limiting factor. The monthly work capacity with culture and DST for a laboratory unit needs to be estimated. For a laboratory facility to conduct culture, DST and molecular tests, it requires a TB containment room that meets certain standards, such as double door airlock, separate air inlet, venting of biosafety via thimble, aerosol containment, negative pressure monitoring, unidirectional airflow, personal protective equipment, and autoclave for waste disposal. Depending on the testing requirement, diagnostic strategy and the selection of laboratory methods, the workload of the laboratory units and additional laboratory units outside the TB programme, may need to be considered when developing a budgeted workplan. Finally, to avoid the situation of diagnosed MDR-TB patients being left untreated due to the unavailability of second-line drugs, this laboratory scale-up plan needs to be carefully linked with the MDR-TB treatment plan, which is linked with the Green Light Committee (GLC) plan. Discussant: Dr Zhao YanLin, Director, National Tuberculosis Reference Laboratory, China CDC China's national TB laboratory network development plan was presented. Currently, culture and DST are available in the national laboratory and all of the 31 provincial laboratories. At the prefectural level, culture and DST are available in 37% and 24% of the 333 laboratories, respectively. At the county level, 13.5% of the 2860 laboratories have culture and 3.4% have DST capacity. The national laboratory plan 2011–2015 has been developed in line with the MDR-TB scale-up plan. Major challenges in laboratory capacity strengthening include inadequate human resources, biosafety concerns in most of the county laboratories, as well as funding gaps. Next steps for TB laboratory scale-up in China include strengthening managerial capacity for the laboratory network, strengthening research capacity at the national reference laboratory, implementing external quality assurance (EQA) for general hospitals, providing training courses, introducing new diagnostics, and improving monitoring and information systems. 2.4 Objective 3: Scaling up the Programmatic Management of Drug-resistant TB (PMDT) Dr Catharina van Weezenbeek presented Objective 3 of the Regional Strategy. It is estimated that 120 000 MDR-TB cases occur annually in the Region, of which 100 000 are in China, 11 000 in the Philippines and 5600 in Viet Nam. These estimates are sometimes misleading because a large proportion of the cases are not identifiable. A fraction of them are not identified as TB in the first place and there is practically no way to diagnose MDR-TB if - 6 - specimens are not cultured for smear-negative and extrapulmonary TB. Instead of using global MDR TB estimates, the WHO Regional Office suggests the use of MDR-TB targets that are based on actual TB notification data and MDR-TB prevalence data according to the drug- resistance surveys. Key challenges include insufficient human resources, the alignment of PMDT scale-up with laboratory expansion plans, designing appropriate care modalities, linking the National Tuberculosis Programme (NTP) with hospitals and private sectors and maintaining a balance between capacity to diagnose and capacity to treat. The following key components are suggested in the proposed Regional Strategy: (1) develop comprehensive national scale-up plans, including laboratory capacity and public-private and public-public mix (PPM) approaches; (2) rapidly increase the capacity to diagnose MDR/XDR-TB, including new diagnostic tools; (3) scale up capacity to provide adequate patient-centred treatment; (4) ensure availability of quality-assured second-line TB drugs; (5) address legal and ethical issues in managing TB patients; (6) build national capacity to train the required human resources; and (7) ensure appropriate infection control measures. To support the implementation of the Regional Strategy, the WHO Regional Office plans to conduct a regional assessment on the alignment of laboratory and PMDT expansion, as well as an infection control inventory assessment. The Strategy also discusses plans to establish a Regional Laboratory Initiative to build upon the Global Laboratory Initiative. The WHO Regional Office will strengthen its capacity to support countries through the decentralization of GLC and increased effectiveness and utilization of the TB TEAM mechanism. It also aims to support the establishment of national training centres to increase in-country human resource capacity. Discussant: Dr Paul Nunn, Stop TB Department, WHO Headquarters Dr Paul Nunn responded to the MDR-TB component of the Regional Strategy by addressing two points: (1) political commitment, and (2) the link with PPM for MDR-TB management. He started by reiterating a serious gap between the size of the MDR-TB epidemic globally and the limited action so far taken by the countries. Notwithstanding two important political milestones for MDR-TB response, i.e. Beijing Call for Action in April 2009 and World Health Assembly resolution WHA62.15 in May 2009, he questioned whether these two meeting documents failed to garner the political commitment for massive scale-up of MDR-TB. It may be too early to come to a conclusion, but the WHO Regional Office should consider how the Regional Strategy can help achieve further political commitment from the countries. The second point he emphasized was the necessity of involving the private sector in MDR-TB management. With growing economic development and diversified health-seeking patterns, the Western Pacific Region should explore the modality of private sector engagement in MDR-TB management. Discussant: Dr Rosalind Vianzon, NTP Manager, Department of Health, Philippines Dr Rosalind Vianzon presented the plan to scale up PMDT in the Philippines, with the target of 15 000 MDR-TB cases treated by 2016. The NTP aims to establish 25 culture centres, five DST sites and 35 treatment centres/satellites. The hierarchy of PMDT facilities has been laid out with a patient management arm (Lung Center of the Philippines at the top, down to treatment sites) and a laboratory arm (National TB Reference Laboratory at the top, followed by DST sites, culture sites and microscopy centres). A plan for technical assistance for PMDT expansion includes the development of a human resource development plan, e-TB Manager (electronic recording and reporting system), a drug management system and infection control training and - 7 - tools. She welcomed the MDR-TB component of the Regional Strategy from the country perspective and agreed on the proposed indicators and targets. 