.. SUMMARY RECORD OF THE SIXTH MEETING
(wpRI RC 30 I SRI 6)
Mandarin Court, Singapore Thursday, 4 October 1979 at 2.30 p.m. CHAIRMAN: Dr A.G.K. Chew (Singapore) CONTENTS
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Study of the WHO fellowship programme ..••..••••......•. Development of biomedical and health services research (including research strengthening and career structures in tropical countries) .•••••••.••.••• Review of the cancer situation in the Western Pacif ic Region .........................................
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Immunization services and their evaluation ••..••••••••• Status of the antimalaria programme •.•••••.••.••.••••••
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STUDY OF THE WHO FELLOWSHIP PROGRAMME: (Document WPR/RC30/16)
Item 18 of the Agenda
The REGIONAL DIRECTOR said that, in 1976, the World Health Assembly had adopted a resolution asking the Director-General to intensify efforts to develop a concept of integrated health services and manpower development. The fellowship programme was, of course, a major component of such development. All involved in the fellowship programme, both governments and WHO, had for some time been concerned to improve the manner in which they were responding to changing trends in training. A thorough review was needed of the progrannne and of the procedures used to select fellows and utilize them on their return home. The arrangements made by host countries to establish and implement training programmes also needed to be studied. In WHO, in particular, new policies could not but affect the Organization's attitude to the award of fellowships. It was clear that the award of fellowships not related to specific national health projects had, in the past, led to fragmentation of health manpower resources. Fellowships had to serve health programmes developed through national health planning or country health programming. The Regional Committee, at its twenty-eighth session, had, on the initiative of the Government of New Zealand, adopted a resolution requesting the Regional Director to convene a meeting to discuss the scope of concerted regional cooperation on such aspects of health manpower development. Thus, the Conference on Regional Cooperation in the WHO Fellowship Programme had been organized in February 1979. It was attended by senior government representatives, able to make recommendations for the improvement of fellowship planning and selection mechanisms at country level; improved administration by WHO; better information sources; action by receiving countries; and monitoring and evaluation of the progrannne. Document WPR/RC30/l6 presented to the Committee a plan for implementing the recommendations of the Conference. Part 3 drew attention to nine recommendations made at the Conference, the activities proposed to implement them, and the targets to be achieved through the activities. Dr CHRISTMAS (New Zealand), stressing his country's special interest in training, commended the Secretariat and the representatives at the Conference on their review, which would be useful to the countries concerned and to the fellows themselves. Dr MENU (Regional Adviser in Health Manpower Development) said that a real evaluation of the .fellowship programme would be difficult in any region. The Western Pacific was no exception. The Conference had reviewed as many aspects of the programme as possible and its conclusions had been annexed to its report. Evaluation had been one of the tasks of the Conference but, though a follow-up system was theoretically possible, in practice it was difficult to follow up fellows once they had returned home. It was hoped to improve that situation, possibly in collaboration with other regions, since the same problem existed everywhere. Dr NICHOLSON (United Kingdom of Great Britain and considered the recommendations to be very satisfactory of them, notably 3.1, 3.2, and 3.7, were already being country was giving priority to relating fellowships to Northern Ireland) and asked if some carried out. His specific country
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projects that were receiving its assistance. Fellows visiting the United Kingdom were well provided with notes and were looked after by the British Council. Dr MENU (Regional Adviser in Health Manpower Development) said that recommendations 3.1 and 3.2 should be considered together as part of the national planning process. Work was being carried out concurrently on the fellowships programme and on the health manpower development programme, which were correlated. Some results had already been achieved. Fellowships would be planned in conjunction with national health plans or specific projects. Other recommendations in course of implementation were the revision of stipends, the production of information notes, and the preparation of a discussion paper. He added that fellows in the United Kingdom were certainly very well briefed • Dr PALACIOS (United States of America) wondered whether an evaluation of the fellowships programme in the Western Pacific Re~i.on could reveal hm~ much the programme had improved health services to the population •. Although that might appear impossible, he was confident that Member States of the Region would collaborate in drawing up reasonable criteria for such an evaluation. An obvious benefit of fellowships was the improved technical knowledge of the recipients, but it was not clear whether that improved technical knowledge was of direct benefit to the people who were supposed to be provided with services·. For instance, the recipient of a fellowship might not be able to put into practice what he had learned, because of a shortage of equipment, drugs, and transport. In such a case, the fellowship would have been a waste of time and money. He was glad that the Northern Mariana Islands had been allowed to benefit from fellowships at the undergraduate as well as the postgraduate level. As a result, it had been possible to have people trained as radiographers, pharmacists, as well as other paramedical personnel. The REGIONAL DIRECTOR said that account would be taken of the need for fellowships in the paramedical professions, if the country concerned submitted its requirements with a justification. In the absence of further comments, the CHAIRMAN asked the Rapporteurs to prepare a draft resolution. (For consideration of the draft resolution, see the seventh meeting, section 1. 7) •
