(WPRlRC48ISRIl)
SUMMARY RECORD OF THE SECOND MEETING Auditorium Level 2 Sydney Convention and Exhibition Centre. Sydney Tuesday. 23 September 1997 at 9 a.m. CHAIRMAN: Dr Michael WOOLDRIDGE (Australia)
CONTENTS
1. 2. 3. 4.
Address by the incoming Chairman .................. ............................................................... Programme budget 1996-1997: Budget performance (interim report) (continued) ............................................................................... ~ ........... ~. Eradication of poliomyelitis in the Region: Progress report ................................... .......... .......... ........ ....... ....... ....... .......... .......... ... ....... Annual report on sexually transmitted diseases, HIV infection and AIDS ..................................................................................................
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I.
ADDRESS BY THE INCOMING CHAIRMAN: Item 4 of the Agenda The Chairman addressed the Committee (see Annex).
2.
PROGRAMME BUDGET 1996-1997: BUDGET PERFORMANCE (INTERIM REPORT): Item 9 of the Agenda (Document WPRlRC48/4 Rev.l) (continued from the first meeting, section 8) Mr Podger (Australia) advised the meeting that Australia did not intend to press for a
resolution on future budgets. However, he wished it go on record, first, that although future regional budgets did not necessarily have to correspond to zero nominal growth, they should be consistent with the global requirement for budget preparation. Second, and more important, was the way in which funds were used. In the context of a seriously constrained budget, priorities had to be
considered carefully and overheads minimized. He requested the Regional Director to pay close attention to resolution WHASO.26, which set a target for efficiency savings of 3%, money which should be redirected to priority programmes. Third, although it would be a challenge for the
Regional Director to meet priorities established at global level while responding to the requirements of individual Member States, global priority setting was important to establish WHO's overall strategies and directions. Organization. The Region's budget should reflect the global priorities of the Organization without compromising the particular needs of Member States. The global priorities reflected assessment of the most effective measures for improving health outcomes, identifying those which were most appropriate for WHO, and those to be carried out by Member States. When reflecting global Regions and Member States are the implementing arms of the
priorities at the regional level, reallocation of resources should be real rather than achieved through reclassification. The Regional Director, when submitting the next programme budget for
consideration should clearly identify the way in which it would address the issue of priorities. Mr KRIEBLE (New Zealand) stated that subsequent to the adoption of resolution WHASO.26, the Regional Committee should not only endorse drafting of an efficiency plan, but also show clear leadership by advising the Director-General and the Regional Director on ways to achieve efficiency gains that shifted greater resources towards activities at country level.
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Dr LI (China), noting that zero budget growth had often been discussed at both regional and global levels, agreed on the need to ihcrease efficiency, reduce costs, and save personnel. There was, however. a limit: it was difficult to do more with less money and fewer people. Future budget discussion should therefore be objective and realistic, striving to achieve a balance rather than accept impossible constraints. The REGIONAL DIRECTOR said that the concerns of the Regional Committee would be reported to the Director-General. The Director-General would take them into consideration when analysing the financial situation. On that basis he would prepare the guidance for preparation of the 2000-200 I programme budget. By resolution WHASO.26 the Organization had been requested to effect a 3% efficiency saving during implementation of the 1998-1999 programme budget. That should not be difficult because it did not mean a 3% reduction in funding, but rather a saving, making it possible to shift funds to other areas. In fact, it corresponded to the reprogramming process to which he had referred earlier. Countries frequently requested reprogramming during a biennium for various reasons; the Regional Office executed those requests and would ensure that any money saved in that exercise would be directed to priority programmes. The DIRECTOR-GENERAL informed the meeting that preparation of the programme budget for the financial period 2000-2001 was under way at headquarters. Two factors had to be considered in addition to the matter of zero nominal growth: the long-term trend of exchange rates between the dollar and the currencies of the regional offices, and the part-payment of dues by certain major contributors. The first made it difficult to draw up a realistic budget in advance; the second made adjustment necessary during the course of implementation, and might eventually affect efforts to achieve efficiency savings. The Assembly had adopted by consensus the 1998-1999 budget based on the principle of zero nominal growth, and he hoped that his successor would be able to maintain that principle. together with full payment of contributions. The principle of a 3% efficiency saving had been agreed upon by Member States so that the money gained could go to priority programmes at country level, and not simply offset the income deficit. He hoped that those savings would be made, and that each regional committee would
identify country priorities within the areas that had been recommended as global priorities.
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3.
