WPRlRC59/SRl5
SUMMARY RECORD OF THE FIFTH MEETING (WHO Conference Hall, Manila) Wednesday, 24 September 2008, at 14:00
CHAIRPERSON: Mr lakoba Taeia ltaleli (Tuvalu) later: Dr Francisco Duque III (Philippines)
CONTENTS page 1.
Prevention and control of noncommunicable diseases (continued) Policy direction concerning the establishment of centres of the Regional Office in countries ...... ....... .......... .................... .......... ........ ...... ...... The Dengue Strategic Plan of Action .................. .......... ...... ........... ........ ................ ............
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PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES (Document WPRJRC59/6): Item 12 of the Agenda (continued) Dr Mareva TOURNEUX (France) expressed her support for the report on NCD. The French Pacific
areas, like other countries and areas in the Region, were experiencing the epidemiological transition to lifestyleassociated diseases. The prevention of diet-related diseases., cancer, tobacco use, and drug and alcohol abuse were public health priorities. Locally adapted action programmes had been formulated to combat them, involving media awareness and information campaigns, education, legislation and patient care. French Polynesia had strengthened its legislation for tobacco control in accordance with WHO recommendations and in line with new French legislation to come into effect on I January 2009, along with awareness and information campaigns. New Caledonia had begun a campaign against the use of cannabis. which was widespread, especially among young people. A media information campaign had been launched. and working groups comprising various institutional partn(:rs had been organized to draw up an action plan for the next three years. Both areas had reinforced their programmes for the prevention of diabetes, obesity. high blood pressure, gynaecological cancers, alcohol and drug abuse, and tobacco use. She asked the Regional Office to organize sociological surveys to help health authorities better understand the health-related behaviour of Pacific islanders. Dr DUOUE took the chair. Dr MAOATE (Cook Islands) said that his country's programme for NCD prevention and control included measures to combat obesity, high blood pressure, diabetes and mental illness. Recently, the tax on imported soft drinks had been increased to 60%. In his view, human rights concerns were sometimes applied differently in developing countries; for example, hI! believed that people who were obese should not be employed by the Ministry of Health. In order to reduce tobacco smoking and alcohol abuse, the taxes on those products had been increased to the same levels as in New Zealand. He asked other representatives for suggestions on convincing people to increase their levels of physical exercise and eat more healthy food, recognizing that education was an essential element. He was not only the Minister of Health in his country, but also the Minister of Finance, so the budget for health was always a priority. Professor VONGVICHIT (Lao People's Democratic Republic) said that work on the prevention and control of noncommunicable diseases was just beginning in his country, although cardiovascular disease, diabetes, cancer and bronchial asthma were common. The risk factors, including tobacco, alcohol, unhealthy diets, pollution and stress, were also common. He asked for support from WHO in fonnulating a strategic plan. Dr Byamba BAATARSUKH (Mongolia) said that a change in the pattern of mortality in his country had begun in 1993, when the incidence rates for cancer, injury and poisoning were found to have increased. Recently, the incidence of diabetes had increased dramatically. A survey conducted in 2005 had shown that nine out of I 0 people interviewed had at least one risk factor for noncommunicable diseases, while one in five had three or more risk factors. In the same year, a national programme for NCD prevention and control had been prepared, based on the Regional Office's action plan; its budget had now been approved and agreements
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reached between the Government and nongovernmental organizations for its implementation and monitoring. A health promotion foundation had been set up, which was funded by a 2% levy on tobacco taxes. Mr Colin SINDALL (Australia) said that his country endorsed the proposed Regional Action Plan, noting its similarity to the Global Action Plan. He welcomed the emphasis on health systems strengthening, which was important for the control of chronic diseases, using a multisectoral approach. The Plan should nevertheless reflect the diversity of circumstances in the Region. In that respect, it might be useful to include a statement that actions could be taken "as appropriate", as had been done in the Global Action Plan. He agreed with the representative of the United States of America that prevention was a priority and should be a key message. He supported the substantive amendment proposed by the representative of New Zealand, and agreed with other representatives concerning the importance of interventions early in life. He was also in agreement with the comments made by the representative of China. He would give the Secretariat a number of minor amendments to the document in writing. His country had provided support for a number of activities and looked forward to continuing work with WHO and the Secretariat of the Pacific Community. Mrs PAUL (Marshall Islands) said that her country endorsed the draft action plan presented in the document. Within a few years, noncommunicable diseases had become a major health problem in her country. The Ministry of Health had used