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DEVELOPMENT OF BIOMEDICAL AND HEALTH SERVICES RESEARCH (INCLUDING RESEARCH STRENGTHENING AND CAREER STRUCTURES IN TROPICAL COUNTRIES): Item 19 of the Agenda (Document WPR/RC30/l7)
The REGIONAL DIRECTOR said that, for the past three years, resolutions of the Regional Committee on the development and coordination of biomedical research had contained an operative paragraph authorizing hi~ to allocate additional funds, as he saw fit, to research activities that conformed to the objectives of the regional programme, with the proviso that he should report on their use to the subsequent session of the Regional Committee. Document WPR/RC30/17 contained such a report. The Japan Shipbuilding Industry Foundation· had been the main contributor •
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The document also contained a resume of the action recommended by the Western Pacific Advisory Committee on Medical Research (WPACMR) at its fourth session, in April 1979, for a comprehensive programme of research in 1979 and future years. 1979 had seen a further consolidation of the research programme in the Region. The impact was measurable in terms of the number of programmes being implemented and the increased relevance of research activities to local needs. Resources, hitherto contained in the research promotion and development programme, had been allocated- to individual technical programmes - mainly communicable disease programmes - for the development of research components. The work of the six technical advisory bodies of WPACMR as task forces had finished and they had become sub~committees. As requested by the Director-Generai, document WPR/RC30/l7 brought to the attention of the Committee the/ serious lack of trained manpower resources to develop research components within the Organization's programmes of technical cooperation with Member States. This applied particularly to tropical countries. There was a real need to strengthen national research capabilities and to improve career structures for research workers. Dr HOWELLS (Australia) was gratified' to note the progress achieved, especially as regards the strengthening of biomedical research in the Region. He had noted with satisfaction the recommendations made by WPACMR, particularly in respect of research in developing countries, as well as resolution WPR/RC29.RlO, requesting Member States to "provide career structures which permit research workers to devote their time fully to research and which attract young workers". When voluntary funds became available, it would be desirable to complement biomedical research with accelerated efforts to provide employment opportunities for research workers. Dr WEINSTEIN (United States of America) agreed with the representative of Australia and commended the Regional Director on his use of extrabudgetary resources for research in the Western Pacific. Dr CHRISTMAS (New Zealand) questioned whether there was a need for research on health hazards of workl.ng populations. If industrial surveys were included under that heading, New Zealand would support the project, but he wondered whether it was necessary to allot stich a high priority to occupational health. He asked in what the programme consisted. Dr HERNlMAN (Regional Adviser in Health Services Development) said that research on occupational health had been discussed at the last session of WPACMR. The Committee had stressed the need to conduct research on that subject, which had received little attention in the Western Pacific Region so far. As stated in document WPR/RC30/l7, a sub-committee had been set up by WPACMR to deal with health services and occupational health and was to report to the next meeting of WPACMR. Dr CHRISTMAS (New Zealand) considered that there was enough basic knowledge on occupational health to provide effective services in the field. There was little point in conducting any more research until
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application of the results already achieved had shown what further research was needed. If a health service review was meant, however, he would support the project. Dr HERNIMAN (Regional Adviser in Health Services Development) said' that the Committee had recognized the need to obtain information on problems of occupational health in the Region. Since the Committee was concerned with research, it had used the term "research on occupational health". Dr TARUTIA (Papua New Guinea) spoke of the proml.sl.ng results of research into pig bel and pneumonia vaccines, which had been carried out in his country, in collaboration with the National Institute of Medical Research in Goroka, Papua New Guinea and with WHO. There being no further comments, the CHAIRMAN asked the Rapporteurs to prepare an appropriate draft resolution. (For consideration of the draft resolution, see the seventh meeting, section 1.8). 3. REVIEW OF THE CANCER SITUATION IN THE WESTERN PACIFIC REGION: Item 20 of the Agenda (Document WPR/RC30/l8)
