Department of Communicable Diseases:

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2 SEA-CD-145 Department of Communicable Diseases: Profile and Vision , India

3 World Health Organization Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for South-East Asia, World Health House, Indraprastha Estate, New Delhi , India. The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. February 2006

4 Communicable diseases are not only a major health problem but they also have a serious socio-economic impact. Controlling these diseases requires scaling up preparation and response mechanisms, strengthening the public health infrastructure, building partnerships, and involving all sections of society, including the poor and vulnerable Samlee Plianbangchang, M.D., Dr.P.H. Regional Director

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6 Contents Preface... vii 1 Introduction Burden of Communicable Diseases in the South-Asia Region The Department of Communicable Diseases: the Vision and the Guiding Principles Objectives, Strategies and Activities Objective One: Communicable diseases surveillance, outbreak alert and response (CSR) Objective Two: Prevention and control of priority communicable diseases: HIV, tuberculosis and malaria (HTM) Objective Three: Eradicating and eliminating communicable diseases (ECD) Challenges and Oppurtunities Ahead Galvanizing political commitment, and building and sustaining partnerships for disease control/elimination Mobilizing and ensuring financial sustainability Ensuring public information and social mobilization in each programme area Building bridges for health system response Evidence-based programme planning Tracking progress through monitoring and evaluation Conclusions Annexes 1 Organogram of the Department of Communicable Diseases WHO Representatives in SEAR Countries v

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8 Preface The South-East Asia Region of WHO suffers disproportionately from the global burden of communicable diseases. Besides diseases such as HIV/AIDS, tuberculosis, malaria, leishmaniasis etc, the Region is also faced with new and emerging diseases which are challenging public health as never before. Unfortunately, many of these diseases affect the poor and marginalized sections of society, and contribute not only to ill health and poverty at micro-level but also have serious socioeconomic implications at the macro-level. Combating communicable diseases is, therefore, one of the topmost priorities for the World Health Organization (WHO). The WHO Regional Office for South-East Asia is striving to focus efforts, in close collaboration with other departments in the Regional Office and, most importantly, with our country offices, to assist Member States of the Region in responding effectively and efficiently to these challenges. This document provides an overview of the Department of Communicable Diseases and the various initiatives underway as well as those being planned to support activities in Member States. These include preparing and responding rapidly to emerging infectious diseases; preventing and controlling HIV/AIDS, TB, and malaria; and targeting communicable diseases for eradication and/or elimination. We firmly believe that working together, in partnership with all stakeholders, we can make a difference and control communicable diseases within a reasonable time frame! Dr Jai P. Narain Director, Department of Communicable Diseases vii

9 Introduction 1 Communicable diseases continue to be one of the most important public health problems in the South-East Asia Region (SEAR). Not only about half of the deaths in some countries are attributable to infectious causes, new agents such as severe acute respiratory syndrome (SARS), avian influenza and Nipah virus are beginning to add to the existing burden of infectious diseases, which include human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis (TB), malaria and leprosy. To make the prognosis even worse, some communicable diseases such as dengue fever are not only expanding geographically, they are also becoming more pathogenic. The emerging diseases are thus becoming a cause for national and international concern. For instance, the sporadic avian influenza H5N1 outbreaks witnessed in Asia are capable of igniting a global pandemic, with potential to cause widespread health and socio-economic disruption. In addition to causing a large number of deaths, communicable diseases result in considerable disability and personal disfigurement. Some examples of these permanent disabilities are severely deformed limbs resulting from lymphatic filariasis (LF) and faces eroded and scarred by leprosy. The threat of these infections becoming resistant to drugs is another mounting concern. While the arsenal of antimicrobial drugs is not expanding, the spread of antimicrobial drug resistant infections is rapidly narrowing the windows of opportunities in the control of communicable diseases

