Sixth Mekong Plus Workshop For Lymphatic Filariasis Programme Managers, Ha Noi, Viet Nam, 24-26 April 2007 : report

(WP)2007/lCPIMVP/1.2/00 1 Report series number: RS/2007/GE/12(VTN)

English only

REPORT SIXTH MEKONG PLUS WORKSHOP FOR LYMPHATIC FILARIASIS PROGRAMME MANAGERS

Convened by: WORLD HEALTH ORGANIZATION WESTERN PACIFIC REGION Ha Noi, Viet Nam, 24-26 April 2007

Not for sale Printed and distributed by: World Health Organization Western Pacific Region Manila, Philippines March 2008 WHO/WPRO LIBRARY MAl\'lLA. PHILIPPINES

NOTE The views expressed in this report are those of the participants in the Sixth Mekong-Plus Workshop for Lymphatic Filariasis Programme Managers and do not necessarily reflect the policies of the Organization

This report has been prepared by the World Health Organization Western Pacific Region for governments of Member States in the Region for those who participated in the Sixth Mekong-Plus Workshop for Lymphatic Filariasis Programme Managers, held in Ha Noi, Viet Nam from 24 to 26 June 2007.

CONTENTS ABBREVIA nONS SUMMARY

I. INTRODUCTION 1.1 Objectives ................................................................................................................. 2

1.2. Participants and resource persons ................................ , ............................................. 2 1.3. Organization ............................................................................................................. 2 1.4. Opening ceremony .................................................................................................... 2 2. PROCEEDINGS 3

2.1. Outline of daily sessions ........................................................................................... 3 2.2. Global Updates ......................................................................................................... 3 2.3 Regional updates ....................................................................................................... 4

2.4 Country presentations of LF endemic countries ......................................................... 6 2.5 2.6 2.7 Country Presentations of Countries already eliminated LF or in the process of achieving elimination of LF) .................................................................. 15 Key Technical Points for Discussion ....................................................................... 19 Final Session-Issues, conclusions and recommendation ........................................ 25

ANNEXES Annex I Annex 2 Annex 3 AGENDA LIST OF PARTICIPANTS REGIONAL DIRECTOR'S OPENING REMARKS

Abbreviations

ABZ ADB ADL AFRO AusAID CGI CMFL COMBI DEC DFID DG EPI FBT GAELF GF GSK ICT IEC IVM LEG LF LFSC LQAS MDA Mf NGO NTD PAL PacELF RPRG RCG TAG TOR WPRO

Albendazole 400mg Asian Development Bank Adenolymphangitis World Health Organization Regional Office for Africa Australian Government's Overseas Aid Programme Clinton Global Initiative Community MfLoad Communication for Behavioural Impact Diethylcarbamazine citrate UK Department for International Development Director General Extended Programme for Immunization Food borne Trematodes Global Alliance to Eliminate Lymphatic Filariasis Global Fund G laxoSmithKline Immunochromatographic test Information, Education and Communication Integrated Vector management Legal Department Lymphatic filariasis Liverpool Lymphatic Filariasis Support Centre Lot Quality Assurance Survey Mass drug administration Microfilaria/microfilaremia Non-governmental organization Neglected tropical diseases Philippine Airlines Pacific Programme to eliminate LF Regional Programme Review Group Representative Contact Group Technical Advisory Group Tropical Disease Research programme Western Pacific Regional Office

SUMMARY

The Mekong Plus region has a diverse range of countries with few highly endemic, few countries close to elimination or others already eliminated Lymphatic Filariasis (LF). Cambodia, the Lao People's Democratic Republic, Malaysia, the Philippines and Viet Nam have made significant progress with Mass Drug Administration (MDA) in recent years. China has been acknowledged as having achieved elimination by the WHO. The Republic of Korea is in the process of documenting the elimination of LF as a public health problem and is to submit a request to WHO for its verification. Mapping in Brunei Darussalam indicated to very focal areas of low level infection which may not require any MDA. This scenario auger well with recent advances in the global programme with an increased interest in Neglected Tropical Diseases (NTD). . In April 2007, eight programme managers from the above mentioned countries, together with some resource persons and WHO staff from the WHO Western Pacific Regional Office met in Ha Noi, Viet Nam to review the status of national lymphatic filariasis elimination programmes in the region and to finalize plans of action for the coming years. The country presentations were followed by related updates on technical issues on clinical management, disability control and alleviation activities, MDA, integration of different disease specific initiatives/programmes. Extensive discussions pursued on some of the key issues identified by the participants, such as defining criteria to stop MDA, identifYing areas of operational research, promoting integration among different programmes, responding to lack human resources and capacity building, improving the role of WHO Collaborating Centres in the Region and effective planning on resource mobilization. The meeting concluded that, despite the fact that progress in LF elimination had been made in the Mekong Plus Region as a whole, there are many country specific issues that need further support. A carefully planned health economic evaluation ofLF control programme (and in general ofNTD control programmes) would be important to identifY the cost efficacy of the programmes. Cost-sharing mechanisms should be explored to ensure sustainability of integrated programmes. A consensus was drawn for some major recommendations, highlighting the following. (I) The MDA coverage should be maintained above 80% at all times for better impact. Coverage and compliance are linked to social mobilization, thus much attention should be paid for social mobilization in countries carrying out MDA. (2) The lack of DEC supplies within countries needs to be tackled, and organizations should be approached to assist the programmes in mobilizing funds to fill the gaps. WHO is in the process of setting up a process of procuring drugs for neglected tropical diseases for which better forecasting of needs is required. (3) Analysis of parasitological and clinical indicators at sentinel and random spot-check sites should be done at appropriate periods to determine the impact of MDA.

(4) The availability of ICT cards should be maintained. More research on improving the shelflife oflCTs should be encouraged. Alternative methods such as ELISA should be explored. (5) In dealing with technical issues it is recommended to identifY the county specific issues and apply strategies applicable to that country. (6) The country specific integration ofNTDs is encouraged where feasible. (7) The difficulties with funding and grants should be sorted out at country level.

(8) The ongoing reviewed new guidelines on morbidity control by WHO should be adopted in addressing the clinical management and disability in LF.

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1. INTRODUCTION

WHO estimates that over 120 million people worldwide are affected by lymphatic filariasis (LF), and 40 million severely disfigured and incapacitated as a result of this infection to this date. At present over I billion people are at risk of being infected, in 83 countries throughout the world. In the Mekong plus countries, LF is endemic in four countries, Cambodia, Malaysia, the Philippines and Viet Nam. After a long period of post-intervention surveillance, it has been acknowledged by the WHO Director-General that China has achieved elimination of LF as a public health problem. The application of Republic of Korea for verification of interruption of LF transmission has been approved by the Mekong-Plus Programme Review Group (PRG) and was sent to the LF -Technical Advisory Group (TAG) for further reviewing. The Lao People's Democratic Republic has completed the mapping with determination of one endemic district. It is estimated that the MDA will be carried out in this endemic area by the end of this year. Brunei Darussalam has also finished mapping and as the prevalence of Microfilaremia (Mf) in the four districts were found to be all below I %, no MDA may be necessary in this country at present. However, the survey showed some positive cases in children that may need further investigation before any decision can be made. The remaining five endemic countries, namely Cambodia, the Lao People's Democratic Republic, Malaysia, the Philippines and Viet Nam have completed the national mapping, with determination ofthe populations at risk, of approximately as 0.43 million, om million, 1,2 million, 26 million and 0.67 million respectively. These five countries are actively implementing the MDA targeting 22.2 million people in 2006. In Cambodia, Malaysia, the Philippines and Viet Nam, the 2006 MDA campaign has covered a greater portion of the at-risk population, achieving a reported drug coverage rate over the total population of78.5%, 70.3%, 68% and 88.9% respectively. The main partners contributing to the LF control in the region are The Gates Foundation, United States Agency for International Development (USAID), Asian Development Bank (ADB), GlaxoSmithKline (GSK) and others. The Gates Foundation donated 11 million for implementation of Global programme for NTD over four years, and USAID pledged 100 million targeting primarily five NTDs, including Lymphatic Filariasis. The ADB provided 30 million USD for NTD targeting three Mekong countries (Cambodia, the Lao People's Democratic Republic and Viet Nam). GlaxoSmithKline (GSK) has made a long term commitment to donate Albendazole during the entire length of the global programme While the Region is ahead of many other regions in controlling the LF situation, countries in the Region share common challenges such as the low coverage ofMDA (less than 80%), lack of proper analysis of the impact of MDA at sentimental sites, the lack of good supply of DEC, problems with procurement of DEC and lCT cards, lack of surveillance systems in detecting resurgence, and financial constrictions in implementing process. This conference is a timely opportunity for Filariasis Programme Managers of Mekong plus countries to review the status of national lymphatic filariasis elimination programmes, share information and experiences of the various stages of elimination activities that has taken place over the past year, and to decide on the next steps and strategies to meet the challengers of the region and to improve the regional collaboration.