a primary health care model designed by the Health Disparities Collaboratives unit of the United States Department of Health and Human Services to introduce health promotion with regard to noncommunicable diseases and community education for preventive measures, for taking medication, and for a healthy diet. The Ministry had helped the Government to draw up regulations for the control of tobacco and alcohol use. Mrs NGUYEN THI MINH CHAU (Viet Nam) said that her country had a national steering committee for NCD prevention and controL It would continue to implement its plan, taking the necessary steps to establish a comprehensive national programme that included control of risk factors and management of disease, with an initial focus on the organizational structure. The office for tobacco control was to be merged with that for noncommunicable diseases, and chronic obstructive pulmonary disease would be included in the programme. The overall programme for noncommunicable diseases would then be restructured into four components, as recommended by WHO. She looked forward to further support from WHO. On returning home, her delegation would report to the chairperson of the NCD steering committee on the outcomes of the fifty-ninth session of Regional Committee and would organize a workshop to draw up a detailed plan for future activities. At the invitation of CHAIRPERSON, statements were made by representatives of Consumers International and the International Agency for the Prevention of Blindness. The DIRECTOR, BUILDING HEALTHY COMMUNITIES AND POPULATIONS, thanked Member States for their input into the draft Regional Action Plan. The numerous meetings held had been productive. WHO STEPwise surveys for noncommunicable diseases had been finalized and five reports had been issued, with more in preparation. Support has been provided to five countries in formulating policies and programmes and to others for implementation of clinical practice guidelines, especially those on diabetes. In terms of capacity-building, she was gratified to hear interventions from representatives who were graduates of the Japan-WHO International Visitors Programme on NCD Prevention and Control; there were
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now 74 graduates from the four courses that had been held. The Japanese Government had indicated its commitment to continuing that programme. In discussion of the Proposed Programme Budget 2010-2011, several representatives had raised the matter of the budget allocation for noncommunicable diseases, and she assured the Committee that it was intended to increase funding for strategic objectives 3 and 6. Voluntary contributions for NCD prevention and control (only 40% of the allotted budget in 2006--2007) were difficult to raise; figures for several strategic objectives in the proposed 2010-2011 budget had been adjusted in order to be more consistent with expected funding. She acknowledged the references to the WHO Innovative Care for Chronic Conditions Framework. a chronic care model that linked the policy environment, health care organizations and communities. Appropriately informed and motivated communities, working with prepared health care teams, \\ould facilitate better health outcomes. She assured the representative of the United States of America that the draft Regional Action Plan contained in the document was designed to support the action plan for the global strategy; it was not a new strategy. Regional actions were specified for each of the six objectives in the Global Action Plan endorsed in resolution WHA61.l4; they represented what Member States thought could be implemented. Examples were given of countries' achievements, and the accumulated experience could be issued as a compendium of best practices. Regarding the focus on prevention and individual re:sponsibility for health, she commented that the document described the causation pathway which formed the basis for interventions. Action on the underlying broad determinants of noncommunicable disease, which fe II largely outside the reach of the health sector, needed to be considered. The health sector had a key role in advocacy and working with partners in more directly involved sectors in order to effect change. Focusing entirely on individual responsibility was not successful without a supportive policy or legislative environment. Strategic objective 3 could be strengthened by the inclusion of the "MPOWER" package of interventions as a tool to help to implement the WHO Framework Convention on Tobacco Control in the Region. In response to the comment by the representative of Japan on the importance of mental health, she referred to the report of the Commission on the Social Determinants of Health and to the first principle of the Regional Action Plan, which is people-centred health care. The Regional Action Plan recognized the diversity of Member States and the importance of prevention, matters raised by the representatin of Australia, and indicated a STEPwise approach to implementation, taking into account such factors as the level of developm,mt and the resources available. Member States could decide which of the plan's proposed activities they would implement. The ASSISTANT DIRECTOR-GENERAL FOR NONCOMMUNICABLE DISEASES, WHO Headquarters, expressed his appreciation for the contribution of Member States ofthe Region to the development of the action plan for the global strategy and congratulated the Region for being the first to adapt that plan into a version that recognized regional specificities. The enormous burden of noncommunicable diseases and the magnitude of their risk factors and determinants in the Region needed an urgent and comprehensive response.