10 There are, however, many success stories. They demonstrate that if effective approaches are scaled up, both in coverage and quality, reinforced by high-level commitment and political will, these problems could be overcome. For example, smallpox and guinea worm disease have been eradicated from the countries of the Region. Poliomyelitis is on the verge of eradication and leprosy elimination is within our grasp. Significant progress has been made towards increasing population access to directly-observed treatment short course, or DOTS, at the community level. Many countries have achieved global TB targets and others are on the way to do so. Highest level of commitment has been expressed by all affected countries for elimination of visceral leishmaniasis (Kala-azar). The progress in LF elimination also is encouraging. Political commitment made in recent years, and the participation of academic institutions, networking, intercountry cooperation, and planning are all contributing to the emerging success. Partnerships among diverse organizations to tackle communicable diseases are expanding and this cooperative trend must be sustained. The partnership with the pharmaceutical industry, in particular, has been very encouraging, as increasing access of common man to lifesaving generic drugs is gradually changing diseases such as AIDS from a virtual death sentence to a chronic manageable condition. Considerable success has also been achieved by Member States in mobilizing substantial funds from the Global Fund to fight AIDS, TB and malaria (GFATM) for scaling up their response against the three diseases. These incidents clearly offer glimmers of optimism in the Region s continual fight against communicable diseases. The vision of the WHO Regional Office for South-East Asia Region (SEARO) is to assist Member States in reversing the trend of communicable diseases, reducing morbidity and mortality, and improving the quality of life, thereby contributing towards achieving the Millennium Development Goals (MDG) and poverty reduction in the coming decade. To translate this vision into reality, the Communicable Diseases (CDS) Department of WHO s Regional Office for South-East Asia (SEARO) has been reorganized to deal with three main objectives:

11 (1) To enhance preparedness to tackle the threat of emerging diseases through strengthened epidemiological surveillance, outbreak alert and response, (2) To intensify control of priority communicable diseases such as HIV/AIDS, TB and malaria in an integrated manner, and (3) To eliminate/eradicate diseases such as leprosy, yaws, kalaazar and lymphatic filariasis. In addition, there are crosscutting areas such as laboratory support, data management and capacity-building activities including training, which also fall within the purview of the vision. The Department works in collaboration with other WHO programmes in the Regional office and with country office, which are now primarily responsible for providing technical support to the Member States. Partnerships are being built with various stakeholders such as governments, academic institutions, civil society, and multi- and bilateral agencies who share common goals of alleviating suffering from humanity, reducing morbidity and mortality, and improving the quality of life, particularly of poor and disadvantaged sections of the society. Equitable access to health services and protection of the vulnerable populations by scaling up effective interventions are other principles that guide the action of the CDS Department. This document presents the profile and the vision of the CDS Department, the principles that guide its work, and the strategies and broad activities that various programmes in the Department plan to undertake. Since the health situation is dynamic and evolving, the document will be updated periodically to reflect the changing scenario and shifting priorities, internationally and within the organization, over time

12 2 Burden of Communicable Diseases in the South-East Asia Region The distribution of infectious diseases globally and in the Region conforms roughly to the distribution of poverty in the world and in the Region. The South-East Asia Region suffers heavily from the burden of communicable diseases. For instance, the Region has 80 per cent of global leprosy burden, 38 per cent of tuberculosis, and the highest rate of drug resistant malaria. An estimated 2.9 million deaths in the Region are caused by infectious and parasitic diseases and an estimated 89 million disability-adjusted life years (DALYs) are lost as a result. Each year, children die of measles and adults die of TB. More than 6.5 million people in the countries of the Region have been living with HIV/AIDS and 250 million are at risk of contracting malaria. Furthermore, epidemics of infectious diseases occur frequently and in new areas; many of them are predictable but some of them take health system by surprise. SARS, avian influenza and Nipah virus are recent examples of such surprises and are capable of causing enormous socioeconomic hardship beyond national borders. Also, dengue/dengue hemorrhagic fever (DHF) and new strains of cholera are spreading to areas where they were not common in the past. Age-old diseases like leprosy and kala-azar still cause considerable suffering and psychosocial disruption in the Region. Resistance of some infectious diseases to drugs is an emerging threat faced across all disease control programmes. The countries of the Region are becoming epicentres of antimalarial drug resistance, putting more than 30% of the populations of the countries at risk. Hot spots for TB drug resistance are emerging and the countries have to