2.5 Objective 4: Expanding TB/HIV collaborative activities (Agenda item 13) According to a UNAIDS/WHO report published in 2008, the HIV epidemic (new infection trend) is stabilizing in the Western Pacific Region (2001 and 2008 estimates compared with the same methodology). However, the percentage of HIV-positive TB cases identified through HIV testing remains low globally (14% in 2005). The Region is not an exception. The 2008 surveillance data show that HIV testing was performed for only 11% of new TB cases in the Region. The prevalence of HIV among new TB cases the same year was 7%. Globally, TB screening remained low (4.0%) among PLWHA and isoniazid preventive therapy (IPT) provision remained low (0.2%) among people living with HIV. To respond to the TB-HIV co-infection in the Region, a framework to address TB-HIV co-infection in the Western Pacific Region was developed in 2004, based on the WHO 12-point TB/HIV policy package. Although progress was observed in some countries, TB/HIV collaborative activities recommended in the framework remained limited in many countries. To scale up the response, the Framework to Address TB-HIV Co-infection in the Western Pacific Region was revised in 2008. The revised Framework recommends HIV testing at TB clinics, and TB screening at HIV clinics to minimize patient loss and the possible transmission of TB infection during referral. One of the major constraints in scaling up TB diagnosis and IPT provision among HIV-positive persons was the technical difficulty in adequately diagnosing/ruling out TB. Based on a study carried out by CDC in South-East Asia and a WHO-CDC meta-analysis, the WHO guidelines for intensified TB case finding and IPT in people with HIV were revised. Four symptoms (i.e. current cough, fever, weight loss and night sweat) instead of chronic cough alone are now strongly recommended for the screening of active TB among people with HIV. Scale-up of liquid culture or other highly sensitive techniques is needed to diagnose TB among people with HIV. The meta-analysis of IPT studies revealed no significant increase in isoniazid (INH) resistance with IPT. IPT is highly effective, especially in longer courses and for use in patients with a positive tuberculin skin test. Discussant: Dr Kevin Cain, Chief, TB/HIV Team, International Research and Programmes Branch, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention Dr Kevin Cain summarized that TB/HIV activities are needed because there is a high risk of progression; TB incidence is very high in HIV-positive persons as is mortality. Therefore, all people with HIV should be screened for TB. The implementation of TB screening and IPT should be led by the HIV programme. For TB screening, a combination of symptoms should be used for TB screening, instead of chronic cough alone. Full collaboration is required from the TB programme and there is substantial room for improvement in terms of TB incidence (isoniazid preventive therapy, antiretroviral therapy [ART], infection control and early TB diagnosis and treatment) and mortality for TB/HIV (early diagnosis of patients with TB/HIV, early initiation of ART and Cotrimoxazole prophylaxis therapy CPT). He also stressed the need for regional targets for other TB/HIV indicators. Discussant: Dr Mao Tan Eang (Director National Center for TB and Leprosy Control (CENAT) Ministry of Health) Dr Mao Tan Eang stressed the need for strong TB/HIV collaborative activities and presented on the development of this area in Cambodia. Since 2006, HIV testing for all TB cases has been part of the standard operating procedures. In 2008, a clinical manual and training curriculum was developed. This year, standard operating procedures for the three I’s (isoniazid - 8 - preventive therapy, infection control, intensified case finding) were finalized and were promoted throughout the country. However, despite the many successes, only 15% of TB/HIV patients were treated with antiretrovirals in 2009 and IPT is not yet routinely provided. Dr Jaap Broekmans summarized the discussion by stressing that more ministerial support for stronger cooperation is required and that improved collaboration between the TB and HIV programmes is needed to further roll out TB screening for HIV-positive patients and for HIV screening of TB patients. Screening should include risk groups as well as health care workers, and the appropriate time frame for TB screening among HIV-positive patients should be considered. Dr Vicky Krause and Dr Shimouchi pointed out that the Region should aim for all TB patients being tested for HIV and vice versa. Dr Kevin Cain proposed to set different targets for areas with high and low HIV prevalence (<1% or >1% general population). The Philippines stressed that the bottleneck for increased activities in this area is the lack of human resources. In addition to training, technical assistance is needed to expand TB/HIV activities. While some countries in the Region reported weak testing and reporting (e.g. Papua New Guinea), others viewed screening for all TB and HIV patients as feasible (e.g. Malaysia). In China, an official Ministry of Health working document on TB/HIV control has been endorsed; all HIV and TB patients in high HIV-prevalence areas and all risk groups in low HIV-prevalence areas are to be tested. CPT and IPT have been implemented for the HIV programme but not yet for TB patients. Free testing for TB patients consists only of X-ray and smear but should also include free HIV testing. China will pursue the discussion on high- and low-prevalence HIV settings, which needs to be explored with the HIV programme. 