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The REGIONAL DIRECTOR referred to the resolution adopted by the Executive Board at its sixty-first session (1978) in which the regional committees were invited to undertake regular reviews of the cancer situation in their regions. l The Regional Committee for the Western Pacific had decided in 1978 that such a review should be included in the agenda of the current session. Document WPR/RC30/18 presented some background material to enable the Committee to make the review. In certain countries or areas of the Western Pacific Region, where the incidence of the communicable diseases was decreasing, national authorities were becoming aware of the magnitude of the cancer, problem and of the need to develop information s~Tstems, particularly popUlation and hospital-based cancer registries. A working group was to meet in Manila, starting on 15 October, to advise him on the future direction to be taken by the regional cancer control programme. The working group would naturally be guided by the Committee's comments. Dr HIDDLESTONE (New Zealand) said that, despite the lack of statistics, the report showed a remarkable range of site incidence in the Region. Better epidemiological information was particularly important in order to pinpoint cancer etiology. He hoped that the working group mentioned by the Regional Director would be able to develop a wider base for statistical information in the Region.
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See resolution EB6l.R29, WHO Handbook of Resolutions and Decisions, Volume II (3rd edition), 1979, page 78.
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Dr HSU SHOU-JEN (China) said that the report should stimulate cancer research and control in the Region. A clear knowledge of the facts was a first essential. In many developing countries, the only morbidity and mortality figures came fTom hospitals in the cities. Statistical surveys were one of the most important elements in a cancer control programme. Only after such surveys could realistic prevention and therapy programmes be established. The Regional Office should make the necessary resources and technical advice available. His country had, through great efforts, carried out surveys covering hundreds of millions of its people, and now had some of the facts it needed. On the basis of the incomplete data, the national cancer incidence was about 800 000 cases a year and the annual mortality from cancer 74 per 100 000. It was known that the disease occupied second or third place among causes of death (not first place as indicated in Table 1 of the report). He believed that if all countries joined together, progress could be made in cancer control. Dr HOWELLS (Australia) supported the representative of China's plea for more facts on which to base action. The Board's resolution had been valuable in prompting countries to examine their own cancer situation. The main message of the report was the lack of knowledge in the Region. Unfortunately, the statement on page 2 that Australia had a population or hospital-based cancer registry was not yet true. Only three out of seven states had active cancer registries, while registries were being planned elsewhere. It was hoped that adequate statistics would be available in two or three years' time. Dr LO (Malaysia) said that although his country shared in the general deficiency of statistics, data to fill the blanks in Table 1 of the report were available. While all deaths had to be reported and recorded in Malaysia, that could be done by physicians or lay authorities, so that ascertaining the cause of death was difficult. Malaysia's cancer statistics were based on returns from government district and general hospitals. The incidence had risen from nearly 7400 cases in 1973 to over 9300 cases in 1977. In 1965, neoplasms had been ranked seventh among the top 10 causes of death in government hospitals in Peninsular Malaysia, but by 1970 they had risen to fifth. The most common sites in 1973-77 had been: the digestive organs and peritoneum, 27%; the genitourinary system, 20%; the lips, oral cavity and pharynx, 11%; the respiratory organs, 10%; and bone, connective tissue, skin and breast, 10%. Apart from surgical, radiotherapeutic and drug treatment, little had been done in cancer control. Publicity on smoking and health had met great resistance. An effort was being made to start a national cancer registry, to carry out a full epidemiological survey with WHO's cooperation, and to step up the health education approach. Dr TAN (Singapore) said that his country had an active cancer registry which should yield accurate statistics on the disease and the results of treatment. He noted th~t lung cancer was increasing rapidly; its incidence
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had doubled from 1967 to 1978. A campaign against smoking was now under way. A greater emphasis on education to prevent cancer would be a sound approach. Dr EN DO (Regional Adviser in Chronic Diseases) said that information for the report had been gathered from many sources, including official documents and consultants' reports. Analysing the data had proved difficult, especially the figures on common sites. He thanked representatives for the additional information provided. At the forthcoming meeting of the second Working Group on the Organization of Comprehensive Cancer Control Programmes, the emphasis would be on methods of collecting information, screening for cancer, and health education against cancer. He anticipated that the working group would produce valuable guidance for the formulation of the regional cancer programme. Dr CHASTEL (France) noted that there were few data relating to French Polynesia in the table on page 4, though many figures were available. The cancer mortality rate, for example, was 44 per 100 000. He would gladly transmit to the Regional Office a document containing data on the relative prevalence of malignant neoplasms in French Polynesia. There being no further comments, the CHAIRMAN asked the Rapporteurs to prepare an appropriate draft resolution. (For consideration of the draft resolution, see the seventh meeting, section 1.9).
