,
(WP)STB/ICP/STB/003 Report series number: RS/2000/GEIl O(NEC) English and French
REPORT FIRST STOP TB MEETING IN THE PACIFIC ISLANDS
Organized by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC & THE SECRET ARIAT OF THE PACIFIC COMMUNITY (SPC)
Noumea, New Caledonia 26-29 June 2000
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines October 2000
Keywords: Tuberculosis - prevention and control I Pacific Islands
NOTE
The views expressed in this report are those of the ~a:ticipants in the .Fir~t Stop TB Meeting in the Pacific Islands and do not necessarily reflect the polIcies of the OrganizatIOn.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific and the Secretariat of the Pacific Community for governments of Member States in the Region and for those who participated in the First Stop TB Meeting in the Pacific Islands, which was held in Noumea, New Caledonia from 25-29 June 2000.
CONTENTS
SUMMARy .............................................................................................................................. i I. INTRODUCTION ............................................................................................................. 1
1.1 Objectives ................................................................................................................. 1 1.2 Organization ............................................................................................................. 1 1.3 Opening ceremony .................................................................................................... 2 2. PROCEEDINGS ............................................................................................................... 3
2.1 Summary of country reports ...................................................................................... 3 2.2 Summary of discussions ............................................................................................ 6 3. CONCLUSIONS AND RECOMMENDATIONS ............................................................ 19
3.1 Conclusions ............................................................................................................ 19 3.2 Recommendations ................................................................................................... 20 ANNEXES: ANNEX 1 ANNEX 2 TIMETABLE ......................................................................................... 23 LIST OF PARTICIPANTS, CONSULTANTS, TEMPORARY ADVISERS, OBSERVERS AND SECRETARIAT ................................ 25 SUMMARY OF COUNTRY SITUATION PRESENTED BY COUNTRY REPRESENTATIVE ......................................................... 31
ANNEX 3 -
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SUMMARY
A tuberculosis crisis in the Western Pacific Region was declared during the fiftieth session of the Regional Committee in September 1999 and the Stop TB special project was launched in response. The Stop TB special project aims to bring about social and political movement for action to reduce the morbidity (i.e. prevalence) and mortality due to tuberculosis in the Region by half by 2010. The Pacific Stop TB Initiative is part of the Stop TB special project for the Pacific islands. The first Stop TB meeting in the Pacific islands was held in Noumea, New Caledonia, in June 2000, and was convened jointly by the World Health Organization (WHO) and the Secretariat of the Pacific Community (SPC). The meeting was attended by 42 participants, including 24 health professionals and officials from 17 Pacific island Member States and areas, 2 representatives from international, governmental and nongovernmental organizations, and 16 secretariat/resource persons. The first Stop TB meeting in the Pacific islands focused on reviewing the Pacific Strategic Plan to Stop TB, including objectives and targets, and sharing ideas with collaborating partners to reach the regional target for the Pacific Stop TB Initiative. The objectives of the meeting were: 1) 2) to raise political commitment for the Pacific Stop TB Initiative in the Pacific islands; to review, finalize and endorse a Pacific Strategic Plan to Stop TB in the Pacific;
3) to strengthen the collaboration between countries and international partners in tuberculosis control; 4) to review the tuberculosis epidemiological situation and the progress of tuberculosis control in the Pacific; 5) to identify system constraints and solutions for effective tuberculosis programme management, including drug supply, laboratory services, information systems, financing and human resource requirements, and; 6) to develop or refine national plans of action to introduce and expand the directly-observed treatment, short course (DOTS) strategy in the context of health systems development. Outcomes of the Meeting By 2005, the Pacific islands should attain or maintain, at a minimum, a DOTS case detection rate for smear-positive tuberculosis cases of 70% and a treatment success rate of 85% in areas covered by DOTS. Meeting participants endorsed these operational targets and agreed that, if achieved on time, the Region could attain a 50% reduction in the tuberculosis burden by 2010.
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The first Stop TB meeting in the Pacific islands recommended the following: 1) National governments should make a commitment to DOTS implementation and its sustainability. 2) Pacific island Member States should finalize country plans of action by the end of 2000.
3) Pacific island Member States should ensure that they have adequate human resources and training for "Stop TB", especially at the central level (including programme managers) to implement country plans of action. 4) Provisions should be improved within the existing infrastructure for the regular supply of good quality fixed-dose combinations, at least INHIRMP combinations, and/or blister packs of tuberculosis drugs, including the following: • • • 5) • • 6) • • • • • establishment of an efficient procurement system, including collaborative arrangements; development of distribution systems, especially in remote areas; and monitoring the drug quality. Laboratory systems and networks should be strengthened, including: commitment to developing a DOTS microscopy centre in each capital town or capital island; and establishment of internal and external laboratory quality assurance systems. Tuberculosis surveillance should be strengthened through the following mechanisms: improved tuberculosis information systems, based on WHO-IUATLD forms, including quarterly tuberculosis reports for case notification and treatment outcomes; monitoring ofTBIHIV co-infection; monitoring of drug resistance; development of appropriate reporting mechanisms for small populations; and improvement in estimates of the tuberculosis burden in the Pacific.
7) collaboration and communication between tuberculosis and HlV programmes should be established or strengthened. 8) • • DOTS mechanisms should be enhanced through: development of systems to facilitate transfer, follow-up of cases and programme monitoring; and strengthening of the programme between DOTS centres, the community and remote islands to ensure successful treatment, especially in the continuation phase in remote areas.
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9) •
Partner support should be enhanced to: strengthen collaboration between the Centers for Disease Control (CDC), the United States of America, SPC, WHO and Member States in order to achieve the objectives and targets of the "Pacific Stop TB Initiative" and monitor the performance of the Initiative; continue and expand the Pacific Regional Tuberculosis Control Project at SPC beyond August 2001; and strengthen the technical assistance of WHO to the Pacific islands through the establishment of a WHO tuberculosis post based in Fiji.
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1. INTRODUCTION
Following a resurgence of tuberculosis in many parts of the world, the fifty-first World Health Assembly in 1998 urged Member States to intensify tuberculosis control as an integral part of primary health care. A tuberculosis crisis in the Western Pacific Region was declared during the fiftieth session of the Regional Committee in September 1999 and the Stop TB special project was launched as a response. The first meeting of the Technical Advisory Group (TAG) to Stop TB in the Western Pacific Region in February 2000, aimed to bring about social and political movement for action to reduce the morbidity (i.e. prevalence) and mortality due to tuberculosis in the Region by half by 20 I o. The regional TAG endorsed the Regional Stop TB Strategic Plan in the Western Pacific including regional objectives and targets. The First Stop TB Meeting in the Pacific Islands was convened jointly by the World Health Organization (WHO) and the Secretariat of the Pacific Community (SPC) through the Pacific Stop TB Initiative. 1.1 Objectives
The First Stop TB Meeting in the Pacific Islands was held in Noumea, New Caledonia from 26 to 29 June 2000 with following objectives: (I) (2) to raise political commitment for the Stop TB project in the Pacific islands; to review, finalize and endorse a .. Pacific Islands Strategic Plan" to Stop TB in the Pacific;
(3) to strengthen the collaboration between countries and international partners in tuberculosis control; (4) to review the current tuberculosis epidemiological situation and the progress of tuberculosis control in the Pacific; (5) to identify system constraints and solutions for effective tuberculosis programme management, including drug supply, laboratory services, information systems, financing and human resource requirements, and; (6) to develop or refine national plans of action to introduce and expand the directly-observed treatment, short course (DOTS) strategy in the context of health systems development. 1.2 Organization
Twenty-four health professionals and officials from 17 Pacific island Member States and areas, attended the meeting as well as two representatives from international, governmental and nongovernmental organizations and 16 secretariat/resource persons. Annex 1 shows the timetable of the meeting and Annex 2 contains the list of participants.