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WHO estimated that mortality due to those diseases would rise globally by 17% over the next 10 years, but the increase would be greatest in the Western Pacific Region. The Secretariat would work with Member States to review national plans in the light of the six objectives of the global strategy. The first report on trends in NCD prevention and control was due in 2010 (Objective 6 of the action plan). Work on a monitoring tool was in hand, but the Secretariat would need help from Member States, especially in data collection and analysis, which in tum could facilitate surveillance. The WHO Framework Convention on Tobacco Control was crucial to the scaling up ofNCD prevention, and the Secretariat was committed to providing support to countries for implementing the Convention and supporting the Convention Secretariat, in particular the second session of the Intergovernmental Negotiating Body on a Protocol on lllicit Trade in Tobacco Products, to be held in Geneva on 20-25 October 2008, and the third session of the Conference of the Parties, to be held in Durban, South Africa, from 9 to 15 November 2008. The MPOWER package of interventions provided a set of proven measures for implementation at the country level. He assured the representative of Consumers International that implementation of resolution WHA60.23 had already started. A set of recommendations on marketing of foods and non-alcoholic beverages to children would be drafted by 2009. The REGIONAL ADVISER FOR NUTRlTION agreed on the need to start NCD screening and prevention as early as possible. Schools and workplaces offered key settings. Also, micronutrient deficiency in pregnancy and obesity needed to be prevented. How did one help people to improve their eating habits? An approach proven against communicable diseases and smoking called COMBI, or Communication for Behavioural Impact, was being introduced; it was based on the stages-of-change approach. The Regional Office was working with the Food and Agriculture Organization of the United Nations, UNICEF and the Secretariat of the Pacific Community to improve the food supply to Pacific island countries in terms of safety and quality, micronutrient deficiencies, and fat and sugar content. As some women were both obese and anaemic, those two problems should be dealt with together. There being no further comment, the CHAIRPERSON asked the Rapporteurs to draft an appropriate resolution for consideration later in the session. 2. POLlCY DlRECTION CONCERNING THE ESTABLISHMENT OF CENTRES OF THE REGIONAL OFFICE IN COUNTRlES: Item 16 of the Agenda (Document WPRlRC59110) The DlRECTOR, PROGRAMME MANAGEMENT, explained that the item had been placed on the agenda in order to obtain the views of the Regional Committee on establishing centres of the Regional Office in countries. The subject had been brought up previously in informal discussions with Member States, and the lack of a clear-cut policy concerning the matter, both globally and in the Region, had prompted the Regional Director to recommend its inclusion to the Chairperson. A centre of the Regional Office was an office responsible for a programme area previously under the direct responsibility of the Regional Office. Such a centre was subject to the same rules and procedures as any WHO office.
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In two WHO regions, the Americas and Europe, WHO centres handling programmes normally located in the regional offices had been established in countries. In Europe, the principal advantage of such centres was that they attracted additional resources and in-kind voluntary contributions. The potential disadvantage was that a priority programme area was physically separated from the other units of the Regional Office, thus the possibilities for interaction were limited. In addition, sustainability was a potential problem. In both regions, centres had initially been established without a clear policy. Subsequently, the policy concerning those centres had been debated in the respective regional committees. In the case of the Regional Office for the Americas/Pan American Heath Organization, the Director, Programme Management, understood that it had been debated since the I 960s, and many issues related to governance, technical mandate, financing and support to countries remained unresolved. The governing bodies had also encouraged the Regional Director to transfer the centres to the host governments. In the European Region, a policy had been adopted by the Regional Committee in 2004. Subsequently, any proposal for establishing a new centre had to be considered by the Standing Committee of the Regional Committee. Document WPRlRC59/10 gave an overall view of WHO's presence in the Western Pacific Region, where there were currently 14 country offices as well as the Regional Office. There were also 194 collaborating centres that supported the work of the Organization. Previously, there had been a centre for environment in Malaysia, called the Western Pacific Centre for the Promotion of Environmental Planning and Applied Studies (PEPAS), and an intercountry team on malaria at the Institute for Medical Research. Both those centres had been closed, largely because of funding difficulties and programme restructuring. The views of the Regional Committee were requested. Dr CHOt (Republic of Korea) observed that the countries 1Tl
the Region were undergoing rapid