13 tackle the problem of drug resistance in Shigella dysentery, enteric fever, and sexually transmitted infections (STIs). Resistance to chloramphenicol for enteric fever and to penicillin for gonococcal infection is also a matter of grave concern. Drugs for the treatment of multi-drug resistant (MDR) TB cost more than 100 times the cost of medicines used to treat simple form of pulmonary TB. Fortunately, however, MDR levels remain low in the Region, due in part to the well-performing TB programmes. In addition to the large number of deaths, infectious diseases often take a heavy toll on human productivity by causing disability and personal disfigurement. Severe and sometimes permanent disabilities affect an estimated population of one billion in the world, according to Global Defence Against the Infectious Diseases Threat (2003). These disabilities include impaired cognitive development, retarded mental growth, deformed limbs (by elephantiasis) and eroded faces (by leprosy), as well as many other related physical problems. The interplay between communicable diseases, poverty and undernutrition adversely affect socioeconomic development in the countries. Evidence also links the occurrence of cancer and some degenerative diseases to infectious causes. For example, hepatitis B and C viruses have been traced to subsequent development of liver cancer. The scenario of infectious diseases is shaped by two factors. Firstly, there is a real and immediate threat of resurgence of infectious diseases, which can be attributable to the natural history of microbes. Pathogens and microbes constantly evolve through processes of multiplication, mutation, migration and adaptation eventually attaining resistance to commonly-used medicines and insecticides. Secondly, cultural aspects such as close animal-human interface where the two share the common habitat also play an important role in the spread of communicable diseases of zoonotic nature such as avian influenza, SARS, and Nipah virus. During the last few decades, while the arsenal of antimicrobial drugs has not expanded, the appearance and spread of antimicrobial resistance has been on the increase, thereby narrowing the limited number of means available for the control of infectious diseases. The spectre of the continual emergence of drug resistant microbes is threatening to undermine the gains achieved in reducing morbidity and mortality due to infectious diseases

14 3 The Department of Communicable Diseases: the Vision and the Guiding Principles The vision and the guiding principles of the Department have been clearly spelled out in the following statement: to, by the end of the decade, reverse the trend of communicable diseases, reduce morbidity and mortality, and improve the quality of life, thereby contributing towards achieving the Millennium Development Goals and poverty reduction. The task ahead is by no means easy, for it demands high levels of commitment and resolve from all partners. The context of involvement becomes even more challenging when we bear in mind that the Region has approximately 30% of the population living below an income of US $ 1 (one) per day, and the interactions between infectious diseases, poverty and undernutrition pose a complicated challenge to the effective control of the diseases. Due to the epidemiological transition, countries in the Region are faced with the burden of non-communicable diseases in addition to that of the infectious diseases. This cumulative burden places a heavy strain on their fragile and overstretched health systems. Based on our experience, and given the ground realities, we have identified the following principles that guide our action: Prioritization. Selection of priority communicable diseases to focus the limited resources and capacity available, with a view to ensuring maximum impact on health and socioeconomic development. Continuing and strengthening WHO s role of enlisting political commitment to solve health problems. Mobilizing additional resources by using advocacy plans and implementing them in the countries