ERADICATION OF POLIOMYELITIS IN THE REGlON: PROGRESS REPORT: Item II of the Agenda (Document WPRlRC48/6 Rev.1 ) The REGIONAL DIRECTOR said that 1997 had brought WHO to the last round in its fight
against·poliomyelitis. In 1996 a total of 5305 cases of acute flaccid paralysis (AFP) had been reported in the Region (as at 25 April 1997). Of these, 4192 (79%) had had two stool specimens collected within two weeks of onset of paralysis. In spite of this intensive search, both in the field and in the
laboratory, wild poliovirus had been isolated from only 21 of these cases. Of the 21, 18 had been found in the Mekong area. The other three had been imported into China. As at 19 June 1997, only eight wild poliovirus associated cases with onset of illness in 1997 had been reported from Cambodia and one case had been reported from the central region of VietNam. The rapid decline in poliomyelitis had been due to a series of national immunization days (NlDs) during which 106 million children under five years of age had been immunized with poliovirus vaccine during each low transmission season since 1992. Surveillance in the Region, which had now reached a high standard, indicated that the transmission of wild poliovirus had finally been restricted to a few districts around the Mekong River and its neighbouring area. The Mekong area, where the last remaining polioviruses had been found, had many waterways, some of which had always been hard to reach. In spite of very successful NIDs, there were still many children in the Mekong area who remained unimmunized. To tackle that difficult problem, and to respond to recent wild poliovirus associated cases, an intensive strategy called "highrisk response immunization" (HRRI) had been implemented in selected districts of Cambodia, the Lao People's Democratic Republic and Viet Nam. The strategy used teams of health staff and
volunteers and included immunizing from house to house or from boat to boat to reach previously unimmunized children. In the last 12 months, four separate rounds of supplementary immunization had been carried out in the areas where these polioviruses had been found. There were plans to conduct another two rounds in November and December 1997. The Regional Director believed that these measures would finally get rid of the virus in the Region. To minimize the possibility of importation of wild poliovirus from outside the Region, WHO had sponsored bilateral meetings between countries from the Western Pacific Region and countries from the South-East Asia Region, to coordinate immunization and surveillance activities in border
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areas. The last such meeting had been held between China and Myanmar in Kunming, China, from 17 to 18 July 1997. In addition to high-quality supplementa~
immunization, all countries that had recently
reported poliomyelitis cases had been improving their surveillance for acute flaccid paralysis and for polioviruses to ensure that no suspected poliomyelitis case would be overlooked no matter where it occurred. In June 1997 the eighth meeting of the Technical Advisory Group on the EPI and
poliomyelitis eradication had been held. As a result of that meeting, it was agreed that countries would collaborate with WHO field staff to step up action against any cluster of AFP cases that might occur during the year. The Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific had established the criteria and standards required for certification during its first meeting in April 1996. Countries that had been free of poliomyelitis for many years had formed national certification committees and were currently preparing national plans of action for certification of eradication to present to the Regional Commission at its next meeting which would take place in November 1997 in the Regional Office. For other countries the process would begin next year. The Subregional Committee for Certification of Poliomyelitis Eradication in Pacific Island Countries and Areas had met for the first time in December 1996. The countries and areas concerned were currently improving acute flaccid paralysis (AFP) surveillance in accordance with the plan of action prepared at that meeting. Their progress would be reviewed at the next Subregional
Committee Meeting in December 1997. The Regional Director thanked all partners who, through their support in the last year with vaccine, surveillance and operational costs had helped to make the poliomyelitis eradication initiative so successful. These included UNICEF, the governments of Australia, Italy, Japan, the Republic of Korea and the United States of America through the Centers for Disease Control and Prevention in Atlanta and Rotary International, and Rotary International District 2650 of Japan. He also thanked the Governments of Canada, Finland, France, Malaysia and Sweden who had supported the campaign in the past. Their continued support could be counted on until WHO and its Member States finished the job. Even though indigenous wild poliovirus transmission would have ceased in 1998, highquality surveillance and supplementary immunization must be maintained throughout the Region until global certification has been achieved.
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The Regional Director assured Member States that he and his staff would spare no efforts to make sure that rapid action would be taken against every suspected wild poliovirus. He was
confident that, with their continued comm itment, l.hey would make 1997 the year when the Region finally would put an end to poliomyelitis. Mr YAMAMOTO (Japan) welcomed the steady progress made towards the eradication of poliomyelitis in the Region. He said that all efforts should now be devoted to that goal. Member States should cooperate in the certification process, strengthening the surveillance of acute flaccid paralysis in areas where wild poliovirus was still observed, and conducting high-risk response immunization wherever cases were confirmed. Poliomyelitis eradication was an important component of Japan's policy for international cooperation. It was collaborating with countries both inside and outside the Region by providing vaccines and cold chain equipment, and strengthening capabilities for surveillance and laboratory diagnosis. Professor WHITWORTH (Australia) conveyed Australia's support of the regional plan for poliomyelitis eradication. This was demonstrated by its active participation in regional efforts, part of which was its establishment of a regional reference laboratory, which functioned as reference laboratory for isolation of virus specimens and typing of isolates, as a source of reference materials, as well as a training centre for the Region. Although a non-endemic country, Australia would be presenting its draft national plan of action to the Regional Commission in November 1997. The success of the poliomyelitis eradication programme was an indication of the benefits of partnership among countries of the Region, and the experience gained could be used as a springboard for measles eradication in the future. Mrs HA (Viet Nam) said that in response to WHO's recommendation for supplementary immunization, Viet Nam had carried out "high-risk response immunization" (HRRI) in May and June this year in a number of southern and central provinces. Its fourth national immunization day would be conducted before the end of 1997. The technical and financial support which Viet Nam received from WHO and from other countries, particularly Japan, was appreciated. continue until poliomyelitis eradication was achieved. Dr DURHAM (New Zealand) while commending the Regional Director and his staff for the results already achieved, requested that, for the future, thought be given to developing a coordinated approach on the use of appropriate vaccines of choice at the country level. While recognizing that She hoped it would
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oral poliovirus vaccine is currently the vaccine of choice as the Region moves towards poliomyelitis eradication. she asked that a coordinated policy be developed with regard to the use of injectable inactivated poliovirus vaccine (IPV) in future. Professor YIN Dakui (China) said that despite immunization campaigns carried out in highrisk areas, three cases, all of which were imported, were found in China. This was attributable to improvements in epidemiological surveillance, which could be further enhanced through support from WHO and from other countries. It was important that eradication was also achieved at the global level ifthe Region were to remain poliomyelitis-free after it had been certified as such. Dr TEMU (Papua New Guinea) stated that national immunization campaigns had begun the previous day in Papua New Guinea at 500 sites across the country and involving both public and private sectors. In that regard, he acknowledged the support received from the governments of Australia and Japan, WHO, and UNICEF in planning and organizing this initiative. Dr HOWELL (France) noted the progress made, particularly in epidemiological surveillance. However, the problem of coordination among laboratory networks still persisted. Epidemiological surveillance along border areas should also be improved. Endemic countries should learn from the experiences of others in that regard. While the production and distribution of vaccines had improved, dependence on international financing was still a major constraint. Dr BART (United States of America), noting the leadership ably provided by WHO in eradication efforts, endorsed the Regional Director's request for Member States to provide the highest level of support to the immunization campaigns. Countries needed to continue to improve epidemiological surveillance, laboratory networking, and immunization of high-risk groups. He
posed the following questions: (I) Were the intensified efforts at case-finding proving effective in finding previously unrecognized AFP or poliomyelitis? (2) Had the multi-antigen immunization campaigns been successful? (3) Bearing in mind the need to prevent imported cases, how good was the coordination with other regions? Dr BOUTTA (Lao People's Democratic Republic) said that, although it was in a period of transition, the Lao People's Democratic Republic had been implementing a programme for the control of communicable diseases, which included an immunization programme. During the
previous year, no case of poliomyelitis had been detected out of 60 cases of acute flaccid paralysis investigated. Although confident of continuing support from WHO and other international agencies, the Government had begun to train its own staff to carry out immunization.