2.6 Objective 5: Strengthening TB programme management capacity supported by sustained political commitment and sufficient financing for TB control (Agenda item 18) Ms Catherine Lijinsky presented the rationale and overview of Objective 5 of the Strategy. Objective 5 addresses the overall complexity of national TB programmes today and the necessary, yet often forgotten, cross-cutting areas in which countries need to build capacity— political commitment, human resource development, coordinated technical assistance, linking with health system strengthening and multisectoral collaboration. Key components of Objective 5 include: (1) sufficient financing for TB control ensured; (2) improved national programme management capacity; (3) integrated human resource development plans; (4) integrating disease control into primary health care networks; (5) political commitment for the effective use of regulatory approaches to support and consolidate TB control efforts; (6) TB infection control integrated into general infection control programme; and (7) evidence-based programme management and policy development through regular monitoring and evaluation activities and operational research. Finally, Ms Lijinsky touched on the issue of sustainability of TB control financing in light of increased funding flows from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Political commitment is needed to enhance national funding contributions to TB control programmes, particularly in light of the current financial crisis and the uncertainty surrounding donor commitments. - 9 - Discussant: Dr Phouvang Vangvichit, Deputy Director, National TB Centre, Ministry of Health, Lao People's Democratic Republic Dr Phouvang Vangvichit presented issues faced by the NTP with regards to programme management capacity, including challenges in financing, legislation, human resources, technical assistance and drug/supply management. Discussant: Dr B Buyankhishig, Health of TB Reference Laboratory, and S Ganzaya, TB Project Officer, Global Fund Project Coordination Unit, Ministry of Health, Mongolia Dr Buyankhishig presented on the progress and achievement of the NTP in Mongolia, highlighting the establishment of a national strategic plan 2010–2015 and revised national guidelines on TB services in 2009. Engagement of the private sector started in 2008 and TB control in prisons is also strong. Programme management challenges include the absence of a comprehensive human resource development plan, difficulty in motivating young health professionals to work in TB control, weak clinical and programmatic capacity to manage MDR-TB and TB-HIV co-infection, poor infection control practices and the need to further increase funding. Discussant: Dr Evelyn Lavu, Director, Central Public Health Laboratory, Port Moresby General Hospital, Papua New Guinea Dr Evelyn Lavu presented an overview of the TB programme in Papua New Guinea and explained programmatic challenges faced by the NTP. The challenges posed by geographical barriers to access and fragile infrastructure are the most serious bottlenecks, which increase the operational costs for travel, training and supervision. DOTS has not yet been expanded to cover the whole country. The sector-wide approach (SWAp) has been a bottleneck to smooth flows of funding for TB control. 2.7 Cross-cutting issues 2.7.1 Infection control Although the basis for TB infection control are proper diagnosis and treatment of infectious TB patients, inadequate TB control has resulted in multidrug-resistant TB globally. Outbreaks of MDR/XDR-TB have illustrated the devastating impact of TB transmission among patients and health care workers in certain settings. TB infection control in health care facilities and congregate settings therefore requires urgent attention to minimize TB transmission. Extensive efforts have been made in response to outbreaks of infectious diseases, such as severe acute respiratory syndrome (SARS), and influenza preparedness in the Western Pacific Region, but TB infection control has been largely ignored. The WHO policy guidelines on TB infection control, published in 2009, recommend four basic measures for TB infection control: (1) managerial, (2) administrative, (3) environmental, and (4) personal protective equipment. As a cross-cutting issue, TB infection control requires good coordination with other infection control efforts at country level. - 10 - 2.7.2 Surveillance Dr Daniel Sagebiel presented recent developments in surveillance and emphasized the comprehensive framework for assessment of TB surveillance data. Special focus should be put on data quality, trends as well as on capturing all cases. The ultimate goal is to rely not on estimates, but rather on notification and vital registration data. He pointed out the changes in the global TB report since the December 2009 update and announced that most countries are now entering their data online. In addition, the level of uncertainty in the estimates is being presented systematically and a special focus concerns the strengthening of surveillance systems in order to increase using data from surveillance and vital registration systems. This is of special relevance as the main TB indicators incidence, prevalence, mortality and thus also case detection rates (CDR) are mainly derived from estimates, which tend to have large margins of uncertainty. In order to improve the quality of data, WHO Headquarters changed the methods of estimation for the 2009 update, which has had implications for CDR target achievement for a number of countries. For the 2010 report, WHO Headquarters is discussing the option to move from sputum smear-positive CDR to all forms CDR The WHO publication on prevalence surveys is currently undergoing a revision and will be published towards the end of the year. He concluded with the recommendations from the recent