- 21.3 Opening ceremony
Mr Akusitino Manuholalo, Minister of Health and Social Welfare of New Caledonia briefly welcomed participants to New Caledonia. Ms Lourdes Pangelinan, Director General of the SPC, welcomed the meeting participants. Ms Pangelinan highlighted the close and cooperative working relationship between WHO and the SPC in the health field, including tuberculosis. Ms Pangelinan also expressed SPC support in the area of tuberculosis control in the Region, acknowledging the importance of continuing the collaboration with WHO and NZODA. The SPC was working to strengthen existing partnerships and forge new relationships between partners within and outside the health field to establish a more unified and efficient input to countries. She congratulated the meeting organizers. Dr Shigeru Omi, Regional Director for the Western Pacific (WPRO), in his welcome remarks highlighted the 1999 Regional Committee resolution that had declared a tuberculosis crisis in the Western Pacific Region. He acknowledged that DOTS implementation was at an early stage in some parts of the Region. He hoped that the Pacific Stop TB Initiative would provide enhanced support to countries so that the goal of 100% DOTS coverage in the Region by 2005, and a 50% reduction in tuberculosis burden in the Region by 2010, could be achieved. Dr Omi concluded that, in addition to being a priority area, tuberculosis control had been identified by all Member States as an issue demanding a special project. Therefore, the Pacific Stop TB Initiative was a special and important activity for the Western Pacific Regional Office. The following office bearers were elected for the strategy and technical sessions: Strategy session 1: Chairperson: Dr Eliuel K. Pretrick, Secretary of Department of Health, Education, and Social Affairs, Palikir, Federated States of Micronesia Vice-Chairperson: Dr Bernard Rouchon, Medecin coordinateur du Comite de prevention, Direction des Affaires Sanitaires et Sociales, Noumea, New Caledonia Rapporteur: Dr Kennar Briand, Director of Public Health, Ministry of Health, Majuro, Republic of the Marshall Islands Technical session 2: Chairperson: Dr Cristie Cabungcal, Acting Director of Public Health Services, Ministry of Health, Bikenibeu, Kiribati Vice-Chairperson: Dr Taniela Lutui, Chief Medical Officer of Public Health, Ministry of Health, Nuku'alofa, Tonga Rapporteur: Dr Cecilia Teresa T. Arciaga, CDC Program Coordinator III Supervisor TuberculosislHansen's Disease Control Section, Hagatna, Guam
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2. PROCEEDINGS
2.1
Summary of country reports
Tuberculosis managers or health professionals from 17 Pacific island Member States delivered presentations on the tuberculosis situation in their countries, highlighting constraints, challenges and plans for the future. A table representing a summary of the tuberculosis situation in each country is presented in Annex 3. Cook Islands The total population is 19 100. Three cases of tuberculosis were reported in 1999, representing a case notification rate of 15.7 per 100000 population. A DOTS implementation workshop was held in May/June 1999. The Ministry of Health aims to maintain 100% DOTS coverage. Federated States of Micronesia The population numbers 112732. A total of 108 cases were reported in 1999 (all types), including 24 new sputum-positive cases. DOTS is accessible to 65 366 people (the main islands - 58% of the population), and enrolment covers 54% of the population (all types), with a cure rate of 55%, a completion rate of 23%, a death rate of 9%, a failure rate of 5% and a default rate of 9% ( 1998 results). There are many constraints: poverty, communication problems, problems of confidentiality. The aim is to reduce the prevalence and mortality of tuberculosis within the next five years. Seventy-three percent of cases are pulmonary tuberculosis, and 42% paediatric cases.
Fiji The population is 790 000. A total of 192 tuberculosis cases (all types), 65 smear-positive, were notified in 1999, representing a rate of 2411 00 000 for all cases and 81100 000 for smear-positive. Case notification has been steady for the past 25 years. The entire population has access to DOTS and the DOTS enrolment rate is 100%. Treatment outcomes have been as follows: cured 83%, completed 7%, died 1%, defaulted 9%, transferred 0%. Constraints include a lack of transport for DOTS implementation and the lack of commitment of staff in the field. Future plans include continued advocacy, reaching a cure rate of at least 90%, and improvement in diagnostic facilities. French Polynesia The population numbers 229 328. There are 101 cases (all forms), representing a case notification rate of 44/100000 population. The entire population has access to the DOTS strategy. Constraints include a lack of medical staff in remote areas, and the fact that social welfare does not cover costs related to prevention. It is planned to improve case detection and registration. Guam In 1999,69 tuberculosis cases (all forms) were notified. The population in 1999 was 151 716. The whole population has access to DOTS, with a cure rate of 86%, and a death rate of3.4%. Constraints include a lack of manpower and a lack of funding. There is a plan to collaborate with the Guam legislature. The aim is to continue implementation of universal DOTS.
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Kiribati DOTS has been implemented since 1998. The population is 88 558. A total of255 tuberculosis cases were notified in 1999, of which 72 were new sputum-positives. The tuberculosis notification rate for smear-positive cases was 811100 000. The treatment success rate was 86% in 1998 and 90% in 1999. The DOTS enrolment rate is 100%. Constraints include funding, diagnostic services, training, supervision, logistics, communications and transport. There is a plan to intensifY health education of the community. Northern Mariana Islands The population is 66 700. A total of 66 cases were notified in 1999, representing a notification rate of 9911 00 000. Active case-finding was introduced in 1998 among migrant people, who represent two-thirds of the popUlation. Universal mandatory DOTS has been practiced since mid-1993. Tuberculosis diagnosis and treatment is free and open to all of the population (tuberculosis culture). The entire population has access to DOTS, which has had an 80% success, with 4% dying, none failing, none defaulting, and 16% transferring. Challenges include the tremendous diversity of the popUlation, the erratic drug supply, field-based DOTS, the few skilled clinicians (nurses), and financial support for the programme. The plan is to maintain mandatory universal DOTS. Marshall Islands The population numbers 50 840. A total of 45 cases were notified in 1999, representing a tuberculosis notification rate of 8811 00 000. There has been a steady decrease in cases since 1997. Passive case finding is implemented. About 68% of the population has access to DOTS. DOTS enrolment is 88%, and case detection 67%. No transfers out were reported. Challenges and constraints include management of the private sector and, drug supply. Nauru The population is about 10 000. One operational TB Unit covers the whole population. Two new smear-positive cases were reported in 1999. No deaths and no treatment failures were reported. DOTS has not been implemented. Much of the population has uncontrolled diabetes which complicates tuberculosis treatment. Niue The population is 1600. Three cases were notified in 1999, including one new smear-positive case. The entire population has access to DOTS which has 100% enrolment. Challenges include the need to actively educate and motivate people, a lack of funds for a survey of tuberculosis status, a lack of manpower and training, the absence of a tuberculosis facility, a lack of any resources for awareness programmes, a reluctance towards voluntary screening, a lack of any facility for voluntary screening, and stigma. DOTS is fully implemented, but the country is seeking assistance for drugs and needs training for three people on tuberculosis management. National guidelines are required for screening and surveillance. It is planned to continue with two doses of BCG (birth and 7 years). Assistance to develop health education resources is required. New Caledonia A tuberculosis register was established in 1989. Seventy-seven cases were reported in 1999 from a population of207 612. There has been a slow decline in incidence, which reached 0.37 in 1999. The highest incidence is in Northern Province. A regimen similar to DOTS is employed. Fifteen out of27
-5cases were cured in 1999. Objectives include creation of an information network and training of a nurse for Loyalty Islands Palau Access in many areas is limited by boat transport. The population is 17225 (1995 census). Seventy-seven per cent are migrants (Filipinos and Chinese). Eleven cases were notified in 1999, representing a case notification rate of 6411 00 000 population. Among the notified cases, seven were new sputum-positives. Efficient implementation of DOTS and early case detection is required. Constraints include a shortage of support staff and a lack of administrative support. Partner agency support will be required in the future. Samoa The population is 170000. DOTS was introduced in 1995. Forty-nine cases were reported in 1993, compared with 31 in 1999. All patients are enrolled in DOTS. In 1999,15 out of 16 patients completed their treatment. The case detection rate is 54.8%. Constraints include frequent travel by the population. There are some problems with registration of cases. Stigma is a problem in relation to passive case-finding. Plans include encouraging the Governrnent to give financial support for drugs, and a need to make the community aware oftuberculosis, especially in relation to case-finding. Tonga DOTS was introduced in 1997 and has 100% coverage. A laboratory service is in place. In 1999,21 cases were reported, 10 of which were infectious. Constraints include a lack of funds. Tuvalu The population is approximately 10000. A single DOTS centre is located on the main island. Passive case-finding is followed. There is no laboratory, so clinical and radiological criteria are used for diagnosis. DOTS is implemented. Major constraints relate to laboratory services and the absence of a safety box. Inter-island transportation is sometimes difficult. In the future it is planned to train laboratory technicians. Vanuatu The population is 193219. DOTS is implemented in two sites in Vanuatu and about 45% of population has access. The case detection rate is 35.6%. In 1999, 124 tuberculosis cases were registered. Constraints include poor follow-up of patients due to lack of transport, insufficient IEC materials, and an unsafe environment for laboratory staff. There is a plan to implement DOTS in three new hospitals. Wallis and Futuna The population numbers 14400. None of the population has access to DOTS. However, the treatment success rate is 100%, with no deaths, no failures, and no transfers. Constraints include a limited budget. There is a microscope, but no culture facilities are available. Samples are sent to New Caledonia.