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Mr ROKOVADA (Fiji) thanked UNICEF, Rotary International, and the governments of Australia. Japan, New Zealand. the Republic of Korea and the United States of America for the financial support they had given to national prog~ammes
on the eradication of poliomyelitis and
control of other communicable diseases, particularly in the area of epidemiological surveillance. Dr MENG (Cambodia) reported that the number of poliomyelitis cases had steadily declined since poliomyelitis eradication activities had started in Cambodia in 1994. Although eight
poliomyelitis cases had been reported early this year, the results of the national immunization days (NIDs) and high-risk response immunization (HRRls) had been encouraging. Two more HRRIs and sub-NIDs were scheduled for 1998. All these were made possible through the support given by WHO, other international organizations, donor countries and nongovernmental organizations. Dr CHAN (Hong Kong, China) stated that Hong Kong, China, had been free from the disease since 1983. A National Certification Committee had been set up in December 1996 and was working closely with WHO towards certification and maintaining the poliomyelitis-free status of Hong Kong, China. The use of new strategies to interrupt the transmission of indigenous wild poliovirus in countries where poliomyelitis was still endemic was to be applauded, but she wondered what the chances of eradicating poliomyelitis in the Region in 1997 were. Dr INFANTADO (Philippines) expressed her country's commitment to the goal of poliomyelitis eradication by 1998. A result of that commitment was the immunization coverage of over 90% already achieved in 1996. Supplemental immunizations had been conducted annually since 1993, and in the face of a strengthened surveillance system, no wild poliovirus had been isolated since then. Notwithstanding, subnational immunization days were planned for 1998 in areas with less than 80% coverage. A National Committee for Certification of Poliomyelitis Eradication was currently being constituted. The progress attained so far was attributable to the involvement of all stakeholders at all levels. Mr KIM (Republic of Korea) said that the Republic of Korea had been poliomyelitis-free since 1984. This was due to a continuing vaccination programme. As recommended by WHO, the Government had organized the Korean Poliomyelitis Eradication Certification Committee in June 1997. Since that time, the Committee had prepared a national action plan and had continued to review laboratory testing procedures to ensure they complied with WHO's guidelines. inspectors had also been appointed and trained for surveillance purposes. Local
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Dr PRETRICK (Federated States of Micronesia) stated that the poliomyelitis outbreak that occurred in Micronesia in the I960s had provided the impetus for the currently active immunization programme. which was targeting nine vaccine-preventable diseases. This had resulted in a high level of vaccine coverage. Ongoing activities to combat the disease. at both global and national levels. had helped prevent Ie-entry of poliomyelitis in his country. However, this had still to be properly
documented. To that end, the Department of Health. in cooperation with WHO, had instituted a hospital-based surveillance network involving four state hospitals. It was unlikely that a case would go undetected through these channels. The continuing support given by the governments of Japan and the United States of America and by WHO was much appreciated. Mr TEKEE (Kiribati) said that. as well as having an active surveillance system, Kiribati was working very closely with WHO and the reference laboratory in Australia. The REGIONAL DIRECTOR thanked representatives for their encouraging words and paid tribute to the work of the reference laboratory in Australia which was providing invaluable services to many countries in the Region. Replying to questions concerning coordination between countries and regions, he explained that two mechanisms had been established. At the regional level. meetings had been instituted
between the Western Pacific and South-East Asia Regions to discuss problems relating to the importation of wild poliovirus across the borders of neighbouring countries belonging to different WHO regions. For example. two meetings had been held to coordinate efforts in China and .
Myanmar with the aim of reducing administrative delays and ensuring immediate cross-border reporting of wild poliovirus and acute flaccid paralysis cases. It had also been agreed to establish regular exchange of surveillance information and to synchronize national immunization days in neighbouring areas. In addition the two Regional Directors had agreed to hold annual meetings to discuss common problems related to certain communicable diseases, including poliomyelitis. HIV /AIDS and other sexually transmitted diseases. The first had been held in New Delhi in 1996 and a second was scheduled for October 1997 in Beijing. Within the Western Pacific Region, neighbouring countries were also working together. For example, Cambodia. the Lao People's Democratic Republic and Viet Nam had organized simultaneous high-risk response immunization rounds in May, June and July 1997. In reply to the representative of the United States of America, he said that during HRRI in Cambodia, the Lao People's Democratic Republic and Viet Nam in 1997, teams had conducted an
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active search for AFP in a number of remote areas, for example around the Mekong River, while immunizing more than 2 million children aged under five. Only two cases of acute flaccid paralysis in previously un immunized persons had been repot1.ed. Such activities would need to continue until the Region had been declared free ofthe disease. Even though many countries in the Region had not reported cases for a number of years, it was essential to maintain high immunization coverage and a high level of surveillance until global eradication had been achieved, despite the cost, since the possibility of importation could not be excluded. He nevertheless hoped that from 1998 onwards no wild poliovirus-associated cases would be reported from the Region. The DIRECTOR, DISEASE PREVENTION AND CONTROL, replying to the representative of New Zealand, said that ihe report of the thirteenth meeting of the Global Advisory Group on the Expanded Programme on Immunization had stated very clearly that for poliovirus eradication oral poliovirus vaccine was the vaccine of choice. Since then there had been no change in policy. The rationale for that recommendation was twofold. First, oral poliovirus vaccine was the only vaccine which had been shown to interrupt