WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Fiftieth session Macao 13–17 September 1999 Provisional agenda item 12
WPR/RC50/8 Rev.1 23 August 1999 ORIGINAL: ENGLISH
TUBERCULOSIS PREVENTION AND CONTROL Following a resurgence of tuberculosis in many parts of the world, the World Health Organization declared tuberculosis to be a global emergency on 23 April 1993. In view of the continuing threat posed by tuberculosis, in 1998 the Fifty-first World Health Assembly urged Member States to give high priority to intensifying tuberculosis control as an integral part of primary health care. This report is a response to concerns about rising levels of tuberculosis in the Western Pacific Region expressed at the forty-ninth session of the Regional Committee in September 1998. The regional notification rate of new infectious cases per 100 000 population increased steadily from 18 in 1994 to 23 in 1998. However, it is estimated that there were 1.96 million new cases of tuberculosis in the Region in 1998 and only 43% of these estimated cases were notified. Since directly-observed treatment, short course (DOTS) was introduced in the Region in early 1990s, it has been implemented in most countries where tuberculosis is a serious public health problem. However, the percentage of notified cases treated with DOTS was only 46% in 1998. Tuberculosis control using the DOTS strategy is one of the most cost-effective health interventions and contributes substantially to socioeconomic development by reducing the burden of disease and death in the most productive age group. All countries and areas are urged to give the highest priority to tuberculosis control using the DOTS strategy within the framework of health sector development and to mobilize and sustain political commitment and financial support for tuberculosis control.
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1. INTRODUCTION
Tuberculosis is the leading infectious killer of youth and adults in the world. Approximately 29% of global tuberculosis cases are in the Western Pacific Region. Of these, almost 70% are in the 15–54 age group, the most productive segment of the population. Following a resurgence of tuberculosis in many parts of the world, the World Health Organization declared tuberculosis to be a global emergency on 23 April 1993, and in 1998 the Fiftyfirst World Health Assembly urged Member States to give high priority to intensifying tuberculosis control as an integral part of primary health care and to ensure the effective introduction of the directly-observed treatment, short course (DOTS) strategy before the year 2000, if it has not yet been implemented (Annex 1). Concerns about levels of tuberculosis in the Region were also expressed at the forty-ninth session of the Regional Committee in September 1998.
2. EPIDEMIOLOGICAL SITUATION
In 1997, 834 722 cases of tuberculosis were notified in the Region, of which 375 787 were infectious (smear- or culture-positive) cases. The regional notification rate of new infectious cases per 100 000 population increased steadily from 18 in 1994 to 23 in 1998, largely because of increased detection in China (Figure 1). However, it is estimated that there were 1.96 million new cases of tuberculosis in the Region in 1998 and only 43% of these estimated cases were notified. The case detection ratio varies, from more than 80% in the Philippines and Viet Nam to around 30% in China and Papua New Guinea (Figure 2). The number and rate of notified cases, estimated number of cases and case detection ratio by country are shown in Annex 2. It is estimated that about 355 000 people in the Region died from tuberculosis in 1998, including 258 000 in China, 48 000 in the Philippines, 20 000 in Viet Nam and 9000 in Cambodia. In the Philippines, which contains a quarter of the Region’ s tuberculosis cases, a national prevalence survey conducted in 1997 revealed that the percentage of the population infected with tuberculosis bacilli had increased from 55% in 1983 to 63% in 1997.