- 62.2 2.2.1 2.2.1.1 Summary of discussions Policy issues Global tuberculosis situation
Dr Leopold Blanc, Medical Officer in the Communicable Disease Cluster, WHO, Geneva, provided an overview of the global tuberculosis situation and pointed out that the main challenge was to expand the DOTS strategy globally. Dr Blanc noted that globally there were approximately eight million new cases of tuberculosis each year. Tuberculosis caused 1.9 million deaths per year with 98% of those deaths in the developing world. It was the commonest cause of death in young women worldwide. Tuberculosis deaths accounted for 26% of preventable deaths in the developing world. Those cases cost each individual around three to four months of lost work time, resulting in up to 20% to 30% loss of household income for a year. The cost to nations was about 4% to 7% ofGDP. Dr Blanc highlighted the progress made towards controlling tuberculosis. In 1991, only 10 countries had adopted the DOTS strategy, while by 1998 the number had risen to 119. Case detection had been about 40% in 1998. WHO had set a target of 70% case finding by 2005. The average cure rate had been stable at 78% under DOTS and 59% worldwide. Two hundred and eleven countries had reported 1998 tuberculosis data to WHO. Twenty-three percent of notified cases had been from the Western Pacific Region, and 36% from the South-East Asia Region. Dr Blanc explained that only about 21 % of estimated cases were enrolled in the DOTS strategy. In some provinces of China, MDR-TB was greater than 10%. MDR-TB emerged in conditions where there was poor or inadequate care. The cure rate for MDR-TB was only 30%. Tuberculosis was a good indicator of health system performance. Involvement of communities was feasible and costeffective and private practitioners should also be involved. Evaluation of treatment by private practitioners was often very weak. However, Dr Blanc said that tuberculosis was still neglected in many countries. The low DOTS coverage in the Pacific island countries and areas, together with the risk of an increasing HIV impact on the tuberculosis burden, and an increasing risk of emerging MDR-TB, required a much broader coalition in overall care of tuberculosis patients. 2.2.1.2 Regional and Pacific tuberculosis overview
Dr Michael O'Leary, Medical Officer WHO, Suva, Fiji, presented the regional situation on tuberculosis. The Western Pacific Region accounts for a significant proportion of the global burden of tuberculosis, with about two million new cases (estimated) per year, or 25% of the global total. The leading cause of death due to infectious diseases, tuberculosis accounts for about 1000 deaths every day in the Region. Notification rates have gradually increased since 1993, in large part due to improved case finding. There is considerable variation in tuberculosis burden among the countries of the Western Pacific Region, from high burden countries such as the Philippines and Cambodia, to low burden countries such as Australia and New Zealand. Overall, the Pacific island countries and areas fall into the intermediate burden category. In 1998,1613 new tuberculosis cases were notified in the Pacific, of which 512 were new smear-positive cases. These figures correspond to rates of 59 and 19 per 100 000 population, respectively. These averages mask a wide range of tuberculosis rates, from countries with rates similar to those in the highest burden countries, to those which harbour very few cases (Figure 1). It is, however, difficult to accurately measure or estimate the tuberculosis burden in small island states, and to monitor the trends overtime.
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DOTS population coverage in the Western Pacific Region (57% in 1997) exceeds the global average of35%. The Pacific fares even better, with DOTS having been adopted by all but a few of the 20 countries and areas. Multidrug-resistant tuberculosis is not yet a significant problem in the Pacific, and rates ofTBIHIV co-infection remain very low. However, national tuberculosis control programmes face a number of challenges, many of which are related to small size and limited financial and human resources. These include transportation problems over the great distances in the Pacific, limited access to laboratory support, and a shortage of trained or specialized staff.
Figure 1
TB case notifications, smear-positive, Pacifi 1998 Kiribati Tokelau Palau
CNMI Solomons Guam FSM Vanuatu Marshalls Nauru Tonga
Fr. Poly. Neweale. Am Samoa Fiji W&F
Cook lsi. Samoa
Rate / 100,000
2.2.1.3
Regional Strategic Plan to Stop TB in the Western Pacific Region
Dr Dong II Ahn, Regional Adviser for Stop TB and Leprosy Elimination in the WHO Western Pacific Regional Office, introduced the Regional strategic plan to Stop TB in the Western Pacific Region. The Regional strategic plan to Stop TB in the Western Pacific details the proposed Stop TB special project, emphasizing objectives, targets, activities to expand DOTS in the context of health sector reform, surveillance, laboratory services, supporting activities, building partnerships and estimated budget requirements. The objectives of the Stop TB special project in the Western Pacific are: 1. to reduce the prevalence and mortality of tuberculosis in the Region by half in ten years time (by 2010); and 2. to ensure that the DOTS strategy is incorporated into country plans for health sector development. Targets to be reached by end of2005 are described below: DOTS implementation: • a treatment success rate of at least 85% for smear-positive pulmonary cases in the DOTS programme; and
-8• enrolment of at least 70% of e~timated smear-positive pulmonary cases in the DOTS programme, i.e. 70% DOTS case detection.
Health Sector Development: • • expansion of DOTS implementation by making it available to countrywide population; and inclusion of DOTS indicators among their health sector performance indicators in the seven high burden TB countries.
Drug supply and quality of drugs: • strengthened National Drug Regulatory Authorities for better quality assessment of antituberculosis drugs at least in the seven high burden countries; and sustainable free treatment for all smear positive tuberculosis patients enrolled in DOTS by obtaining an increase ofin-country resources to provide at least 80% of the needs of quality anti tuberculosis drugs.
•
Monitoring and evaluation: • • development and implementation ofa surveillance system to assess DOTS expansion and quality; development and implementation of tuberculosis prevalence surveys in at least six high tuberculosis burden countries, including interim surveys in China and the Philippines; establishment ofTBIHIV co-infection surveillance in six countries; and monitoring of drug resistance in six countries.
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Countries will be grouped according to level of priority, reflecting the tuberculosis burden, the status of DOTS implementation and the type of activities that need to be implemented. The highest priority will be given to group I. (See Table I: Grouping of countries). Table 1: Grouping of countries
Group 1 High TB burden CAM* CHN* LAO MOG* PHL* PNG
Group 2 Intermediate TB burden BRU KOR SIN HOK JPN MAA MAC
Group 3 Less than 1 M inhabitant Pacific Island Countries
Group 4 Low TB burden & low incidence AUS NZE
VTN
* Countnes belongmg to the top 22 high-burden countnes m the world
DOTS case detection is the notified new smear-positive tuberculosis cases in DOTS areas over estimated new smear positive tuberculosis cases. To reach 70% DOTS case detection rate it is required to detect 70% of estimated smear positive tuberculosis cases and to enrol all detected cases in DOTS strategy.