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1.1

Objectives By the end of the meeting, participants would have, (I) reviewed the status of national lymphatic filariasis elimination programmes and finalized

plans of action for the next 12 months; (2) exchanged information and experiences among countries at various stages of the elimination process; and (3) been updated on key technical matters including monitoring, evaluation, social mobilization, and disability control and alleviation activities. 1.2. Participants and resource persons

Eight programme managers as country participants from Brunei Darussalam, Cambodia, China, the Lao People's Democratic Republic, Malaysia, Republic of Korea, the Philippines, and Viet Nam, representing the Mekong Plus region, attended the meeting. In addition, there were five temporary advisers, four observers and eight WHO secretariat members at the meeting. The agenda and list of participants are attached as Annexes I and 2. 1.3. Organization

The meeting was held in Ha Noi, Viet Nam, from 24 to 26 April 2007. The two and a half working days were divided into global and regional reviews, country reviews, extensive discussions on key technical points including case studies and conclusions and recommendations. There was adequate time for discussion after each presentation and on technical issues. 1.4. Opening ceremony

During the opening ceremony welcome address was delivered by Dr Lokky Wai, Officer in Charge of the WR's Office in Viet Nam on behalf of Dr Shigeru Omi, WHO Regional Director for the Western Pacific. He welcomed all participants to the VI Lymphatic Filariasis Programme Managers Workshop, on behalf of the host country and pointed out the magnitude of the problem caused by LF globally. Dr Lokky Wai further acknowledged World Health Organization's (WHO) efforts to launch a global initiative to eliminate LF, which poses a major public health problem today. He stated that Viet Nam is committed to eliminate LF by the year 2020. He urged the participants to use this conference as a good opportunity to review activities that have taken place over the last year and discuss the future steps and strategies. The text of the WHO Representative's speech is in Annex 3. Prof Le Khanh Thuan, LF programme director in Viet Nam, on behalf of the Ministry of Health of Viet Nam, extended his gratitude to the secretariat, consultants, partners, and participants for their cooperation towards elimination of LF in the region and in Viet Nam. He noted that this workshop was a timely initiative to encourage countries to continue their good work. Dr Antonio Montresor introduced Dr John Ehrenberg and his functions as MVP's new Regional Adviser, followed by self introduction of the participants. Dr John Ehrenberg proposed Professor c.P. Ramachandran as the Chairperson, Dr Simuon as the Vice-Chairperson. Dr Sulaiman, Dr Haji Junaidi, Dr Raman Velayudhan and Dr Antonio Montresor were proposed

-3-

as the Rapporteurs for the duration of the workshop. Dr John Ehrenberg further provided brief comments on the achievements towards the target of elimination of LF in the Region, expressing his desire to follow on Dr Kevin Palmer's footsteps and work closely with the programme managers. Professor C.P. Ramachandran acknowledged Dr Palmer's outstanding leadership and his contributions to the Region. He suggested that the meeting is a means of acknowledging the experience and talent of the participants working in areas of LF control. He extended his appreciation to the present participants for their contributions towards the progress made in the region. The administrative remarks were delivered by Dr Montresor.

2. PROCEEDINGS

2.1.

Outline of daily sessions

On the first day the workshop started with Global update by Dr Biswas and Regional updates by Dr Ramachandran followed by country updates. Cambodia, Philippines, Malaysia and Viet Nam presented the country presentations on the first day including the history ofLF, mapping situation, MDA situation, monitoring and evaluation, and the plans for scaling up ofLF control in the future. The second day first session began with country presentations from Brunei Darussalam, the Lao People's Democratic Republic, Republic of Korea, and China and second session started with the technical points and discussions. Technical sessions and discussions started on the second session ofthe first day, included case studies of Philippines and Samoa with regard to MDA and updates on clinical case management. Third day continued with the technical issues and further discussion on the integration of neglected tropical disease (NTD) control programmes and exploring of opportunity for synergies. Finally, Professor C.P. Ramachandran presented the milestones, challenges and a summary of the meeting including the issues discussed and all participants jointly reviewed the conclusions and recommendations. 2.2. Global Updates

Dr Gautam Biswas, Medical officer for filariasis Elimination of the Department of Neglected Tropical Diseases ofWHO/HQ, presented the updates on the global programme to eliminate LF. There are critical issues that need to be addressed concerning the burden of LF associated disabilities. Programmes need to identifY the priority areas and plan measures to prevent further disabilites. All patients with lymphoedema need to be provided with access to the knowledge of self-care regardless of the aetiology and an element of social and economic rehabilitation also needs to be incorporated into these programmes. Referral services for patients with complications and for those below the age of 15 years needs to be planned. Management of acute lymphangitis needs to be located within the primary health care settings. Both Adenolymphangitis (ADL) acute attacks criteria and its treatments are now dealt within a draft guideline protocol prepared by the WHO. The outcome of this meeting was mentioned in the WER Publication, Volume 81, No. 40 pages 373-384

- 4-

MDA is now implemented in forty two countries. Half of the total population at risk is now covered with MDA. In 2005 and 2006 the overall treatment coverage was more than 60% in the treated community. However, the implementation and continuation of the MDA needs to be more sustainable. Countries will need to allocate resources within the national and district health plans for sustainable implementation and up-scaling to cover the entire population at risk. Progress has been made with MDA but a lot of challenges still remain. After reviewing the data from 700 sentinel sites around the world, we were able to see how one round of MDA resulted in a 60% decline in microfilaraemia in regards to the baseline. This declined increased further after five rounds of treatment. It is estimated that at this point, a significant reduction would have been achieved and resurgence is unlikely to occur. However, in certain situations based on lower drug coverage, high initial infection level and specific parasite vector situation, more than five rounds of treatments may be required before the criteria for stopping MDA can be met. It has become evident that the systematic collection of data on programme impact is critical for evaluation purposes. For areas with high levels of microfilaraemia, more than five or six rounds of MDA may be required. This calls for studies of alternative cost-effective interventions. Timely procurement of DEC continued to be a challenge and is being addressed through better forecasting and procurement process. The global programme must complete the mapping in the African Region and in Indonesia. There have been key advances in the global programme with an increased interest in NTDs. The Gates Foundation donated II million for implementation over four years, and USAID pledged 100 million for NTD targeting primarily five NTDs, namely lymphatic filariasis, onchocerciasis, schistosomiasis, soil transmitted helminths, and trachoma. Proposals are requested for the up coming year for possible funding. The Asian Development Bank (ADB) provided 30 million USD for NTD targeting the three Mekong countries. The Director General of WHO also had shown her interest to NTDs in her recent speech in Thailand and again at headquarters. During the past five to six years the main focus was on LF. Now we must work within the broader scenario which calls for a wider frame encompassing other NTDs and integrating them into the existing health care systems in order for them to be more sustainable. Resources must be mobilized from the health care budgets at national level, as well as Provincial or District levels. Capacity building at District level is crucial which includes monitoring & evaluation, and not only MDA. Corrective actions can then be implemented at a local leveL Vector control needs to be assessed where it would be more cost-effective in supporting MDA. 2.3 Regional updates

On behalf of Dr Kevin Palmer, Professor Ramachandran presented an overview of the current impact ofMDA in the Mekong-Plus countries of the Western Pacific Region. The Region as a whole has a lower LF burden rate as compared to the South-east and African Regions of WHO. There are few highly endemic countries, which have low rates of clinical disease. (Map I) Significant progress has been made in the four countries (Cambodia, Malaysia, the Philippines and Viet Nam) implementing MDA in the Region. Disability prevention has been more important in the Philippines and to some extent in Malaysia. The focus on this has been less in other countries, partly because it poses a lesser problem for them. The Philippines needs to scale up the control of disability alleviation programme for LF patients. China is close to obtaining approval by WHO for elimination ofLF as a public health problem. Brunei Darussalam, the republic of Korea, and the Lao People's Democratic Republic are close to eliminating LF although there had been recent reports of four positive cases in the Laos-Viet Nam border. The discussion followed by the presentation among key stakeholders brought up issues such as cross border population movement and the migrant workers from endemic areas and the importance of surveillance in determining the extent of the actual

- 5-

problem. It was pointed out that remnant and resurging cases can only be detected if a proper surveillance system is functioning in these areas. Dr Andy Wright, Director of LF Elimination Programme ofGlaxoSmithKline (GSK) presented the updates from GSK and on behalf of the Executive group/GAELF. He mentioned that he had taken personal interest towards the elimination Programme in the Region. He explained he is wearing two hats during this meeting, one on behalf ofGSK and another for the executive group of the Global Alliance for the Elimination ofLF (GAELF). The GSK's flagship ofLF programme has been extended into a long term commitment by the company to donate Albendazole during the entire length of the global programme. The Mekong Region is the recipient so far of II % of all of the Albendazole tablets donated globally by GSK. The the Lao People's Democratic Republic had neither applied nor received any Albendazole so far, the Philippines is the largest recipient of the drug in the Region. Dr Andy Wright further mentioned that the LF programme is an elimination programme, and this focus of elimination should not be lost during the NTDs integration approaches. He mentioned that a new executive group was recently elected with six members for GAELF. New terms of reference were established followed by a work plan, budget and communications' plan. This was funded by the GSK. Advocacy has been a key element to the Global Alliance. The Pilipinas Shell Foundation Inc. awarded US$ 10,000 to support MDA in the country. The Gates foundation has recently awarded of 11.7 million USD to the Global Alliance to be successfully mobilized over four years, for the project entitled "Resolving the Critical Challenges Now Facing the Global Programme to Eliminate LF". Dr Eric Ottesen works in the capacity of the Principal Investigator (PI) in this project. The grant was developed by the LF research community and will be managed by the LF Support Centre in Atlanta on behalf of GAELF. Its goal is to ensure the success ofthe GAELF in finding solutions for the operational challenges and potential barriers of today. Most of the successful fundraising efforts by the GAELF were however to support Africa for LF elimination programmes. Sponsors are currently more interested in an integrated approach for NTD. The Gates Foundation supported a few projects in AFRO, with a budget of US$5 to US$ 10 million each, for implementation of research on integrated NTD control. Discussions took place on the global NTD control network spearheaded by Dr Peter Hotez in Washington D.C. The USAID has decided to grant a US$ 100 million to be utilized over five years for NTDs including LF. It is meant to support an integrated control ofNTDs world wide. At present there is a call for letters of interests which will be repeated before the end of this year. The Clinton Global Initiative (CGI) and the Jeffrey Sachs' Millennium Village Initiative, has become an active group of partners linking with GAELF recently. The next GAELF meeting will be held in Fiji, from 1-3rd of April, 2008. The executive group of the GAELF has made significant progress in mobilizing resources effectively. Feedback from involved country would be appreciated on the work of the GAELF for an effective and successful meeting next year. Ms Joan Fahy, the Programme Coordinator of Lymphatic Filariasis Support Centre (LFSC) at Liverpool School of Tropical Medicine, briefed on the support centre activities and GAELF, and mentioned that the representative contact group had not been very effective in communicating with the GAELF and revealed about the lack of feedback. It was expected that this meeting would provide good feedback on how to improve the effectiveness of GAELF. This Region has a vacancy for the Representative Contact Group (RCG).