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4.
IMMUNIZATION SERVICES AND THEIR. EVALUATION: (Document WPR/RC30/l9)
Item 21 of the Agenda
The REGIONAL DIRECTOR said that the twenty-ninth session of the Regional Committee had chosen "Acute Respiratory Infections" as the subject for the Technical Presentation during the thirtieth session only after it had been agreed to discuss immunization services as an item on the agenda. Document WPR/RC30/l9 provided a basis for discussion. The target of the expanded programme on immunization was to provide immunization against the six diseases covered by the programme - diphtheria, measles, tetanus, tuberculosis, pertussis and poliomyelitis - for all children by the year 1990. That could be achieved, through using the primary health care approach within the health services delivery system, only if an adequate information base, both regional and national, were established to enable adequate evaluation of the programme. Dr HIDDLESTONE (New Zealand) congratulated the Regional Director and his staff on the report, which was brief but summarized the basic principles well and contained good suggestions for aspects to be considered in the future. The plan to immunize all the world's children effectively against six major communicable diseases by the year 1990 was indeed an inspiring one, but he feared that enthusiasm and even effort would not suffice without public relations action to enlist the cooperation of parents. His country's experience had been that, even where immunization was available readily
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and free of charge, it was hard to get adequate coverage, because,of the sad paradox that, as the incidence of a disease waned, awareness among young parents of the threat it posed waned too. The techniques for overcoming that block and for subsequently monitoring the effectiveness of the programme as measured by the incidence of the disease and - more important - the maintenance of adequate antibody levels, were something countries would have to share. He would also like to stress the importance of simple records, so that field workers would not be hampered in their task by excessive paper work. Dr HOWELLS (Australia) said he agreed with the previous speaker and also enthusiastically supported the programme, which represented one of the simplest and most effective activities the Organization could encourage. He was also glad to note that both the document and the Regienal Director in his introduction highlighted the importance of evaluation. He saw no reason why the targets should not be reached, through the primary health care approach, by the assigned date of 1990. Dr NICHOLSON (United Kingdom of Great Britain and Northern Ireland) said that his country was particularly interested in research on the cold chain, in which it was participating both through WHO and at the national level. He would therefore like to know what progress had been made in the Region with regard to solar-powered refrigerators and ice-makers and ice-boxes generally, and how long such boxes would stay sufficiently cold. Dr HERNIMAN (Regional Adviser in Health Services Development), replying to the last speaker's questions, said that two models of solar-powered refrigerator, one developed in the United States of America and the other produced within the country itself, were being tried out in Papua New Guinea. With regard to ice-makers, he had no information regarding any current activities in the Region. With regard to cold-boxes, which were a fundamental link in the cold chain for many countries of the Region, there was intensive activity. As the representative of the United Kingdom had mentioned, WHO Headquarters in Geneva was involved both in designing cold boxes' and in inventorying those available in various countries. But local resources had also been used to develop cold-boxes within the Region, notably, as ,had been mentioned in another context, one ~hat had been developed in the Philippines and had proved very suitable for use in certain ceuntries. In some areas, especially of the South Pacific, there was the special problem of designing an ice-box for use in boats, and some progress had been made in developing a suitable model. Dr HSU SHOU-JEN (China) congratulated the Regional Director on his excellent report and observed that the success of the expanded programme on immunization would be crucial for the attainment of health for all by the year 2000. It was therefore essential that the Regienal Office should push forward with the programme and continue to seek solutions to the problems involved. As far back as 1963, directives for the implementation of an immunization programme had been issued in China. In the light of new technical developments, the methods were now being revised and plans were afoot to make immunization coverage universal in China in 3-5 years' time. ".