socioeconomic changes that brought in their wake a range of health and environmental problems. In addition, climate change threatened health. Her Government considered that a WHO centre should be established in the Region for the prevention and management of the associated diseases, and strongly supported the idea of such a centre for capacity-building in environmental h.:alth. The Republic of Korea would be hosting the Second Ministerial Regional Forum on Environment and Health in 20 I o. To determine the feasibility of establishing such a centre, her country would willingly participate in the work of the Sub-Committee on Programmes and Technical Cooperatiotl. Dr REN Minghui (China) said that the document contained little information and asked the Regional Office for more. His country cooperated closely with the Secretariat and the Regional Office, and had 69 WHO collaborating centres. WHO offices provided coordination and organization, and technical work was handled through collaborating centres, academic institutions or technical bodies in order to capitalize on their expertise and low costs. The document indicated mixed experiences and di ffering opinions on centres of the regional offices in two other WHO IC1:;iuns. Given that WHO was reducing the number of collaborating centres, caution was needed in considering the establishment of other centres. He agreed with the setting up of a contingency working group. Dr SHIMIZU (Japan) recognized the many contributions of WHO collaborating centres relationships with WHO activities were reviewed and evaluated. [0
WHO's
work. Nevertheless, improvements could follow if the role of such centres, their plans of action and their Geographically dispersed offices had
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advantages and disadvantages, and the need for such offices and the feasibility of their establishment should be examined carefully. Ms BENNETT (Australia) acknowledged that the Philippines had been an excellent host to the WHO Western Pacific Regional Office over many years. Member States expected sound financial management and value for money, and the Manila office continued to meet those criteria. The Sub-Committee on Programmes and Technical Cooperation should be re-established to examine the establishment of centres of the Regional Office and report to the Regional Committee at its sixtieth session. Mrs BLACKWOOD (United States of America) pointed out that her country could look back on 60 years of experience with centres in the Region of the Americas, each of which had its own story. The Pan American Health Organization (PAHO) had a separate assessed budget, and the centres were able to draw on finance and facilities from host governments, with some funding from the PAHO budget, although the trend was now to take centres out of the assessed budget of the PAHO. A lack of clear benefit, or evidence of duplication of effort, had led to several recent closures, although others performed well and had good support from the countries involved. The centres were regularly evaluated by the PAHO governing bodies. The Western Pacific Region could use new business practices and partnerships to achieve health goals, and new technology for the gathering and analysis of data in order to promote best practices. The questiqn was: What was the best way to achieve the goals? In that respect, the establishment of such centres should be considered as a last option, especially in view of the information from Europe on the initial and recurrent cost of such regional centres for the hosting government. Dr TANGI (Tonga) said that, in the light of the comments from the representative of the United States of America, he shared the view of the representatives of Australia, China and Japan, since the options were not clear from the document, and there was a matter of cost, which had to be studied more carefully before an informed decision could be made. Dr VILLAVERDE (Philippines) noted that, even in regions where the practice was in place, there was a lack of consensus. Potential weaknesses were physical separation, which limited interaction among regular staff; the sustainability of funding, with added administrative and transaction costs; and a certain deviation from the technical priorities of the Regional Office. Ms ROCHE (New Zealand) agreed on the need for more information, and suggested that any new development should take account of the United Nations reform programme and the notion of "delivering as one"; in that connection, the results of the pilot project in Viet Nam should be considered. Mrs GlDLOW (Samoa) echoed the concerns of Member States, but supported the proposal that the Sub-Committee on Programmes and Technical Cooperation be re-established. The DIRECTOR, PROGRAMME MANAGEMENT, thanked representatives and acknowledged the consensus. The Republic of Korea was thanked for its offer to support WHO in establishing a centre on environmental health, especially for its emphasis on climate change. Nevertheless, the issue of a WHO centre outside the Regional Office was a policy matter on which the Regional Director would speak.
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The REGIONAL DIRECTOR also thanked the delegation of (he Republic of Korea, and noted that the proposal was a policy issue to be decided by the Regional Committee. There was the option of a subcommittee, which was the operational body mandated by the Regional Committee to discuss such issues. Given that Member States were interested but reserved in their judgement, he proposed the establishment of such a sub-committee. One had been established in 1985 before being disbanded in 1998, to meet only when required. In 2001, when the membership lapsed, it was decided that new members would be appointed only when a specific task was in view. If the Regional Committee wished, the Secretariat would assist in that process. Membership of the sub-committee should be decided, perhaps at the informal consultation that was to take place later that day. Member States wishing to take part should therefore make themselves known. That sub-committee could then work on the subject. The CHAIRPERSON asked whether Member States would support a resolution to reactivate the SubCommittee on Programmes and Technical Cooperation. Dr REN (China) asked whether the Secretariat could clarify the responsibilities of the sub-committee. He asked what were the channels of consultation, whether there was funding for it. Ms BENNET (Australia) echoed those questions, although she expressed readiness to propose a resolution. The DIRECTOR, PROGRAMME MANAGEMENT, said that the Sub-Committee on Programmes and Technical Cooperation had been formed in 1985 by merging two previous committees. In 1988 it had had eight members, looking at programme areas in Member States and reporting to the Regional Committee. Only four members at