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Map 1: The Map on LF status in Mekong-Plus area in April 2007

..

• ..

Endemic countries Non-endemlc countries

Applied 10 WHO for veriflcallon of LF ellmlnatiOflll8s public health problem

•

SEAR countries

2.4 2.4.1.

Country presentations of LF endemic countries Cambodia

The LF distribution within the country is demonstrated in Map 2. 10 Cambodia the initial activities for LF elimination began in 1999-2000. 10 2003 a National task force for LF was established. MDA started in 2005 in the country and aiming for completion by 2009. Two rounds of MDA have been completed so far. MDA was carried out by modes of door-to-door, schools, pagoda, and gathering people to the central of the villages etc. Drugs used include DEC in combination with albendazole. The main side effect reported during the MDA in 2006 from the endemic provinces has been dizziness of mild degree (39% of all reported side effects) and moderate degree (2.3% of all reported side effects). Other side effects noted have been nausea, fever, fatigue, headache, vomiting, diarrhoea and abdominal pain.

-7 -

Map 2: Lymphatic Filariasis distribution in Cambodia

The impact of MDA was measured by the increase of MDA coverage and the reduction of Mf prevalence. Treatment coverage in 2006 was more than 85 % in alIlmplementation Units (TU). Results of surveys of Microfilariasis in sentinel sites in two provinces and four districts for 2006, all proved to be negative. The budget for the third round of MDA in 2007 is currently pending. Total funds required to maintain the MDA is estimated as US$ 58,000. Committed donors so far have been ADB, CDC, as well as some contributions from the government for IEC materials. The total number of lymphoedema cases detected within the country has been 58 (Graph I), while hydrocoele cases have been 19. 50 cases selected had been trained on health and personnel care and followed up long term. The MDA programme has been integrated with the deworming programme since 2005. Monitoring is carried out through household visits by evaluation of clinical manifestations or by looking at the morbidity component. The programme requires 820,000 DEC tablets as specified in the 2007 Plan. Other plans for 2007 are to carry out sentinel site and spot check site before third round of MDA, and to initiate activities on the prevention of morbidity and disability management.

-8-

Graph 1: Clinical cases of detected in 14 Provinces in Cambodia 70 60 50 40 JO 20 I

58

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4

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_______ L ___---- 4 6

10

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In principle, the government agreed to use ADB funds for LF programmes. Finances are yet to be decided based on prioritized funding allocations. The government of Cambodia has so far contributed 50% of the total budget, although apparently funds have been distributed by MOHlMinistry of Finances, and not by the ADB. A key point is advocacy. The WHOIWR office in conjunction with the MOH is to mobilize funds for the purchase of DEC. 2.4.2. Malaysia The vector-borne disease control was established as an integrated programme in Malaysia in 1983. Filariasis was integrated with other vector-borne diseases such as malaria, dengue fever, Japanese encephalitis and scrub typhus. There were 17 Filarial control teams throughout Malaysia, headed by a medical assistant. However, programme integration led to the dilution of these special teams. Many medical assistants transferred, were promoted, or retired, and were replaced by public health assistants. Their functions were quite similar, though the latter were not specifically trained for clinical examination. They took night blood samples during 'probe surveys' and treated microfilaraemic cases. They also conducted mass drug administrations in localities with positive infection rate of 3% or more. Urban W. bancrofti was eliminated in early 1980 and filariasis was removed from the notifiable disease list. However, expansion of the filariasis programme has been limited due to lowered priorities for LF funds.

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Map 3: LF distribution in Malaysia ,.-,...,-,,----:---:---,

•

Endemic areas Non-endemic In Malaysia, 6 out of 12 states in the peninsula have endemic areas as shown by the Map 3 above. As some endemic areas can be too small to be seen on the map, they are represented by districts, making the endemic areas seem larger than they actually are. Microfilaraemic (Mf) rates have come down to less than 1% in the peninSUla. The IU is the mukim (sub-district) at in Peninsular Malaysia and Sabah, and sector/wne in Sarawak. In 200S it was determined by household census that 117 endemic IUs contributed a total endemic population of I 202390 people (about 4.6% of the total country population at that time). MDA was started in Sabah in 2003 as a pilot programme. The National Lymphatic Filariasis Elimination Programme was also launched in Sabah in October of the same year. The first cycle of MDA for the whole country was completed in 2004. The fifth MDA cycle is expected to be completed by 2008. Lymphatic ftlariasis e1imination status is expected to be achieved before the end of 2013. The mode of MDA has been door-to-door delivery, with follOW-Up mapping carried out to achieve higher population coverage. For each IU, the period taken to complete the MDA is about one month or less. However, there were occasional areas that took longer. Reasons for delays included barriers to accessibility (such as floods or collapsed roads) and disease outbreaks of a higher priority requiring redeployment of personnel. States are given flexibility to complete the particular cycle of MDA for all their IUs within a year, though they usually take four to six months. The coverage of MDA in the treated IU is about 70% of total population. In Sabah this rate is as high as 90% of the population, but in Sarawak the drug coverage has remained lower. There was a significant left-over of Albendawle and DEC tablets from the 2006 administration. This partly resulted from redefinition of endemic areas, and hence the programme did not request albendawle for 2006. A request for 2007 was placed.

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' ill . 1u~ I 2007 Table 1 U IpC dateddataon MDA coverage 0 fTota vs El" atJon .!B!'ble~uI State Kedah (2) Perak (12) TotalIU population 21.468 50.584 17.683 300.676 125,024 54,837 168.048 447.254 1,185,574 Total eligible population 19,885 44,316 16,804 266,861 111,911 50,815 149,696 253,045 913,333 Total population who ingested dru~

% coverage of

% coverage of

total population 88.49 76.97 80.70 80.76 83.87 90.45 82.34 50.55 70.34

eligible ~Iation

18,996 38,935 14,271 242.839 104.860 49,598 138.364 226.070 833,933

95.53 87.85 84.93 9100 93.70 97.61 92.43 89.. 34 91.31

lohor (17) Pahang (28) Terengganu (19) Kelantan (3 ) Sabah (6) Sarawak (30) Total

There is no proper structure in place to address morbidity or disability alleviation in Malaysia at present, though the access to health care is fairly satisfactory within the country. It was initially planned that each endemic state was to have at least one designated filariasis clinic. However, over the years of implementation of the elimination programme, not a single acute case was detected, A few chronic cases were detected and they were seen at the hospitals, The allocated budget from 2006-2010 should be RM$3.2 million a year, and these costs have already been absorbed into the operational budget. Funding for the elimination programme in Malaysia can be sustained to the end. The government is committed to see to its success, The Malaysian government is committed to the success of the elimination programme, and funding can be sustained until the end of the program. The main issues the programme is facing are poor central coordination and a lack of supervision. This is naturally expected in an integrated system, where supervision is expected to be decentralized. Other challenges include maintenance of a proper flow of reporting and assessment of reports, and the need of independent evaluation. There is a lack of financial resources at the Institute of Medical Research (lMR) to support some of the research on technical issues. The IMR as a research institute is more interested in the agent and host (especially animal) aspects of the disease, whereas the programme side is more interested in the operational technicalities, As far as elimination programme implementation is concerned, there have been no new technical issues, and the technical committee has not been convened after its first sitting. The technical committee should convene again to prepare for the main technical issue that is coming which is the evaluation of prevalence (antigenemia) in the endemic areas after the completion of the fifth cycle ofMDA in 2008. The spot and sentinel surveys are conducted in the endemic areas. However, since most areas have now shown a very low prevalence or zero prevalence, microfilarial density is almost a non-issue. In summary, in many areas of Malaysia, except for Sabah, Mfrates reported have been less than I %, and there have been very few clinical cases reported, The zoonotic nature of the infection is important to keep in mind, as it can lead to a resurgence of the infection, Socio-economic development in the region would certainly have a positive impact on disease

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control and elimination. Specifically, the introduction of lymphatic filariasis by foreign workers from endemic countries is a big challenge when the vectors are still abundant. 10 2006, 80% of 172 total cases were contributed by foreigners. The rapid diagnostic tests such as the BrugiaRapid will be used in prevalence evaluation post-MDA, after 2008. They have also been used in screening 2.4.3. Philippines In the Philippines Mf prevalence was recorded as 9.7 per 1000 popUlation in 1998, and selective treatment with DEC had been used during the past. 40 endemic areas and 38 non-endemic areas have been identified during mapping of disease burden except for one province which is under validation at present. The LF elimination programme had decided on the Province level as the IV as there were too many municipalities in the country. However in the cities, the IV had been agreed as the district. Out of 40 endemic areas, 39 have Mf prevalence of> I %. There are 39 endemic areas where MDA was taking place. The MDAs starting dates varied from 2002-2006 in different endemic areas, and is expected to complete between 2006-2010. The modes used for MDA have been house to house, fixed sites/ health fairs and combination of both. It was calculated that MDA coverage rates as a whole were 68% over total population, and 76% over eligible popUlation. The national geographical coverage was over 80%. However, six provinces had coverage of 65% or less in 2006. Using ICT, two provinces out of six where Lot Quality Assurance Survey (LQAS) was done, were found to have high positivity rates. Among the 39 MDA carried out areas, only two sites showed an increase in MFR while the majority of the sites revealed a decrease in MFR (Among all 41 sites of survey, 39 sites recorded decrease in MF Rates).