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However, tuberculosis is a public health concern not only in developing countries but also in newly industrializing and developed countries. In Australia; Hong Kong, China; Malaysia; and
Singapore, the number of newly notified cases has not decreased for several years. This is partly due to increased or continued detection of new patients among immigrant communities. In Japan, the number of tuberculosis cases increased in 1997 for the first time in 38 years, due to an increase in the elderly population (among whom the incidence of tuberculosis is higher than among the general population because of decreased immunity), and transmission of the disease from elderly tuberculosis patients to adolescents and young adults in some areas of the country. In response, Japan declared a “tuberculosis emergency” in July 1999. HIV/tuberculosis co-infection is still low in the Region as a whole. However, in Phnom Penh, Cambodia, the percentage of pulmonary tuberculosis patients with HIV-related tuberculosis almost doubled from 8% in 1994 to 15% in 1997. This percentage is expected to rise in the next few years. In Malaysia, HIV-related tuberculosis cases increased by more than eight times between 1991 (31 cases) and 1996 (262 cases). In Johor state, 12% of tuberculosis cases are due to HIV infection. Figure 1. Notification rate of tuberculosis in the Western Pacific Region and in China (1993–1997) 30
No. of cases per 100 000 population
20
New smear-positive (Western Pacific Region)
10
New smear-positive (China)
0 1993 1994 1995 1996 1997
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Figure 2. Case detection ratio by countries in the Western Pacific Region in 1997 (WHO global target: 70%)
90 80 70 60 50 40 30 20 10 0 Cambodia China Lao People's Democratic Republic Mongolia Philippines Papua New Guinea Viet Nam Western Pacific Region
3. REGIONAL STRATEGY FOR TUBERCULOSIS CONTROL
3.1
Objectives The objectives of the tuberculosis control programme are to reduce the transmission of
infection, and decrease tuberculosis morbidity and mortality through appropriate control measures using the DOTS strategy.
3.2
Effectiveness of DOTS In response to the global tuberculosis emergency, WHO has adopted an effective tuberculosis
control strategy known as DOTS. 1 DOTS is the most effective way of controlling tuberculosis. The tuberculosis case fatality rate in China decreased from 30% in 1991 to 7% in 1994 in areas implementing DOTS. Over the same period, DOTS was responsible for reducing the number of deaths
1
DOTS is composed of five key elements. (1) Government commitment to a National Tuberculosis Programme as a public health priority. (2) Detection of infectious cases by sputum smear microscopy examination in general health services. (3) Standardized short-course anti-tuberculosis treatment to, at least, all smear-positive tuberculosis cases, with direct observation of treatment. (4) Regular, uninterrupted supply of anti-tuberculosis drugs. (5) A monitoring system for programme supervision and evaluation of treatment outcome.
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from tuberculosis in these areas from 72 000 to 17 000 per year. In the Republic of Korea, a strategy utilizing four out of the five components of DOTS has been implemented since the early 1980s. As a result, the prevalence of infectious tuberculosis cases decreased from 420 cases per 100 000 population in 1985 to 160 per 100 000 in 1995. DOTS cures nine out of ten tuberculosis patients. No other tuberculosis control strategy has consistently demonstrated such a high cure rate. DOTS stops transmission of tuberculosis by curing the source of infection. It also prevents the emergence of drug resistance by ensuring patients take their medication regularly. DOTS also extends the lives of AIDS patients who suffer from tuberculosis.
3.3
Cost-effectiveness of DOTS Tuberculosis control is one of the most cost-effective health interventions. According to the
1993 World Development Report, tuberculosis control is the third most cost-effective intervention in low-income countries and the least expensive intervention in terms of cost per DALY2 in middle-income countries. The same report also estimated that tuberculosis control is 200 times more cost-effective than dengue control or treatment of leukaemia.3 A document on the tuberculosis burden and the socioeconomic impact of DOTS in the Region is being prepared by the Regional Office.
2
3
Disability-adjusted life years (DALYs), are a measure of years of life lost owing to premature mortality and years of life lived with disability. For each healthy year of life saved/DALY, tuberculosis control costs only US$ 5, compared with more than US$ 1000 for environmental control of dengue or treatment of leukaemia. A cost-effectiveness study in Indonesia indicated that every dollar invested in implementing DOTS will lead to an average return to society of US$ 55 (The economic impact of tuberculosis in Indonesia. New Delhi, WHO, 1994).