the transmission of circulating wild poliovirus. Second, the vaccine was administered in oral drop form, avoiding the logistical problems associated with the use of syringes and needles and facilitating safe administration even by volunteer health workers. However, use of the injectable inactivated poliovirus (IPV) vaccine might be appropriate in some industrialized countries with high standards of sanitation where there was no circulating wild poliovirus and where vaccine cost was not an issue. Even in such countries, oral poliovirus vaccine was the vaccine of choice during poliomyelitis outbreaks. There was a potential role for IPV once global interruption of transmission of poliovirus had been achieved. In reply to the representative of the United States of America, he said that in countries where wild poliovirus continued to circulate, WHO did not recommend inclusion of other antigens together with oral poliovirus vaccine since it complicated immunization operations. However, it was an option, after careful consideration, for countries where wild poliovirus was no longer circulating and operational problems could be overcome. The DIRECTOR-GENERAL said that despite the significant progress made towards the eradication of poliomyelitis there remained some regional discrepancies, with countries in Africa, the': Eastern Mediterranean Region and South-East Asia still giving cause for concern. In 1996 the
numbers of cases reported were 1005 in India, 942 in Nigeria, 341 in Pakistan, 264 in Ethiopia, 219 in the Democratic Republic of Congo, 215 in Chad, 121 in Rwanda and 100 in Egypt. Within India
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most of the cases had been reported from two States, Uttar Pradesh and Bihar. The situations in Afghanistan and southern Sudan were also serious. In these areas lack of political will, political instability or armed conflict had made it difficult to organize immunization days or systematic surveillance. There was no clear picture of the situation in the east of the Russian Federation and the newly independent States. WHO was focusing support on efforts in problem areas, especially those where national immunization days and systematic surveillance had not yet been initiated, and it was still hoped that eradication of poliomyelitis would be achieved by the target date in most countries. The countries of the Western Pacific Region and the Regional Office were to be congratulated on their considerable progress towards eradicating the disease. The CHAIRMAN requested the Rapporteurs to prepare a suitable draft resolution for consideration at a later meeting, taking into account, in particular, the comments made by the representative of France.
4.
ANNUAL REPORT ON SEXUALLY TRANSMITTED DISEASES, HlV INFECTION AND AIDS: Item 10 of the Agenda (Document WPRlRC48/S) The REGIONAL DIRECTOR said that document WPRlRC48/S outlined the current
epidemiological situation with regard to sexually transmitted diseases (STDs) and included the latest data on the status and trends of HIV and AIDS. The document also described current and future activities in the prevention and control of sexually transmitted diseases as an entry point for HIV/AIDS control in the Region, and current developments in the Joint United Nations Programme on HIV/AIDS (UNAIDS). He reported that the number of HIV infections and AIDS cases reported in the Region had continued to increase every year. A cumulative total of 6S 170 cases of HIV infection and 12 liS cases of AIDS had been reported by the end of 1996. However, there was significant underdiagnosis and underreporting of HIV infections and AIDS cases. It had been estimated that, by the end of 1996, a cumulative total of more than 300 000 people in the Region had become HlV-infected and that the cumulative total of AIDS cases was 24 000 (8000 of which had occurred in 1996). By the year 2000, the total number of HI V-infected people in the Region was expected to more than double, while the annual number of new cases of AIDS was expected to increase fourfold.
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HIV transmission varied from country to country and even between areas within countries. In Australia and New Zealand, where there had been intensive prevention programmes, incidence of HlV infection was decreasing. Most of the islands of the South Pacific, Japan, the Philippines and the Republic of Korea did not seem to be experiencing substantial increases in HIV infections and AIDS cases. Unfortunately, epidemics were emerging or were already established in some other countries in the Region, such as Cambodia, parts of China, Malaysia, Papua New Guinea and Viet Nam. It was projected that the upward trends would continue in the next few years. The Regional Director reported that transmission of HIV infection was predominantly through sexual contact in most countries, although a few countries were experiencing epidemics among injecting drug users. In some countries, the high prevalence of sexually transmitted diseases, up to 40% among individuals with high-risk behaviours such as commercial sex workers, was playing an important role in the spread of HIV infection. The Regional Director then explained that WHO's work on sexually transmitted diseases and AIDS in the Region fell into four main areas. First, WHO's main emphasis was on the prevention and control of sexually transmitted diseases. Essentially, this was done through the promotion of STD syndromic case management, which was a highly effective method of treatment for symptomatic STD infections. STD syndromic case management was effective because it could be provided by basic health care workers, since it did not rely on costly and often inaccessible laboratory support. WHO was also involved in
advocacy with key decision-makers in order to develop STD programmes, improve STD awareness and promote STD health-care-seeking behaviours. The second area of WHO's work included activities which improved epidemiological surveillance of STDs and HIV/AIDS. Strengthening surveillance of HIV and sexually transmitted diseases should generate sufficiently accurate data to support rational planning, targeting, implementing, and monitoring of the programme. In collaboration with national epidemiologists, the Regional Office had continued to reinforce surveillance systems and the collection, analysis and dissemination of data. The Regional Director explained that a surveillance report had been
distributed every six months and a regional computerized epidemiological database had been developed. Estimations and projections of the numbers of HIV infections, AIDS cases and STD cases had also been provided for the largest countries in the Region. Support for the monitoring of gonococcal antibiotic susceptibility had been continued.
