(WPR/RC37/SR/6)
SUMMARY RECORD OF THE SIXTH MEETING WHO Conference Hall, Manila Wednesday, 17 September 1986 at 2.30 p.m. CHAIRMAN: Dr Sung-Woo Lee (Republic of Korea)
CONTENTS
1.
Sub-Committee on Programmes and Technical Cooperation (continued) •••••••••••••••••••••••••••••••••••• 1.2 Membership of the Sub-Committee ·····~··················
148 148 148
2.
Regional contribution to the Eighth General Programme of Work: Report of the Sub-Committee, Part III • • • • • • • • • • • •
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1. 1.1
SUB-COMMITTEE ON PROGRAMMES AND TECHNICAL COOPERATION: Agenda (continued from the fifth meeting, section 3) Membership of the Sub-Committee: Item 10.2 of the Agenda
Item 10 of the
the current members of the The REGIONAL DIRECTOR said that Sub-Committee were Australia, China, Cook Islands, Fiji, Japan, Malaysia, the Republic of Korea, Samoa, Singapore and the United States of America. The three-year period of tenure of the representatives of Fiji, Malaysia, the Republic of Korea and Singapore would expire with the present session of the Regional Committee. The Committee had to decide which Member State should appoint representatives to replace them. It might wish to consider designating New Zealand, Papua New Guinea, the Philippines and Viet Nam. In the absence of any comments, the CHAIRMAN took it that the Regional Director's proposal was approved, and invited the Rapporteurs to prepare an ap-propriate draft resolution. (For consideration of the draft resolution, see the seventh meeting, section 1.3). 1.2 REGIONAL CONTRIBUTION TO THE EIGHTH GENERAL PROGRAMME OF WORK: REPORT OF THE SUB-COMMITTEE, PART III: Item 12 of the Agenda (Document WPR/RC37/8)
Dr WELCH (Australia), Rapporteur of the Sub-Committee on Programmes and Technical Cooperation, introducing the item, said that the Sub-Committee had noted that the Eighth Genera 1 Programme of Work, being the second of three programmes spanning the period covered by the strategies for health for all by the year 2000, would follow the same general principles as those of the Seventh General Programme of Work. The programme would emphasize action at country level; preparation of the regional contribution had accordingly involved consultations at country level to ensure that the priority needs of countries were reflected. The regional contribution consisted of regional objectives for the major programme areas, and regional targets and approaches for each of the programmes included in the classified list of programmes for the Eighth General Programme of Work, representing the Region's contribution to Chapter 7 of the Eighth General Programme of Work. The Sub-Committee had reviewed the regional targets and approaches for each of the programmes and, based on its comments, some amendments had been introduced to the text of the regional contribution, as shown in Annex 1 to Part III of its report. Part III also included other specific comments by the Sub-Committee. The Sub-Committee had recommended that the regional contribution be accepted by the Regional Committee and forwarded to WHO Headquarters for consideration during preparation of the draft of the Eighth General Programme of Work. The latter would be submitted to the Executive Board in January 1987 and then to the Fortieth World Health Assembly in May 1987. Dr KOBAYAKAWA (Japan) welcomed the successful completion of the draft regional contribution to the Eighth General Programme of Work. In common with other Member States, Japan supported the goal of health for all by the year 2000. The Eighth General Programme of Work, covering as it did the
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crucial period 1990-1995, was most important for the attainment of that goal. Representatives should therefore examine the proposals most carefully before forwarding them to Headquarters. It might be appropriate to present the draft regional contribution together with the Seventh Report on the World Health Situation, which was approved at the Thirty-ninth World Health Assembly and which identified shortcomings in the present situation, primarily as perceived by each government. The Eighth General Programme of Work would show the objectives and actions to be taken by the Organization and Member States during the period 1990-1995 and required some introduction identifying current issues to make it more meaningful. It would be the first of the two programmes before the target year 2000, and yet the draft under discussion had no real sense of urgency aimed at the attainment of the goal, and few new objectives. It was to be hoped that the draft regional contribution would be further refined in the light of the Committee's comments. Some of the WHO jargon used was difficult for newcomers to understand, and the addition of some form of glossary might be useful. Dr KHALID (Malaysia) commended the Sub-Committee for their efforts in preparing what amounted to the general framework and direction of activities to be undertaken in the Region in the period 1990-1995. It was important to ensure that the regional contribution was consistent with the regional situation. Several elements had to be ta~en into consideration in preparing the draft: (1) the world health situation or, for the regional