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3.4
Programme indicators and targets The indicators and targets of the tuberculosis control programme are contained in Table 1. Table 1. Indicators and targets of the tuberculosis control programme Programme indicators Definition of indicators Target (to be achieved by 2005) 70% 85% 100% 100% 100% a
Case detection ratio Cure rate DOTS implementation a) Access to DOTS b) Patients under DOTS c) Health facilities implementing DOTS
Percentage of new tuberculosis cases that are notified Percentage of newly registered cases that are cured a) Percentage of population with access to DOTS b) Percentage of notified cases treated with DOTS c) Percentage of health facilities treating tuberculosis that are implementing DOTS
a
Patients are considered to be cured if they have completed the course of treatment and two of their smear tests, including the final test, have proved negative.
3.5
Health system development and tuberculosis control The relationship between poverty and ill-health is clearly illustrated by the high prevalence of
tuberculosis among low-income populations. In the prevalence survey conducted in the Philippines referred to above for example, it was demonstrated that in low-income urban populations the tuberculosis prevalence rate was double that of the general urban population. This is partly because tuberculosis is a communicable disease transmitted easily in large crowded households, with poor ventilation. It is also because poor people generally delay seeking care for what may first be perceived as a minor illness. By the time the diagnosis of tuberculosis is made among such patients, the disease may have progressed significantly and several other family members may be infected. In poor
populations, we therefore see higher prevalence rates, higher case fatality rates and more rapid spread of the disease. Health systems must take this relationship between tuberculosis and poverty into account when carrying out tuberculosis control activities. Good tuberculosis control is not just about technical excellence, it is also about developing a system that works within the prevailing political and institutional situation. A network of laboratories with an efficient quality assurance system, an uninterrupted supply of anti-tuberculosis drugs, involvement of heath workers and the community in directly-observed treatment, a built-in information system for surveillance, management and evaluation of treatment results, and staff trained and
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supervised within the general health services are all essential parts of the DOTS strategy. In other words, DOTS is heavily dependent on the functioning of the health care system and the population’ s access to it. A good tuberculosis control programme can both contribute to and benefit from
improvements to the health system. Tuberculosis services applying the DOTS strategy are a particularly good way of measuring the impact of the health sector reform process, as these services have demonstrated that they deliver one of the most cost-effective health interventions in low-income countries. The long-term care required for the successful case management of tuberculosis cases is a sensitive indicator of the ability of the health services to deliver adequate services.
4. MAIN ACTIVITIES AND ACHIEVEMENTS
4.1
DOTS implementation in the Region Since the DOTS strategy was introduced into the Region in the early 1990s, most of the
countries in the Region where tuberculosis is a significant public health burden now implement the strategy and have adapted it to their own particular situations. In areas covered by DOTS, 88% of patients starting treatment are cured, compared with only 51% in areas where DOTS is not available (Figure 3). The percentage of the Region’ s population with access to DOTS increased from 44% in 1996 to 57% in 1998. The percentage of tuberculosis patients who are enrolled in DOTS programmes increased from 30% to 46% over the same period (Figure 4). This is mainly due to the successful introduction and expansion of the DOTS programme in countries such as Cambodia, China, the Philippines and Viet Nam (Figure 5). However, as it is estimated that only 43% of cases are notified, this means that only 20% of the total estimated number of infectious patients are given DOTS.