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The third area of WHO's work focused on activities targeting individuals most exposed to HIV/AIDS and STD infection. These were primarily individuals involved in commercial sex work or injecting drug use. Specific programmes, such as model clinics in the Philippines, had been initiated to reduce STDs and HIV among commercial sex workers. These programmes took place primarily through the delivery of health services and peer education activities. Provision of technical support to establish harm reduction programmes for injecting drug users had also been continued. Finally, WHO had been working to ensure the safety of blood transfusions and blood products. An expert in blood safety, funded by the French Government and appointed through
UNAIDS, would soon be based in the Regional Office and would support Member States' efforts to provide safe blood and blood products. The Regional Director then summarized the collaboration between WHO and the Joint United Nations Programme on AIDS (UNA IDS). Since the establishment of UNAIDS at the
beginning of 1996, eleven theme groups had been formed in the Region, eight of which had been chaired by WHO representatives. In addition, five country programme advisers and one intercountry programme adviser had been assigned to countries in the Region. Financial support of US$ 300 000 and, more recently, one staff position, had been provided by UNAIDS to WHO's programme on STDs and HIV/AIDS in the Regional Office. However, since 1996, many countries had experienced a reduction in external funding and technical support for HIV/AIDS programmes. As a result, many Member States had found it difficult to maintain HIV/AIDS programmes at previous levels. That was a matter of concern, especially in the context of an expanding HIV epidemic in some countries. One reason for the shortfall in funding, as the Regional Director had explained at the previous session of the Regional Committee, was that, in the transitional period between the WHO Global Programme on AIDS and UNAIDS, the latter was only commencing work, including fund-raising. The Regional Director declared that WHO and its Member States were at a crucial point in their campaign to prevent and control the spread of HIV/AIDS. The disease could be controlled. WHO should be doing everything in its power to ensure that the recent declines in the HIV epidemics in Australia and New Zealand were replicated across the Region. The Chairman then gave the floor to Dr Piot. Dr PlOT (Executive Director, UNAIDS) thanked Dr Han and the Regional Committee for the invitation to speak. With regard to the AIDS epidemic itself, he said he had read in various places that the epidemic was over because of the new drugs now available; this of course was untrue,
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because there were at a conservative estimate 8 500 new infections per day. AIDS was now one of the major causes of death worldwide and would soon overtake malaria, with a devastating effect on the people and the economies of heavily affected countries. As the Regional Director had said, many countries in the Region were still less exposed than other parts of the world, although some countries were reporting a rapid rise in HIV infections. However, there was a window of opportunity in the Western Pacific Region to stop the development of a major epidemic. As Australia had shown, HIV prevention could work, given strong leadership, strategic partnerships and evidence-based prevention. Thailand (in the South-East Asia Region) was having some success in reducing new infections, and several countries had a solid basis for AIDS control programmes. Dr Piot reminded representatives that UNAIDS was not a separate agency but a programme cosponsored by WHO, UNICEF, UNDP, UNFPA, UNESCO and the World Bank. It provided
coordination in the United Nations system, advocacy on HIV prevention, sharing of best practices through technical cooperation and research, and provision of seed funds to countries. The
Programme was now 20 months old. There were now UNAIDS theme groups in most countries of the Region, and eight out of eleven were chaired by the WHO representatives. This approach
provided an example of what was required of United Nations reform at country level as advocated by the Secretary-General of the United Nations. A successful response called for partnerships - both within the UN system and in society at large, including business and religious leaders. UNAIDS was neither a fund nor a bank, but it had allocated US$ 3.9 million for activities in the Western Pacific Region, including funding for National AIDS Programmes (NAPs), catalytic funding for country activities, and funding to enable the Regional Office to provide technical support. The sum did not include salaries. The Programme Coordinating Board had called for a survey of national and international financing of HlV activities throughout the world. In several countries of the Western Pacific Region - including Cambodia, China, the Lao People's Democratic Republic, Mongolia, the Philippines and Viet Nam - the work of the theme groups had greatly increased financial support to national AIDS activities of the UN system, not including the World Bank. In other countries, however, support seemed to have
decreased. Collaboration with the Regional Office had greatly improved, thanks to the Regional Director; there was now a clear division of responsibilities. A meeting on epidemiological
surveillance had been organized on behalf of the whole United Nations system. Other cosponsors had also defined their roles: UNICEF was concentrating on community mobilization and prevention
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among young people, UNFPA on reproductive health. The United Nations Drug Control Programme (UNDCP. not a cosponsor) was helping with the problem of intravenous drug users. Old and new challenges would have to be faced. These included continuing denial of the epidemic, new complacency arising from the success of new drugs, and ignorance of the fact that HIV prevention works and is cost-effective. This called for sustained leadership at national and community levels, a truly multisectoral response in which each country defined its own objectives and strategies, and increased preventive efforts, especially for the benefit of young people and those most exposed to infection. In this way the Region could take the opportunity to prevent the HIV epidemic from reaching the levels found elsewhere in the world. Dr ITO (Japan) expressed satisfaction with the analysis made and the measures described in the document under discussion. He enquired what was being done in respect of intravenous drug users. His Government was promoting an initiative on population dynamics and AIDS, engaging in bilateral cooperation, conducting study programmes and seminars at home and abroad, contributing to the Regional Office through UNAIDS and cooperating with Asian countries in coordination with UNAIDS. The Japanese Government had been involved with UNAIDS from the outset; it was a member of the Programme Coordinating Board (PCB) and a donor country. As the document
showed, concern was expressed at the reduction of direct financial support from UNAIDS. UNAIDS had started as a non-funding agency, although to alleviate the problems caused by the disappearance of funding from the WHO Global Programme on AIDS, it had continued to provide some assistance through the 1996-1997 budget. As of 1998-1999 the theme group, in conjunction with the country concerned, would have to apply to UNAIDS for direct or indirect support with fund raising. Although the Government of Japan did not criticize that PCB decision, it did ask that every effort be made to support fund-raising by developing countries. Dr Ito remarked that coordination of activities by cosponsoring organizations in the theme groups was inadequate. The Japanese Government had raised the matter frequently at the PCB and had requested that cosponsoring organizations provide information on HIV/AIDS related activities at country and regional levels, insisting that the cosponsoring organizations should coordinate their programmes and provide sufficient financial and human resources. He maintained that UNAIDS could succeed only with the cooperation of each cosponsoring organization. Dr TEMU (Papua New Guinea) said that his country had recorded 745 HIV-positive cases since 1987 mainly in the age bracket 1-5 and among young women 17-30 years of age. This was a cause of great concern. Alarmingly high incidence rates were reported for heterosexual transmission.