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- 9Group 1: Seven countries with a high tuberculosis burden: Cambodia (CAM), China (CHN), the Lao People's Democratic Republic (LAO), Mongolia (MOG), the Philippines (PHL), Papua New Guinea (PNG) and Viet Nam (VTN). Group 2: Seven countries with an intermediate tuberculosis burden and a good health infrastructure: Brunei Darussalam (BRU), Hong Kong, China (HOK), Japan (JPN), the Republic of Korea (KOR), Malaysia (MAA), Macao, China (MAC), and Singapore (SIN). Group 3: Pacific island countries with populations ofless than one million. Group 4: Industrialized countries with a low tuberculosis burden and low incidence: Australia (AUS) and New Zealand (NZE). 2.2.1.4 Political commitment and partnership for tuberculosis control
Dr Eliuel K. Pretrick, Secretary of Department of Health, Education, and Social Affairs of the Federated States of Micronesia, delivered a speech on the political commitment in his country. The Secretary noted that there was an international agreement that tuberculosis was no longer a technical issue but a managerial and financial concern. Political commitment was the key to ensuring that tuberculosis control efforts would be successful. Partnership between the Government and private sector was essential to tuberculosis control. The involvement of political leaders and dignitaries strengthened advocacy as experienced in the leprosy control programme in the Federated States of Micronesia, and would be replicated for tuberculosis. Political commitment included the provision of financial and human resources. All levels of the health system must work together. The community must also be involved, especially at the beginning of any public health activity. 2.2.1.5 Framework for effective tuberculosis control
Dr Janet O'Connor, TB Specialist, Secretariat of the Pacific Community introduced the framework for effective tuberculosis control. A framework for effective control of tuberculosis is an outline of the minimal essential elements required to be put into place in order to implement DOTS. The essential elements of the tuberculosis control framework consist of a goal, objectives, targets, strategies, a national tuberculosis programme body, a communication network system and indicators. The DOTS strategy forms the nutshell of this framework. The goal in this framework is the mission statement of the Pacific Strategic Plan to Stop TB: 'To significantly reduce the morbidity and mortality due to TB in the Pacific by promoting accessibility and sustainability of the DOTS strategy as part of health system development'. The objectives, targets and strategies of this framework are outlined in the Pacific Strategic Plan that was endorsed by Pacific island countries and territories at the First STOP TB meeting in the Pacific islands. This document provides the background information for the tuberculosis control framework and should be used as the guideline for DOTS implementation in the Pacific islands. Countries are encouraged to prepare and develop their national tuberculosis control programme manual from this document. A national tuberculosis programme (NTP) must be formed as a central unit to coordinate all tuberculosis control activities in a country. It should have a manager, a coordinator and clerical staff for data collection and compilation. Its main responsibility is to oversee the NTP and ensure that all
- 10 individual tasks are properly performed, data collected are reliable and case management follows the guidelines stipulated under the DOTS strategy. A network system should be put in place to link all sections and activities involved in the DOTS programme. Regular surveillance of the programme should be conducted by the NTP manager or coordinator to ensure that the objectives are met. Monitoring of all aspects of the programme should be done regularly and special attention given to problems and unmet needs.
2.2.1.6
Building partnership
Ms Michele Vanderianh-Smith, Health Management Adviser/Focal Point Health Secretariat of the Pacific Community, provided the context in which partnership on tuberculosis control must be considered. Tuberculosis incurs major direct and indirect costs. The burden falls mostly on the economically productive age group. Tuberculosis is a serious economic and social problem. Coordinated and concerted action between government, nongovernmental organizations and community groups is required to ensure success and sustainability. It is necessary to define roles and critically assess the impact of joint actions. Such a partnership between community, government and nongovernmental organizations will ensure that public health programmes have a greater impact. Cooperation and partnership exists in many areas of Pacific regional activities, including between SOPAC, the Fiji School of Medicine, United Nations agencies, and WHO. A formal partnership already exists between WHO and SPC. Building partnerships is about people-centred development. "Shared ownership" and "ownership for action" are important principles. The Stop TB programme is an excellent example of "ownership for action". The Pacific Elimination of Lymphatic Filariasis Initiative is a good example ofa programme where strong partnership has already been developed.
2.2.1.7
Group discussion on political commitment and partnership for the Pacific Stop TB Initiative
GROUP 1: Participants: Dr Cecilia Teresa T. Arciaga (Guam), Dr Nang Si Si Win (Nauru), Dr Helen Sokau (Palau), Mrs Minemaligi Hetutu Pulu (Niue) The group noted that it was important for all countries in the Pacific to have common goals and common approaches to tuberculosis control. This coordinated action could be achieved through establishment and implementation of the Pacific Stop TB Initiative. Within each country there are many potential important partners (traditional leaders, schools, other government departments) and at the regional level there is a need for collaboration. In principle, political commitment among the countries in Group I is good. However, there is a need for more commitment, particularly in relation to financial support and the provision of resources. The group made the following conclusions: Establishment of a Pacific Stop TB Initiative • • • A common understanding of tuberculosis as a unique curable chronic infectious disease is required. The Pacific Stop TB initiative will help put quality tuberculosis control (DOTS) on national agendas. A certain amount of standardization of tuberculosis control programmes is required.
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•
There is strong support for a Pacific-island-wide initiative which includes flexibility at country level.
Regional partnerships • • • There is a need for collaboration between Pacific island countries in tuberculosis control. There is a need for regular Pacific regional tuberculosis control meetings. Nongovernmental organizations concerned with tuberculosis control at regional Pacific island level need to be involved. SPC and WHO require clear statements on approaches to tuberculosis control in Pacific island countries. There is a need for partners in DOTS implementation (especially nongovernmental organizations), but too many partners can cause problems and coordination is required
•
•
National commitment to tuberculosis control • • • • • • Insufficient priority is often accorded to tuberculosis control at national level. Political commitment requires community awareness through health education. The community needs to be involved and to participate in tuberculosis control. Tuberculosis control requires the support of the traditional authority structure. Partnerships are required with other branches of the health department, especially those concerned with EPI and control of other infection diseases. The economic importance of tuberculosis control in minimizing future expenditures is often not appreciated.
Support for DOTS • • DOTS has started in most countries and the task is to increase emphasis, and strengthen and further develop programmes. There is a strong similarity between DOTS programmes in different countries, but there are some variations and flexibility is required. Involvement of nongovernmental organizations (especially churches) and traditional authorities is required.
•
Resources and implementation • There is competition for resources with other disease control programmes, especially noncommunicable diseases (NCD), but it needs to be emphasized that tuberculosis is transmissible and curable. There is a need for the knowledge of the present generation of those involved in tuberculosis control to be passed on to younger public health workers.
•
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Training of manpower in tuberculosis control is required. There are cultural impediments to tuberculosis control is some Pacific island countries, relating to the social stigma attached to a diagnosis of tuberculosis in a family.
GROUP 2: Participants: Dr Bernard Rouchon, Dr Michel Cortembert, Dr Martine Noel (New Caledonia), Dr Dominique Megraoua (Wallis & Futuna), Dr Artin Mahmoudi (NMI), Docteur Vincent Dupont (French Polynesia), Ms Tae Nootutai (Cook Islands) The group concluded that: (1) The programme should be formalized as a priority: • • • (2) in the different health organizations in the Region; by including it in a health plan written by technicians; and by validating it through policies.
The power of the media should be utilized: • • in order to involve the population; and putting emphasis on prevention.
(3)
Practitioners should be made aware of DOTS; • • • through training by implementing an evaluation programme; and by defining common objectives at the regional level.
(4)
A supra-national mechanism should be organized, which would: • • • define and ensure key directions; be able to offer logistic support and service at any given moment; and create a regional surveillance and monitoring network.
GROUP 3: Participants: Dr Cristie Cabungcal, Dr Taketiau Beriki (Kiribati), Dr Kennar Briand (Marshalls), Dr Eliuel K. Pretrick, Mrs Lerina J. Nena (FSM), Dr Taniela Lutui (Tonga) Participants in Group 3 were in support of the DOTS strategy as the main framework of the Pacific Stop TB initiative. DOTS in the countries represented in this group are at different operational levels, requiring different levels of assistance. However, the countries recognized the importance of political commitment and support in enhancing the DOTS in their respective situations. Other important aspects discussed that should be addressed by political commitment were:
•
funding support for maintaining and sustaining tuberculosis control activities;
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the need for training in all areas of the tuberculosis control programme; establishment of all five components of DOTS strategy; particularly in the Marshall Islands and the Federated States of the Micronesia where some components (microscopy services) are not in place and have to rely on external laboratory support; involvement of traditional healers in tuberculosis control by training them so they can help in early referral of suspects; and community awareness and education to improve compliance.