contribution, the regional health situation; (2) current programmes, and whether they should be continued; (3) the recommendations and decisions arrived at in various consultative forums - seminars, workshops, etc.; (4) recent resolutions of the Regional Committee for which outstanding work remained; and (5) other relevant documents. He approved the draft in general and supported the introduction of the five new programmes, which focused on issues of current or potential interest. It might also be appropriate to consider the addition of a programme entitled "Alcohol or health" at some stage. He supported the proposed modification of three programme titles. The proposed programme 2.6 Informatics management should be related to the existing programme 3.1 Health situation and trend assessment, which it should support. He had attended two international consultations on informatics held at Headquarters and was pleased to learn that a regional working group on the subject was planned for the .Region. It was an area that needed strengthening at both regional and country levels. He asked why no individual regional target had been listed for programme 10.2 Prevention and control of alcohol and drug abuse. Alcohol and drug abuse were problems of increasing seriousness in many countries and had led to the holding of the Conference of Ministers of Health on Narcotic and Psychotropic Drug Misuse in London in 1986 and the forthcoming United Nations International Conference on Drug Abuse and Illicit Trafficking, to be held in Vienna in 1987. The Regional Committee had adopted resolutions WPR/RC27.R5, WPR/RC3l.R25 and WPR/RC33.Rl5 relating to the same area, and the concern indicated by those resolutions would have to be duly reflected in the regional contribution. Programme 13.3 Malaria had s.lready been discussed extensively by the Committee during consideration of the Regional Director's report, the review of budget performance, and the review of the proposed programme budget for
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The Committee had adopted four resolutions related to malaria in the period 1976-1985. The number of resolutions adopted by the Committee on any one issue or programme reflected the seriousness of the problem in the Region. There was certainly a need to train many more malariologists for the Region. In most cases the relevant elements had been taken into consideration in the preparation of the draft, which, together with his proposed additions, he would support. Dr TAPA (Tonga) commended the Sub-Committee and the Secretariat on the preparation of the draft regional contribution, which would be considered by the Executive Board during the preparation of the Eighth General Programme of Work, in accordance with constitutional requirements. He endorsed the proposed five new programmes, which were all important to the work of the Region, and noted the proposed modification of three programme titles. He supported the specific recommendations made by the Sub-Committee, especially in relation to programme 6 Public information and education for health, programme 8.3 Accident prevention, programme 10 Protection and promotion of mental health, and programme 13.1 Immunization. He also supported the proposals made by the representative of Malaysia. Dr DE SOUZA (Australia), while supporting the way in which the draft regional contribution had been prepared (largely along the 1 ines suggested by the Executive Board), was rather disappointed that it had not proved possible to propose the rundown of any of the existing programmes. Resources would not stretch to cover an ever-increasing number of programmes. As pointed out by the Executive Board, the Sub-Committee should look seriously at all existing programmes to see where cuts could be made. It was essential to make cuts if new areas were to be opened up. -Dr REILLY (Papua New Guinea) joined others in commending the Sub-Committee and the Secretariat for their work in preparing the draft and supported the comments made by the representative of Malaysia concerning malaria. The expansion of programme 13 •.14 to include deafness was most welcome as it was an area too long neglected. Successful implementation of the Eighth General Programme of Work would only be achieved if emphasis was given to monitoring. The dissemination of comparisons and other data resulting from such monitoring would stimulate Member States to further efforts to reach the targets set. Dr KOBAYAKAWA (Japan) expressed reservations regarding programme 12.4 Traditional medicine. While it was necessary to integrate scientifically proved components of traditional medicine into modern medicine, he could not advocate the development of a separate system. Either the targets and approaches should be universally applied or they should be substantially changed. He expressed satisfaction regarding programme 13, in particular immunization and acute respiratory infections. Indeed, so much had been achieved that he wondered whether it might be possible to be a bit more ambitious. Mention was made of immunization against the six target diseases; hepatitis B, Japanese encephalitis and rabies were also diseases that were serious problems 1n the Region but could be prevented by immunization.