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The Government had recently approved the establishment of a multisectoral national AIDS council. The Prime Minister had called for high priority to be given to the development of a national strategy; the National Planning Office was taking a lead, with UNAIDS support. Initial difficulties with the channelling of f1.nds from UNAIDS were easing with improved coordination, thanks to the Regional Director and the Executive Director of UNA IDS. Papua New Guinea concurred with the four main conclusions of the document. It
acknowledged WHO's support, together with that from the Government of Australia, in HlV/AIDS activities. He sought information on the availability of affordable HIV-therapeutic agents. The next report should incorporate such aids for countries' policy guidance. Dr ABDUL LATIF (BlUnei Darussalam) said that in his country, too, HIV infection was on the increase, with 422 cases reported by July 1997, all but 16 (4%) being foreign nationals; of 10 AIDS cases, 8 had died. About 95% ofHIV/AIDS cases were male, and 90% were in the age-group 20-39 years. Heterosexual transmission was predominant. There had been one case of HIV caused by intravenous drug use, and one of perinatal transmission. Small nations like Brunei Darussalam, with a much-travelled population, were very vulnerable. Increased international travel for tourism and trade was a major challenge, calling for concerted, innovative control strategies. Professor YIN Dakui (China) noted with concern the development of HIV/AIDS in the Region, together with the increase in sexually transmitted diseases (STDs) as a whole. Chinese national surveillance of STD and AIDS indicated that the infection rates were increasing yearly, particularly in certain provinces and areas, drug abuse being a major contributory factor. In some of these the infection rate was very high. In 1996 almost 6000 HIV-positive cases had been found through surveillance of high-risk groups, and 155 AIDS cases had been identified, of which 103 had died. Studies indicated that some ISO 000 people were infected. China was grateful to the Regional Office for support provided in spite of financial difficulties, and in 1997 technical staff had visited the country to provide guidance for HlV/AIDS projects. The cofunding from UNAIDS had so far been very limited. The difficulties of coordination
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were understandable, but he hoped that overall support for China's efforts against HIV/AIDS would be strengthened. The measures taken by the Chinese Government included formation of a coordinating group representing 34 sectors. headed by a State Councillor. A meeting of the committee on AIDS control had been held in 1996. It would be followed by another in 1997 and a national health conference to be attended by all Party Secretaries and Governors would feature seminars on HIV/AIDS. High-level political leadership must, in China as elsewhere, be involved in measures to ensure the implementation of country programmes. Since 19%, China had had a special budget for HIV/AIDS prevention and control. Management of HIV-infected persons was a major problem and had been the subject of a one-year consultant study, the report of which had been submitted to the State Council. Education and public information were recognized to be very important in prevention and control; a report had been submitted on multisectoral measures for education and information on HlV/AIDS. Surveillance was being strengthened, especially for high-risk populations, in preparation for measures to combat trafficking and prostitution, which were serious problems. Blood transfusion services had had to be reviewed throughout China for two or three years as a result of suspicion that some transmission had occurred through transfusions. Traditional medicine practices had been the subject of studies to ascertain their possible contribution to AIDS prevention and control. Furthermore, since 1995 medical workers had been given special courses to increase awareness of the problems and causes of HIV /AIDS. It was thus hoped, through training, that improved understanding of the disease would become the main means of preventing its spread. Dr DURHAM (New Zealand) welcomed the report. With regard to the Annex., she urged that in future the assumptions and methods used to make predictions should also be included. Also the report did not mention the effect of the use of antiretroviral agents, although Dr Piot had raised the matter in his introductory remarks. surrounding the subject; New Zealand was concerned about the complacency
the treatment with such agents could compromise the promotion and
maintenance of safe sexual behaviour. In addition, such treatment was very costly, and the very significant "opportunity costs" would have a serious effect on prevention of STDs, HlV infection and AIDS, as welI as on general pharmaceutical costs. She therefore requested that an analysis be made of such effects in future reports.
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Dr HOWELL (France), commending the report, said that France's interest in the prevention and control of STDs and HIV I AIDS was demonstrated by its financing of two posts in the Region. He requested more information on cooperation bet.veen WHO and UNAIDS and the advantages, in particular, for island states. Control measures should be intersectoral to combat the disease's multiple causes. WHO's role should be predominant because of its technical capacity for disease control. Since no vaccine was available against HIV/AIDS. preventive measures should be given their proper weight alongside treatment with drugs. France wished to be associated with others in a resolution that would incorporate: an appeal to States to mobilize resources; a call for reinforcement of epidemiological surveillance; bettertargeted programmes of prevention for high-risk populations; and commitment to better coordination of regional and national control. Professor WHITWORTH (Australia) welcomed annual reporting on HIV/AIDS; the disease had to be followed closely to prevent its devastating spread. HIV/AIDS decimated the young adult productive population and left a terrible legacy of destitute orphans and older people, often themselves infected. With its long experience of the disease, Australia was greatly interested in the regional response, which deserved high priority. HIV infection in Asia had increased from I million to
3 million cases in the last three years, and projections exceeded 10 million by 2000 (25% of the global total). It seemed almost inevitable that a major epidemic would centre on the Pacific Region early in the 21 st century. In 1996 the Regional Committee had agreed that Member States should strengthen their commitment to STD and HlV/AIDS prevention and control. Success depended on strong national leadership and political commitment to open and pragmatic responses to the epidemic. An important element in a strong political response lay in developing strong links beyond the health sector, especially with national leaders and ministers with key economic portfolios. Australia was following with great interest the Regional Office's progress in mobilizing and coordinating national decision-makers and regional bodies in order to improve national responses to SID prevention and control, as announced at the last session.