Map 4: LF mapping in Philippines in 2007

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Endemic Non-endemic areas Under validation

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in Philippines Graph: 2: Mean increase/decrease in MFD (%) by Province of MDA areas 100.00

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~

Province

medium , high), on There was a clear association between coverage classification (i.e., low, sites (72%) 26 MFDs, e baselin with sites the degree of reduction on the MFR. Out of the 36 ed MFDs. increas showed (28%) sites showed decreased MFDs after four rounds of MDA. Ten red with at registe (9.5%) As for the impact of MDA on antigen levels, 2 out of21 municipalities in child r anothe and least one child found positive using ICT, (one child in South Cotabato ces provin e in other Mindoro Oriental were found positive for ICT), no child was found positiv MDA was formally integrate with the de-worming campaign in 2006. campaign, such as Several local organizations have provided funding for LF elimination Shell Foundation, the the Culion Foundation, Peace and Equity Foundation , Insular Life Inc., drugs. Priority areas with ments govern Coalition to eliminate LF (CELF), and the municipal 12) where governors 11& n (Regio have been those with low MDA coverage, such as Mindanao mme "Kick off progra LF and mayors in the country have contributed to the launching of the International for ment Filariasis campaign 2006". External donors such as WHO, UK Depart ID) and GSK (AusA mme Development (DFID) , Australian Government' s Overseas Aid Progra . have provided financial support to the programmes within the country event The available budget for purchase of DEC has been limited . A fund raising president of former , Ramos Fidel Mr of ment organized by DOH and WHO with active involve mobilize the to effort an as (00) 19 $US ly the Philippines, had raised PHP 800 000 (appro ximate for two DEC of se purcha red sponso local resources. Furthermore, the Shell Foundation had leT cards of lack the are, mme provinces. The main problem s faced by the LF elimination progra tablets DEC of size for surveillance at the sentinel sites, delay in shipment of DEC, and the makes the ingestion difficult for some people including children. have been the Some of the achievements made in Philippines during the recent years partners, establiShing a strengthening multi sectoral partnerships with both local and international ation and improving clear action plan, improving health promotion and advocacy, social mobiliz an LF elimination created Health of ment Depart monitoring and evaluation of programmes. The also generated has It n. entatio implem of database which has helped generate reports at all levels The plan is lance. surveil for g a master list for MDA, a drug inventory, and an endemic mappin coming the in mmes progra is to integrate Soil Transmitted Helminths (STH) and Schistosomias years.

- 13-

Though some disability data has been available (such as 106 cases ofhydrocoele available from Davao Sur), actual information on overall disability situation needs further study. Around 1 million people live at risk of LF infection in conflict stricken areas. The control programme has proven difficult in these areas to integrate with other programmes (e.g. EPl) for effective programme expansion. UNICEF is one of the UN agencies which have been teamed up in these areas. EPI volunteers from these areas are recruited and trained centrally to integrate MDA with routine immunization where ever feasible. The financial support offered by Global Fund programme may help in integration of programmes in these areas in the future. There are "good village health worker programmes" in the country that have been functioning for two or three decades. These workers have been visiting households to monitor implementation of the LF programme. They also conducted MDA and implement COMBI (communication for behavioural impact). 2.4.4 Viet Nam There are two species that cause LF, in Viet Nam, namely Brugia malayi in the North accounting for 80-95% of infections, and W. bancrofti in the South. In the North during the time from 1960-1975 the infection rate was 6.0 I %. But it has gradually reduced to 2.01 % during the time period of 1976-2002. In the South LF is localized in some focuses, and the infection rate have been varying from 0.39% to 13.3% during the time period of 1977-2000. The distribution of LF in Viet Nam is seen in Map 5. Total estimated number of elephantiasis patients in the country is about 5,000 at present. The treatment was given only to some positive cases before the Programme to Eliminate Lymphatic Filariasis in Viet Nam started in 2003. Since then the programme has made very good progress, especially with the increasing number of learning courses aiming at self care aspects in elephantiasis patients (12 courses in 2005 had risen to 27 courses in 2006). The feed back information after six months of completion of the courses showed, there was a good improvement in the life aspects of patients, such as having less complicated signs, and increased levels of self-confidence. The IEC activities in the country include distribution of leaflets, posters, slogans about LF, through mass-media, through loudspeaker system, and through direct lEC. The results from annual KAP surveys, showed that the number of persons knowledgeable about LF, the complications and the treatment modalities had increased over time.

- 14-

Map 5: Endemic areas of LF in Viet Nam

PhuCu Binh Luc

Ninh Hoa

-

Dien Kbanh Endemic an

Non-endem Unknown a

•

BacAi

• Graph 3: Drug coverage by tota] population and by eligible population in Viet Nam in 2006

MDA fust started in 2003 in Viet Nam with 6 IUs at the District level. It was implemented by house to house and gatherings in some public places. Three rounds have shown to bring down the MF infection rates in sentinel sites and spot check sites. Impressive treatment coverage ahove 90% was achieved in the 6 IU (Graph 3). 0.17% of the total treatments

- 15 -

experienced adverse drug reactions. However, they were reported slight and transient. Funding for one round of MDA in 2008 is available in the resources granted by WHO and ADB. Efforts should be taken to develop proper surveillance systems even after LF has been eliminated. More attention has to be paid in recording of severe and adverse events rather than mild side effects. (Most mild side effects are normal and do not need to be recorded). As all the other countries in region, Viet Nam also should pay attention to improve the quality annual report. 2.5 CountrY Presentations of Countries already eliminated LF or in the process of achieving elimination of LF)

Steps for applying for verification of interruption of transmission appear as below: The country interested in applying for verification needs to contact WHO to inform the Organization that it has eliminated LF as a public health problem, with evidence of proper surveying. The Regional Programme Review Group (RPRG) then reviews the case and provides recommendations to HQ. HQ's will submit the report to the consideration of the Technical Advisory Group (TAG) for review and recommendations to the Director General (DG) of the WHO. The DG then considers endorsement. The letter requesting DG to acknowledge China as a country eliminated LF is now in process. The recommendation of the TAG-ELF was that China keeps up surveillance to prevent a resurfacing of LF. RPRG also calls upon this country to maintain its active involvement and continue providing its technical expertise through the RPRG and other technical bodies. 2.5.1 Brunei Darussalam Brunei with a popUlation of 383 000, consists of densely forested swampy areas. Presence of Brugia Maliya in the country was noted in the past. LF is regarded as a notifiable disease although active surveillance was discontinued in 1992 due to low incidence rates. WHO has conducted a review of vector borne diseases program in Brunei in 2004, and reviewed the filarial status in 2005. Map 6: Brunei Darussalam BOfItIt

Ohm. Sa

- 16-

As per WHO advice, the National Filarial Survey began as a measure of identifYing the true situation of filariasis in Brunei in 2006, and is currently in progress. The objectives of this survey were, to ascertain prevalence of filariasis in Brunei Darussalam, to ascertain the level of disease transmission, and to identifY key actions to achieve eradication of filariasis in the country. The survey covered all four districts with cluster sampling and expanded over one year with Part I and Part 2. Currently part 1 has been completed and part 2 is ongoing. Preliminary results of the night sampling survey showed overall low prevalence of filariasis with <1% of positive samples in all districts tested. (Table 2) Table 2: Prevalence of Filariasis in Brunei Darussalam

DISTRICT

POPULATION

NO. OF SAMPLES TAKEN 9,135 2,492 1,791 993

NO. OF POSITIVE SAMPLES 2 (0.02%) 13 (0.52%) 8 (0.45%) 6 (0.60%) 29 (0.20%)

BRUNEI MUARA TUTONG BELAIT TEMBURONG TOTAL

264,700 44,400 63,900 10,000 383,000

14,411

Certain districts had higher prevalence rates compared to others, for example Tutong 0.52% and Temburong 0.60%. Out of the few cases detected in the survey, most were found among the oldest age group (>61 years of age). There were few positive cases in the primary school LQAS, and presence of Brugia malayi in school age children strongly suggested transmission of LF in these areas. First cases were picked up accidentally. No morbidity was picked up during these surveys. MDA is currently being considered in certain Districts in Brunei Darussalam. The districts which were revealed as ongoing transmission, by positive night blood samples, among school children, can be to be targeted by MDA. Since the prevalence was below 1%, it was considered to continue the selective treatment of the Mfpositive cases and to continue with the current LF surveillance, as it is surrounded by endemic Malaysian border (Map 6). Consideration was given to hold the initiation ofMDA at present, to complete the analysis of the data from the survey and to reassess the situation next year for a final decision. Since the health system in the country is among the best in the world, the system is in place to provide MDA through schools and to the general population, if MDA is to be initiated in Brunei Darussalam. 2.5.2 the Lao People's Democratic Republic LF is a considered to be a rare disease in the Lao People's Democratic Republic. The first case detected was in 1925 and was described as a single case ofW. bancrofti in Vientiane. Very few cases also have been reported with Lao patients diagnosed with microfilaria over the years before the initiation of the National LF control (NLFC) in 2003. From 2003 onwards the LF activities have scaled up with surveys, mapping and identifYing individual cases and treating accordingly. Between 2003 and 2005 two National surveys were carried out in 14 provinces of the Lao People's Democratic Republic, involving 30 districts, but found no positive LF cases among 9286 people examined. The third National survey in 2007 in three provinces, involving