1988-1989.
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He reiterated that Japan's priority in international cooperation was It now accorded to communicable disease control, including immunization. had already dispatched four study missions - and another one jointly with WHO - to assess the feasibility of cooperation with selected countries. A possible area of cooperation that had been iderttified was technology transfer for vaccine production in countries where the infrastructure and cold-chain facilities permitted. Regarding tuberculosis, he would not propose any changes to the proposed progranune, but expressed concern that there had been no improvement in the situation in many developing countries. He would draw the Committee's attention to the magnitude and importance of the problem. Over the past 20 years more than 600 experts - mainly from the Region - had been trained in the Japanese/WHO international training courses on tuberculosis, so there should be a considerable resource of well-trained and motivated manpower. He urged that WHO take more active steps for tuberculosis control; Japan, for its part, would continue to collaborate with Member States - both through WHO and on a bilateral basis - in training, . research and the provision of experts. Concerning research and development in the field of vaccines, it was important to develop vaccines appropriate to the situation in developing countries - for example, heat-resistant and single-shot vaccines. The REGIONAL DIRECTOR said that discussion in the Executive Board and elsewhere on the elaboration of the General Programme of Work had repeatedly shown two schools of thought - some considering that the programme should be a selective list, and others that it should be comprehensive. The remarks made by the representative of Japan concerning tuberculosis touched on a very sensitive question. In fact, despite the great overall increase in manpower over the past 20 years in developing countries, in many cases there had been little improvement in the situation regarding cert a in diseases in many countries. Tuberculosis was a case 1n point, perh a ps particularly because it was a social disease. Moreover, a large number of those trained in the international courses in Tokyo had become public health specialists and were not working specifically 1n tuberculosis control activities. Regarding traditional medicine, there was no intention of developing it as a separate entity; the emphas is wa s on integration, the main obj e ct in many developing countries being to find wa ys of i ntegrating both traditional medic i ne and other systems into a health care syst em bas ed on primary he alth c are. Dr HAN (Di rector, Programme Management} ex pla i ne d the background of t h e process of formulation of the Ei ghth General Programme of \vork , and s aid tha t at its May 1986 ses s ion the Executive Board had r evi ewed the Director-General's proposals concerning the nature , struc ture and method of pre paration of the Programme. He outlined the structure of the Programme , which wou ld f o ll ow t he s ame general lines as the Seventh General Programme of Work, th e only difference be ing th a t approaches would be elaborated und er t h ree leve l s : g l oba l, r egional and country. The document before the Committee 1n fact
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represented only Chapter 7 of the Programme (being the programme outline according to the classified list of programmes); it did not cover the part of the Programme concerning the strategy for health for all and the Seventh Report on the World Health Situation, to which the representative of Japan had referred. The Regional Committee had at its previous session reviewed the first evaluation of the implementation of the regional strategy for health for all, and that would form the regional portion of the Seventh Report on the World Health Situation. Regarding the problem of understanding the health-for-all terminology, he drew attention to the fact that Headquarters had published in the "Health for All" Series a glossary of terms; copies were available for those who wished to receive them. The representative of Malaysia had raised several important points firstly, that the Eighth General Programme of Work should be related to the medium-term programme. The intention was that the General Programme of Work should serve as the basis for formulating and developing medium-term programmes in all programme areas. While preparing the General Programme of Work, the Regional Office had therefore concurrently prepared the skeleton for the medium-term programme; the objectives and approaches would be elements common to both, but details of activities would have to be developed later. The regional health situation had in fact been the drafting of the document, even though it was not Medium-term programmes had in them a section on embodied the resolutions adopted by the regional governing bodies. taken into account in explicitly mentioned. policy basis, which committees and other