15 Clear strategic framework and evidence-based planning. Developing and refining regional strategic plans that would guide the work of the CDS Department and could be a framework for action at country level, leading to countryspecific plan of action. Identifying interventions that are practical and cost-effective, and scaling them up for the control of communicable diseases. Enhancing research capacity to address the problems with the help of WHO collaborating centres (WHO CCs) and national centres of expertise. Consensus building. Regional technical advisory groups have been established to provide technical guidance to countries in the control, elimination and eradication programmes and in monitoring activities. Emphasis on an integrated and collaborative approach. Promoting and supporting intercountry collaboration and horizontal cooperation among countries. Encouraging interdepartmental collaboration, which is critical to effective control of communicable diseases. Harmonizing such collaboration, especially among departments involved, in the elimination and eradication of diseases preventable by vaccination, and control of childhood communicable diseases. Increasingly adopting, where relevant, an integrated approach with an increased focus on addressing crosscutting issues, strengthening public health laboratories and containing antimicrobial drug resistance. Supporting the preparation of harmonized work plans and tracking progress through regular monitoring and evaluation. Focusing on results. Identifying some key outcome and impact indicators as well as targets for each programme areas, indicating how (or by using what methods) the targets will be measured, and systematically measuring the progress towards the targets. If the progress is not on track, finding ways to assess bottlenecks to successful implementation, and devising correctional measures to overcome them. Communication. Placing increased focus on communication, media interaction and information technology as important tools for risk communication and management

16 4 Objectives, Strategies and Activities To fulfill the above vision, CDS Department has been organized into three major areas of focus (Annex). These are: (1) Communicable disease surveillance, outbreak alert and response (CSR), (2) Prevention and control of priority communicable diseases such as HIV/AIDS, TB and malaria (HTM), and (3) Elimination and eradication of targeted communicable diseases such as leprosy, lymphatic filariasis, kala-azar and yaws (ECD). Furthermore, crosscutting areas such as laboratory support, communication and social mobilization as well as data management are integral parts of the operation of the Department of Communicable Diseases. In these areas, the Department works in tandem with various units in a coordinated and complementary manner. Given the scarce resources available, it is necessary to prioritize infectious diseases for control, elimination or eradication. The following important considerations, therefore, are used in the prioritization of communicable diseases: Diseases (such as TB, malaria, HIV/AIDS, diarrhoea and pneumonia) that produce a large-scale impact on morbidity, disability or mortality are considered important

17 Diseases (such as cholera, influenza, meningitis) that occur as epidemics or have an epidemic potential are a priority. Diseases with potential for effective control through available interventions that are cost-effective. Availability of reliable and convincing information, evidence and data on diseases so as to initiate public health actions. Identifying diseases that could be specifically targeted for control, elimination or eradication based on international, either global or regional, consensus. (Examples of regional consensus are elimination of kala-azar, yaws eradication, and control of dengue and dengue hemorrhagic fever.) Apart from addressing the crosscutting areas such as strengthening of public health laboratories and containment of antimicrobial drug resistance, data management and analysis, and communication and information exchange, the Department works closely with other departments in the South-East Asia Regional Office (SEARO) in mainstreaming its activities. However, prevention of communicable diseases by vaccination and management of communicable diseases of young children like diarrhoea and acute respiratory infections are not specifically included in this document, since these concerns are dealt with by other units in the Regional Office. The objectives of CDS Department and strategies and activities that follow include the following: 4.1 Objective One: Communicable disease surveillance, outbreak alert and response (CSR) 4.2 Objective Two: Prevention and control of priority communicable diseases: HIV, tuberculosis and malaria (HTM) 4.3 Objective Three: Eradicating and eliminating communicable diseases (ECD)

18 4.1 Objective One: Communicable disease surveillance, outbreak alert and response (CSR) This programme addresses preparedness, outbreak alert and response to emerging communicable diseases, which are taking a heavy toll on human life and contributing to socioeconomic disruption in the Region. Present situation and future challenges New infectious diseases emerge while old foes are on the rise as never before. The last three decades have witnessed the emergence of new infectious diseases, including SARS and avian influenza, which affected several Member States (Fig 1). Figure 1: Cumulative data of confirmed human cases of avian influenza A (H5N1) in Asia as reported to WHO (2005) This map shows countries and regions that have reported confirmed and suspected H5 outbreaks = date of first report of outbreaks in animals Sources of data: World Organization for Animal Health, World Health Organization, Food and Agriculture Organization of the United Nations