- 17 -

six districts confirmed four human cases in Anopeu province, bordering with the district of Ngoc Hoi, in Viet Nam. These cases detected were treated on individual basis only. Since the initiation of NLFC, mapping of LF in IUs has been in progress and being corrected based on the outcomes of the blood surveys. Mapping of LF in suspect areas would be completed by the end of 2007 (Map 7). Based on the current results only one IU is categorized as endemic, 57 categorized as non-endemic and 82 IUs as unknown, out of 140 IUs. Table 3: Results of LF

from the 3'" round of MD~

provinces

IU districts

villages

pers. tested

outcomes

Kbong Attopeu

Phouvong

Map 7: Status of LF affected IUs in the Lao People's Democratic Republic

_

Endemic areas Non-endemic areas Unknown areas

c::::J

Thougb the Lao People's Democratic Republic is a very low prevalence country of LF, it is important carry out additional surveys, especially in areas of difficult accessibility, as the magnitude of the country' s morbidity rates are yet to be identified. Suggestions were made to review cases of morbidity. The leT testing positive in four cases in the South, should lead to

- 18-

discussion whether there would be a need to conduct MDA. ADB is setting up a health system in the country which could benefit the NTD programmes including LF. A large scale treatment program of Soil Transmitted Helminths (STH) is scheduled to take place in the province of Attapeu and in the rest of country, together with the deworming programme in schools. It was recommended strongly not to implement the MDA of LF and STH treatment in combination, as a measure of minimizing adverse reactions of the drugs involved. Further funding is needed for completion of the mapping project, for continuation of the LF morbidity control and disability clinical management, and for implementation of MDA, if decided to carry out in near future. It is expected that the current situation of funding from ADB may change by 2008. 2.5.3 Republic of Korea Korea has eliminated LF as a public health problem (the programme handed a report to WHO and other participants during the RPRG meeting which was also sent to HQ's). The LF is expected to be an imported disease in Korea, through commercial operations of navigation routes from China and South East Asia during the Koryo dynasty (935-1368AD). LF infection in Korea was due to B. malayi, with few if any complications encountered in W. bancrofti infections, such as hydrocoele or elephantiasis. Endemic filariasis was reported from south middle part (Chungcheongnam-do) of Korea in 1929. During the I 950s, several investigations showed that night blood smear positive rate was 8.6-22.2%. There had been three main foci in the Republic of Korea, namely Northeastern part ofGyeongsangbuk-do, Western coastal areas of Jeollanam-do, and Jeju-do. Vector mosquito was Aedes togoi in Jeju-do, and An. sinensis in inland. Mass treatment with diethylcarbamazine was introduced in endemic areas. Jeju island in the South had the highest MF rates during the period of 1952-1979. Seo et al reported differences of microfilaria among night blood samples of soldiers (3.5%) and inhabitants (17.6%) of the island in 1968. Overall night blood smear positive rate in country was 8.6%. MDA was done nationwide back in the 1970's resulting in a drop in the prevalence rates from 8.2% to 0.3%. In Gyeongsangbuk-do, no case was detected since the 1980s. A survey carried out between 1986 and 1989 revealed there was still a foci in Jeju island. The programme implemented MDA with Ivermectin and Albendazole. A subsequent survey was conducted between 2002 and 2006 as part of the elimination programme. Two cases were found in individuals above 60 years of age in Jeju island. Dr K. Palmer and Dr c.P. Ramachadran visited the site as WHO advisory members in 2005, for evaluation of the programme and to further advice on next steps. An antibody test based survey was conducted in 3000 elementary school children aged 10-13 years, for active transmission, but all found to be negative. The factors possibly contributed to the elimination of filariasis in Korea were, proper detection of the patients by repeated surveillance surveys, mass chemotherapy of the patients, which resulted in both treatment ofthe patients and reduction of microfilaria transmission, rapid growth of economic status resulted in improvement of generalized personal hygiene and sanitation, and housing conditions, environmental changes that minimized the mosquito breeding sites by construction of new town and villages, behavioural changes of Koreans by avoiding mosquito bites, seeking medical attention.

- 19 -

Korea is now ready to apply for the verification of elimination of LF as a public health problem. 2.5.3 Peoples' Republic of China During the time period of 1950-1980 the total "at-risk" population was 341916000 out of which nearly 6.9 million people were positive with microfilariasis. Both filarial species of W. bancrofti and B. malayi were present in China The "National Programme of Agricultural Development from 1956 to 1967 (Draft)", which was publicized by the Central Government of the Chinese Communist Party in 1956, established the objective for filariasis control in the country. In 1977, it was proposed to achieve basic elimination of filariasis in the whole country. The technical measures adapted since then were, the control of infection sources (by selective treatment, mass treatment and DEC salts followed by Blood survey results), the treatment of chronic filariasis, and conduction of proper health education. Graph 4: Microfilaria rate in endemic areas in China from 1950-2005 16 14

.-. 12 'V

'l

10 8 6

·s 's

i ..

~

4 2

0

year

s; !i! iI! ... ~ s; ... ~ ~ ... I! ... §! ... ... ... III ... ~

--~ ~

§! ...

§ N

By 1994, the entire country had achieved basic filariasis elimination. Based on direct reporting network system established for Infectious Diseases, each reported chronic cases had been checked, and no microfilaremia cases were found since 2006. The National report for elimination of LF was also completed in 2006. A photo album for recording the history of controlling filariasis was prepared and published. The provincial reports of LF situation of each province would be published soon. The MOH in China has developed a scheme for community care of chronic filariasis patients. The future activities of it would include post elimination surveillance, training workshops for community care of chronic patients, setting up clinics in township hospitals to provide guidance in self-care and health education for chronic filariasis patients. The regional office will take steps to acknowledge China's achievements. 2.6 Key Technical Points for Discussion

2.6.1 When to stop MDA in the countries? - Examples and experiences/rom the region This has been an issue that is coming up at different levels and in different regions over time.

- 20-

2.6.1.1

Philippine Scenario - Dr Leda Hernandez

Selected IUs in the three island regions of Philippines namely, Luzon, Visayas and Mindanao have already completed five rounds of MDA. It is high time to consider what would happen after these five rounds. Usually health workers and the community get weary of continuous MDA and naturally expect some answers as to what impact it has on the disease and if there would be a change of action plans. Sorsogon province recorded the highest rate of morbidity cases in the past, and it still remains with microfilaremia rate of 1%. No positive ICT results were found in children aged 2-4 years. It was raised whether there was a need to carry out MDA in South Leyte as well. It was discussed and decided that areas that have a MFR of less than I % can probably stop the MDA. Those areas which have MFR > 1% will need to go for a 6th round ofMDA to minimize the transmission. The country has not conducted the ICT test on the 3000 individuals to make the final decision on the requirement of an additional round of treatment. A sixth round can still be implemented, if a neighbouring District poses a higher risk of the infection. It was also observed that malaria incidence rate has undergone a 70% reduction after the bed net usage in the areas. Since same vectors are involved in Malaria and LF in these areas, it would be important to carefully analyse and determine the potential effect of incorporation of vector control and the side benefits of the malaria programme on LF. There are some research issues which are being analysed, such as the impact of combining MDA of LF with Long Lasting Impregnated Nets (LLIN) distribution for Malaria especially in the island ofPalawan. 2.6.1.2 Samoa Case - Dr Kevin Palmer

The country is affected by the diurnally sub periodic form of the parasite W. bancrofti. Four vectors are involved in LF transmission. The main vector is Aedes poiynesiensis which breeds in crab holes and is extremely difficult to control. MF prevalence was more than 20% in 1964. MDA using DEC alone was then implemented, and the prevalence dropped below I %. However, em transmission returned. In 1982 a survey in 21 villages found a prevalence of 5.2%. In 1999 the country engaged in yearly MDA using DEC and Albendazole and completed its 6th round of MDA in 2006. The society in Samoa is highly organized down to the village structure, which facilitates the communication. However in the past few years, the reported coverage reached 90% during the first round only and ranged 54% to 80% in the following years. Although the entire country is considered as one Implementation Unit (IU), it was actually clustered into 16 sub implementation units (SIU) and further subdivided into village units. A "C" survey was carried out in 2004, using cluster sampling method after the 5th round ofMDA. Seven sub-IUs did not meet elimination criteria (the antigenemia prevalence was still above 1%), with predominance of males. It was noted the reluctance of men to take the treatment provided. No drug coverage surveys had taken place before the fifth round so there is no information about the true MDA coverage. The 6th round was in 2006, two years after the fifth round, which took place in 2004. The programme skipped a year before the next initiation and was not able to assess coverage after the completion of the 6th round of MDA. It was discussed as how to proceed further with MDA considering the above situation. A second "C survey" was implemented in 2007 using a stratified cluster sampling methodology based on the level of endemicity found in 2004. The final results are still pending but the preliminary information received show that the target for elimination has not been reached. It also suggests that a higher prevalence is observed in males and in groups excluded