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Figure 3. Percentage of patients and cure rate in DOTS and non-DOTS areas in the Western Pacific Region (1998) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cure rate Proportion of patients
88 DOTS area non-DOTS area
51
54 46
Figure 4. Regional DOTS implementation from 1996 to 1998 and projected implementation from 2001 to 2005 120%
100%
80%
Percentage of tuberculosis patients who are treated with DOTS
60% Percentage of population with access to DOTS
40%
20%
0% 1996 1997 1998 2001 2005
In the Philippines, a new initiative using DOTS began in three of the country’ s 78 provinces in 1996 in collaboration with WHO. As a result, the cure rate in these provinces increased from 55% to about 80%. One of the key elements of the initiative is the involvement of community voluntary health workers as treatment partners. As of May 1999, DOTS is being implemented in 25 provinces and 28 of the 70 cities in the Philippines. The initiative is supported by various partners, including WHO, the World Bank and the Japanese International Cooperation agency (JICA). The success of the future expansion of DOTS nationwide by 2001 depends on the political commitment to ensure an uninterrupted drug supply and to provide qualified human resources.
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DOTS was successfully introduced in China in the early 1990s and 798 million people now have access to DOTS. Close collaboration between the Government, the World Bank and WHO has been an important element of the successful implementation of the strategy. To sustain momentum and to implement DOTS all over China in the next five years, there is a need to mobilize more resources, in particular for anti-tuberculosis drugs. Since DOTS was introduced in 1994 in Cambodia, DOTS coverage has expanded gradually. Since early 1998, all health facilities at district level have been implementing the strategy. Case detection increased to around 10% in 1997 and domiciliary DOTS was successfully implemented in Phnom Penh in 1998. The cure rate in areas of Cambodia implementing DOTS is about 90%. Tuberculosis control activities have been in place in Viet Nam since 1985. During the last 10 years, there has been a gradual implementation of DOTS in collaboration with WHO and the Royal Netherlands Tuberculosis Association (KNCV). The strong government commitment to tuberculosis control, the extensive infrastructure for general health care and the high quality of the staff assigned to the programme have meant that, by the end of 1998, DOTS was accessible to more than 90% of the population. In 1998, close collaboration began between WHO and the Secretariat of the Pacific Community (SPC) to implement or expand the DOTS strategy in four Pacific island countries. This programme is funded by the New Zealand Options for Development Assistance. To facilitate the implementation of DOTS in Pacific island countries, WHO published Guidelines for the control of tuberculosis through DOTS strategy in Pacific island countries in May 1999.
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Figure 5. Implementation of DOTS in selected countries of the Region (1996–1998)
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cambodia China Lao People's Democratic Republic Mongolia Philippines Solomon Islands Viet Nam Western Pacific Region
1996 1998
4.2
Drug resistance surveillance In 1995, the Regional Office, WHO Headquarters, the International Union Against
Tuberculosis and Lung Disease (IUATLD) and three WHO collaborating centres in the Region began a drug resistance surveillance project. By 1998, surveys had been completed in six countries and in Henan Province, China and Hong Kong, China. Henan Province in China (which was not
implementing DOTS) showed a high level of primary multidrug resistance (11%) because of the large number of elderly tuberculosis patients who had not been treated properly. Drug resistance surveillance in China has since been strengthened by conducting surveys in five more provinces.
4.3
Human resources development To disseminate the DOTS strategy more widely and to strengthen the capacity of national staff,
in 1997 and 1998 the Regional Office organized training courses on tuberculosis management, a laboratory quality control workshop and a meeting for national tuberculosis programme managers.
4.4
Stop TB Initiative The Stop TB Initiative was officially launched in November 1998 as a special project of the
Communicable Diseases cluster in WHO Headquarters. The objective of the initiative is to push tuberculosis further up the political agenda in countries where tuberculosis is a significant public health
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problem and to mobilize international support for the expansion of the DOTS strategy, for surveillance and for research.
5. CONSTRAINTS
Constraints facing the fight against tuberculosis in the Region include the following: − − − DOTS is still not accessible to more than half of the people in the Region. In most countries there is no sustainable mechanism to ensure an uninterrupted drug supply. Political commitment has not yet been translated into increased resources for tuberculosis control. − − There is a lack of qualified human resources to operate the DOTS programme successfully. The number of HIV-related cases is increasing in Cambodia and, to a lesser extent, in Malaysia and Viet Nam. − The emergence of drug resistance is a significant threat.