• •
GROUP 4: Participants: Dr Bera Kaitani (Fiji), Dr Titi Lamese, SN Sa'eu Tualima Penaia (Samoa), Dr Griffith Harrison, Mr Georges Bule (Vanuatu) Participants from Group 4 supported the establishment ofthe Pacific Stop TB Initiative which they considered a major support to enhancement of tuberculosis control in Pacific island countries. They recognized tuberculosis as a public health problem affecting the poorest. A regional partnership between SPC, WHO, JICA, bilateral partners and nongovernmental organizations is required, although this raises coordination issues. More effective political commitment is necessary to achieve better results and to control tuberculosis. Effective commitment should result in higher funding for tuberculosis. It was noted that other activities such as EPI and filariasis programme were more successful in attracting funds than tuberculosis. Political commitment requires a larger involvement from the following:
•
politicians (parliamentarians, government and legislative authorities); traditional authorities village level, as well at a more central level; and representatives from health workers and traditional healers. The community needs to be involved and participate in tuberculosis control.
•
•
2.2.2 2.2.2.1
Technical issues DOTS and other strategies (preventive therapy and BCG vaccination)
Dr Pierre-Yves Norval presented strategies to control tuberculosis, starting with DOTS, the only strategy that can impact the tuberculosis epidemic. The place and role of the preventive therapy in selected high-risk groups of the population, as well as WHO recommendations on the use of single BCG vaccinations (without re-vaccination) were also mentioned. DOTS is the basic strategy of the Pacific Stop TB Initiative and has five key components: (1)
government commitment to sustain tuberculosis control activities; case detection by sputum-smear microscopy among symptomatic patients;
(2)
(3) a standardized treatment regimen of six to eight months for at least all confirmed sputum-smear-positive cases, with directly observed treannent for the entire regimen. A single category 1 and 2 regimen is proposed in the Pacific and includes Rifampicin during the initial and continuation phase;
- 14 -
(4)
a regular uninterrupted supply of all antituberculosis drugs; and
(5) a standardized recording and reporting system that allows assessment of treatment results for each patient, as well as for the overall tuberculosis control programme. The five components of DOTS represent the minimum package that is necessary for tuberculosis control. Implementation of the strategy requires flexibility and adaptation to a wide variety of contexts. In the Pacific Stop TB Initiative, the main aspects of DOTS will be adapted in order to meet the specific challenges of the islands. Preventive therapy in the general population should be stopped because it is not feasible or cost-effective, and will divert from priority areas of work. Preventive therapy should only be considered among high-risk groups, starting with contacts of smear-positive cases under five years old. HIV-positive cases could also benefit from preventive therapy if DOTS is successful (over 85% success rate). BeG is recommended at birth, especially in countries with a high prevalence of tuberculosis, because it prevents dissemination after infection, avoiding the severe form of tuberculosis among children (meningitis, milliaris). BeG does not prevent multibacillary infection and has no epidemiological impact in control of tuberculosis. There is no scientific evidence that BCG revaccination is beneficial and WHO does not recommend it. 2.2.2.2 Information systems
Dr Carmine Diletto, Stop TB and Leprosy Elimination, WHO Western Pacific Regional Office, presented the WHO recommended informatIOn system for tuberculosis control. The tuberculosis information system is the establishment and maintenance of a standardized recording and reporting system that allows assessment of treatment results for each patient and the overall performance of the tuberculosis control programme. This information system is one of the five key components of the DOTS strategy and, because is results-oriented, enables quality assurance of programme implementation. The system is simple and within the capability of the most peripheral health workers. Data collection is limited to data that will be used and can be analysed by the health workers operating at the DOTS centre. The system consists of the following forms and registers:
• • • •
Laboratory register: This contains a log of all patients who have had a smear test done and is kept at all laboratories performing sputum examination. It differentiates between patients that have sputum examinations for diagnostic purposes, and those examined for follow-up. Patient treatment card: Each person diagnosed with tuberculosis has a patient treatment card. The card records basic epidemiological and clinical information as well as the administration of drugs. Tuberculosis register: This is used by the DOTS coordinator, a health worker responsible for supervising each administrative area implementing the DOTS strategy. It lists all patients starting treatment and monitors their individual and collective progress towards cure. Quarterly report on case finding (new and retreatment cases): This is prepared by the DOTS coordinator from the tuberculosis register. It gives information on new and retreatment cases. From this report the following key indicators can be obtained: cases notified and rate; proportion of sputum-positive cases among all cases.
- 15 -
•
Quarterly report on the outcome of treatment: This report is also prepared by the DOTS coordinator from the tuberculosis register. It gives information on the results of patient treatment, especially on cure and completion rates.
The two quarterly reports are the key management tools used to evaluate the effectiveness of tuberculosis control activities in any given DOTS centre. The analysis of the two reports gives any middle- or high-level manager timely, concrete indicators of achievement or of problems requiring action. Action can, therefore, be taken if cure rate is low, higher than expected sputum-negative cases are reported, or a lower or higher number of cases than expected are reported. The DOTS recording and reporting system allows for monitoring of individual patients as well as assessment of the overall performance of each DOTS centre, district and country. It also has a strong system of accountability and a way of crosschecking that makes false reporting of data difficult.
2.2.2.3
Laboratory service
Mr D. Dawson, Chief Scientist, Diagnostic and Reference Laboratory for Mycobacterial Diseases Brisbane, Australia, presented the laboratory services. Laboratory diagnosis is one of the key components of all tuberculosis control programmes and one of the five DOTS components. Positive acid-fast microscopy on sputum from symptomatic patients confirms the presence of active tuberculosis and will lead to enrolment in treatment programmes. Subsequent testing will be used to measure the effectiveness of treatment. Thus, countries/regions adopting DOTS must have laboratories that provide microscopy services of a high standard. The location of a microscopy laboratory in the Pacific island countries will depend on factors such as population, population distribution and internal transport, as well as the location of existing laboratories and DOTS centres. Although tuberculosis microscopy requires only basic facilities, microscopy services will generally be located only in the large population centres in Pacific island countries and areas. Quality assurance is essential in maintaining confidence when interpreting laboratory results. Key elements are microscopy performance, technician training and supervision, standard methodology and internal and external quality control. Expert personnel (e.g. from WHO Collaborating Centres) can provide technical guidance, external quality control and supervision, as appropriate.
2.2.2.4
Drug supply
Dr Budiono Santoso, Regional Adviser, Pharmaceuticals WHO Western Pacific RegionaJ Office mentioned in his presentation that a regular supply of drugs of assured quality was a component of the DOTS strategy. Drug management includes selection and quantification, procurement and financing, distribution and management of supplies. Tuberculosis drugs should comply with WHO recommended strengths from the WHO Essential Drugs List. There are already various mechanisms or initiatives to improve pharmaceutical management and use for Pacific island countries. These could be utilized in the tuberculosis programme to improve the efficiency of the supply of antituberculosis drugs. They include:
• • •
the existing Fij i collaborative phannaceutical purchase arrangement; information exchange on pharmaceuticals supplies, management and use through an electronic discussion group for Pacific island countries; development of a local capability in quality control of pharmaceuticals for Pacific island countries.
- 16 -
The following steps need to be taken in support of DOTS implementation in Pacific island countries: • Existing effective drug procurement mechanisms, such as the Fiji collaborative pharmaceutical purchase arrangement, can be utilized, but should be strengthened. Another altemati ve for small Pacific island countries is a collaborative purchase arrangement through WHO. A mechanism for collaborative quality control of antituberculosis drugs needs to be initiated. This should involve local laboratories, such as the Fiji Medical School, as well as referral laboratories, such as WHO Collaborating Centres in Australia, Singapore and Malaysia. Coordination and collaboration at country level between tuberculosis programmes and essential drug programmes in the area of selection, procurement and distribution of anti -tuberculosis drugs is of utmost importance in support of DOTS implementation. Fixed drug combinations, especially those containing isoniazid and rifampicin should be made available to Pacific island countries Human resources and training
•
•
•
2.2.2.5
Dr Richard Taylor, Associate Professor, Department of Public Health and Community Medicine, Australia, presented a key component of successful tuberculosis control, which is however, not one of the five DOTS components: staff need to be multiskilled. Pacific island countries face transportation difficulties, both in sea and land transportation, and it is important that tuberculosis coordinators, who trained and experienced in tuberculosis control and also possess numerical and managerial skills, are available within countries. Drug procurement at the national level requires trained pharmacists. The human resources required for tuberculosis control include managers, clinicians, laboratory technicians and health statisticians. Many of these staff will have roles in other areas of the health system. Training is required at all levels and requires careful planning. Training programmes should be ongoing and will require evaluation and revision.