impact measurement workshop held in Ho Chi Minh City, Viet Nam, where it was suggested that countries should consider the following: incorporate MDR-TB and TB/HIV routine data into surveillance systems; move towards integrated real-time electronic case-based recording and reporting surveillance systems where feasible; perform regular in-depth reviews of surveillance data at subnational levels to understand gaps in performance and needs for policy changes; and conduct operational research to identify and eliminate duplicate and misclassified records. There was much discussion surrounding the revised estimates of the CDR. The Philippines asked how the new estimates were better, considering that the CDR for smear-positive cases is not going to be reported in the new report. They raised the concern of consistency with the Millennium Development Goals, which implies looking into the CDR. Even though there is agreement with the technical considerations surrounding the decision, the Philippines wondered how this may affect the new national plan, which refers to the CDR for smear-positive cases, and the country budget if officials notice that the previously achieved targets have not been achieved with the revised estimates. Cambodia also suggested to reconsider the change to all forms of CDR and advised to continue using the CDR for smear-positive cases. Malaysia pointed out that, technically, the case notification rate is better than the CDR but suggested to keep old estimates, while informing stakeholders of introducing better ways of detecting cases in countries. Dr Jaap Broekmans agreed that, technically, the change in estimation methods is an improvement and that the CDR has been difficult in the past. However, he advised to be careful when shifting to new methods of estimation (e.g. PDR) and suggested the phasing in and out of methods as opposed to undergoing drastic changes. He also acknowledged that better communication and consultation from WHO Headquarters is needed and that this shift may be problematic for countries, programmes and budgets. Dr Paul Nunn underlined that the changes in indicators are the result of a huge amount of work and that the sputum smear-positive CDR has huge confidence intervals and is not very reliable. Even though the revised estimates are the result of a series of regular workshops, and technically there is agreement, the country concerns remain. He also stressed that more precise forms of measurement than estimates are needed. He acknowledged that countries are facing constraints and will report back to WHO Headquarters. - 11 - Countries facing constraints should communicate with staff in the WHO Regional Office and Headquarters in order to get as much support as necessary. Dr van Weezenbeek promised to follow up on this issue and that the WHO Regional Office will discuss further with WHO Headquarters and the countries. 2.7.3 Initiatives to promote operational research Dr Nobuyuki Nishikiori presented on the WHO Regional Office's initiative to promote TB operational research. Operational research that addresses programmatic gaps is a critical component of any public health programme. For modern TB control programmes, following the success of DOTS expansion and overall progress made in the last two decades, the importance and value of TB operational research is even higher now because innovative TB control approaches and pilots require good scientific documentation and evaluation. The WHO Regional Office is going to embark on a three-pronged approach for promoting TB operational research. The first prong is “capacity-building” through a research workshop. The first such activity is being planned in November 2010 and will focus on proposal-writing skills. The second prong is the “Western Pacific TB Operational Research Grant.” Countries and partners in the Region will be invited to submit proposals for grants up to US$ 20 000 (per proposal). The last prong is “TB research agenda-setting.” In coordination with the ongoing move of the Disease Reference Group at the global level, the WHO Regional Office is going to take the lead in regional TB research agenda-setting and in promoting national agenda-setting in each of the high burden countries. - 12 - 3. CONCLUSIONS AND RECOMMENDATIONS 3.1 General The Technical Advisory Group (TAG) strongly endorses the Regional Strategy to Stop Tuberculosis in the Western Pacific Region (2011–2015), recognizing the importance of the five core objectives. TAG appreciates that the Strategy addresses the diversity of countries within the Region. TAG recognizes the significant accomplishments in the Region and encourages the WHO Regional Office to include some of these achievements in its communications, including number of lives saved, as progress in the past 10 years has been substantial. Specifically, TAG: (1) notes with concern the stagnation of financial support for TB control from countries and of progress with regard to case finding, and emphasizes the need to increase political commitment for TB control, including control of MDR-TB; (2) recognizes that the insufficient laboratory capacity to meet the current needs of TB control is a crisis, and strongly endorses the prominence of laboratory strengthening in the strategy; (3) welcomes the recognition of the importance of achieving results in all countries, not just in the four TB high-burden countries in the Region, and proposes that the WHO Regional Office develop an approach for making substantial progress in the next five years in countries where the most progress is needed in achieving current and past goals; (4) recognizes that while countries agree with the scientific basis for changes in TB incidence estimation procedures, these changes can create problems with political commitment and undermine confidence in programme performance at higher levels, and therefore suggests that the Region hold a specific meeting to address these issues as soon as possible and that the Region and countries communicate concerns and issues to WHO Headquarters; and (5) emphasizes the crucial role of operational research in the Region across all five core objectives, welcomes the special initiatives outlined by the WHO Regional Office for promoting research, and encourages the WHO Regional Office and Headquarters to work to increase political commitment for research among countries and donors. 