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The document before the meeting set out fully and clearly the targets and the methods to be applied for reaching them. To ensure adequate results, the following points should be borne in mind: (1) immunization units should be set up to establish plans adapted to local conditions and ensure that all vaccines reached the population for which they were intended within the shortest possible time; (2) immunization personnel should receive special training and the number of trainees should be determined according to the volume of work to be done; 0) the masses had to be educated to realize the importance of immunization; and (4) a card system had to be instituted so as to ensure that there was full coverage but that nobody was immunized twice. Mr NGUYEN XUAN THU (Viet Nam) spoke of the conclusions that could be drawn from twenty years of vaccination experience: mass immunization was effective in preventing many diseases; it could often replace other preventive measures; and it was both economical and easy to apply on a large scale. In Viet Nam, immunization was carried out through the basic health services according to a programme established by the National Institute of Hygiene and Epidemiology. Procedures had been standardized. Increasing reliance was placed on the use of the dermojet, considered superior to conventional methods of injection. Vaccination was given mostly against the common epidemic diseases. BCG vaccination protected 100% of the infant population, with revaccination between the ages of 7 and 15 years. Similarly, 100% of the children under five years of age in day care centres and kindergartens, were vaccinated against poliomyelitis. 90 to 95% of the population was immunized against typhoid/paratyphoid and cholera. Depending on epidemiological indications, immunization was undertaken against plague. Since Viet Nam did not yet produce the whole spectrum of the vaccines needed, or the quantities it required, it still expected much from international cooperation. Dr LO (Malaysia) commended the Regional Director's report, which represented a systems approach to the evaluation of immunization programmes. In Malaysia, the immunization programme included all the six major diseases except measles, which it was hoped could be added when, following a survey conducted in 1976, certain weaknesses detected in the cold chain could be remedied with WHO technical cooperation. Immunization in his country was an integrated service within the medical and health services and was coordinated and supervised at the national level by the maternal and child health and epidemiology units in the Ministry of Health. Evaluation, aimed at measuring input, output and impact and at problem solving with regard to the cold chain, was conducted on a continuous basis. Much cooperation and assistance were received from WHO, especially from Dr Perkins (Chief, Biological Standardization) at Headquarters, regarding the cold chain, potency of vaccines, specifications of vaccines to be purchased, etc. Malaysia purchased DPT and polio vaccines abroad but produced its own smallpox, rabies, TAB and cholera vaccines. Smallpox vaccination had been the earliest form of immunization made compulsory, but since 1961 there had been no cases of the disease and the legislation was now being reviewed with an eye to making other forms of
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immunization that were still necessary compulsory in its place. Andof course his Government was eagerly awaiting the announcement of global smallpox eradication at the end of the current year. Given the existing infrastructure and the fact that cooperation by the population was generally good - for even where immunization had been compulsory it had never been necessary to enforce it - his Government hoped that with constant vigilance and evaluation it would eventually achieve effective prevention and control of the communicable diseases covered by the programme. Dr LAM (Singapore) said that, in her country, immunization services were well developed and were provided as part of maternal and child health services against all six diseases covered by the WHO Expanded Programme. The coverage of infants with BCG, DPT and poliomyelitis vaccination was 85-95%. Diphtheria and poliomyelitis had been virtually eradicated. Measles presented a problem. Vaccination, introduced in 1976, had been resisted by Chinese parents who believed that the disease should be allowed to run its natural course, and a health education campaign had been necessary to prepare the way to acceptance of immunization. Dr PALACIOS (United States of America) said that the 85-95% coverage achieved under the immunization programme in the Northern Mariana Islands compared favourably with any part of. the Uriited States, but it had taken many years to gain that victory, in which the only measure that had proved really decisive had been the health workers' house-to-house visits for