- 17 2.2.2.6 Group discussion on developing or refining country plans of action to Stop TB
Summary of DOTS adoptation and expansion AdoU! DOTS 1993 1999 1-1994 1997 1989 1997 1-1998 6-1997 1999 1999 1995 1995 4-1999 1999 1999 2000 100 % DOTS exoansion DOIS centres 3 in 1991 1993 1 in 1999 1999 4 2002 4 in 2005 1998 4 in 1999 1999 1997 3 5-2000 2 9-2000 2 3 in 1999 1999 1 1999 1 1995 5 in 2005 1996 4 4-2000 1 2000-1 6 in 2005 2005 2 in 2000 2000 46
CNMI Cook Islands FSM Fiii French Polvnesia Guam Kiribati Marshall New Caledonia Niue Palau Samoa TOlllLa Tuvalu Vanuatu Wallis & Futuna Total
- 18 Identification of constraints and proposed plan to overcome them Gro ups New Caledonia, Wallis&Fut una, CNMI, Fr Polynesie Cook lsI. Constraints Proposal to overcome constraints
•
• • •
•
Isolation, lack of communication, limited exchange of experience Lack of advocacy tools Limited partnership Lack of DOTS training, staff turn over
•
• •
• •
No cohort analysis in public Lack of RIR in private sector No systematic culture and DST DOT not systematic Use of loose tablets sometimes Lack of social welfare in rare case BCG revaccination No PT among contact children Insufficient funding and transportation means Lack of trained and motivated staff Insufficient partnership, no links with traditional healers Physician resistance No EDL, loose tablets Lack of laboratory QA Unreliable or lack or RlR Low community awareness BCG revaccination Insufficient funding and transportation means Lack of trained and motivated staff Insufficient partnership, no links with traditional healers Insufficient and inadequate TB drugs and drug management Inadequate sputum specimen referral
• • • • • • Niue, Guam, , Nauru, Palau,
•
•
• • • • • • •
•
Establish a French speaking countries inter country Committee, + WHO + French MOH Develop adapted advocacy tools in French Involve Social welfare department, health service in working places Training, 2 years minimum post, tillage of staff Improve patient files to include standardized treatment outcomes items Apply existing legislation for mandatory registration and tracing of treatment outcomes Systematic culture + referral laboratory Establish official Technical Advisory group FDCs more systematics Special assistance in case of social emergency Stop BCG revaccination PT for contact under 5 years old Seek funds from Government and external support Training workshop Establish an Advisory Committee
• • • • •
• • • •
• • • FS M, Tonga, Kiribati, Marshall
•
• • •
•
Sam oa, Vanuatu, Fiji
Unreliable recording/reporting system • Low community awareness • Lack of funds and political commitment • Lack of trained and motivated staff • Insufficient partnership and community participation • Poor communication and difficulty in delivering OOT • Poor laboratory performance
•
Training workshop Purchase FOCs • Establish QA protocols • Implement WHO recommended forms • lEC • Stop re-vaccination policy • Seek funds from Government and external support • Training workshop, peers meeting, study tour abroad, incentives • Advisory committee (church, local partners, private clinics) Replace loose tablets with FOes, Establish regular • inventory of stocks • Establish new referral system for sputum containers • Improve recording/reporting through regular supervisory visits • lEC • Seek funds from Government and external support; improve advocacy tools • Training workshop and study tour and incentives • Steering Committee, community groups, IEC Use of community leaders and traditional leaders More training and establishment of Quality Assurance system
• •
- 19 -
3. CONCLUSIONS AND RECOMMENDATIONS
3.1
Conclusions
Tuberculosis is a serious public health concern in Pacific islands, with a case notification rate of 59 per 100000 population, higher than the case notification rate of 51 per 100 000 for the entire Western Pacific Region. DOTS coverage has also increased slowly and is still in the early stages of expansion. In response to the growing tuberculosis burden in the Pacific islands, the first "Stop TB Meeting in the Pacific Islands" launched the "Pacific Stop TB Initiative" as a means to achieve greater political and community commitment and strengthen partnership for "Stop TB" between Pacific island Member States and areas, and partner agencies. The meeting also endorsed the "Pacific Strategic Plan to Stop TB" as the technical guidelines for "Stop TB" in the Pacific. The meeting concluded that DOTS implementation was the key strategy for the "Pacific Strategic Plan to Stop TB" and that strong political commitment and community involvement from all Pacific island Member States and areas was needed to improve DOTS implementation. During the first Stop TB Meeting in the Pacific Islands, representatives from the Pacific island countries and areas present at the meeting, together with representatives from international, governmental and nongovernmental organizations agreed on: (1) establishment of the "Pacific Stop TB Initiative" to reduce the tuberculosis burden in the Pacific by half by 2010; (2) recognizing the flexibility in DOTS approaches, that the essential elements of the "Pacific Strategic Plan to Stop TB" in relation to DOTS implementation were: • • • • incorporating the DOTS strategy into country plans for health systems development; adopting DOTS as the primary TB control strategy in all countries and areas by 2002; ensuring 100% of detected new smear-positive cases are enrolled under DOTS by 2005; ensuring a treatment success rate of at least 85% for smear-positive pulmonary cases in the DOTS programme; and detecting 70% of estimated new smear-positive cases in the Pacific;
•
(3) setting national targets for the "Pacific Stop TB Initiative" specifically for DOTS implementation through country plans of action, in accordance with the "Pacific Strategic Plan to Stop TB"; and (4) initiating and strengthening partnerships among national tuberculosis programmes, government ministries, nongovernmental organizations and parmer agencies.
- 20-
3.2
Recommendations
In order to achieve the objectives and targets of the "Pacific Strategic Plan to Stop TB", the following recommendations were made at the "First Stop TB Meeting in the Pacific Islands": (1) National governments should make a commitment to DOTS implementation and its sustainability. (2) Pacific island Member States should finalize country plans of action by the end of 2000.
(3) Pacific island Member States should ensure that they have adequate human resources and training for "Stop TB", especially at the central level (including programme managers) to implement country plans of action. (4) Provisions should be improved within the existing infrastructure for the regular supply of quality fixed-dose combinations, at least INH-RMP combinations and/or blister packs of tuberculosis drugs, including the following: • • • (5) establishment of an efficient procurement system, including collaborative arrangements; development of distribution systems, especially in remote areas; and monitoring of the drug quality.
Laboratory systems and networks should be strengthened, including: • • commitment to developing a DOTS microscopy centre in each capital town or capital island; establishment of internal and external laboratory quality assurance systems.
(6)
Tuberculosis surveillance should be strengthened through the following mechanisms: • • • • • improved information systems for tuberculosis, including cohort analysis, notification of cases and outcomes oftreatrnent; monitoring ofTBIHIV co-infection; monitoring of drug resistance; development of appropriate reporting mechanisms for small populations; and improvement in estimates of the tuberculosis burden in the Pacific.
(7) Collaboration and communication between tuberculosis and HIV programmes should be established or strengthened. (8) DOTS mechanisms should be enhanced through: • • development of systems to facilitate transfer, follow-up of cases and programme monitoring; and strengthening of the programme between DOTS centres, the community and remote islands to ensure successful treatment, especially in the continuation phase in remote areas.
- 21 -
(9)
Partner support should be enhanced to: • strengthen the collaboration between the Centers of Disease Control (CDC), the United States of America, the Secretariat of the Pacific Community (SPC), WHO and Member States in order to achieve the objectives and targets of the "Pacific Stop TB Initiative" and monitor the performance of the Initiative; continue and expand the Pacific Regional tuberculosis project at SPC beyond August 2001; and strengthen the technical assistance of WHO to the Pacific islands through the establishment of a WHO tuberculosis post based in Fiji.