3.2 Objective 1: Promoting universal and equitable access to quality TB diagnosis and treatment for all people TAG endorses strategic directions articulated under the Objective 1. Specifically, TAG: (1) recognizes the value of the prevalence surveys conducted in the Region and the potential value of the patient diagnostic rate (PDR) but cautions about over-interpretation, particularly with respect to sub-group analyses; - 13 - (2) proposes that the highest priority groups for intensified case finding are people living with HIV and contacts of patients with TB, and that the priority of other groups should be further defined; (3) strongly endorses the scale-up of TB case finding and management in children; and (4) emphasizes the development of public-private mix (PPM) programmes of care. 3.3 Objective 2: Strengthening TB laboratory capacity TAG endorses the strategic directions articulated under Objective 2. Specifically, TAG: (1) welcomes new TB diagnostic technologies as a tremendous opportunity to improve TB control and strongly endorses the critical importance of national laboratory network plans, informed by local programme data, in all countries; (2) notes that exciting developments do not mean that we do away with existing technologies and laboratory capacity, but that plans must take into consideration integration of new technologies within existing laboratory services and plan for systematic transition; (3) notes the need to ensure that implementation of new WHO-endorsed technologies occurs in a manner that minimizes disruption to programmes, e.g. in a phased approach, and recommends that the WHO Regional Office should take a strong role in supporting programmes in implementation to address this; (4) notes the need for expanded support for supranational laboratories; (5) suggests that expansion of laboratory capacity includes all essential components of laboratory strengthening and access to those services including specimen transport networks; (6) recognizes the crucial role of human resources, including the importance of laboratory management staff with a public health perspective and the need for training of laboratory programme staff in management; (7) strongly supports the need for a comprehensive plan for the introduction of new diagnostic technologies that have multiple uses (e.g. using polymerase chain reaction for TB, malaria, and HIV) to maximize efficiency of laboratory services; (8) suggests establishing quantitative regional indicators to measure successful implementation; and (9) endorses the planned laboratory inventory and supports the establishment of a Regional Laboratory Initiative (as was proposed by the WHO Regional Office during the laboratory consultation meeting). 3.4 Objective 3: Scaling up programmatic management of drug-resistant TB (PMDT) TAG endorses the strategic directions articulated under Objective 3. Specifically, TAG: - 14 - (1) emphasizes that the scale-up of diagnostic and treatment services should be coordinated and that drug-susceptibility testing should always be matched with capacity to deliver adequate treatment with quality drugs to all identified patients with drug-resistant TB (as is stressed in the Regional Strategy); (2) notes that ALL countries should have a plan for PMDT scale-up and advises the WHO Regional Office to provide technical assistance to assist in making the scale-up as efficient as possible; (3) accepts the revised targets for PMDT scale-up, including DST for at least 60% of MDR-TB suspects among notified cases, and access to cost-free treatment for 100% of patients diagnosed with MDR-TB (*Note, with the expectation that >90% will be enrolled in treatment as some patients may not meet medical eligibility criteria) and stresses the importance of obtaining in-country buy-in for targets; (4) strongly supports regionalization of GLC functions to maximize efficiency as part of the MDR-TB/GLC architecture review process; (5) supports the use of notified cases (by treatment category), rather than estimates, for setting targets to guide PMDT scale-up; and (6) supports development of national leadership to determine the way forward for training and/or capacity-building. 3.5 Objective 4: Expanding TB-HIV collaborative activities TAG considered the strategic directions articulated under Objective 4. Specifically, TAG: (1) notes that the Region needs clear regional targets for HIV testing of TB patients, provision of ART and CPT to patients with TB-HIV co-infection, and intensified TB case finding in people living with HIV (indicators 4.2, 4.3, 4.4 and 4.5);
HIV testing of TB patients: TAG recommends that all patients with TB should be tested for HIV. Where this is not the policy, at a minimum, TAG strongly recommends that by 2015, all patients with TB are tested for HIV in settings where HIV prevalence of TB patients is known to exceed 1%, or, when not known, where the setting is otherwise known to have a high prevalence of HIV. When neither of these criteria apply, testing should at least be offered to patients with HIV risk factors in all areas, and surveillance for HIV in patients with TB should be implemented.
Provision of ART and CPT to patients with TB-HIV co-infection and intensified TB case finding in people with HIV are recognized standards of care that do not vary with respect to the HIV prevalence in the country or setting, and therefore are not country-specific.
TAG strongly recommends applying the international targets as regional targets for these three indicators.