vaccination. Even when centres had previously been set up in villages, many villagers had not come voluntarily for vaccination. Dr FAAIUASO (Samoa) said that, in his country, effective vaccination had saved many lives. There had been no case of poliomyelitis in Samoa for 10 years, no diphtheria for 20 years, and typhoid incidence had fallen from 230 cases in 1960 to four in 1978. However, improvements in the cold chain for the delivery of vaccines were necessary. He agreed with the remarks of the representative-of the United Kingdom in that connexion. An epidemic of tropical ulcer had occurred in June 1979, affecting especially children. He wondered whether other countries of the Region had experiences to share in that respect. The cases in Samoa had been subjected to the Schick test to try to determine the cause, which was thought to be a particular bacillus. Dr LINDNER (Regional Adviser in Communicable Diseases) said that the epidemiology of diphtheria, the bacillus of which was one cause of tropical ulcer, was less well known than that of any other of the six diseases included under the Expanded Programme on Immunization. Cases of cutaneous diptheria had been reported in the South Pacific many years earlier. He agreed that studies were necessary, especially to determine the role of the cutaneous form in natural immunity. Dr CHRISTMAS (New Zealand) said that quality control of vaccines was the key to the success of the Expanded Programme. He asked what facilities there were for such control in the Region. Bulk buying of vaccines might
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offer opportunities for technical cooperation comparable to those afforded with pharmaceuticals. Dr HERNIMAN (Regional Adviser in Health Services Development) agreed that such questions would become increasingly important as the programme developed, and the facilities would be especially valuable in the South Pacific. The advantages of regional vaccine supplies over those from European and ~orthAmerican countries would have to be examined, and a p-ian of vaccine requirements drawn up. The proposed South Pacific Joint Pharmaceutical Service might indeed be suitably extended for the supply of vaccines, especially in the South Pacific area.
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There being no further comments, the CHAIRMAN asked the Rapporteurs to prepare a draft resolution. (For consideration of the draft resolution, see the seventh meeting, section 1.10). 5. STATUS OF THE ANTIMALARIA PROGRAMME: (Document WPR/RC30/20) Item 22 of the Agenda
The REGIONAL DIRECTOR said that, in response to the Committee's request in 1978, document WPR/RC30/20 contained a review of the status of the antimalaria programme in the Region. It was quite comprehensive and required little elaboration. It was disheartening, however, to note that some national authorities had failed to provide budgetary support to maintain the programme at the required level. Sustained government commitment remained a prerogative for progress. Development of adequate manpower and orientation with regard to malaria of general health services staff must h~ve priority. Operational research activities were also of importance in determining the best approaches to control, and also cost-benefit ratios. Applied field research had to continue. Dr NICHOLSON (United Kingdom of Great Britain and Northern Ireland) said that his Government was cooperating with those of four countries, - two of them in the Western Pacific Region - with UNDP and WHO, in antimalaria work. The importance of multisectoral activities was receiving increased attention, and he had been particularly interested to learn that China was associating the efforts of the community, industry and agriculture with those of the health services, in its attempt to eradicate the disease • He noted that the figures given in the document for cases of malaria in Peninsular Malaysia, Sarawak and Papua New Guinea, for example, were those of 1978, and asked whether any change in incidence was revealed by the quarterly returns for early 1979, and whether there had been further development of chloroquine resistance in Papua New Guinea, in particular in the area of Bougainville. On the integration of services, he wondered whether antimalaria operations should not perhaps be the last to cease to be vertical. Dr VAN DIJK (Regional Adviser in l-falaria) replied that returns were received annually, but that available information suggested that the trends of malaria incidence were continuing.
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Chloroquine resistance had been found in the Bougainvi11e area of Papua New Guinea. The regional antima1aria team had reported resistance from all malarious countries of the Region except Solomon Islands and New Hebrides. On integration of services he agreed that there were still advantages to be gained from specialization among malariologists, but they were increasingly aware that they could not "go it alone".
