Death of humanitarian worker major loss for tuberculosis control in Africa.

852 Bulletin of the World Health Organization 2003, 81 (11) WHO News Death of humanitarian worker major loss for tuberculosis control in Africa Dr Annalena Tonelli, the Italian humanitarian worker famous for her pioneering work in the fight against tuberculosis (TB), was shot dead on 5 October in the grounds of her TB hospital in Borama, north-western Somalia. The circumstances of her death remain unknown. Tonelli had been treating TB patients from nomadic and refugee families in Kenya and Somalia for 33 years and had helped raise awareness of HIV/AIDS. WHO Director-General, Dr LEE Jong-wook, described her killing as a major loss for TB control. Tonelli had been instrumental in developing the TB treatment strategy, DOT — Directly Observed Treatment — among communities in Kenya and Somalia. In line with the DOT strategy, she had insisted that patients remain in her care until they had completed their course of medication — an essential element in the prevention of multidrug-resistant TB. “Annalena Tonelli personified courage and selfless dedication and was a model for TB workers around the world,” said Dr Nils Billo, Acting Executive Secretary of WHO’s Stop TB Department. “Her death is a loss for all of us,” he said. Tonelli’s death has drawn attention to the often dangerous conditions faced by TB and other health workers operating in conflict situations. Such conditions have contributed to a growing recruitment crisis within the TB community (see story below). “Her death reminds us of the perils facing people who risk their lives in the service of the health of others,” said LEE. O Workforce crisis a major obstacle in global tuberculosis control Tonelli’s death coincided with the release of a draft report at a meeting of tuberculosis experts in the Hague on 7 October citing a growing “workforce crisis” as one of the major obstacles to successful global tuberculosis (TB) control. Poor pay and conditions, unhealthy and often unsafe working environments, together with HIV- related illness among staff, are restricting progress towards the global target of detecting 70 per cent of all new infectious cases and curing 85 per cent of them by 2005, the report said. Delegates from the DOTS [directly observed treatment strategy] Expansion Working Group, a group of TB experts from the Stop TB Partnership (a global network of individuals and organizations committed to eradicating TB), reviewed the current status of DOTS and its impact on the global targets. The report concluded that a rapid expansion of DOTS across the world is now required if the targets are to be reached. It also identified key constraints including the slow and ineffective recruitment and training of TB health workers in developing countries. “We are clearly seeing a general ‘workforce crisis’ in the TB community,” said Dr Mario Raviglione, Director of WHO’s Stop TB Department. “The challenge we face with TB is too great for this to occur. Other priority health programmes will also face the same problem,” he said. According to the report, 17 of the 22 high burden countries which account for 80% of the world’s TB cases, said that their efforts to reach the 2005 targets are being hampered by staffing problems. “We need to promote improved working conditions for TB control staff that are attractive and also an incentive for them to stay working in TB,” said Dr Leopold Blanc, Coordinator of WHO’s Stop TB Department. Other areas for action included enhancing political commitment by raising the position of TB on the development and poverty reduction agendas, intensifying advocacy, strengthening primary health care and accelerating the response to the HIV emergency by speeding up the delivery of antiretroviral treatment to patients co-infected with HIV and TB. The final report will be released at the Stop TB Partners Forum in Delhi at the beginning of December 2003, when partners will gather to assess the status of global TB control. O WHO launches guidelines to speed up delivery of anti- retroviral drugs to HIV/AIDS patients Experts from WHO’s HIV/AIDS programme are developing a standardized set of guidelines to simplify and speed up the delivery of antiretroviral (ARV)Annalena Tonelli at her 200 bed tuberculosis hospital in Borama, north-western Somalia. UN HC R/ E. P ar so ns 853Bulletin of the World Health Organization 2003, 81 (11) WHO News medicines and treatment to HIV/AIDS patients all over the world. The guidelines which are due to be unveiled on World AIDS Day on 1 December will be followed by a massive training programme to instruct thousands of nurses and other medical workers in the new procedure. Both guidelines and training are part of a new WHO drive to address the failure to deliver ARVs to the millions of people who need them in the developing world. WHO declared this a global public health emergency on 22 September at the UN General Assembly High-Level Meeting on HIV/AIDS in New York. “ARV [antiretroviral] treatment is still very tailored to individual patients