Regarding the importance of informatics management at the country level, reference had been included in the section Approaches not only to WHO's use of informatics but also to the development of national capability. -.·
The target for programme 10.2 was in fact shown together with those for programmes 10.1 and 10.3, since the Secretariat felt that it was difficult to separate the three. The Secretariat had taken into account all relevant resolutions in the preparation of the Programme. An example was programme 8.3, which was confined to the prevention of road traffic accidents because the relevant resolution adopted by the Regional Committee had related only to that aspect. It was up to the Committee to decide whether it wished to expand the scope to include accidents in the home. The representative of Australia had referred to the need to eliminate non-priority programmes. That could be dealt with at the regional level, although the Classified List of Programmes was developed at the global level (an example being the replacement of smallpox eradication by the programme on research and development in the field of vaccines). If the Committee so wished, a lower priority could be accorded to certain programmes, or the scope of activities could be narrowed in some cases. He agreed with the representative of Japan regarding the desirability of extending the immunization programme, and proposed that a reference might be included in the Targets section to the selection of one country in the Region in which one more vaccine was to be introduced in addition to the six vaccines currently used.
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Dr UMENAI (Director, Disease Prevention and Control) said that hepatitis B virus infection was highly endemic in the Region. Immunization with hepatitis B vaccine was the most effective approach for its control, but the cost of vaccines had been a constraint. WHO, with the cooperation of Australia, Japan and the United States of America, was collaborating with China in the large-scale production of hepatitis B vaccine through technology transfer from Japan. Nine million doses of hepatitis B vaccine would be produced in 1986. Production would be doubled to 18 million by 1987, the target being to immunize 85% of all newborns by 1995. In the South Pacific a collaborative scheme for hepatitis B vaccine production with the cooperation of the Government of Japan was also 1n progress. It involved the establishment of a collection system for hepatitis B virus antigen positive sera to be processed into vaccine in Japan and sent back to the South Pacific countries. The scheme would enable the small countries of the South Pacific to have a supply of hepatitis B vaccine produced from locally collected sera. The possibility of adding hepatitis B vaccine to the six included under the expanded programme on immunization was being explored in China. A number of Japanese encephalitis vaccines were currently being produced, and early next year WHO would establish requirements in that respect. High costs, however, still constituted a problem, and research on the production of a low-cost effective vaccine using recombinant DNA technology was being supported. Rabies was an important problem in some countries of the Region. A vaccine prepared in human diploid cell was available but its high cost was prohibitive for mass vaccination. The search for cheaper methods of production, particularly using recombinant DNA technology, needed to be pursued. Regarding dengue virus vaccine, a live attenuated dengue 2 vaccine had been successfully prepared in Thailand. That was a step towards the development of low-cost recombinant DNA dengue 2 vaccine, other serotype dengue vaccines and, eventually, multivalent dengue vaccine. Bivalent Japanese encephalitis vaccine composed of Nakayama strain and Beijing strain had been prepared in Japan; the results of the field test conducted in Thailand would be presented during a WHO meeting, to be held in Osaka in February 1987. As regards heat-stable vaccines, a measles vaccine had been successfully prepared in Japan; a plasma-derived hepatitis B vaccine had also been prepared, and a recombinant DNA hepatitis B vaccine was being developed. Dr DE SOUZA (Australia) said that it was still a little disappointing to find no indication in the report as to which projects might become eligible for termination in the period covered by the Eighth General Programme of Work, although he realized that it was necessary to look far ahead to the 1990s and that it was particularly hard to expect project staff to see their own projects in terms of their finalization. As a member of the Executive Board, he realized that the necessary assi gning of priorities