19 At the same time, malaria, dengue, cholera, meningitis and tuberculosis have re-emerged on an unprecedented scale often flaring up into epidemics. Many communicable diseases such as dengue are not only moving geographically, to newer areas, but are also becoming more virulent. Emerging drug resistant strains of TB and malaria are posing a serious challenge to disease prevention as well as to case management. While a few Member States have a strong surveillance system that can detect the dangers early and respond effectively, most still need to develop a reliable and responsive surveillance system. This requires formulating sound policies, developing feasible and evidencebased strategies, adopting guidelines to implement these strategies, and building core capacity in epidemiology, public health, and in laboratories. Promoting strong partnerships and networking among stakeholders is also essential. It is imperative to invest in developing and sustaining strong national surveillance and response systems which are district-focused, and flexible to the dynamics of emerging and reemerging infectious disease threats. In this regard, the international health regulations ((2005) adopted by all member countries present an excellent opportunity for building core capacities at the country level for early detection and verification of disease outbreaks through prompt and proper case investigation followed by prompt institution of containment measures. In the CSR area, the following WHO activities are under way: Advocacy for strengthening surveillance and response, A regional strategy for integrated disease surveillance, Development of guidelines and tools for comprehensive assessment of surveillance systems, Ongoing comprehensive assessments of national surveillance systems and development of strategic plans, Technical and logistical support for verification and response to disease outbreaks, Capacity development through FETP and other short training courses in collaboration with WHO collaborating centers, and Development of proposals for funding to strengthen disease surveillance, public health laboratories, early warning systems and epidemic preparedness and response

20 Strategies and activities The goal of the CSR Unit is to support Member States in developing capacity to identify, detect and respond to emerging and re-merging infectious diseases, with a focus on epidemic-prone communicable diseases. The objectives are: To devise strategies to develop and strengthen feasible and sustainable surveillance systems, including laboratory-based surveillance, To develop a system for early detection, warning, alert and response to outbreaks (EWARS), To develop national epidemic preparedness and response plans (EPR), To strengthen surveillance data collection, analysis, interpretation and use, To strengthen public health laboratories for disease surveillance, and To promote communication and timely information sharing and feedback. To realize these objectives, the following strategies and activities are needed: Comprehensive assessment of existing national disease surveillance, epidemic preparedness and response systems, Establishment of coordination mechanisms and systems at regional and national levels including expert groups, and surveillance units and focal points in ministries of health, Capacity building through training and horizontal exchange of experience among Member States and other WHO regions, Use of GIS/Health Mapper for data display in national surveillance systems, Establishment of early warning, alert and response systems (EWARS) for epidemic-prone diseases, and

21 Plans for epidemic and pandemic preparedness and response, and assistance in their implementation. Specifically, WHO will: Provide technical support for verification of and response to outbreaks, Assist in the implementation of the revised IHRs, Provide support in data management, analysis, interpretation and use (including GIS/Health Mapper), Develop a regional database of expertise and centres of excellence for mobilization during outbreak/emergency situations, Formulate a legal framework and institutional mandate to support and work with Member States, and Disseminate field experiences/lessons from national, regional and global disease surveillance and response, including emerging infectious diseases. Road map for Having pandemic/epidemic preparedness plans ready and management structure in place in all countries of the Region. Specifically, national influenza pandemic plans (along with a regional plan) will be ready in all Member States. A new strategy for dengue prevention and control will be adopted for implementation. Regional Outbreak Alert and Response Network (ROARN) will be established. Field Epidemiology Training Programme (FETP) will be rendered active in six countries, with training arranged to suit needs of individual countries