which means that a huge number of ARV combinations are possible,” said Gottfried Hirnschall from WHO’s HIV/ AIDS department, adding that this makes drug procurement and training unnecessarily complicated, time- consuming and more costly. The idea of a single standardized ARV procedure was inspired by WHO’s recent success with DOTS, a standardized treatment strategy for people with tuberculosis. Standardization is one of a number of new initiatives launched in October to tackle the worsening global epidemic. The Global Fund to fight AIDS, Tuberculosis and Malaria said that of the US$ 623 million in funds it has raised and approved for new grants, about 60 per cent would be channelled into HIV/AIDS programmes. Other agencies have joined WHO in their challenge to achieve the global “3 by 5” target of delivering ARV medicines to 3 million people by 2005. The World Food Programme (WFP), for example, has joined UNAIDS to boost the UN’s response to the HIV/AIDS epidemic by working to deliver food supplies to people with HIV/AIDS in the developing world. The Bill and Melinda Gates Foundation has responded by doubling its grant to fight AIDS in India to US$ 200 million, its largest single donation so far. According to UNAIDS, around 3.97 million adults in India were infected with HIV in 2001, and warned that the disease may become, within the next decade, the main cause of adult mortality in the world’s second most populous country. As with the SARS global alert, WHO has promised to send emergency response teams of experts, at the request of governments, to poor countries with a high HIV/AIDS prevalence. So far WHO has received a number of queries and formal requests for help. A WHO emergency response team has already visited Nairobi, the Kenyan capital, and teams were due to leave for Burkina Faso, Malawi, and Zambia by the end of October. “The teams will assess the current situation in the country, agree on the WHO’s role there, help strengthen WHO’s country teams and recruit additional technical experts,” Dr Hirnschall said. WHO wants to encourage countries with a high prevalence to set more ambitious targets for delivering ARVs. Brazil is the only developing country that delivers ARVs to 100 per cent of patients that need them. WHO will also be pushing countries to raise their targets from 10 per cent in the next few years to the 50 per cent target set by WHO for 2005. This is believed to be a realistic goal because 50 per cent of people with HIV/AIDS have access to formal medical services. Another major obstacle to getting the drugs to the people who need them is price. Despite heavy discounting by pharmaceutical firms and a recently agreed trade deal to let poor countries import cheap copies of patented drugs, ARVs may still be too expensive for many countries, especially those in sub- Saharan Africa. To address this, WHO wants to help negotiate bulk orders of a standardized ARV drug combination for groups of countries, or regions, to knock prices down even further. Research published in a recent issue of the Lancet (Lancet 2003;9392:1267- 74) which presented new evidence that ARV therapy is extremely effective has provided added backing to WHO in its push to achieve the “3 by 5” target. O WHO launches blindness prevention “Tool Kit” The World Health Organization and the International Agency for the Prevention of Blindness (IAPB) has launched a CD Rom Tool Kit intended to help governments, nongovernmental organizations and health professionals to develop National Prevention of Blindness Plans. The kit, launched on World Sight Day on 10 October 2003, contains the latest information, documents, web sites and slide shows offering practical guidance on how to prevent blindness. WHO estimates that globally between 40 to 45 million people are blind and 135 million have low vision. This despite the fact that 80 per cent of visual loss can be prevented or cured, according to WHO and IAPB. “The latest research shows that the numbers of people who needlessly become blind are increasing. WHO is committed to reversing that trend,” said WHO Director-General, Dr LEE Jong-wook. The majority of blindness — an estimated 90 per cent — occurs in developing countries where it takes a heavy economic toll at all levels of society through lost productivity. “The cost of education, rehabilitation and lost productivity due to blindness has a significant impact on individuals, families, communities and nations — particularly in the poorest areas of the world. WHO will support countries in developing the right to sight,” said LEE. The leading causes of avoidable blindness and visual impairment are cataract, trachoma, river blindness and conditions in children such as vitamin A deficiency and retinopathy of pre-maturity. Their impact is accentuated by the lack of glasses and low vision aids. VISION 2020: The Right to Sight is a joint initiative of WHO and IAPB working in partnership with other UN agencies, governments, eye care organizations, health professionals, institutions and individuals. Launched in 1999, it aims to eliminate