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was one of its tasks, but it was one in which regional committees could be expected, and were being asked, to give guidance, rather than engage with the Executive Board in mutual buck-passing. Dr KHALID (Malaysia) said that predictions about disease patterns and economic recovery would assist in defining tasks for the period under consideration. Caution must be exercised in accepting the proposed addit i on of target diseases to the expanded programme on immunization, remembering that, for some of the six existing target diseases and in some areas, the rates of vaccination coverage and goals for protection were not being met owing, for example, to infantile diarrhoea and malnutrition. A second reservation concerned cost, which for hepatitis immunization, for example, was still very high. A third concerned efficacy of some of the vaccines used in the Programme. Fourthly, the beneficial effects of sanitation and other alternative methods of preventing communicable diseases should not be underestimated. Finally it should be remembered that once a vaccination programme started it would have to be continued; if it was premature, it could involve considerable extra expense and unending complications. Dr NOBLE (United States of America) endorsed the remarks of the representative of China and the Regional Director concerning the value of traditional medicine and its incorporation with modern medicine. However, the wording of the target in section 12 .4, which indicated that "By 1995 most countries or areas will have developed and strengthe ned traditional medicine activities", suggested that countries which did not have certain traditional medicine practices might "develop" them de novo. He proposed substituting wording such as "most countries or areas will have identified' evaluated and strengthened e xisting useful and safe traditional medicine activities". It should also be made clear that in evaluating traditional medicine activities the same rigorous standards should be applied as in testing new medicines. The CHAIRMAN said he had understood the representative of Tonga to have wished to add domestic accidents to the subjects for accident prevention. The views of the Secretariat also on the apparent disagreement over the possible addition of new target diseases for the expanded programme on immunization would be appreciated. The REGIONAL DIRECTOR, recalling that in considering the Eighth General Programme of Work it was necessary to think ahead to the 1990s, replied on the latter point that the identification of possible target diseases for addition to the expand'e d programme on immunization would be a reasonable regional target if it was carefully worded. Hepatitis was perhaps exceptional in that the major aim of vaccinaiion was to i nterrupt transmission from mother to child, which required a single series of three vaccinations without hepatitis B immunoglobulin. Current epidemiological studies showed an efficacy of over 75% among children using plasma-derived vaccine of acceptable potency. Such immunization using heat-stable h e patitis B vaccine was therefore feasible, and there were no cold-chain problems. If blood supplies were cheap enough, the vaccine could be produced for as little as approximately one US dollar per dose 1.n an
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efficient production programme. Technology for the preparation of recombinant DNA vaccine had been developed and prices were expected to fall. It had therefore been concluded that such vaccination could be incorporated in the expanded programme on immunization to prevent mother-child transmission. Those conclusions were supported · by the Task Force on Hepatitis B, which included experts from within and outside the Region. The question of "development and strengthening" of traditional medicine activities could be solved by adding some reference to its incorporation in the general health care system. Dr REILLY (Papua New Guinea) said that traditional medicine meant so many things to many people that it would be advisable to specify what . was meant in the relevant part of the Programme. It meant di ffereilt things in different parts of his country, from methods of bone setting using coconuts to the harmful practice of inserting slices of bamboo under the skin. In China, it referred principally to acupuncture and moxibustion and, while Papua New Guinea was interested in those, it. could not accept many local practices based on superstition. Dr LIU GUO-BIN (Director, Drug Policy and Environmental Health and Health Technology) said that the definition of traditional medicine had already exercised members of the Regional Committee at the Technical Discussions held at its last session, and it would take hours to do the topic justice. It would be advisable to limit attention to evidence of therapeutic value in substances used in the history of man's fight against disease as revealed by modern methods of scientific evaluation. In all regions it was necessary to have the texts relating to a particular