a time would make a country visit annually, and members had a three-year term. In 1998, the Regional Committee had decided that the Sub-committee should meet only when required to perform a specific task. In 200 I, the Regional Committee had decided that members should be nominated only when a task was to hand. Membership had previously been decided during the caucus meeting. If the Sub-committee were re-established, then there would be costs, which would have to be covered from the Regional Committee allocation. Ms BENNET (Australia) proposed that, in the absence of any other mechanism, the Sub-Committee be re-established. Dr TANGI (Tonga) agreed that it could be re-established, but required more information before even fonning a sub-committee; it was not necessary to check costs, since that information could be obtained from other sources. Endorsement of a resolution should include the financial information. The less costly gathering of information by the Secretariat should continue in the interim. Mrs GIDLOW (Samoa) agreed with the representative of Australia. Dr REN (China) said that if no other sub-committee could do the work, the Sub-Committee on Programmes and Technical Cooperation should be established. Rather than undertake country visits, however, it should analyse information from other regions. whethl~r
there was a need for the sub-committee, and
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Mrs BLACKWOOD (United States of America) asked whether reactivation ofthe old Sub-Committee on Programmes and Technical Cooperation was the way forward, rather than forming a new one with different procedures. The REGIONAL DIRECTOR, in response to comments from the representatives of the United States of America, Tonga and China, elucidated the response of the Secretariat. The purpose of the previous SubCommittee on Programmes and Technical Cooperation had been to visit countries. If a new sub-committee was not to visit countries but to gather information, that was not a problem. More information was needed in the first place; Member States could then establish a sub-committee to gather information and present options to the Regional Committee, The CHAIRPERSON asked once again what a sub-committee could do that the Secretariat could not. Analyses of cost-benefit, budget and feasibility could be obtained from the Secretariat on the basis of country information. The DIRECTOR, PROGRAMME MANAGEMENT, said thatthe cost of a four-member sub-committee would be US$ 20 000 per meeting, If the Regional Committee did agree to its establishment, it would be with ad hoc terms of reference, and it would be disbanded on completion of its tasks. The matter had been discussed in the Secretariat, which had its views, but the decision lay with the Regional Committee. The CHAIRPERSON repeated his question. He believed that the Secretariat could do the work just as we II, and present options. He saw no compeIIing reason to establish a sub-committee. Dr MALAU (Papua New Guinea) agreed with the Chairperson, and therefore moved'that the Secretariat review all the details and present the options to the Regional Committee at its next session. Dr REN (China) seconded that motion. The CHAIRPERSON said that it was proposed that the matter be returned to the Secretariat. 3. THE DENGUE STRATEGIC PLAN FOR THE ASIA PACIFIC REGION: Item 14 of the Agenda (Document WPRlRC59/8) TheACTING DIRECTOR, COMBATING COMMUNICABLE DISEASE, introducing agenda item 14, said that dengue fever had emerged as a major public health problem of international concern. Its geographical distribution had greatly expanded over the previous three decades and the Region had experienced several dengue outbreaks between 1991 and 2008, some quite serious. Human activities, demographic changes and the rapid growth of urban areas had created new opportunities for vector breeding, More recently, changes in weather patterns and human populations were believed to be among the leading factors contributing to the expansion in the habitat range of Aedes aegypti, the principal vector for dengue fever. Unfortunately, dengue was a neglected disease in some countries, attracting attention only during outbreaks, when it was almost al ways too late for effective action. Moreover, dengue programmes consistently faced shortages of human and financial resources, both during and between outbreaks. A revised biregional dengue strategic plan had been developed with the active involvement of Member States, the Regional Offices for the Western Pacific and South-East Asia, and leading experts in the field,
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The logical framework (log frame) approach of the biregional plan called for indicators to monitor the key components of the integrated strategy and provided a tool to mobilize financial resources. The Dengue Strategic Plan for the Asia Pacific Region (2008-2015) recommended concrete steps to reduce the case fatality rate, while providing sound guidance on the environmental management of urban development and vector control. It also encouraged Member States to educate their popUlations on the prompt recognition of dengue and the need to seek medical care early. The plan also called for improved surveillance and data reporting, allowing public health professionals to analyse trends and improve outbreak response preparedness. Opportunities to include dengue control activities in existing public health initiatives should be explored. The International Health Regulations (2005) could provide a platform for capacitybuilding in support of that key component. The Regional Committee was encouraged to endorse the Dengue Strategic Plan for the Asia Pacific Region (2008-2015), a critical action that would send an important message to the international community regarding the concern and commitment of Member States in the Region to a more comprehensive approach to dengue fever prevention and control. Dr WAQATAKIREWA (Fiji) endorsed the Strategic Plan and noted with interest its use of the logical framework approach. Dengue was indeed a neglected disease, although Fiji was striving to change that situation. The country was currently facing