- 21 -

from MDA (severely sick people, elderly, etc). Under six year old children were found positive which indicates that transmission is still occurring. The next steps needs to be discussed when the final results become available. The following are among the possible options that will need to be discussed: a repeat of previous MDAs with a focus on reaching previously untreated persons; targeted MDA focused on adult men and persons with chronic health problems or a "test and treat" programme for all adult males. Whatever the decision is, Notice should be taken on the importance of ensuring that everyone is treated on the seventh round, with special attention paid to men who were reluctant in taking medications.~ Also, Recommendation had been made by Dr P. Lamy of CDC, to rely on all three methods, ICT card, night slides and antibody testing to verify the prevalence. 2.6.2 Updates on ICT Cards - Dr Gautam Biswas The issues raised regarding ICT cards during the meeting are listed as below. Since ICT cards are heat sensitive, stability can be compromised under different storage conditions. Normally the shelf life is I year in refrigerated conditions. Persistent uncertainty in delivering conditions in the countries. Recipient countries must provide a no objection certificate before ICT cards can be shipped to the respective country. Cost (US$ 2.60 cents) of the ICT cards has nearly doubled. This company produces other things but has been also committed to producing the ICT cards under the new trademark. The policy has been not to produce less than 25,000 ICT cards per batch, up to four times a year. These cards at room temperature have a shelf life of three months. (Once they were taken out of the refrigeration). The lines of positive and control were included in the card. The issues that if the company could invest more to increase shelf life of ICT cards in room temperature or set up an alternative system to cut down on the cost were raised. The latter was preferred during the discussion. The alternative to ICT cards was the ELISA Ag test which has been available with TROPBIO Company in Australia. Unlike a rapid test, this would need an ELISA reader to read the result. Blood can be collected on standard filter-papers in the field to be processed later in the laboratory. This test would is at least equally sensitive and specific and also quantitative. In a batch of 400 cards, each test could cost US$ 1.13. The Night blood test (slides) has been critical in Brugia sp, especially in the areas where there is no antigen test available. When applying antigenemia tests, the following needs to be taken into consideration: a) ICT card is useful in the initial mapping b) Able to use for quick assessment of the prevalence, so can be used as a criteria to stop MDA c) Brugia rapid test is also useful in the initial mapping d) These tests require proper facilities to process

- 22-

Professor Ramachandran highlighted the importance for this Region to secure enough funds for the continued procurement of lCT as well as DEC. 2.6.3 Clinical Management - Dr Leda Hernandez The main objective of Philippine's plan of action on morbidity control is, to enable every LF patient in the IU to enjoy a better quality and productive life and to fully participate in the community both socially and economically. Progress has been made so far is the completion of mapping in selected IUs and field testing of the Disability Management Manual from HQ's (in progress in Sorsogon and Davao areas). The future plans of Philippines include, to create employment prospects and avoid all forms of discrimination for patients of LF, sourcing out funds for the morbidity control, (Philippines Airlines (PAL) has offered to provide free transportation to the patients to come to Manila for hydrocoelectomy and member of Medical missions to visit selected IUs for surgery), development of integrated indicators (frequency of acute attacks, impact of disability alleviation programme and productivity) and continue pilot projects integrating LF patients and leprosy patients through home-based self-care approach in selected sites.

The steps ta befallawedfram Philippine experiences are asfallaws; Establish a sustainable health case delivery system in each of the LF Implementation Units (IU).

Mapping clinical cases in selected IUs Field testing of Disability Management Manual from HQ COMB! like approach in getting key messages on self care out into the community When sponsorship is an issue where surgical interventions are considered for example for hydrocoele correction, integration opportunities can be sought out with interventions for leprosy etc. Partnership with NGOs for implementation & funding 2.6.4 Activities of the Global Alliance and the Representative Contact Group (RCG) discussion Dr Muth Sinoun chaired the group session which focused on the following issues: (1) Improvement of the functions of the RCG. (2) Feedback mechanism between the RCG function and Programme Managers (3) Fundraising opportunities at international, regional or national levels.

THE EXPERIENCES IN LF AND STH INTEGRATION 2.6.5 Global Neglected Tropical Diseases (NTD) - Dr Antonio Montresor NTD control programmes are frequently overlapping in these countries, and integrated control could facilitate higher intervention capacity for achieving better control and cost

- 23 -

effectiveness of programmes. The cases of Cambodia, the Lao People's Democratic Republic and Viet Nam were raised as examples, where opportunities of integration done successfully by overlapping of several NTD. There is a grass root level demand in the Philippines to integrate de-worming campaign with MDA during the same months. Additional opportunities for integration would be Vitamin A distribution campaigns, bed net distribution campaigns and nutritional supplements to women of child bearing age. Dr Strandgaard explained her experience in the Lao People's Democratic Republic and about the importance to sensitizing donors and partners at country level to create visibility and proceed to plan jointly. It is a labour intensive preparation exercise, before the actual Plan of Action is implemented. Different Ministries should be engaged at governmental level for joint planning of integration of programmes. In Lao, de worming campaign relies on a good coordination between the Ministry of Health and the Ministry of Education. Plans were decentralized at a provincial level, which had organized them very effectively. The key issue being discussed was the coordination of programmes under different agencies. Possible challenges would be if different institutions were responsible for the different interventions they would not be interested in integration, or if different donors were supporting the different interventions they may not be interested in increasing the coverage of other interventions or staff responsible for the distribution activities could prefer separate interventions due to multiple per diem. Suggestion was made to assemble ajoint Coordination Task Force. Coordinating integration would not be simple as it requires intensive backing up by WHO country office and focal points, in its role as the Secretariat of the "Coordination Task Force". It is also required that WHO involves in coordination among programme managers. The Inter-sectoral Task Force Meetings should be convened at the highest possible level to assure adequate participation. It was noted that the national counterparts are reluctant to integrate with WHO programmes. However, WHO office can influence integration within a country for example, through IVM (Integrated Vector Management). The Malaria Regional Strategic Plans for Western Pacific Region could offer further opportunities for integration. Dr Gautam Biswas pointed out that a downward effect can be expected if the integration is arranged from the top level. 2.6.5.1 Cambodia case: Dr M. Sinuon

National Helminth control programme in Cambodia comprises of three areas, Soil Transmitted Helminths (STH), Schistosomiasis and LF. Pilot studies on Schistosomiasis control began in 1995. In 1997 they integrated it with STH and in 1998, LF assessments started. In 2002 school based de worming programmes were implemented. These programmes were all backed by policies in alliance with the private sector (GSK). Wide support was obtained from various other external sources including TOR, the Sasakawa Foundation, UNICEF, MSF and other NGO's at local level. The National Helminths programme established ambitious elimination goals for LF and Schistosomiasis, control targets, and assessments of Food Borne Trematodes (FBT). Integration resulted in cost-effective interventions and savings for the programmes and for the MOH in Cambodia. The technical advantages ofthis integration were greater gain of political support on LF control, greater coverage of MDA and blood slide survey for Mf in communities and schools due to increased awareness, the health education programmes target the three parasitic diseases at the same time and reduction of cost for transportation and human resources needed for the interventions. Success was established in terms of the protection provided through preventive chemotherapy to 75% of school age children against parasites and thus becoming the first

- 24-

country to reach the global target. Overall LF MDA coverage also exceeded 80% and in Schistosomiasis endemic areas> 80% coverage of children by MDA. Some problems included the delay in DEC distribution by the MOH, ADB funding process was complicated at the beginning, and MDA was difficult in rainy season and transport problems limiting access to some areas. Legislation/Political Commitment is the key to success. Good integration with malaria control programme (e.g. by using the same microscopy for both tests), Cambodia is now a role model for the whole Region. Part of its success lies on the fact that the LF Programme Managers coordinates extremely successfully with other programme managers. Mapping helps visualizing the overlapping ofNTDs and is a good tool in sensitizing decision makers. WHO HQ is currently working on a manual with simplified version of monitoring drug coverage of preventive chemotherapy. Dr Hernandez raised the issue of the difficulties in filling up different survey forms for survey per programme and in collecting different information from different programmes. It would be important as future measures for improvement that the budgets for the activities to be approved as the action plans within the same time frame and the drug supplies to be distributed as scheduled during the interventions without any delay. 2.6.5.2 Philippines case: Dr Leda Hernandez

Most parasitic diseases are neglected, and the affected individuals live in hard to reach, resource-poor communities, where problems with peace & order persist and where there is little or no access to health services at present. Philippines faces constraints in implementing programs due to lack of resources, especially the human resources which is critical to the programs success. The gravity of the problem is further compounded by the exodus of medical doctors and nurses to developed countries. STH offer a good entry point for the NTD due to high visibility of worm expUlsion and can be used as a convincing tool for the acceptance of the community. Coordination of activities, advocacy, health promotion and strengthening M & E are all key components in integration of programmes. Efforts are in place to maximize the cost-effectiveness of integration. Points of integration involve same target population where there are similarities in endemicity, in strategy, activities and treatment protocols, advocacy, in drug choice, in evaluation indicators and in schedules. STH programme also cover pre-schoolers integrating with other programme such as maternal-child health (e.g. Vitamin A. breast feeding, etc.). School age children (6-12 years old) have a different schedule for deworming than that of pre-school children, usually in July and January. The Department of Education is responsible for the deworming of this age group children. In LF areas, for 2-12 year old children, the first (de worming) dose is provided in June, and the second dose in November, as part of the MDA LF elimination programme. The Regional Health Units (RHU) cover pre-schoolers and children in school age not attending schools. IEC materials on de worming and on LF are amply distributed throughout the country. Schistosomiasis/STH/Food Borne Trematodes treatments are also being integrated in some provinces. On disability prevention, integration has been done with Leprosy programme, where it is co-endemic with LF. Dr J. Ehrenberg suggested the programme cost integrated strategy can be done as part of a cost-efficacy study. The programme has not estimated costs for the Schistosomiasis programme as yet. Dr Biswas inquired if the LF Programme Managers could collect all related information on age groups. Dr c.p Ramachandran explained about the Programme Managers Meeting of Pacific Programme to eliminate LF (PacELF) that would be