•
•
Timetable of the First STOP TB meeting in the Pacific Islands 26-29 June 2000, Noumea, New Caledonia Monday 26 June 2000 Session 1: Stralegy Tuesday 27 June 2000 Pacific Stop TB Initiative Wednesday 28 June 2000 Technical aspects (continued) • Mechanisms afDOTS and prevention (Dr P.Y. Norval) • Discussion and finalization of Pacific Strategic Plan (coordinated by Dr. M Hodge) COFFEE BREAK Introduction to group work. session 2 Group work, session 2 Developing or refining country plans of action to Stop TB Thursday 29 June 2000
0830 0900 0920
0830
Presentation of Plan of Action by each group (10 min. each) I or 2 other group members highlight specific points (10 min. each)
0800 0830 0915 0930 1000 1010 1025 1040 1055 1200 1330 1330 1345 1400 1415 1435 1500 1530 1630 1830
Registration Master of ceremony - Yves Corbel Opening, self introduction and selection of officers for strategy and technical sessions Group photograph COFFEE BREAK Meeting objectives (Chairperson of session I) Chairman to present meeting objectives Glohal overview (Dr L. Blanc) Regional and pacific overview (Dr M. O'leary) Regional Strategic Plan (Dr D. Ahn) Country presentations (7 min. each) Cook Islands, Fiji, French Polynesia, Guam, Kiribati, Nauru. Niue. Northern Mariana Islands, Marshall Islands Questions & Answers lUNCH BREAK Pacific Strategic Plan to Stop TB (3 x 15 min presentationsl20 minutes discussion)
0830
Group work, session 1
0930 1000 1030
. · ·
Consideration fOT a Pacific Stop TO Initiative
Discussion (Plenary)
Plenary (continued) Establishment of a Pacific Stop TB Initiative Conclusions and recommendations
1030
1030 1100 1145
Country plan of action (continued) Discussion and finalization of overall conclusions and recommendations Closing
1145 1200 1330
Closing LUNCH (pnss Conferenec)
Session 2: Technical Opening for technical session (Chairperson, session 2) Technical aspects (3 X 15 min presentations/I 5 min discussion) Information syslems (Dr C. Diletto) Laboratory services (Mr D. Dawson) • Drug supply (Dr B. Santoso) Discussion
1200 1330
· · · ·
lUNCH BREAK Group work, session 2 (continued) Developing or refining country plans of aclion to Slop TB N W
Framework (Dr J. O'Connor) Political commitment for the Pacific Stop TB initiative (Dr E. Pretrick) Building partnership (Ms M. VanderlahnSmith) Discussion I Questions & Answers
1340 1400 1420 1440 1530
Country presentations (continued): Federated States of Micronesia, New Caledonia, Samoa Country presentations (continued); Palau, Tonga, Tuvalu, Vanuatu, Wallis & Futuna Introduction to group work, session I COCKTAIL
· · •
COFFEE BREAK Discussion continued Human resources and training (Dr Richard Taylor)
1530
Group work, session 2 (continued)
26/06100
I-'
~
- 25 -
ANNEX 2 List of participants, consultants, temporary advisers, observers and secretariat. 1. PARTICIPANTS
COOK ISLANDS Ms Tae Nootutai Health Inspector in Charge of Disease Control and Quarantine Services Public Health Department Rarotonga Tel. no.: (682) 29110 Fax. no.: (682) 29100 E-mail address:aremaki@oyster.net
FIJI Dr Bera Kaitani Programme Manager Twamey Memorial Hospital Private Mail Bag Suva Fiji Tel. no.: (679) 321066 Fax.no.: (679) 321559
GUAM Dr Cecilia Teresa T. Arciaga CDC Program Coordinator III Supervisor Tuberculosis/Hansen's Disease Control Section P.O. Box 2816, Hagatna Guam 96932 Tel. no.: (671)735-714517157 Fax no.: (671)735-7318 E-mail address:carciaga@mail.gov.gu KIRIBATI Dr Cristie Cabungcal Acting Director of Public Health Services Ministry of Health P.O. Box 268 Bj!cenjhell
Tel. no.: (686) 28330 Fax no.: (686) 28107 E-mail: mohtskI.net.ki Dr Taketiau Beriki Coordinator tB Control Programme Ministry of Health P.O. Box 268 Bjkenjhell
FRENCH POLYNESIA Docteur Vincent Dupont M6:lecin coordinateur a la Direction de la Sanre Division de la Sante BP 611 Papeere - Tahiti Tel. no.: (689) 46 00 64 / 46 00 02 Fax no.: (689) 430074 E-mail address: Vincent.dupont@sante.gov.pf
Tel. no.: (686) 28100 Fax. No.: (686) 28152 E-mail: mhfp@tskI.net.ki
- 26 Annex
2
COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS, Dr Artin Mahmoudi Medical Director for Tuberculosis Control Division of Public Health and Chairman, Depanment of Medicine Commonwealth Health Center Sajpan Tel. no.: (670)234-8950 Fax no.: (670)234-8930 E-mail address:mahmoudi@gtepacifica.net
NEW CALEDONIA Dr Bernard Rouchon Mwecin coordinateur du Comitede pr&lention de la Nouvelle Calwonie Direction des Affaires Sanitaires et Sociales B.P.3278 98846, Noumm Cedex Tel no.: (687) 24 37 00 Fax no.: (687) 24 37 02 Dr Michel Cortemben Mwecin charge de la pr&lention Direction des Actions Sanitaires et Sociales de la province Nord H6 tel de province BP 41 98860, Kone Tel no.: (687) 47 72 30 Fax no.: (687) 47 71 92 Dr Martine N oil Mwecin du Centre Mdlical Polyvalent Direction des Actions Sanitaires et Sociales de la province Sud Centre Mc1:!ical Polyvalent BP 660 98845, Noumm Tel no.: (687) 28 54 14 I 27 27 73 Fax no.: (687) 28 55 28 Dr Christian Therville Mwecin coordinateur Direction des Actions Sanitaires et Sociales de la Province des lIes Loyaute Immeuble Oregan BP 1014 98845, NouIDm Cedex Tel no.: (687) 24 27 40 Fax no.: (687) 2427 44
REPUBLIC OF THE MARSHALL ISLANDS Dr Kennar Briand Director of Public Health P.O. Box 1456 Majuro
Tel no.: (692)625-3355 Fax no.: (692)625-3432
FEDERATED STATES OF MICRONESIA Dr Eliuel K. Pre trick Secretary, Department of Health, Education, and Social Affairs P.O. Box PS-70 I21iliI Tel no.: (691)3202619 Fax no.: (691)320 5263 E-mail address:fsmhiv@mhil.fm Mrs Lerina J. Nena FSM TB/Leprosy Program Coordinator P.O. Box PS-70 Pobnpei Tel no.: (691)3202619 Fax no.: (691)320 5263 E-mail address:fsmhiv@mail.fm
NAURU Dr Nang Si Si Win Medical Officer Ron Hospital Tel no. (674) 4443882 Fax no. (674) 4443877 E-mail: nangsisiwin@yahoo.com
NIUE Mrs Minemaligi Hetutu Pulu Charge Nurse, Family Health Unit Health Depanrnent Alofi Tel. no.: (683) 4100 Fax no.: (683) 4265
- 27 -
Annex 2
REPUBLIC OF PALAU Dr Helen Sokau Division of Communicable Disease Manager Ministry of Health PO Box 6(f27 Koror, Palau PW96940 Tel no. (680) 488-1757/3116/2450 Fax no. (680) 488-3115
VANUATU Dr Griffith Harrison Resident Physician Central Hospital Port Vila Tel. no.: (678)22100 Fax no.: Mr Georges Bule Assistant TB/L~prosy Coordinator Ministry of Health PMB 009, Port Vila Tel. no.: (678)22512 Fax no.: (678)26204