a major dengue outbreak and had recorded more than 1000 cases in the previous three weeks, mainly in two city areas. The urban focus of the disease suggested that its spread could be attributed to vector-breeding opportunities resulting from unplanned urban development, poor water storage and unsatisfactory sanitation and waste management conditions. Before the Fiji outbreak, the disease had been reported in other Pacific island countries, indicating that international efforts were needed to control its spread. The International Health Regulations (2005) could playa useful role in that regard. During the current outbreak in Fiji, there had been belated notification of the outbreak by clinicians, and thanks were due to the WHO Office in Suva for support in that area. Moreover, mechanisms for laboratory confirmation had been slow; the dengue case definition was not well understood by clinicians and vectorelimination work had fallen behind schedule. The inclusion of those and other key actions in the Dengue Strategic Plan were therefore most welcome. Fiji would work with WHO to implement the Dengue Strategic Plan and endorsed the inclusion of dengue fever as a notiliable disease under the appropriate schedule in its Public Health Law. Dr GRANGEON (France) endorsed the Dengue Strategic Plan forthe Asia Pacific Region (2008-2015), which responded to an important public health problem. S,everal deaths from dengue fever had been recorded since the start of 2008 in the French areas in the Region and dengue control programmes were therefore being given priority. Activities included measures to raise public awareness of the disease, including regular media briefings and designation of an annual dengue day and dengue information days during outbreaks. In addition, a procedure for evaluating the risk of an epidemic was being developed with the support of French research institutes. It took into account criteria that included the number of cases, serotype, regional epidemics, meteorological conditions and entomological surveillance. An effective surveillance network had been established based on early case detection by trained physicians and rapid confirmation using polymerase chain reaction technology to test for the NS I antigen, enabling interventions to be put in place around the homes of infected individuals within 24 hours to contain the outbreak. When regional epidemics were
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reported, body temperature checks were instituted for arriving air passengers, using thermal cameras. In 2007, that initiative had prevented the introduction of the dengue virus into New Caledonia by detecting 60% of imported cases and sensitizing other travellers on their arrival. Such action, which could be undertaken with limited resources, such as infrared or aural thermometers, could make a valuable contribution to the detection of dengue fever and other diseases, such as avian influenza, especially for island countries. Given the presence of numerous vectors capable of transmitting arboviruses and other more serious viral pathogens, such as yellow fever virus, the Dengue Strategic Plan should prove an excellent pilot activity with the potential to provide a model for use in other circumstances and enhance the mobilization of resources, for example, for laboratory facilities. A common policy would promote sharing among Member States of research findings, for example, on knowledge, attitudes and behaviour in relation to dengue, an aspect that might be included as an eighth expected result in the Dengue Strategic Plan. Ms Noriko TOUYAMA (Japan) welcomed the development of the Strategic Plan, which should provide an opportunity to develop a proactive approach to dengue control. Given the conclusions in the fourth assessment report by Working Group II of the Intergovernmental Panel on Climate Change (Impacts, adaptation and vulnerability), released in April 2007, it was important to recognize that seasonal outbreaks of dengue might become less obvious because of changes in dengue-vector habitats. The Strategic Plan was comprehensive and would therefore require multisectoral implementation. The Regional Office should continue to playa leading role in dengue control. Dr NGUYEN HUY NGA (Viet Nam) recalled that epidemics of dengue fever and dengue haemorrhagic fever had first been recorded in Viet Nam in 1959. They were currently a major public health problem, with an average of 75000 cases and 100 deaths recorded annually. Incidence was highest in the Mekong Delta and on the central coast, where common use of water storage containers had resulted in high densities of the vector mosquito, Aedes aegypti. As elsewhere, control activities had historically focused on adulticide, using ultra-low-volume spraying to kill mosquitoes during outbreaks. However, the measure was often taken too late to reduce virus transmission. Trials of other measures, such as the use of lids on water containers and fish in water tanks, had not proved effective in the long term. Since 1999, the national dengue control programme had developed an active mosquito control strategy comprising: a combined vertical and horizontal approach based on community development; prioritized control activities according to larval productivity in major habitat types; use of predatory fish and cope pods as biological control agents; and delivery of control measures by health volunteers, schools and the public. The programme had reduced dengue morbidity and mortality considerably. However, dengue outbreaks continued to occur, especially in the southern provinces, in 2008 resulting in 50 000 cases and SO deaths up to September. Contributory factors included human and financial resource constraints, uncontrolled urban development, popUlation movements, traditional water storage in containers in and around homes, inadequate water supply systems, and a lack of political commitment by local authorities. Further international, government and community support for the control programme was needed. Viet Nam endorsed the Dengue Strategic Plan and looked forward to cooperating further with WHO in combating dengue fever in the Region.