TAG urges programmes to meet with their HIV counterparts to develop an implementation plan within the next 12 months. - 15 - (2) recognizes the value of IPT for TB prevention, and recommends that countries develop plans for IPT scale-up with technical assistance, as needed, from the WHO Regional Office; (3) notes the need for strong political commitment at higher levels (e.g. ministries) in supporting TB/HIV collaborative activities as a cross-cutting issue of crucial importance; and (4) recommends introduction of new diagnostic algorithms and the use of liquid culture or other highly sensitive diagnostic techniques to screen for and diagnose TB among people living with HIV. 3.6 Objective 5: Strengthening TB programme management capacity supported by sustained political commitment and sufficient financing for TB control TAG endorses the strategic directions articulated under Objective 5. Specifically, TAG: (1) suggests that programmes demonstrate in their plans the consequences of investment in TB control, including the high cost of insufficient action, and the benefit of substantial improvement in TB control and therefore reduction in funding required in the long term; (2) endorses the pro-active regional approach to support countries in strengthening regulatory aspects of TB control, including addressing counterfeit and sub-standard drugs, regulating who can prescribe and dispense TB drugs, and use of insurance schemes to cover TB diagnosis and treatment; (3) strongly supports the need for implementation of infection control and laboratory biosafety measures, starting with raising awareness among all staff and ensuring that managerial and administrative controls are in place in all settings, as well as implementing a minimal package of environmental controls and health protection (respirators) in high-risk settings such as laboratories and MDR-TB wards; (4) strongly supports the need to address TB among all staff of health care facilities and the need to identify a designated responsible party for infection control at all relevant levels of the programme; (5) urges countries to conduct regular in-depth analysis of surveillance data and proposes that an indicator be included regarding a formal assessment of TB data quality according to international standards; and (6) strongly encourages countries to develop plans for human resource development for TB control. 3.7 Future of TAG TAG urges the WHO Regional Office to consider how best it can help them during the coming years and agrees to work with the Region to develop a comprehensive set of terms of reference, including rotation of members, which is strongly recommended. - 16 - ANNEX 1 TIMETABLE SEVENTH STOP TB TECHNICAL ADVISORY GROUP MEETING FOR THE WESTERN PACIFIC REGION 26 - 28 July 2010, Tagaytay, Philippines Time Monday, 26 July Time Tuesday, 27 July Tim e Wednesday, 28 July 09:00 09:30 Registration (1) Opening ceremony - Welcome remarks: Dr Shin Young-soo Regional Director, WHO/WPRO - Self-introduction of participants - Administrative announcements 08:30 9:30 Objective 2: Laboratory Strengthening (9) New diagnostics and consequences for TB control (10) Discussion on Objective 2 of the Regional Strategy 08:30 09:30 Objective 5: Programme management (18) Challenges in programme management capacity (19) Discussion on Objective 5 of the Regional Strategy 10:00 PHOTO – COFFEE BREAK 10:30 COFFEE / TEA BREAK 10:30 COFFEE / TEA BREAK 10:30 10:45 11:15 (2) Introduction of TAG members, meeting objectives and agenda of the meeting (3) TB situation and the updated of the Global Plan to Stop TB (4) Presentation of the Regional Strategy to Stop TB (2011-2015) Discussion 11:00 12:00 Objective 3: MDR-TB scale-up (11) Ambitious, yet realistic scale-up plans (12) Discussion on Objective 3 of the Regional Strategy 11:00 11:40 12:20 Cross-cutting issues (20) Infection control Discussion (21) Surveillance: What's new? Discussion (22) Initiatives to promote operational research Discussion 12:15 LUNCH BREAK 13:00 LUNCH BREAK 13:00 LUNCH BREAK 13:30 14:30 Objective 1: Intensified case finding (5) Intensified case finding: Why and How? (6) Discussion on Objective 1 of the Regional Strategy 14:00 15:00 Objective 4: HIV/TB (13) Expanding HIV/TB services (14) Discussion on Objective 4 of the Regional Strategy 15:30 COFFEE / TEA BREAK 16:00 COFFEE / TEA BREAK 16:30 (15) Laboratory consultation meeting (SRL representatives, GLI, and WPRO) 16:00 16:30 18:30 (7) Secretariat meeting (8) Meeting of TAG Members Cocktails and dinner 17:30 (16) Meeting of TAG members (17) Secretariat meeting 14:00 14:30 16:00 (23) Secretariat meeting (24) Conclusions and recommendations Close - 17 - ANNEX 2 SEVENTH STOP TB TECHNICAL WPR/DCC/STB(4)/2010/IB/2 ADVISORY GROUP (TAG) MEETING 27 July 2010 FOR THE WESTERN PACIFIC REGION Tagaytay City, Philippines ENGLISH ONLY 26-28 July 2010 INFORMATION BULLETIN NO. 2 FINAL LIST OF PARTICIPANTS 1. TAG MEMBERS Dr Jaap Broekmans Former Executive Director KNCV Tuberculosis Foundation Koningin Emmakade 174 2518 JN The Hague The Netherlands Tel.: 31 (0)70 3352696 Fax: 31 (0)6 53906054 E-mail: broekmansj@tbconsult.nl - 18 - Dr Donald Enarson Scientific Advisor International Union Against Tuberculosis and Lung Disease (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 Kevin P. Cain CDR, U.S. Public Health Service Chief, TB/HIV Team, International Research and Programmes Branch Division of Tuberculosis Elimination National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention U.S. Centers for Disease Control and Prevention 1600 Clifton Rd., MS-E-10 Atlanta, Georgia 30333 United States of America Tel. No.: 1 (404) 639-2247 Fax No.: 1 (404)-639-1566 E-mail: kcain@cdc.gov; bvz1@cdc.gov Dr Sang Jae Kim Emeritus Director Korean Institute of Tuberculosis Korean National TB Association 101-703 Mabuk Ssaryong Apartment, Gihunggu, Yonginsi Kyeonggido 446-560 Republic of Korea Tel.: 82 31 287 4301 Fax: 82 31 304 4301 E-mail: ksj3519@gmail.com Dr Vicki Krause Director Centre for Disease Control Department of Health and Families Northern Territory Government Ground Floor, Building 4, Royal Darwin Hospital TIWI, NT 0810 PO 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 - 