- 25-

held in Fiji in July 2007 and mentioned there were some key issues which need to be addressed in that meeting were relevant to this workshop as well. (For example issues regarding available DEC quality). 2.7 Final Session-Issues, conclusions and recommendation - Dr C.P. Ramachandran

2.7.1 Fiji report Most relevant programmatic and strategic issues were dealt with during this meeting. Ms Patricia Grave's presentation on sampling was of great interest. It was obvious that we needed to highlight the importance ofM&E. Global guidelines indicate this clearly. Sampling difficulties should be addressed through methodology as per Global Guidelines. Vector control was neglected in this meeting. It was a critical point in the discussions on A. polinisiensis in the Pacific and on the issue of shared vectors. Vector control needs to be part of the discussions. Research needs, ICT reliance as were epidemiology & transmission studies supported by TDR were also addressed in Fiji. Some of these issues were also discussed in this meeting. TDR is still supporting LF studies. Mentior. was also made of progress in Xenomonitoring. Dr c.P. Ramachandran talked about the Copenhagen meeting and the discussions concerning Xenomonitoring as a tool to assess t~ansmission level. PCR picks DNA form all stages, not specifically L3 related. This method needs to be better refined as an assessment tool for interruption of transmission. Current guidelines are still valid for verification of interruption of transmission. 2.7.2 Other issues on programme implementation The Gates Foundation donated USD 11 million for the NTD control and research activities which would be coordinated by Dr Eric Ottesen. It should address all technical and financial gap areas. Dr Biswas mentioned some of the targeted gap areas identified as; a) The definition of indicators needs to be finalized so managers can assess whether MDA was successful. b) The issue of persistent non-compliance of drug intake during the MDA c) Possible changes in the drug association to improve drug efficacy (e.g. increase dosage of ivermectin or albendazole) d) The issue of increasing the MDA coverage in the implementation areas e) The issue of mobilizing additional funds in an effective manner f)

The issue of improving the role of vector control (further studies should be done to verify the cost -effectiveness ofthe vector control intervention)

It was mentioned about the IVM workshop to be held in WHO HQ in Geneva, in the following week. The Gates donation also contemplates some aspects related to IVM. Dr Biswas mentioned that it is critical to plan carefully to avoid waste of resources and maximize the benefit. Dr Velayudhan questioned which entomological indicators would need to be specifically looked at in the guidelines. Dr Graham White is coordinating vector control aspect within the Gates Fund. Mainly focusing on Malaria, there have been ongoing integrated vector control activities (to some degree) in this Region. The approach has proven to be effective, although it is not necessarily considered important in WPRO as yet. Dr Kevin Palmer mentioned that the sustainability factor would be to keep away the critical

- 26-

issue of transmission from reappearing. The situation would get complicated when different vectors have been involved. In Malaysia & Brunei the vector is Mansonia, in Laos and Viet Nam it is Culex, and in the Philippines they are Culex & Aedes. In Philippine vector control is focused mainly on malaria, and not on LF. On networking and on the role of WHO's Collaborating Centers (CC) in Region (three for LF, several for Schistosomiasis), Dr Biswas expressed his views on these Centers as having played only a sub-optimal role in the Region. The question remains as is how they can be challenged to support the Regional needs. Malaysia would continue to support the programme, through the WHO's Collaborating Centers in capacity building. The Region needs to increase its training requests in capacity building in programme management, M&E, Vector Control and entomology. The IMR in Kuala Lumpur has ongoing training programme in parasitology and medical entomology. This 6 month course has been very well received in the Region. They have 16-18 candidates from AFRO, EMRO, and other regions. The main sponsors are the Malaysian Government, WHO, & ADB. These centres would be eligible to apply for the Gates grant for expansion. Collaborating Centers should think about designing simple, short courses, or distance learning materials to meet programmatic needs ofthe region and emphasize the entomology component. A lot of discussion was focused on advocating the need for entomologists within the MOH of respective countries, as a measure for the reduced career prospective for entomologists. These entomologists would also have an increasing role in Programme M&E. The new ten year vision of Tropical Diseases Research Programme (TDR), also focuses on NTDs: Each WHO Collaborating Centre (CC) has a different role for example, while James Cook University will be more active in supporting the Pacific Island Region, China will continue to collaborate more on schistosomiasis in Mekong countries. Effort should be made to cancel the centres which are at the functioning level. The Lao People's Democratic Republic talked about its own training capabilities. They are waiting to change the curriculum conditioned upon availability of resources. The need of a careful health economic evaluation ofLF control programme (and in general ofNTD control programmes) would be important to identifY the cost efficacy of programmes 2.7.3 Recommendations 2.7.3.1 The MDA coverage should be maintained above 80% at all times for better impact. Lower the coverage, longer it takes to bring it down below threshold level. Modelling has indicated that below 65% coverage, it may not be possible to bring it below the threshold in reasonable time. Coverage & compliance are linked to social mobilization, thus much attention should be paid for social mobilization in countries carrying out MDA. 2.7.3.2 The lack of DEC supplies within countries needs to be addressed. Organizations like The Global Alliance should be approached to assist the programme in mobilizing funds to fill the gaps and speed up production from pre-qualified suppliers. 2.7.3.3 Analysis of impact of MDA at sentimental sites should be pursued at appropriate periods to determine the success of MDA.

- 27-

2.7.3.4 The availability of ICT cards should be maintained. More research on improving the shelf life of ICTs should be encouraged. Alternative methods such as ELISA should be looked into as a mean of cost reduction, although this would need more facilities and infrastructure. 2.7.3.5 In dealing with technical issues it is recommended to identify the county specific issues and apply strategies applicable to that country. 2.7.3.6 The ongoing reviewed new guidelines on morbidity component by WHO should be adopted in addressing the clinical management and disability in LF. 2.7.3.7 The country specific integration ofNTDs is encouraged where feasible.

2.7.3.8 The difficulties with funding and grants should be sorted out at country level. (Ex ADB funding in Cambodia)

ANNEX I

AGENDA

Tuesday, 24 April 2007 08:30 09:00 Registration RD's opening remarks - by Dr Hans Troedsson, WHO Representative in the Socialist Republic of Viet Nam Welcome address - ProfLe Khanh Thuan, Director, National Institute for Malariology, Parasitology and Entomology, Ministry of Health, Viet Nam Self introductions Designation of Chairperson, Vice-Chairperson and Rapporteur Administrative announcement- Dr Antonio Montresor Introduction to the workshop - Dr John Ehrenberg Group photograph Coffee break Global and Regional Update Global Programme- Dr Gautam Biswas Mekong-Plus - Dr Kevin Palmer Update on GlaxoSmithKline activities and on Executive Group/GAELF - Mr Andy Wright Representative Contact Group discussion - Professor c.P. Ramachandran and Dr Leda Hernandez Lunch break Country reports Cambodia (25 min for presentation and 20 min for discussion) Malaysia (25 min for presentation and 20 min for discussion) 15:00 15:3017:00 Coffee break Country reports (continued) The Philippines (25 min for presentation and 20 min for discussion) Viet Nam (25 min for presentation and 20 min for discussion)

10:00 10:20

12:00 13:30

Wednesday, 25 April 2007 08:30 Country reports (continued) Brunei Darussalam (15 min for presentation and 10 min for discussion) the Lao People's Democratic Republic (15 min for presentation and 10 min for discussion) Republic of Korea (30 min for presentation and 25 min for discussion) Coffee break Country reports (continued) China (25 min for presentation and 20 min for discussion) Report trom the STAG meeting and the Global Forum - Dr Ehrenberg

10:00 10.30 11:15

12:00 13:30

Lunch break Key technical points for discussion: Case study: what to do if criteria are not met after 5 rounds of MDA? Philippines case: Dr Leda Hernandez and Dr Raman Velayudhan Samoa case: Dr Kevin Palmer Alternatives to ICT card - Dr Biswas Coffee break Key technical points for discussion (continued) Clinical management: a neglected component - Dr Hernandez and Dr Velayudhan

15:00 15:30 17:00

Thursday, 26 April 2007 08:30 09:00 Global neglected tropical diseases (NTDs) strategy and integration of programmes - Dr Montresor Integration of neglected tropical diseases control programmes at country level: opportunity for synergies Cambodia case - Dr Muth Sinuon Philippines case - Dr Leda Hernandez Discussion Coffee break Wrap-up: milestones, challenges and recommendations - ProfC.P. Ramachadran Closing ceremony

10:30 11:00 12:00

ANNEX 2

LIST OF PARTICIPANTS, TEMPORARY ADVISERS, REPRESENTATIVES/OBSERVERS AND SECRETARIAT

1. PARTICIPANTS

BRUNEI DARUSSALAM

Dr Ahmad Fakhri Haji lunadi Medical Officer (Disease Control Division) Ministry of Health Commonwealth Drive Bandar Seri Begawan Tel. No.: +673-2382023 Fax No.: +673-2382755 E-mail: fakhri@doctors.org.uk Dr Muth Sinuon Programme Manager, Parasitic Disease National Centre for Parasitology, Entomology and Malaria Control 372 Monivong Blvd. Phnom Penh Tel. No: +855-12-926266 Fax No: +855-23 426034/426841 E-mail: sinouonm@cnn.gov.kh Dr Chen Zhao Programme Officer Division of Schistosomiasis Prevention and Management Department of Disease Control Ministry of Health No. I Xizhimenwai Nanlu Beijing 100044 Tel. No.: 86-10-68792374 Fax No.: 86- J 0-68792342 Dr Sam lane Phompida Director Center for Malariology, Parasitology and Entomology Ministry of Health Vientiane Tel. No.: (856 21) 214040/252673 Fax No.: (856 21) 218131 E-mail: cmpe@laotel..com