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Dr RAHMAH SAID (Brunei Darussalam) said that, like other countries, Brunei Darussalam had experienced more frequent outbreaks of dengue fever in recent years, and epidemiological investigation in 2006 had indicated that the disease was endemic. The disease had been notifiable since 2003. Each case was investigated rigorously, including serological screening of immediate contacts to ascertain spread. A simultaneous entomological survey was conducted, followed by vector-reduction activities, including environmental interventions and raising of public awareness. Further, individuals providing laboratory samples found to show low platelet counts were given serological screening. Brunei Darussalam supported the attention being given to the disease by the Regional Office and endorsed the Dengue Strategic Plan. It would appreciate WHO support to the country in the areas of capac it; building, research collaboration and the sharing of information on dengue fever. Dr BAI (China) commended the Regional Office on its analysis of the situation. China's dengue contrul measures in recent years had included an annual increase in the central budget allocation for dengue control, establishment of a national dengue surveillance network, modification of the case definition, improvement of testing procedures, standardization of treatment protocols, institution of training programmes, development of working norms to ensure sound scientific investigations, mobilization of community participation in control activities and outbreak responses, and international cooperation, including notifying WHO of outbreaks. Endorsing the Dengue Strategic Plan, he suggested that WHO should continue to provide technical and financial support to developing countries with a high prevalence of dengue fever, establish and improve outbreak notification procedures and enhance information-sharing among Member States. Ms TEO (Singapore) endorsed the Dengue Strategic Plan, which had first been discussed in Thailand in March 2006 and subsequently revised and finalized in Singapore in May 2008. Dengue fever should no longer be neglected since the Region carried 70% of the global disease burden and the number of cases was rising. Given the absence of a vaccine against dengue fever and a drug to treat the disease, vector control was paramount and should receive adequate funding. It was therefore timely for WHO to provide support in developing surveillance and vector control. Countries must work together, with a common strategic approach to control the disease alongside national plans. The emergence of chikungunya fever, transmitted by the same vector, reinforced the importance of such action. Singapore stood ready to collaborate with WHO in f:lcilitating the exchange of information on dengue fever and its control and, with the Organization, was jointly organizing the first regional workshop on dengue in 2009, in which all Member States were invited to participate. The workshop would provide training on evidence-based dengue surveillance and control to ensure effective allocation of resources and appropriate targeting of national control efforts. Mr TARIVONDA (Vanuatu) fully endorsed the Strategic Plan as a timely and important step in addressing the increasing incidence of dengue fever in the Region, which resulted in part from the effects of climate change. The Strategic Plan would help Member States to improve their outbreak preparedness and response, develop national plans for prevention and control and, in conjunction with the Asia Pacific Strategy on Emerging Diseases, fulfil some of their obligations under the International Health Regulations (2005), which had had a significant impact on how Member States prepared for and responded to disease outbreaks.
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His country had been spared the recent dengue outbreaks in the Region. However, although dengue was not endemic to Vanuatu, the Aedes mosquito was common in rural and urban areas and outbreaks tended to occur. Those outbreaks had a major impact on health service delivery because oflimited human and financial resources; it was important to plan in advance because reacting to such diseases as they occurred reduced the opportunity for effective outcomes. He acknowledged the work of the Secretariat of the Pacific Community, through the Pacific Public Health Surveillance System, in reporting epidemic-prone diseases to the Pacific islands and helping them to build their response capacities. At the national level, Vanuatu depended on regular surveillance and the dengue early warning system to signal impending outbreaks. Mr VILLAVERDE (Philippines) endorsed the Dengue Strategic Plan, which called for a change in the perception that dengue fever required to be tackled only during outbreaks. The persistence of dengue outbreaks reflected a failure in health system performance. The Philippines was currently strengthening its dengue control initiatives through a package to improve case management strategies and integrate vector control management. Measures were also being taken to enhance delivery of the package, including improving reporting mechanisms, increasing and rationalizing resource allocation, strengthening social mobilization and communication strategies, intensifYing outbreak responses, and instituting innovative research initiatives. The Philippines had welcomed the opportunity to participate in the drafting of the logical framework for the Dengue Strategic Plan, which had been incorporated in the country's 2009 operational plan for dengue prevention and control. Member States in the Region should be encouraged to increase collaboration in pursuit of regional solidarity aimed at reducing the dengue burden, developing a culture of evidence-based decision-making to guide interventions, furthering vaccine development initiatives, improving diagnosis and treatment, and introducing opportunities for affected households and communities to participate in surveillance. Mr ZIBE (Papua New Guinea) said that his country was committed to implementing the International Health Regulations (2005) and to strengthening disease surveillance systems; however, effective detection of dengue fever outbreaks relied on a greater capacity and a stronger surveillance system than were currently available in his country. Papua New Guinea shared a border with Indonesia, part of the WHO South-East Asia Region, and special arrangements between the Regional Offices for the Western Pacific and SouthEast Asia would be required for technical support for cross-border activities. His country remained focused on integrating national activities into disease surveillance and control programmes, and looked forward to participating fully in implementing the Dengue Strategic Plan. Dr KUARTEI (Palau) said that cyclical outbreaks of dengue fever had been reported in his country since the 1940s up until May 2007; since then, cases had been reported monthly. Anecdotal evidence seemed to suggest that increased rainfall had contributed to dengue becoming endemic in Palau. A national electronic disease surveillance system allowed the country to monitor the emergence of reportable diseases closely; however mobilizing communities to tackle mosquito breeding sites had been difficult. He thanked the Government of the United States of America for assisting with blood testing and serotype identification, and expressed strong support for the development of better access to improved national laboratories and reference laboratories.