Dr LO (Malaysia) said that in Peninsular Malaysia there had been 10 365 confirmed cases of malaria in 1978, compared to 13 649 in 1977. From January to June 1979, 5118 confirmed cases had been reported. In 1978, 75% of the cases had been due to plasmodium falciparum infection, 24% to P. vivax, and the remaining 1% to P. malariae and mixed infection. The ratio of falciparum to vivax infections remained unchanged at 3:1, indicating that active transmission was still going on, especially in the hard-core, under-developed central area of Peninsular Malaysia. In 1978 about 1116 malaria cases, or 11% of the total, had been among members of the security forces, and had been detected after their return from operations in the deep jungle areas. Another 1032 cases, or 10% of the total in 1978, had been among the deep jungle Orang Asli aborigines. Workers in land development schemes accounted for another 1621 cases, or 16% of the 1978 total. The total for those three groups of population accounted for about 37% of the total number of cases in 1978, while the remaining 63% of the cases were from the general kampong population. Many of the infections among the kampong people were actually infections secondary to those of the first three groups. In 1978, 226 cases, or 2% of the total, had been reported in the pre-maintenance areas - all of them "imported" cases from other parts of the Peninsula. Another 1822 cases, or 18%, had been reported in the consolidation areas, the majority of them "imported" cases. The remaining 8317 cases, or 80%, had been from the late attack phase areas situated in the hilly central areas of the Peninsula. The common characteristics of the problem areas were a very unstable population and difficult accessTbTH.ty. In 1978,158 cases were impo-rted.: from Democratic Kampuchea (2), India (53), Indonesia (10), Sabah (13), Sarawak (6), Singapore (1), Sri Lanka (1), Thailand (70), and Viet Nam (2). On 7 July 1979, 18% of the population in Peninsular Malaysia was living in the late attack phase, 40% in the consolidation phase, and 42% in the pre-maintenance phase. Malaria was already included in the curricula for the training of various categories of health personnel. Orientation seminars and refresher courses on malaria were being actively organized for the general health services personnel. Integration was also facilitated by the malaria action cornrnittees at the national, state and district levels. Steps were being taken to amalgamate the malaria eradication programme with the malaria (anti-larval) control services.
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Malaria had been included as a topic for discussion at the various meetings of the border health committees between Peninsular Malaysia and Singapore, Thailand and Indonesia. Arrangements were being finalized for a joint study by the Ministry of Health and WHO on chloroquine~resistant falciparum infections in Peninsular Malaysia. Mr NGUYEN XUAN THU (Viet Nam) said that the particularly encouraging results obtained with malaria control in his country were due to the action of a whole specialized system, from the Hanoi Institute of Malariology, Parasitology and Epidemiology, down to the commune health outposts: through provincial units and district malaria teams, the active participation of the population, appropriate·technical direction, and adequate supplies of drugs and equipment. Among the many targets set forth in the Programme for 1980 figured the reduction of incidence to 1 per 10 000 in the north and 10 per 10 000 in the south. The programme included scientific research activities, especially on resistance and on the potential contribution of traditional medicinal plants; vector and larvae eradication; training of staff; and health education, particularly in the use of mosquito netting, the destruction of thickets close to houses, fumigation and chemotherapy. Dr CRUZ (United States of America) said that his Government had been concerned to note the increase of "imported" malaria in some countries of the Region. Guam was fortunate in having recorded only a few such cases in latter years. The importance of surveillance was particularly great for an area equivalent to the size of Singapore involved in the promotion of tourism. Guam's vector control unit was integrated in the general department for health and social services. An army survey had found a potential anopheline vector for malaria. There was a campaign under way to rid the island of debris and disused vehicles as eyesores and potential breeding places for mosquitos. House-to-housevisits to identify health hazards, health education, and sanitary code enforcement were all part of the campaign, in which police, public works and other departments and the mass media were also associated. Procedures for disinsection of aircraft arr1v1ng in Guam were being revised. A WHO consultant was assisting with the surveillance measures necessary to keep the Island malaria-free. He expressed appreciation of WHO's cooperation and in particular of the interregional malaria training course in Kuala Lumpur. Dr TARUTIA (Papua New Guinea) said that the antimalaria programme was the second most important public health programme in his country, where the services were being reoriented with a view to integration. Obstacles were the refusal by the population of certain measures, difficult terrain, and the lack of personnel. Focal indoor spraying
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continued, but spraying in the highlands had been interrupted. The building of new roads and the movement of popula.tion with the changing economy had led to an increase in the number of malaria cases. It was hoped that it would be possible to introduce improvements under the new four-year plan, especially in coastal areas. Vector control involving environmental measures was in progress in urban areas, and a trial cornmunityspraying operation had been started in one province. It was hoped: that evaluation of the results by the end of 1979 would indicate the value of extending it to other areas. Chloroquine resistance had been found in three areas. A pilot project for the distribution of antimalarial drugs was planned, with WHO cooperation in an area where no spraying had been carried out. (For continuation of discussions, see the seventh meeting, section 2).
The meeting rose at 5.00 p.m.