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~
l
With the completion of the establishment of UNA IDS, the focus should shift to effective joint action at the country level. The document argued that funding for national programmes had fallen since the disestablishment of the Global Programme on AiDS and said that transitional core funding for
•
country programmes would be discontinued by UNAIDS in the 1998-1999 biennium. However, in that biennium UNAIDS would be allocating a comparable level of funding (US$ 16 million) for country-level programme development. Such funds offered a different mechanism for country
financial support and would be disbursed through the country-level United Nations theme groups on HIV/AIDS. The United Nations theme groups on HIV/AIDS were the key mechanism to meet the challenges that HIV I AIDS posed to individual countries. Professor Whitworth argued that the Regional Office, Member States and donors must act to ensure that the theme groups functioned effectively and that all involved were actively represented, including United Nations organizations, national governments and donors. She therefore urged the Regional Office to extend increased administrative and financial assistance to theme group action in support of country responses. As cosponsors increase their country-level support for theme group action, UNAIDS funds could be used for catalytic activities to expand country responses, such as advocacy and mobilization of additional resources. As one of the largest cosponsors WHO had a responsibility to contribute materially to that process. At present, the Regional Office's commitment to HIV/AIDS from core funding was modest, with most HIV/AIDS-related expenditure appearing to come from extrabudgetary funds. This was a matter of real concern to Australia; she urged WHO to provide increased contributions from core funding in support of national HIV/AIDS programmes. She said that the Regional Office should also work more closely with the theme groups on joint planning, parallel programming and resourcesharing. As a donor nation Australia regarded the theme groups as the key mechanism in facilitating integrated responses. They also indicated and facilitated collaboration by United Nations and other external donors. UNAIDS offered a significant opportunity to meet the challenges that countries faced in HlV/AIDS, but it must be seen as a coordinating mechanism, not an implementing agency.
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Its success or failure would depend on the commitment of its cosponsors and on the degree to which Member States and the Regional Office were able to maximize its potential. Australia would
continue to work actively with Member States, the Regional Office and the United Nations theme groups on HIVI AIDS. Dr CHHEA THANG (Cambodia) said that the rapid increase in cases of HIV infection and AIDS in Cambodia was of great national and international concern. It was estimated that 100 000 people were affected, mostly by heterosexual transmission, giving an infection rate of 2% in the sexually active population - the highest in the Region. considered to be the main causes. Joint measures by government and national organizations had reduced the number of new cases in the high-risk groups, but the epidemic had already spread to rural areas where present resources were inadequate to keep up the campaign in an extensive and timely manner. New and more extensive international support was needed if the epidemic was to be controlled. Tan Sri Dr ABU BAKAR bin Suleiman (Malaysia), commending the report, noted the alarming increase of HIV infection in the Region, together with STDs, a key contributor to its incidence, as well as injecting drug use. The Regional Office's estimates of prevalence and its technical support, as well as training institutes and the establishment of a regional STD, HIV and AIDS database, were invaluable. In Malaysia nearly 42% of HIV-positive cases were from those aged 20-29 years, 43% were from those aged 30 to 39. Young people were thus at greater risk, being sexually more active and more susceptible to drug abuse. Emphasis must be placed on programmes of prevention and health promotion for these age groups. Malaysia had had a programme, PROSTAR <an acronym for the Bahasa Malaysia term for "healthy young people without AIDS") since November 1996, training youth leaders to train others. It would be happy to share its experience with other countries. He called on WHO to intensify behavioural research to determine how moral and religious values could be developed to help prevent the spread of HI VIA IDS in the Region. He wished to adjust the figures given in the report for projected prevalence in Malaysia. They should read: by the end of 1996, 20 092 HIV cases, 858 AIDS cases; by 2000, 30 400 HIV cases, 1500 AIDS cases. Poverty and lack of education were
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In view of the strong correlation between HIV/AIDS and STDs, he advocated strong commitment to integrated prevention and control.
The meeting rose at 12 noon.
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ANNEX ADDRESS BY THE INCOMING CHAIRMAN
Distinguished Representatives, the Director-General of the World Health Organization, Dr Nakajima, the Regional Director, Dr Han, Representatives of agencies of the United Nations, intergovernmental and nongovernmental organizations, WHO secretariat, Ladies and Gentlemen: Welcome to Australia, a country described as a nation of 100 languages. One of the proudest features of our country is that one in four of our people have emigrated to this country and now call Australia home. Many Australians, in fact, came here from countries represented in this meeting. So I hope you will feel doubly at home here in Australia which, like this regional meeting, is proud of its cultural diversity. Our meeting this week reminds me of another gathering of people interested in improving health. In 1888 in Paris, the eminent scientist Louis Pasteur spoke with great passion and reminded his colleagues of their true role as medical scientists. "If (medical) science has no country, then every (medical) scientist should have one and ascribe to it the influence which their works may have." Pasteur urged his colleagues to work within their countries with their minds open to "the law of humanity, that law of peace, work and health, ever evolving new means of delivering human beings from the scourges which beset them. Only in being committed to this universal law of humanity, ... [can] we assert that science will ... extend the frontiers of life". In our meeting this week we have the opportunity to extend the frontiers of life by working in concert with the World Health Organization to deliver our fellow human beings from the scourges of disease which still beset them. We can do that by working in our own countries to achieve greater equity in health outcomes, and through WHO, by building on what we have become: a regional body comprising countries committed to working together and drawing on each other's experience to fulfil the vision of health for all. This Western Pacific Region of WHO has already developed a distinguished tradition of cooperation in health. In the 1970s, the Region saw a significant growth in its membership, as new states joined the Organization. In this period, considerable effort went into the building of basic health infrastructures in countries. In the 1980s, this work received fresh impetus from the
commitment to Health for All, which had at its core the universal provision of primary health care.