22 4.2 Objective Two: Prevention and control of priority communicable diseases: HIV, tuberculosis and malaria (HTM) There is a global consensus with respect to prevention and control of HIV/AIDS, TB and malaria. Additional resources have been committed and WHO is assisting countries in their efforts to reverse the trend of these diseases in order to attain the Millennium Development Goals. GFATM has approved about US $ 1 billion for the next five years to support the efforts to control these diseases in the Region. HIV/AIDS Present situation and future challenges With more than 6 million people living with HIV/AIDS, the South-East Asia Region is the second most affected after sub-saharan Africa. The Region has one of the most rapidly growing HIV/AIDS epidemics globally. Because of the large population base and factors that enhance the spread of HIV (including poverty, gender inequality, mobility and social stigma), the impact of the disease on this Region is likely to be severe. The majority of HIV infections in the Region occur through unprotected sex between men and women (Fig 2). In addition, injecting drug use is adding to the rapid spread of the epidemic, particularly in the north eastern states of India, Indonesia, Nepal, Myanmar and Thailand. The main constraints to effective control include the following: Stigma and discrimination continue to be major hurdles in the access to HIV prevention, care and treatment interventions. Health systems are weak in many Member States. This places a constraint in the successful introduction of antiretroviral (ARV) treatment. Coverage of effective interventions to prevent HIV transmission remains low in most Member States. Resource allocation is insufficient for successfully scaling up prevention programmes and for reducing gaps in treatment

23 Figure 2: HIV/AIDS burden and transmission routes, 2005 Route of HIV transmission (-) Unknown or minimal HIV transmission; (+) limited HIV transmission; (++) moderate HIV transmission; and (+++) major HIV transmission Costs of antiretroviral drugs are high even though they have decreased considerably in recent times. There is a pressing need to enact suitable patent laws to ensure availability of low cost, effective antiretroviral drugs since all countries in the Region with the exception of Democratic People s Republic of Korea and Timor-Leste are members of WTO. Prevention interventions to decrease HIV transmission are being implemented in a number of countries with technical and managerial support from WHO. These interventions include condom promotion, management of sexually transmitted infections (STI), ensuring blood safety, strategies for reducing drug-related harm that targets injecting drug users, and prevention of mother-to-child-transmission. By initiating steps to scale up voluntary counselling and testing, care and antiretroviral therapy (ART), countries of the Region with a

24 high-hiv burden have taken the crucial initial steps to start ART programmes. Policy announcements have been made, demonstrating commitment to the 3 by 5 initiative and plans for ART scale-up are being implemented, gradually moving towards ensuring universal access to HIV prevention, care and treatment by More than US$ 400 million has been committed to HIV/AIDS programmes in the Region through resources from the Global Fund. Additional resources for treatment have been pledged by voluntary donations to WHO, with recent pledges for 3 by 5 from Canadian and Swedish International Development Agencies. Strategies and activities Our vision is to have strengthened health system capacities in all countries to effectively scale up interventions for the prevention, care and treatment of HIV/AIDS and STIs. The aims are: (1) To prevent HIV transmission by promotion of safer sex (including condom use), prevention and treatment of other STIs, prevention of mother-to-child transmission, and harm reduction among injecting drug users, (2) To improve the quality of life of those living with HIV/AIDS through treatment and care, including voluntary counselling and testing (VCT), psychosocial support, care and antiretroviral therapy, and (3) To alleviate the impact of HIV/AIDS on individual household and local communities by adopting enabling health sector policies and institutional environments as part of wider social and economic development policies. To achieve these aims, the following strategies and activities will be pursued in : Advocacy and policy: In collaboration with partners, the Department will continue to promote health within the developmental agenda, using HIV/AIDS as an entry point for strengthening health systems and for health sector reform

25 This action would support development of policies, strategies and operational plans. WHO will continue to mobilize communities and people living with HIV/AIDS (PLWHAs) in increasing access to prevention, care and treatment services. Normative function: Development of tools, guidelines and training modules. Technical support: Provision of guidance and support to governments in assessing the extent and nature of the epidemic; prevention of new infections, and provision of treatment, care and support to those in need. Mobilize resources: Assisting countries in mobilizing resources to implement HIV prevention, care and treatment programmes. Procurement of drugs and diagnostics: Coordinating ongoing efforts to improve access to HIV/AIDS medicines. (AMDS intends to provide a range of support services according to country needs.) Strategic information: Provision of direction and leadership on surveillance, monitoring and evaluation, and research priorities, including development of vaccines, microbicides and operational research. Specifically, WHO will take a lead in health sector response to HIV/AIDS within the context of intersectoral response required for the prevention and control of the disease. It will provide technical and operational support to the countries, as stipulated in the health sector strategy adopted by the World Health Assembly, for planning and implementing health sector response to HIV. WHO will coordinate technical support and guidance to countries, particularly in the area of advocacy, strategic information, STI management, HIV care and support, and information sharing and exchange among programme managers. Furthermore, WHO will embark on advocacy for, and mobilization of, additional resources for accelerating and sustaining HIV prevention and care including for the 3 by 5 initiative