19 - Professor Eng Huot Secretary of State for Health Ministry of Health 151-153 Kampuchea Krom Ave. Phnom Penh Cambodia Tel.: (855) 23-427956 Fax: (855) 23 427956 Email: enghuot@online.com.kh Dr Nobukatsu Ishikawa Director The Research Institute of Tuberculosis 3-1-24 Matsuyama Kiyose Tokyo 204-8533 Japan Tel.: (81) 424 92 4767 Fax: (81) 424 92 4600 Email: ishikawa@jata.or.jp 2. COUNTRY PARTICIPANTS CAMBODIA Dr Mao Tan Eang Director National Center for TB and Leprosy Control (CENAT) Ministry of Health No. 1, Str. 278-95, Boeung Keng Kang 2 Khan Chamkar Morn Phnom Penh Tel: (855) 12 916 503 Fax: (855) 23 218090 E-mail: mao@online.com.kh Dr Pheng Sok Heng Chief of National TB Reference Laboratory National Center for TB and Leprosy Control (CENAT) Ministry of Health No. 1, Str. 278-95, Boeung Keng Kang 2 Khan Chamkar Morn Phnom Penh Tel.: (855) 15 655623 Fax: (855) 23 218090 Email: sokhengpheng@yahoo.com - 20 - CHINA, PEOPLE'S REPUBLIC OF Dr Shi Ying Medical Officer Bureau of Disease Control Ministry of Health 1 Xizhimenwai, South Road Beijing 100044 Tel.: (8610) 6879 2364 Fax: (8610) 6879 2554 E-mail: shiying@moh.gov.cn Dr Zhang Hui Assistant Director National Center for TB Prevention and Control China CDC 27 Nanwei Road, Xuanwu District Beijing 100050 Tel.: (8610) 8313 6116 Fax: (8610) 8313 7006 E-mail: zhanghui@chinatb.org Dr Zhao Yanlin Director National Tuberculosis Reference Laboratory China CDC, Ministry of Health No. 97 Machang, Tongzhou Distict Beijing 101149 Tel.: (8610) 89509359 Fax: (8610) 69559710 E-mail: zhaoyanlin@tb123.org Dr Huang Hairong Deputy Director National Tuberculosis Reference Laboratory China CDC, Ministry of Health No. 97 Machang, Tongzhou Distict Beijing 101149 Tel.: (8610) 89509359 Fax: (8610) 69559710 Email: hairong.huangcn@gmail.com LAO PEOPLE'S DEMOCRATIC REPUBLIC Dr Phouvang Vangvichit Deputy Director National Tuberculosis Centre Ministry of Health Vientiane Tel.: (856) 021 414259 Fax: (856) 452 855 E-mail: phouvang_v@hotmail.com - 21 - Mr Phasouk Senephasiri Head, National TB Reference Laboratory National Tuberculosis Center Ministry of Health Dongpalane thong Village, Sisattanak District Vientiane Tel.: (856) 021 414259 Fax: (856) 021 452 855 Email: phontong3@hotmail.com MALAYSIA Dr Jiloris F. Dony Sector Head TB/Leprosy Disease Control Division Ministry of Health Level 3, Block E10, Complex E Federal Government Administrative Centre 62590 Putrajaya Tel: (603) 8883 4527 Mobile: (6013) 8602897 Fax: (603) 8889 1013 Email: jiloris@moh.gov.my Dr Norazah Ahmad Head, Department of Bacteriology Institute for Medical Research Jalan Pahang 50588 Kuala Lumpur Tel: (603) 2616 2658 Fax: (603) 2691 9716 Email: norazah@iMrgov.my drnorazah@yahoo.co.uk MONGOLIA Ms Ganzaya Sukhbaatar TB Project Officer Global Fund-supported HIV/AIDS/Tuberculosis Project Ministry of Health San-Business Centre 3rd Floor Prime Minister Aman's Street-29 Sukbaatar District Ulaanbaatar Telefax.: (976) 99154536 E-mail: ganzaya@aids.mn - 22 - Dr Buyankishig Burneebaatar Head, National Reference Laboratory National Center for Communicable Diseases (NCCD) Nam-Yan-Su Street Ulaanbaatar 210648 Tel.: (976) 96662700 Fax: (976-11) 450492 E-mail: bbuyankhishig@yahoo.com PAPUA NEW GUINEA Dr Evelyn Lavu Director Central Public Health Laboratory Port Moresby General Hospital Private Mail Bag Boroko, N.C.D. Tel: (675) 324 8197 Fax: (675) 325 6342 Email: lavuek@gmail.com PHILIPPINES Dr Rosalind Vianzon Medical Specialist IV NTP Coordinator Infectious Diseases Office National Center for Disease Prevention and Control Department of Health Sta. Cruz, Manila Telefax: (632) 711 7808 E-mail: rgvianzon10@yahoo.com Dr Noel Macalalad Medical Specialist III Head, National TB Reference Laboratory Research Institute for Tropical Medicine Filinvest Corporate City Alabang, Muntinlupa City 1781 Tel.: 632 809 7599 / 807 2628 Fax: 632 842 2245 Email: nmacalalad5000@yahoo.co.uk Dr Sylvia Somontan City Health Officer Center for Health Development – Caraga Department of Health Corner Narra and Pizarro Streets Butuan City Philippines Tel.: 685 342 5208 - 23 - VIET NAM, SOCIALIST REPUBLIC OF Dr Vu Xuan Phu Vice Director National Lung Hospital Ministry of Health 463 Hoang Hoa Tham Ha Noi Tel.: 84-4-37615662 Fax: 84-4-37615662 E-mail: xuanphu.vu@gmail.com Dr Nguyen Van Hung Head of Department/Chief of National Reference Laboratory National Lung Hospital Ministry of Health 463 Hoang Hoa Tham Ha Noi Tel.: 84-4-37615662 Fax: 84-4-37615662 Email: hungmtb75@yahoo.co.uk 3. RESOURCE PERSONS Dr Kai Man Kam Consultant Medical Microbiologist Centre for Health Protection Department of Health Wu Chung House, 17th & 21st Floors 213 Queen's Road East, Wan Chai Hong Kong Tel.: (852) 2319 8303; 2776 1901 Fax: (852) 2776 1446 E-mail: kmkam@dh.gov.hk Dr Akira Shimouchi Vice-Director The Research Institute of Tuberculosis/ Japan Anti-Tberculosis Association 3-1-24 Matsuyama Kiyose Tokyo 204-8533 Japan Tel.: (81) 424 92 4767 Fax: (81) 424 92 4600 Email: shimouchi@jata.or.jp - 24 - For the Laboratory Consultation Meeting (28 July): Dr Christopher Coulter Director Queensland Mycobacterium Reference Laboratory Pathology Queensland Central Laboratory Floor 5, Block 7 Royal Brisbane and Women's Hospital Herston Road, Herston Queensland 4029 Australia Tel: 61 7 3139 4344 Fax: 61 7 3139 4553 Email: Chris_Coulter@health.qld.gov.au Dr Chang-ki Kim Director Laboratory Medicine Department KIT 14 WooMeyeonDong Seochogu Seoul 137-140 Republic of Korea Tel.: (822) 577-5766 Fax: (822) 575-3595 E-mail: psoas95@gmail.com 4. REPRESENTATIVES OF PARTNER AGENCIES AND OBSERVERS DAMIEN FOUNDATION BELGIUM (DFB) Dr Liu Zhentian Medical Advisor for China DFB – China Room 0601, Guangming Hotel Liangmaqiao Road Beijing 100125 China Tel.: 8610 6467 8020 Fax: 8610 8451 2250 E-mail: liu.zhentian@damien-bel.org.cn DEPARTMENT OF HEALTH, PHILIPPINES Dr Jaime Lagahid Director III National Center for Disease Prevention and Control Department of Health Sta. Cruz Manila Telefax: (632) 711 7808 Email: drlagahid@yahoo.com - 25 - JAPAN INTERNATIONAL