CAMBODIA

CHINA

LAO PEOPLE'S DEMOCRATIC REPUBLIC

MALAYSIA

Dr Lokman Hakim bin Sulaiman Head of Environmental Health Research Centre Institute for Medical Research Ministry of Health Malaysia Jalan Pahang 50588 Kuala Lumpur Tel. No: +603 2698 6033 Fax No: +603 26926542 E-mail: lokman@imr.gov.my Dr Kim Tong Soo Head, Division of Malaria and Parasitic Diseases Korea Centre and Disease Control and Prevention National Institute of Health Seoul 122-70 I Tel. No.: (822) 3801505 Fax No.: (822) 3801560 E-mail: nihkim@nih.go.kr Dr Amebella Taruc Regional Programme Manager for the Elimination of Lymphatic Filariasis Center for Health Development-XII ORC Compound Cotabato City Tel. No.: (064)421-9807 Fax No.: c/o (0632)- 732-2493 Professor Le Khanh Thuan Director, National Institute of Malariology, Parasitology and Entomology Ministry of Health 245 Luong The Vinh Street HaNoi Tel. No.: (+844) 854 3035 Fax No.: (+84 4) 854 3015 E-mail: lekhanhthuan@hn.vvn.vn

REPUBLIC OF KOREA

PlllLIPPINES

VIETNAM

2.

TEMPORARY ADVISERS

Dr Leda Hernandez Medical Specialist IV, Infectious Disease Office National Center for Disease Prevention and Control Department of Health, Sta Cruz, Manila, Philippines Bldg 13, Third Floor, San Lazaro Compound Tel. No. (632) 711 6808;Fax No. (632) 7116808 E-mail: drleda@edsamail.com.ph/drledahm@yahoo.com

Professor Dato (Dr) c.P. Ramachandran 8A-4-4, Belvedere, Jalan 1-63 Off lalan Tunku, Bukit Tunku 50480 Kuala Lumpur, Malaysia Tel. No: +603 298 6152; Fax No: +603 2986152 E-mail: ramacp@hotmail.com Dr Hj Rahmah Mj Md Said Director of Environmental Health Services Department of Health Servcies, Ministry of Health Bandar Seri Begawan BB391 0, Brunei Darussalam Tel./fax No.: (6732) 382-755 E-mail: rahmahms@gmail.com Dr Doung Socheat Director, National Centre for Parasitology, Entomology and Malaria Control Ministry of Health, 372 Monivong Blvd Phnom Penh, Cambodia Tel. No. (+855-12) 815901; Fax No: (+855-23) 219271 E-mail: socheatd@cnm.gov.kh Dr Wu Weiping Associate Professor, Institute of Parasitic Diseases Chinese Center for Disease Control and Prevention (China CDC) 207 Rui Jin Er Lu, Shanghai 200025 People's People's Republic of China Tel. No: +86-21-64452663; Fax No: +8621 6433 8670 E-mail: wpwu@shI63.net

3. REPRESENTATIVES/OBSERVERS

GLAXOSMlTHKLINE

Mr Andy Wright, Director, LF Elimination Programme GlaxoSmithKline, 980 Great West Road Brentford, Middlesex .TW8 9GS United Kingdom Tel. No.: +44 (0)208 047 5515; Fax No.: +442080470684 E-mail: andy.l.wright@gsk.com Ms Joan Fahy, Programme Coordinator Lymphatic Filariasis Support Centre Liverpool School of Tropical Medicine Pembroke Place, Liverpool, L3 SQA United Kingdom Tel. No.: 44 (0) 151 705; 3145 Fax No.: 44 (0) lSI 7090354 E-mail: fahy@liverpool.ac.uk

'II "

LIVERPOOL SCHOOL OF TROPICAL MEDICINE

REPUBLIC OF KOREA

Dr Cheun Hyeng II, Senior Researcher Dept Tropical and Endemic Parasitic Diseases National Institute of Health, Seoul, 122-701 Tel. No.: +82-2-380-1505; Fax No: +82-2-380-1560 E-mail: ilcheun7@yahoo.co.kr Dr Kong Yoon, Professor Department of Tropical and Endemic Parasitic Diseases, Sungkyunkwan University 300 Cheoncheon-dong, Jangan-gu, Suwon Gyeonggi-do 440-746 Tel. No.: +82-031-299-6251 E-mail: ykong@med.skku.ac.kr

4. SECRETARIAT

WHOIHQ

Dr Gautarn Biswas, Medical Officer Lymphatic Filariasis Elimination (CDS/CPE/CEE) Strategy Development and Monitoring for Eradication and Elimination World Health Organization CH-1211 Geneva 27, Switzerland Tel. No.: +4122 7913850 Fax No.: +4122 7914777 E-mail: biswasg@who.int

WHOIWPRO

Dr Hans Troedsson WHO Representative in the Socialist Republic of Viet Narn, World Health Organization P.O. Box 52, Ha Noi Socialist Republic of V iet Narn Tel. No.: (833)943-3734; 943-3735 Fax No.: (844) 943-3740 E-mail: TroedssonHla>vtn.wpro.who.int who@vtn.wpro.who.int Dr John Ehrenberg (Responsible Officer) Regional Adviser in Malaria, Other Vectorborne and Parasitic Diseases, World Health Organization Western Pacific Regional Office United Nations Avenue. P.O. Box 2932 1000 Manila, Philippines Tel. No.:(632) 528 9725 Fax No.: (632) 521 1036 E-mail: ehrenbergjla>wpro.who.int

Dr Kevin Palmer WHO Representative in Samoa P.O. Box 77, ~ Western Samoa Tel. No.: (685) 24-976 (direct line) Fax No.: (685) 23-765 E-mail: palmerk'alsma.wpro.who.int who@sma.wpro.who.int Dr Antonio Montresor Public Health Specialist, Office of the WHO Representative in the Socialist Republic of Viet Nam World Health Organization. P.O. Box 52 Ha Noi, Socialist Republic of Viet Nam Tel. No.: (833)943-3734; 943-3735 Fax No.: (844) 943-3740 E-mail: montresora@vtn.wpro.who.int Dr Tran Cong Dai National Professional Officer (Malaria) Office of the WHO Representative in the Socialist Republic of Viet Nam, World Health Organization P.O. Box 52, Ha Noi, Socialist Republic of Viet Nam Tel. No.: (833)943-3734; 943-3735 Fax No.: (844) 943-3740 E-mail: dait@vtn.wpro.who.int Ms Hanne Strandgaard Endemic Disease Expert Office of the WHO Representative in the Lao People's Democratic Republic P.O. Box 343, Vientiane, Tel. No.: (856) 21-413-431; Fax No. (856) 21 413-432 E-mail: strandgaardhralao.wpro.who.int Dr Le Anh T uan Technical Officer Malaria, Other Vectorborne and Parasitic Diseases World Health Organization Western Pacific Region United Nations Avenue, P.O. Box 2932 1000 Manila, Philippines Tel. No.: (632) 528-97-54; Fax No. (632) 521-\036 E-mail: tuanl@vtn.wpro.who.int Dr Raman Velayudhan Scientist, Malaria Office of the WHO Representative in the Philippines P.O. Box 2932, Manila, Philippines Tel. No.: (632) 338-7479; Fax No.:(632) 731-3914 E-mail: velayudhanriWphl. wpro. who.int

ANNEX 3

RD'S OPENING REMARKS AT THE SIXTH MEKONG-PLUS WORKSHOP FOR LYMPHATIC FILARIASIS PROGRAMME MANAGERS 26 APRIL 2007, HA NOI, VIET NAM

FRIENDS AND COLLEAGUES,

LADIES AND GE1"TLEMEN,

I would like to extend my warmest welcome to all of you to this Sixth Mekong-Plus Workshop for Lymphatic Filariasis Programme Managers; and on behalf of the host country, let me also welcome you to Ha Noi, Viet Nam. Among the Mekong-Plus countries, China is now embarking in the final process of veri tying interruption of transmission. This should be completed in early 2007. The Republic of Korea should be also ready for verification for the interruption of transm iss ion interruption of transmission towards the end 01'2007; Brunei Darussalam is completing some final surveys to verity ifthe old pockets of transmission are no longer active before proceeding to the verification process. The Lao People's Democratic Republic is implementing the final mapping surveys. The remaining countries (Cambodia, Malaysia, the Philippines and Viet Nam) are actively carrying out annual mass drug administration campaigns all of which have achieved high levels of coverage. It is very exciting to see how China is close to being declared free of lymphatic filariasis. This will mark an important accomplishment for this country, for the Region, and for the global programme to eliminate lymphatic filariasis. I also understand that in the Philippines the programme continues to achieve high levels of coverage and has planned to scale-up the mass drug administration in order to cover all endemic areas this year. This is really an important milestone since more than 90% of the population at risk for lymphatic filariasis infection in the Mekong-Plus region come from the Philippines. Over the next two and a half days, you will review the progress made during the past 12 months. You will also have the chance to exchange experiences, work on solving common problems, and make plans for the next 12 months. The key to success in eliminating lymphatic filariasis is hard work and a strong team spirit. WHO fully appreciates the efforts that have gone into producing the excellent results achieved by this Region but there is still a long way to go. My WHO colleagues and I look forward to working along with you and your staff to achieve the important goal of eliminating lymphatic filariasis from our Region. Please let me wish you fruitful discussions during the workshop and I hope that you will have the chance to enjoy Ha Noi.