method, especially irt the case of those which the Chinese had developed over 2000 years earlier and which had spread to neighbouring countries, which had varied them. WHO was concentrating on two aspects: acupuncture and herbal medicine. Other practices, sometimes distinguished as "folk medicine" were under investigation for possible development. Spiritual or magic medicine or witch doctors were not encouraged. The REGIONAL DIRECTOR said that he thought a consensus could be arrived at with the suppott of scientists in the Region on a definition using the process of elimination, remembering that modern medicine as practised in the Western Pacific Region was all "imported". Each country had had its secular experience in the manifestation of man's instinct for survival, and the main aim was to develop traditional medicine, first by identifying practices within the Region. Like it or not, there was a traditional basis to medical practice in each country, even if it had in some cases been suppressed or banned. Before deciding whether they were good or bad and suitable for integration with primary health care, an evaluation of the effects and of the possible applications in various settings must be made. In Chinese traditional medicine for example, the medicines were generally preserved and could therefore be used elsewhere; locally collected fresh herbs, as used for example in Solomon Islands, were a different matter until their active ingredient had been identified and compared. It would be arrogant and foolish to exclude the possible beneficial effects of such new herbs and , other substances when that was how many modern medicines had been developed, especially when there were still many diseases, such as some forms of cancer, for which no effective treatment yet existed. He recalled the case of Qinghaosu, a Chinese medicine which had been discovered to provide a
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quick route to the brain for relief in acute malaria. He also recalled that American Indians had known of the properties of ginseng, which was generally thought to be an Asian discovery. The United States was now a major exporter, and the different properties of many varieties of that root were now being investigated by modern methods. It was therefore clearly desirable and necessary to develop research capability in that area, and many countries in the Region had well-documented traditional medical practices and their effects and had expressed willingness to cooperate with WHO. If the term was misleading WHO was prepared to change it, but he thought it expressed the consensus of opinions in many countries of the Region. Dr REILLY (Papua New discussion but had wished used in the preparation of was true that WHO limited of provable efficacy. Guinea) said he had not meant to start a lengthy to see a less vague or misleading general term the General Programme of Work if, for example, it its attention to acupuncture and herbal remedies
Dr BIUMAIWAI (Fiji), while agreeing with the representative of Papua New Guinea, said it must be accepted that the interpretation of traditional medicine varied from one country to another and there were various ways and means of practising it. It might vary from the simple use of leaves in medicine to witchcraft. One of the recommendations of a working group meeting held at the Regional Office in October 1983 had been that WHO should extend its cooperation to Member States which had not formally adopted the integration of traditional medicine in primary health care. The idea had merely been to encourage countries to consider the incorporation of traditional medicine in their programme if it was possible to practise it. Two workshops had been conducted in Fiji with WHO funding and consultant support. Fiji was also considering the need for training traditional medicine practitioners, and was studying the scope of their activities and responsibilities. The idea had not as yet been accepted totally, but each country should consider whether it could assist the primary health care programme in that way. Dr KHALID (Malaysia) said that, if hepatitis B was to become a seventh target disease, Malaysia would have to make a reservation on the subject, since it could not believe that the cost of vaccine to the developing countries would be as low as had been stated. Dr RHIE (Republic of Korea) welcomed the direction taken by the programme in general, but considered that the targets for some sectors, such as health of the elderly or workers' health, might be made more specific, the target levels improved, and the target year amended, bearing in mind that the present target year (1995) was some ten years ahead. Dr HAN (Director, Programme Management) said that what he was seeking was a clear-cut mandate from the Committee in order to finalize the immunization targets. Guidance was needed as to whether to leave them unchanged or whether to make any additions or deletions.