6. CONCLUSION
Although tuberculosis was declared a global emergency by WHO in 1993, only limited progress has been made in controlling tuberculosis in the Region. As of 30 June 1999, only 18 countries and areas in the Region were implementing the DOTS strategy. Although the percentage of tuberculosis patients treated by DOTS increased from 30% of notified cases in 1996 to 46% in 1998, this still means that more than half of notified tuberculosis patients in the Region are not enrolled on a DOTS programme. Tuberculosis incidence in the Region will only decrease if case detection, cure rates and DOTS coverage are improved. Figure 6 shows the projected incidence of tuberculosis under different
scenarios for DOTS implementation. If DOTS implementation remains at the current level, the number of tuberculosis cases will not decrease for two decades. However, if DOTS coverage expands rapidly
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and is established regionwide by 20054 as planned (Table 1), it is likely that the number of tuberculosis cases in the Region will be halved in ten years. However if the expansion of DOTS is slow, for example if DOTS is not expanded regionwide until 2015, it will take almost two decades to halve the number of tuberculosis cases. Figure 6. Projected regional incidence of new tuberculosis cases under different scenarios for DOTS implementationa
2500 At current levels of DOTS implementation
2000 New cases ('000/year)
1500
If DOTS is implemented regionwide by 2015
1000
500 If DOTS is implemented regionwide by 2005
0 1995
2000
2005 Year
2010
2015
2020
a
Provisional projection. Projection currently being re-calculated using updated data.
If significant reductions in the number of tuberculosis cases are to be achieved, special efforts will be required in countries with high tuberculosis prevalence. These include Cambodia, China, the Lao People’ s Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam. Efforts will also be required to adapt the DOTS strategy to Pacific island situations, as DOTS has not yet been introduced in many Pacific island countries and areas (Annex 3).
4
A good quality of service (meaning that 70% of estimated cases are detected and more than 85% of detected cases are cured) must also be maintained.
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Even in newly industrializing and industrialized countries in the Region, there has been little or no decrease in the number of tuberculosis cases, partly because of the number of imported cases from countries with a high prevalence of tuberculosis. Increases in the number of tuberculosis cases can also be observed in ageing societies in the Region. Unless urgent action is taken now, in both developing and developed countries, there will be no reduction in the Region’ s tuberculosis burden. Therefore all Member States are requested to give the highest priority to tuberculosis control and to mobilize and sustain political commitment and financial support for tuberculosis control.
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WPR/RC50/8 Rev.1 page 15 ANNEX 1
FIFTY-FIRST WORLD HEALTH ASSEMBLY Agenda item 20
WHA51.13 16 May 1998
Tuberculosis The Fifty-first World Health Assembly, Aware that tuberculosis is strongly associated with social and economic inequalities, especially those related to low income and gender; Aware also that tuberculosis remains one of the most important causes of death in adults despite the existence of the highly cost-effective strategy known as “directly observed treatment, short course (DOTS)” to control the disease, and that poor treatment and inadequate control of antituberculosis drugs will result in the development of drug-resistant strains that may make tuberculosis incurable; Recognizing that the already serious situation is worsening in many countries that have been slow to implement the strategy, and that in some the disease is rapidly spreading owing to HIV infection, itself facilitated by sexually transmitted diseases; Convinced that tuberculosis can be controlled using the DOTS strategy even under difficult conditions, although the strategy presupposes strong political commitment; Appreciating WHO’ s leadership in persuading more countries to adopt the DOTS strategy (from ten in 1990 to nearly a hundred in 1997); Acknowledging that many countries will achieve the global targets for the year 2000 set by resolutions WHA44.8 and WHA46.36; Concerned that most of the countries with the greatest disease burden will be unable to meet the targets; Aware that the delay in introducing the DOTS strategy will lead to significant increase in tuberculosis prevalence and cause millions more preventable deaths, 1. URGES all Member States: (1) to give high priority to intensifying tuberculosis control as an integral part of primary health care; (2) to improve social and economic conditions for vulnerable groups in their communities;