avoidable blindness by the year 2020. Govern- ments have already indicated their commitment to the initiative by the unanimous adoption of a resolution on Elimination of Avoidable Blindness at the 56th World Health Assembly in May of this year. It urges governments to develop, evaluate and implement National Prevention of Blindness Plans by 2007. O Global burden of musculo- skeletal disease revealed in new WHO report “The Burden of Musculoskeletal Conditions at the Start of the New Millennium,” a WHO report released on 27 October, aims to better prepare WHO News 854 Bulletin of the World Health Organization 2003, 81 (11) nations for the increase in disability brought about by the global rise in musculoskeletal conditions. Written in collaboration with the Bone and Joint Decade Initiative, (see our theme issue, Volume 81(9), for further details), the report provides a snapshot of the extent of the problem and its impact. It is also intended to act as a baseline against which the effects of health interventions can be measured. The 150 musculoskeletal conditions mentioned in the report affect millions of people in both developing and developed countries all over the world. They are the most frequent cause of disability and are amongst the most costly illnesses because of the long-term care and support they require. Total costs of musculoskeletal disease in the US in 2000 have been estimated at US$ 254 billion. In developing countries, the figure is estimated at US$ 100 billion, nearly twice that of total foreign aid for these nations. These figures are expected to rise. “There will be a marked increase in requirements for health care and community support in the coming years,” said Dr Catherine Le Galès- Camus, WHO Assistant Director- General for Noncommunicable Diseases and Mental Health. One of the major diseases mentioned in the report is osteoporosis. In 1990 there were 1.7 million related hip fractures worldwide and this figure is expected to increase to 6 million by 2050. (See the article, “Exercise interventions: defusing the world’s osteoporosis time bomb,” on pp X-X in this issue of the Bulletin). The reasons for the continuing rise in numbers of those affected by musculoskeletal conditions include, in the developing world, successful treatment of communicable diseases combined with a rapid increase in road traffic accidents. The increasing number of elderly people has been a major contributing factor to a similar rise in developed countries. O WHO manual on child health awarded the 2003 Prescrire Prize The 2002 French edition of “Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for care at the first-referral level in developing countries” has been awarded the 2003 Prescrire Prize for Medical and Pharmaceutical Books. “This guide about clinical practice, written in a simple language, entirely devoted to clinical practice with clear explanatory drawings will be understood by all health workers. It deserves to be widely distributed to all hospitals in developing countries,” said the panel of independent judges. Prescrire is a French monthly, non- profit, medical journal aiming to promote the international exchange of quality information on new drugs and thera- peutics. Each month Prescrire selects medical and pharmaceutical literature for independent review and at the end of the year, the best are shortlisted for nomination for the annual Prescrire Prize. Judges examined seven nominations selected from publications reviewed in the journal between October 2002 and September 2003 (issues 232 to 242). Three of these were awarded, in equal merit, the 2003 Prescrire Prize. The manual on child health, originally published in English in 2000 by WHO’s Child and Adolescent Health and Development Department was one of the three winners. It is intended for use by doctors, senior nurses and other health workers who are responsible for the care of young children at the first referral level in developing countries. It presents up- to-date clinical guidelines, prepared by experts, for both inpatient and outpatient care in small hospitals where there may be limited resources. The publication is a result of an international collaborative effort between specialists in child health from WHO and other experts in developing and developed countries. “The challenge was how to devise effective methods and treatment without relying on sophisticated equipment and medicines that readers would not have access to,” said Dr Olivier Fontaine of WHO’s Child and Adolescent Health and Development Department. Another WHO publication, International Travel and Health published in 2002 by the Department of Communicable Diseases, was among this year’s list of seven nominees. O Erratum In “WHO News”, in the article “New low-cost meningitis vaccine developed in record time” on page 776, of Vol. 81, issue number 10, 2003, Dr Asamoa-Baah’s remark on the importance of delivering the new vaccine should read: “The tragedy of meningitis will be compounded if we cannot get this new vaccine to those who need it most”, and not as quoted.