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The Australian representative had suggested that consideration should be given to setting priorities for the various programmes. In preparing the Sixth General Programme of Work, WHO had produced a small booklet in which the various programme areas were given priority ratings A, B or c. If the Committee considered that such ratings could he attached to the various programme areas after review of the programme content, it might consider delegating such ali exercise tci the Sub-Committee at its 1987 session. Once that had been done, there would still be time to use the priorities l.n programme budgeting for 1990-1991. The REGIONAL DIRECTOR, replying to the representative of Malaysia, said that the official price for a ten microgramme dose of hepatitis B vaccine was 5 yuari (US$1.5) - the same as the cost of production. An efficacy study was being undertaken and there was a good possibility that a 5 microgramme dose would be sufficient. It was thus hoped that the cost per dose would be less than one US dollar, although that would not include any profit or amortization of production costs. The CHAIRMAN said he understood that the Committee's views would be conveyed to WHO Headquarters, to be taken into account in the Eighth General Programme of Work and to be submitted to the Executive Board in January 1987. Dr TAPA (Tonga) said that there appeared to be some confusion. His understanding · was that the six target diseases were concerned specifically with the expanded programme on immunization adopted by the World Health Assembly, and he agreed with the representative of Malaysia that there should be no addition to them. Any countries that had made sufficient progress could include a further target disease of their own, but that should not be added to the six WHO target diseases. Dr KHALID (Malaysia) said that the representative of Tonga had correctly understood what he had had in mind. There was nothing to prevent countries pursuing their own immunization programme but nothing should be added to the six target diseases referred to in the document. Dr HAN (Director, Programme Management) suggested as a compromise that, instead of placing the proposed addition under the section Targets; a sentence should appear under. the section Approaches, to the effect that, in those countries where it might be feasible, additional vaccination such as that for hepatitis B would be included. Some countries might already have eliminated some of the six target diseases and might wish for such inclusion. Mr CAO YONGLIN (China) said that his delegation in principle endorsed the regional contribution to the Eighth General Programme of Work. , He was not certain to what extent universal immunization would have been achieved by the target date of 1990, and he therefore agreed that there should be some flexibility. Countries in favourable conditions could add other diseases to their immunization programme. With respect to traditional medicine, any therapy or remedy outside western medicine that was traditionally used with proven effect could, theoretically speaking, be considered traditional medicine. The system of traditional medicine in China was fairly well developed; with its own unique theoretical system. He hesitated to limit the traditional medicine in the
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Eighth General Programme of Work to acupuncture and herbal medicine because, as understood in China, traditional medicine also included the use of animals, plants and minerals. Dr NGUYEN TANG AM (Viet Nam) said that in his country the implementation of the expanded programme on immunization had called for considerable technical and human resources, and still further inputs were required to achieve further vaccination coverage. There were areas in which Japanese encephalitis was endemic, with a high mortality rate, and it was desirable to vaccinate children in those areas. The needs varied according to the conditions prevailing in individual countries. It would be useful to integrate vaccination against Japanese encephalitis in northern Viet Nam, where there were endemic foci, with protection against the six target diseases. Vaccination against hepatitis B in his country was carried out on the basis of epidemiological indications and of an appropriate supply of vaccine. Viral hepatitis was predominant in western countries, while infectious hepatitis A was prevalent in his country. Hepatitis B was likely to increase in the future in view of producti~n and supply difficulties. Conditions were not as yet favourable for offering protection against that disease, but it would be desirable to focus on Japanese encephalitis in certain selected areas in the north, while in the south it would suffice to apply the immunization programme against the six target diseases. Dr REILLY (Papua New Guinea) said that among the major killers of children in his country were acute respiratory infections. Vaccines were being developed against haemophilic and pneumococcal bacilli. It would be difficult to say what would be the position with respect to the target diseases and vaccine available by 1995, but his country would be aiming for the two vaccines mentioned in preference to hepatitis vaccines. He would like to see the removal of the words "the six" before the words "target diseases" since there were likely to be many vaccines against many diseases by 1995. The CHAIRMAN suggested that representatives should get together at the closure of the meeting with a view to finding a compromise solution. Dr KHALID (Malaysia) said that he would prefer to adopt Dr Han's suggestion and dispense with such a meeting. In the absence of further comments, the CHAIRMAN invited the Rapporteurs to prepare an appropriate draft resolution for consideration at the next meeting. (For consideration of the draft resolution, see the seventh meeting, section 1.4).
The meeting rose at 5.5 p.m.