COOPERATION AGENCY (JICA) Dr Kosuke Okada Chief Advisor CENAT/JICA National TB Project for the Second National Prevalence Survey c/o CENAT (3rd Floor) St. 278/95, Sangkat Keng Kang II Phnom Penh, Cambodia Tel.: (855) 23-218091 Fax: (855) 23 218090 Email: okadak@jata.or.jp KOREAN INSTITUTE OF TUBERCULOSIS (KIT) Dr Hee Jin Kim Director KIT 14 WooMeyeonDong Seochogu Seoul 137-140 Republic of Korea Tel.: (822) 576 4984 Mobile: (010) 8150 9439 E-mail: hatchingbird@yahoo.co.kr PROGRAM FOR APPROPRIATE TECHNOLOGY IN HEALTH (PATH) Dr Jiankang (Jack) Zhang PATH China Representative Suite 2113 Ruoy Chai International Bldg. No. 8, Yong An Dong Li Jian Guo Men Wai Chaoyang District Beijing 100022 China Tel.: (86-10) 8528-8211 ext 201 Fax: (86-10) 8528 8210 Email: jzhang@path.org UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT (USAID) Ms Amy Piatek Senior TB Technical Advisor Global Health Bureau USAID/Washington 1300 Pennsylvania Ave. NW Washington D.C. Untied States of America Tel.: 1-202 712 1683 / 1-646-460-5256 Email: apiatek@usaid.gov - 26 - Ms Carrie Ramussen Health Officer USAID/Philippines Manila Tel.: (632) 552-9865 Email: crasmussen@usaid.gov 5. SECRETARIAT WHO WESTERN PACIFIC REGIONAL OFFICE (WHO/WPRO) Dr Shin Young-soo Regional Director WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9903 Fax: (632) 521 1036 E-mail: shiny@wpro.who.int Dr John Ehrenberg Director Division, Combating Communicable Diseases WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9701 Fax: (632) 521 1036 E-mail: ehrenbergj@wpro.who.int Dr Catharina van Weezenbeek (Responsible Officer) Team Leader Stop TB and Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9706 Fax: (632) 521 1036 E-mail: vanweezenbeekc@wpro.who.int - 27 - Dr Katsunori Osuga Medical Officer Stop TB & Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9709 Fax: (632) 521 1036 E-mail: osugak@wpro.who.int Dr Daniel Sagebiel Medical Officer Stop TB & Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9720 Fax: (632) 521 1036 E-mail: sagebield@wpro.who.int Dr Nobuyuki Nishikiori Medical Officer Stop TB & Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9726 Fax: (632) 521 1036 E-mail: nishikiorin@wpro.who.int Ms Catherine Lijinsky Technical Officer Stop TB & Leprosy Elimination WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9726 Fax: (632) 521 1036 E-mail: lijinskyc@wpro.who.int - 28 - Mr Bernard Tomas Technical Officer Global Health Partnerships Country Support Unit WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel.: (632) 528 9727 Fax: (632) 521 1036 E-mail: tomasb@wpro.who.int WHO/WPRO COUNTRY OFFICES Dr Fabio Scano Medical Officer, Stop TB & Leprosy Elimination Office of the WHO Representative in China 401, Dongwai Diplomatic Office Building 23, Dongzhimenwai Dajie Chaoyang District Beijing 100600 China Tel.: (8610) 6532 1288 Fax: (8610) 6532 2359 Email: scanof@chn.wpro.who.int Dr Wang Xuejing National Professional Officer Stop TB and Leprosy Elimination Office of the WHO Representative in China 401, Dongwai Diplomatic Office Building 23, Dongzhimenwai Dajie Chaoyang District Beijing 100600 China Tel..: (8610) 6532 7189 Fax.: (8610) 6532 2359 E-mail: wangxu@chn.wpro.who.int Dr Rajendra Yadav Medical Officer Stop TB & Leprosy Elimination Office of the WHO Representative in Cambodia No. 177-179 corner Pasteur (51) and 254 Phnom Penh Cambodia Tel.: (855) 23 216610 Fax: (855) 23 216211 E-mail: yadavr@wpro.who.int - 29 - Dr Yamuna Mundade Medical Officer, Stop TB & Leprosy Elimination Office of the WHO Representative in Papua New Guinea 4th Floor, AOPI Centre Waigani Drive Port Moresby Papua New Guinea Tel. No.: (975) 325 7827 Fax No.: (975) 325 0568 E-mail: mundadey@wpro.who.int Dr Woo-jin Lew 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: leww@phl.wpro.who.int Dr Mariquita Mantala National Professional Officer, Tuberculosis Office of the WHO Representative in the Philippines P.O. Box 2932 Manila Philippines Tel. No.: (632) 5289767 Fax No.: (632) 7313914 E-mail: mantalam@phl.wpro.who.int Dr Nguyen Nhat Linh Medical Officer, Stop TB & Leprosy Elimination Office of the WHO Representative in the South Pacific Level 4 Provident Plaza One Downtown Boulevard 33 Ellery Street Suva, Fiji Tel.: (679) 3-304600; 304631 Fax: (679) 330 0462; 331-1530 Email: nguyenli@wpro.who.int - 30 - Dr Giampaolo Mezzabotta Medical Officer Tuberculosis and Health Systems Office of the WHO Representative in Solomon Islands Ministry of Health Building, Chinatown Honiara Solomon Islands Tel: (844) 3943 3734 Fax: (844) 3943 3740 Email: mezzabottag@wpro.who.int Dr Cornelia Hennig Medical Officer, Stop TB & Leprosy Elimination Office of the WHO Representative in Viet Nam 63 Tran Hung Dao Street Hoan Kiem District Ha Noi Socialist Republic of Viet Nam Tel.: (844) 943 3734 Fax: (844) 943 3740 Email: hennigc@wpro.who.int Dr Pham Huyen Khanh National Professional Officer Stop TB & Leprosy Elimination Office of the WHO Representative in Viet Nam 63 Tran Hung Dao Street Hoan Kiem District Ha Noi Socialist Republic of Viet Nam Tel.: (844) 943 3734 Fax: (844) 943 3740 Email: phamh@vtn.wpro.who.int Dr Jacques Sebert WHO Consultant, Tuberculosis Office of the WHO Representative in Laos Ban Saphanthong, Sisattanak District Vientiane Lao People's Democratic Republic Tel.: (856) 21 413 431 Fax: (856) 21 413 432 E-mail: sebertj@wpro.who.int - 31 - WHO HEADQUARTERS Dr Paul Nunn Coordinator MDR-TB/GLC Operations (MDR) Stop TB Department World Health Organization Avenue Appia 20 CH – 1211 Geneva 27 Switzerland Tel.: 4122 791 2963 Fax: 4122 791 4199 E-mail: nunnp@who.int Dr Malgosia Grzemska Coordinator Technical Support Coordination (TSC) Stop TB Department World Health Organization Avenue Appia 20 CH – 1211 Geneva 27 Switzerland Tel.: 4122 791 3989 Fax: 4122 791 4199 E-mail: grzemskam@who.int Dr Karin Weyer Coordinator TB Diagnostic and Laboratory Strengthening (TBL) Stop TB Department World Health Organization Avenue Appia 20 CH – 1211 Geneva 27 Switzerland Tel.: 4122 791 1272 Fax: 4122 791 4268 E-mail: weyerk@who.int