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Annex
Its implementation was guided by the growing recognition of the essential link between health and development. At the same time, our Region was working to combat the communicable diseases which so often destroy the capacity of individuals to realize their own potential and to contribute to the development of their societies. Now in 1997, we are on the verge of declaring our Region poliomyelitis free. And leprosy, an ancient scourge that doubly condemns its victims, is rapidly disappearing from the Region. This proud record of cooperation provides us with a rich starting point for our meeting, as does the role WHO can playas the world's health conscience. The basic principle of morality is to "do the best you can". WHO has a unique role in guiding nations to provide health systems which use scarce resources prudently and for the greatest benefit of all. WHO also has a vital role to play in sharing with us the new opportunities provided by the vast explosion of scientific knowledge collected in international collaborative efforts and which manifests itself in such movements as evidence-based medicine. WHO also provides the technical leadership in international health work that draws together the complementary efforts of the agencies of the UN system and the international community. Yet, as the Regional Director's report on the work of WHO in the Region for this year makes clear, we will need all of this and more if we are to face up to the health challenges of our Region. As the Director notes, our Region has a mixed record in the area of communicable diseases, with progress in the fight against poliomyelitis, cholera and malaria but new challenges presented by reemerging diseases such as tuberculosis, diphtheria and dengue fever. Last year's meeting in Seoul recognized this and the further challenge of new diseases, nominating as a seventh regional priority, the management and control of emerging or re-emerging diseases. None will be more challenging or daunting than HIV/AIDS. In a Region where our people cross national borders in unprecedented numbers for tourism, work, trade and education, this pandemic, knowing no respect for borders, is a problem of all of us. I am very pleased to see that this subject is on the agenda and that the head of UNAIDS, Dr Peter Piot, is joining us in our deliberations.
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ADDex
The Regional Director's report also reflects on the growing and common problems with noncommunicable diseases. In New horizons in heLl/th. WHO has encouraged national governments to strengthen their capacity for disease prevention and health promotion. While regional initiatives such as the Expanded Programme on Immunization have meant an overall decline in vaccine-preventable diseases, we ignore WHO's health urgings on noncommunicable diseases at our peril. Cancers, cardiovascular diseases and diabetes, for example. are diseases which are more easily prevented than treated. As WHO warns, health systems should strive to work vigorously to promote full health and prevent illness as to treat it. As countries, we also need to work together to fulfil the Action Plan on Tobacco or Health. In 1995 our regional meeting set out a four-year plan which included ambitious targets to have the region free of tobacco advertising by the year 2000. The plan is an outstanding example of a comprehensive regional approach to the tobacco epidemic. This plan will only work with the resolve of governments working in concert internationally to ensure that the vast international trade in tobacco is severely limited. I understand that the meeting last month in Beijing to discuss implementation of the Action Plan showed some impressive achievements in tobacco control in many countries of the Region. However, we still have a long way to go to achieve all of the targets we have set for ourselves under the Plan. This meeting provides a further opportunity to work together to lessen the deadly human and financial. cost of tobacco smoking in a region where an estimated 60% of males and 8% of females over 15 years of age smoke. Of course, in my own country many more than 8% of females smoke, and lung cancer is the second largest cancer killer of women after breast cancer. With lung cancer among women rising at a faster rate than the increase in breast cancer, we can expect in the future that lung cancer in women. as in men, will be the largest cancer killer in this country. Our Region also faces the common challenges posed to the health of our people by accelerating urbanization, the degradation of the environment and the problem of ensuring an adequate health infrastructure in remote and sparsely populated areas. The viability of a modern society - from villages to vast cities - is dependent on the basic infrastructure for clean air, safe water, safe food and management of the hazardous by-products of our society. promote basic infrastructure is one that works. WHO's injunction to
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Annex
In Australia we are finding that the provision of access to clean water, basic infrastructure and a reduction in overcrowding in remote areas can effectively improve the health of indigenous Australians. Of course, the simple public health approach works everywhere else in the world. It is just a pity that it has taken us until the 1990s to discover what much of the world has known for decades. As we know well in the Western Pacific Region of WHO, common health challenges do create common bonds between countries. This forty-eighth session of the Regional Committee gives us a unique opportunity to contribute to WHO's vision for the next century, through our discussions on Renewing the Strategy of Health for All. This can appear a daunting subject but we must generate some clear directions for WHO or our voice as a region and as individual countries risks being lost in the wide consultations taking place on the subject. This meeting is particularly well placed to discuss this as our own regional document, New horizons in health. was one of the early and high quality inputs to this process. However, our own approach must clearly complement and contribute
constructively to the global strategy. As Member States, we all endorse the global process under way to renew the strategy of health for all. We should work together to ensure that this becomes a practical, achievable vision which we can all endorse and to which we can contribute, as part of a global community, as a region and as Member States. Finally, as well as looking outward, we must pay attention to the health of our Organization and make sure it is the best possible vehicle for performing its mission and function. There has been much talk of reform at WHO, and some important changes have been made over the last five years. The pace of reform should not be allowed to slacken and reform should be institutionalized at all levels of WHO. The work of the Executive Board special group reviewing the Constitution has given us the chance to consider current arrangements with a view to ensuring that our structures provide a workable framework for achieving the Organization's important mission. Regions are a major pivot in the current structure in translating global objectives at country level and their role and allocation of resources must be set out if implementation of policies and priorities set by governing bodies, and programme delivery in country, are to be effective.
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ADDes:
This meeting is one of the most important forums for the development of our health policies and practices both in the Region and in our own c(luntries. The more WHO speaks with one voice, the sharper its strategic direction and the more it will be the leader in international health. One hundred and nine years ago, Pasteur spoke to his colleagues and set out a vision for health for the then approaching twentieth century. As we approach the twenty-first century, Pasteur's words find modern expression in declarations such as the one made at the Alma-Ata Conference in 1978 which launched Health for All to underline that large numbers of people, and even whole countries, were not enjoying acceptable standards of health. The dream of Pasteur and WHO is for a world in which medical science, working within borders and across them, can extend the frontiers of life. We have a chance in this meeting to take important steps in this new unexplored territory. I am confident that our meeting will pursue the same type of practical outcomes that were the motivating force behind the creation of WHO and drive us still to overcome inequities in health within and between countries.