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Discussion of climate change played an important part in trying to understand changing weather patterns and the subsequent increase in dengue fever in the Region. The application of modern technology, such as a global positioning system, to monitor the behaviour of vector-related diseases should be investigated. A broader definition of environment would help to involve: communities in ensuring healthy settings and would contribute to a reduction in the incidence of dengue fever in the Region. He requested WHO to help define a strategy for tackling communicable and noncommunicable diseases, and to place dengue fever surveillance at the centre of the environmental health programme, where surveillance was done on vectorrelated indicators. Mr VILLAGOMEZ (United States of America) endorsed the Strategic Plan and commended the Western Pacific and South-East Asia Regions on their collaboration to address the increasing threat from dengue. His country was committed to working internationally and multilaterally for the prevention of dengue and dengue haemorrhagic fever, but he advocated that Member States should prioritize activities based on epidemiological evidence and country-specific variables. He noted that the Strategic Plan did not differentiate between endemic and hyperendemic situations, nor between large populous countries and small island nations. WHO's role was to provide technical assistance to Member States based on nationally identified health priorities. He urged the Organization to review existing strategies and tools to address regional dengue disease burdens and encouraged Member States to make use of Dengue Net, the WHO global surveillance system for dengue fever and dengue haemorrhagic fever that had been designed to improve prevention through surveillance. He also asked WHO to ensure that future reports on dengue showed cases disaggregated according to subtype, in order to give a clearer picture of the changing rates of infection. He reminded Member States of their responsibility under the International Health Regulations (2005) to report dengue outbreaks in a timely and transparent manner. Dr KWON Iun Wook (Republic of Korea) said that global warming was expected to expand the geographic distribution and increase the number of outbreaks of dengue. While dengue fever was still not endemic in some areas of the Western Pacific Region, the steady increase in the number of imported cases and the effects of climate change meant that it could eventually spread throughout the Region. The Regional Office should establish the regional infrastructure for vector and clinical surveillance, and information-sharing on changes in the distribution of vectors and cases should be encouraged. Dr Rose MUDIN (Malaysia) said that her country's national dengue strategic plan, based on the recommendations from a meeting concerning the Denguf: Strategic Plan for the Asia Pacific Region held in Singapore in May 2008, provided a general framework for dengue prevention and control activities for 2009-2013, including multisectoral consultations and coordination of all stakeholders. Malaysia endorsed the Strategic Plan and noted the importance of the specifi,; objectives. Her country had already adopted all six programme areas and the implementation of the national strategic plan was a step towards strengthening infrastructure and capacity. The results of a survey in Malaysia showed that more than 80% of respondents knew how dengue was transmitted and that the Aedes mosquito was the vector of transmission; however, only 34% knew about breeding areas. That lack of knowledge had resulted in ineffective preventive action and was a contributing factor in the continuing high incidence of dengue fever. In 2000, Malaysia had implemented a programme to increase community awareness of and participation in dengue prevention and control, which had resulted in the number of new dengue cases remaining the same or decreasing.
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She drew Member States' attention to an increase in chikungunya transmission in her country, a disease also borne by the Aedes mosquito, and asked those countries with similar experience to share information on how they had tackled that disease. She also asked WHO for input and assistance to deal with the issue. The meeting rose at 17:00.