WPR/RC50/8 Rev.1 page 16 Annex 1 (3) to ensure before the year 2000 the effective introduction of the strategy known as “directly observed treatment, short course (DOTS)” as an integral part of primary health care if it has not yet been implemented; (4) to monitor implementation of the strategy and establish an effective disease surveillance system; (5) to take the necessary steps, especially in those 17 countries with the highest burden of disease that are not expected to meet the targets by the year 2000: (a) to improve and sustain political commitment at national and local levels; (b) to review the constraints faced in meeting the targets, if necessary with support from WHO, development agencies or nongovernmental organizations; (c) to meet the targets through implementation and expansion of the DOTS strategy; (d) to develop a detailed plan to meet the targets as soon as feasible after 2000, clearly specifying the type, amount and phasing of support to be provided by their governments, WHO, donors or nongovernmental organizations as appropriate; (6) to coordinate the observance of World Tuberculosis Day on 24 March of each year as an opportunity throughout the world for organizations concerned to raise public awareness of tuberculosis as a major urgent public health problem and for countries to assess progress in tuberculosis control; 2. CALLS ON the international community, organizations and bodies of the United Nations system, donors, nongovernmental organizations and foundations: (1) to mobilize and sustain external financial and operational support;
(2) to encourage cooperation from other organizations and programmes for health systems development, and prevention and control of HIV/AIDS and sexually transmitted diseases and lung diseases; 3. REQUESTS the Director-General: (1) to use all appropriate existing fora where Member States, including those 17 with the highest burden of disease, may present problems faced in implementation of the DOTS strategy and other strategies in order to overcome these problems and mobilize external technical, financial and other support needed; (2) to encourage the accessibility of poor countries to an adequate supply of good quality medication and diagnostic equipment; (3) to encourage the establishment of networks for the surveillance of multidrug resistance at country level or in groups of poor countries;
WPR/RC50/8 Rev.1 page 17 Annex 1 (4) to encourage research to ensure sustainable, cost-effective programme implementation, as well as action to prevent multi-drug-resistant tuberculosis, including the development of tools to monitor multidrug resistance, and to develop new tools to supplement the DOTS strategy (including vaccines); (5) to intensify collaboration and coordination with UNAIDS and other programmes and agencies; (6) to take all possible steps to maintain WHO’ s regular budget contribution for global tuberculosis control; (7) to keep the Executive Board and Health Assembly informed of progress.
Tenth plenary meeting, 16 May 1998 A51/VR/10
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WPR/RC50/8 Rev.1 page 19 ANNEX 2 Notified cases, new smear (+) estimated cases and detection ratios in 1998a Population Countries/areas (’ 000) 1997 American Samoa Australia Brunei Darussalam (1993) Cambodia China Cook Islands Fiji French Polynesia Guam (1994) Hong Kong, China Japan Kiribati Lao People’ s Democratic Republic Macao Malaysia Marshall Islands (1996) Micronesia Federated States of Mongolia Nauru (1994) New Caledonia (1996) New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Republic of Korea Samoa Singapore Solomon Islands Tokelau (1996) Tonga Tuvalu (1995) Vanuatu Viet Nam Wallis & Futuna TOTAL a b
Notified cases No. All types 6 1 145 160 15 629 418 903 0 171 91 94 6 983 42 190 32 1 923 589 13 539 56 108 2 987 4 205 328 0 93 15 7 977 208 301 26 202 32 1 977 318 1 21 36 184 84 964 14 834 722 b
Estimated cases Rate/100 000 No. New smear (+) 23 657 79 25 317 630 243 8 323 90 62 2 562 16 547 32 3 895 447 10 538 23 52 2 373 4 74 83 19 6 5 041 98 521 17 777 67 747 161 39 4 71 65 065 6 880 956 93.0% 82.5% 16.7% 42.7% 68.7% 0.0% 116.7% 23.7% 84.6% 56.0% 20.9% 57.8% 70.2% 30.8% 20.4% 45.6% 64.5% 60.0% 82.0% 34.4% 31.7% 68.0% 72.1% 73.9% 21.2% 49.3% 50.0% 50.1% 29.9% Detection ratio New smear (+) 26.1% 26.0%
Rate/100 000 All types 10.3 6.3 58.4 148.6 33.7 0.0 21.1 40.1 63.9 111.7 33.6 39.5 37.0 130.6 64.4 101.8 83.1 116.3 36.4 111.4 9.0 0.0 189.8 88.2 177.3 294.5 57.3 19.0 57.5 78.7 50.0 21.2 360.0 103.4 111.0 93.3 50.9 b
No.