SAMOA Dr Titi Lamese Registrar, Outpatient and Emergency Department Tapua Tamasese Meaole Hospital Private Mail Bag Apia Tel no.: (685) 21212 Ext. 410 Fax no.: (685) 22905 SAMOA SN Sa' eu Tualima Penaia Nurse Manager, CNC Department of Health Apia Tel no.: (685) 21212 Ext. 373 Fax no.: (685) 21440
WALLIS AND FUTUNA Dr Dominique Megraoua Chef du Service d'Hygiene et de Pretention Responsable des Dispensaires Mttiecine G(n{rale B.P. 4G Mata Utu 98600 Uvea Wallis et Futuna Tel no.: (681)72 20 34 Fax no.: (681)72 18 10 E-mail address:megraoua@wallis.co.nc
TONGA Dr Taniela Lutui Chief Medical Officer of Public Health Ministry of Health Nuku'alofa
2. CONSULTANT Dr Pierre-Yves Norval Public Health Medical Inspector Minisrere de 1'Emploi et de la SoIidarite Direction Dq:,artementale des Affaires Sanitaires et Sociales du Lair et Cher 41 rue d' Auvergne 41018 Bloix Cedex France Tel no.: (33 2) 54557843 I (33 6) 84377005 E-mail: norva1@wanadoo.fr
Tel. no.: (676) 23200 Fax no.: (676) 24291
TUVALU Dr Stephen Homasi Chief Public Health P.O. Box 8 Funafuti Tel. no.: (688) 20480 Fax no.: (688) 20480 120832
- 28 Annex 2
3. TEMPORARY ADVISERS Dr Richard Taylor Associate Professor Department of Public Health and Community Medicine Faculty of Medicine Building A27, University of Sydney Sydney NSW 2006 Australia Telephone no.: 61-2-9351-4375 Facsimile no.: 61-2-935HI79 E-mail address: Mr Peter Crippen Centers for Disease Control and Prevention (CDC) c/o Department of Health, Education and Social Affairs Federated States of Micronesia P.O. Box PS 70 Palikir Pohnpei PM 96941 Fax: (691)320 5263
Dr Corine Capuano/Reisinger Ambassade de France B.P. 88 - Port Vila Vanuatu Tel/Fax: (678) 24725 E-mail:cmandgpcapuamo@vanuatu.com.vu
4. OBSERVERS/OBSERVATEURS
Community Health and Anti-Tuberculosis Association (CHATA) Dr Peter Pigot Respiratory Disease Unit Royal North Shore Hospital St. Leonards NSW 2065 Australia
Dr Masashi Suchi Chief, Program Development and Management Division Research Institute of Tuberculosis Japan Anti-Tuberculosis Association 3-1-24 Matsuyama, Kiyose-shi Tokyo 204, Japan Telephone no.: (81) 424 93 5340 Facsimile no.: (81) 424 92 8258 E-mail address:suchi@jata.or.jp Mr David Dawson Chief Scientist Diagnostic and Reference Laboratory for Mycobacterial Diseases The Prince Charles Hospital Brisbane, Australia Telephone no.: (61) 7 3212 5149 Fax no. (61) 7 33 50 8553 E-mail: dawsond@health.qld.gov.au
New Zealand Official Development Agency (NZODA) Ms Bronwyn Shanks Official Vice-consul New Zealand Consulate-General BP 2219, Noumffi Nouvelle Calwonie 98846 Tel: (687) 27 25 43 Fax: (687) 271740 E-mail: bronwyn.shanks@mfat.govt.nz
5 . SECRETARIAT
WHO/WPRO Dr Michael O'leary Medical Officer (Epidemiologist) Office of the WHO Representative in the South Pacific Level 4 Provident Plaza One Downtown Boulevard 33 Ellery St. P.O. Box 113 Suva, Fiji Telephone no.: (679) 304600 or 300727 Facsimile no.: (679) 300462 E-mail address:
-29Annex 2 Dr Cannine Diletto Short-tenn Professional, Stop TB and Leprosy Elimination WHO Regional Office for the Western Pacific Manila Philippines Telephone no.: (63-2)528 8001 ext. 9967 Facsimile no.: (63-2) 526 0279,5260362, 521 1036 E-mail address:dilettoc@who.org.ph SPC Dr Janet O'Connor TB Specialist Secretariat of the Pacific Community BPD5, 98848, Noumea Cedex New Caledonia Telephone no.: (687) 26 20 00 Facsimile no.: (687) 2638 18 E-mail address:JanetO@spc.org.nc Ms Michele Vanderlanh-Smith Health Management Adviser/Focal Point Health B.P. D5 98848 Noumea Cedex Telephone no.: (687) 260122 Facsimile no.: (687) 263818 E-mail address: micheleV@spc.int DrYvan Souares Epidemiologist B.P. D5 98848 Noumea Cedex Telephone no.: (687) 2601 43 Facsimile no.: (687) 26 38 18 E-mail address: yvans@spc.int Ms Mina Vilayleck Surveillance Information Officer B.P. D5 98848 Noumea Cedex Telephone no.: (687) 26 20 00 Facsimile no.: (687) 26 3818 E-mail address: minav@spc.int Mrs Elise Benyon Data Processing Officer B.P. D5 98848 Noumea Cedex Telephone no.: (687) 26 20 00 Facsimile no.: (687) 26 3818 E-mail address: eliseb@spc.int
Dr Dong II Ahn Regional Adviser, Stop TB and Leprosy Elimination WHO Regional Office for the Western Pacific Manila Philippines Telephone no.: (63-2) 528 9977 Facsimile no. (63-2)5260279; 5260362; 521 1036 E-mail address:ahnd@who.org.ph
Dr Budiono Santoso Regional Adviser, Pharmaceuticals WHO Regional Office for the Western Pacific Manila Philippines Telephone no.: (63-2) 528 9977 Facsimile no. (63-2) 526 0279; 5260362; 521 1036 E-mail address:santosob@who.org.ph
Dr Marcus Hodge Medical Officer, Expanded Programme on Immunization Office of the WHO Representative in the Socialist Republic of Viet Nam 2A Van Phuc Quarter - Ba Dinh Ha Noi Viet Nam Telephone no.: 84-4-845-7901 Facsimile no.: 84-4-823-3301 E-mail address:
-30Annex 2 WHO/HQ
Ms Odile Rolland Secretary to the Community Health WHO/HQ Programme Secretariat of the Pacific Community (SPC) BPD5 9848 Noumea Cedex New Caledonia Telephone no.: (687) 26 20 00 or (687)26 01 27 Facsimile no.: (687) 263818 E-mail address: Odiler@spc.int
Dr Leopold Blanc Medical Officer Strategy Development and Monitoring for Endemic Bacterial and Viral Diseases (EBV) Control, Prevention and Eradication (CPE) CDS Cluster World Health Organization Geneva, Switzerland Tel. no.: 41-22-791 4266 Fax no.: 41-22-791 4278 E-mail address:bJancl@who.ch
Summary of country situation presented by country Representative during the Noumea meeting, 26-29 June 2000 Case notification 1999 Pop. No. TB Rate No. Sm+ 19100 15.7 0 3 790000 192 65 24.3 229328 43 101 44.0 151716 45.5 47 69 88558 255 287.9 72 66700 66 15 99.0 50840 45 16 88.5 112732 24 108 95.8 10000 2 207612 27 77 37.1 1600 I 3 187.5 17225 7 11 63.9 170000 31 18.2 16 99 ·821 21 21 10 193219 14400 124 21 64.2 145.8 DOTS coverage pop % All types 81.8 8.2 100.0 100 100.0 18.8 100 100.0 31.0 100 93.2 100 81.3 22.5 100.0 100 68.0 31.5 47 58.0 54 21.3 20.0 0.0 0 13.0 ,--100.0 100 62.5 40.6 71.4 90 9.4 r~ 100.0 100 10 69 86 ~--~
,
Rate
Sm(+) 100 100 100 100 100 88 70 0 100 100 100 80
Tt outcome Succes rate 90 86.2 90 80 75 78 100 56 w
'Cook Islands IFiji French Polynesia Guam Kiribati Northern Mariana Islands Marshall Islands Federated States of Micronesia Nauru New Caledonia Niue Palau Samoa Tonga Tuvalu Vanuatu Wallis and Futuna
94 80
.....
---
48 6
24.8 41.7 ~-
45 0 '------
---
74.2 0
54 -
----69 100
0
w
~