New smear (+) New smear (+) 6 171 68 12 686 188 529 0 66 41 40 1 536 13 571 11 1234 304 7 596 17 11 1171 2 26 57 0 7 1195 83 353 9 957 14 432 113 1 12 6 66 53 647 1 375 787 10.3 0.9 24.8 120.6 15.2 0.0 8.2 18.1 27.2 24.6 10.8 13.6 23.8 67.4 36.1 30.9 8.5 45.6 18.2 14.1 1.6 0.0 0.0 41.2 26.6 117.9 21.8 8.3 12.6 28.0 50.0 12.1 60.0 37.1 70.1 6.7 22.9
58 18 250 274 10 516 1 243 738 20 809 227 147 6 249 125 638 81 5 194 451 21 018 55 130 2 568 11 184 3 641 2 49 17 4 500 70 724 45 717 168 3 439 404 2 99 10 178 76 548 15 1 641 131
Bold figures are from 1998. Other figures are from the years indicated in the column “ Countries/areas” . All types includes new smear-positive, relapse, smear-negative and extrapulmonary tuberculosis cases.
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WPR/RC50/8 Rev.1 page 21 ANNEX 3 DOTS implementation and future directions for tuberculosis control in the Western Pacific Region Groups of countries Group 1: Countries with a high burden of tuberculosis and low implementation of DOTS Group 2:Countries with a high burden of tuberculosis and high implementation of DOTS Group 3: Newly industrialized countries which still have a high or intermediate tuberculosis burden Countries DOTS implementation and current issues DOTS < 80% Financial constraints
Future directions
Expected outcome DOTS to be expanded nationwide by 2002–2005
China Lao People’ s Democratic Republic Papua New Guinea Philippines Cambodia Mongolia Viet Nam
Enhance social mobilization (financial and political) Continue to provide technical support
DOTS >80% Sustainability issues High HIV/tuberculosis coinfection in Cambodia Unique R/R system in each country High tuberculosis among migrants in some countries
Sustain DOTS Enhance social mobilization Enhance HIVtuberculosis surveillance Develop standardized R/R system for monitoring of treatment outcome Develop special approach for migrants
Tuberculosis cases to be reduced by half by 2005–2010
Brunei Darussalam Hong Kong, China Macao Malaysia Republic of Korea Singapore
Cohort analysis of treatment outcome to be made available DOTS coverage to be enhanced among migrants
Group 4: Pacific Most of the island countries countries in the South Pacific
DOTS < 10% WHO guidelines for DOTS in the South Pacific published May 1999 Strong private sector Unique R/R system in each country
Apply DOTS strategy according to island situation
DOTS to be expanded across in the whole South Pacific by 2005
Group 5: Industrialized countries and countries with a low burden of tuberculosis
Australia Japan New Zealand
Develop standardized R/R system for monitoring of treatment outcome Develop special approach for elimination of tuberculosis in selected countries
Tuberculosis to be eliminated in some countries by 2020 Cohort analysis of treatment outcome to be made available
Note: R/R = reporting and recording