26 Road map for Target of 50% treatment coverage and significant progress towards universal access will be achieved in all five highburden countries. Coverage of prevention interventions will be increased at least by 100%. HIV-related surveillance will be evaluated and improved in all Member States. Indicators/targets will be adopted in Member Countries to measure progress towards achieving universal access to prevention and antiretroviral (ARV) treatment as well as the MDG targets. Tuberculosis Present situation and future challenges Every single day, people are newly infected with TB in the world and die of the disease. The yearly figures are daunting: 3 million new cases and deaths. One out of every three tuberculosis patients worldwide is in the South-East Asia Region (Fig 3). Bangladesh, India, Indonesia, Myanmar and Thailand (5 of the 22 high burden countries in the world) together account for 95% of the TB burden in the Region. Tuberculosis is the most common life-threatening opportunistic infection among the HIV-infected in this Region and there are over 2.5 million people estimated to be co-infected with both HIV and TB. Tuberculosis primarily affects the economically productive age groups and, therefore, poses significant threats not only to health but also to social and economic development in the Region. As long as TB persists, reducing poverty will be an enormous task, and global progress to TB control will be in jeopardy. Some of the challenges faced in combating TB are the following: Overstretched health systems Inadequate work force Weak infrastructure

27 Figure 3: South-East Asia accounts for a third of all tuberculosis cases world wide Health sector reform undertaken without adequate preparation Varying commitment for TB control, particularly at the local level Inadequate involvement of other sectors/potential partners Low community awareness and utilization of services Need to address emerging MDR-TB and HIV-associated TB under programme conditions In spite of these challenges, DOTS is making rapid progress. Almost 90% of the population in the Region now lives within access of facilities offering diagnosis and treatment under DOTS. In all countries, treatment success rates for cases registered either exceed or are close to the 85% global target. Case detection rates have risen steadily and if the current momentum is maintained, the Region could expect to reach the 70% target by 2007 (Fig 4). This could be achieved through technical expertise, close collaboration with national TB programmes, assistance in formulating policies and strategies, health system strengthening, advocacy for resource mobilization and through an effective monitoring system

28 Figure 4: Trends in case detection * Data from National TB Programmes in the SEA Region (as of May 2005) Note: The circles indicate the number of new smear-positive cases notified under DOTS, expressed as a percentage of the estimated cases for each year. The dotted line is an extrapolation, based on the current annual increment. Strategies and activities The Stop TB programme targets for 2005 were: (1) 100% coverage of DOTS services in all countries of the Region, (2) Detection of at least 70% of all estimated new smear-positive cases, and (3) Achieving treatment success rate of at least 85% among all those detected. Sustaining the accomplished success would lead to achieving the MDG set for TB control, which is to halt and begin to reverse the incidence of tuberculosis by Tuberculosis is completely curable with the short-course treatment, DOTS, given for 6-8 months. Successful treatment of TB cases, especially of those who are infectious, is the most effective means of eliminating TB from a population. All eleven countries of the Region have adopted the internationally recommended DOTS which aims to halt transmission of TB in the population

29 The objectives set out for elimination and control of TB will be achieved through a strategy which has five essential components: Sustained political commitment to ensure adequate resources for TB control, Access to quality assured diagnosis through sputum smear microscopy, Ensuring an adequate and uninterrupted supply of good quality anti-tb drugs, Standardized short course chemotherapy to all cases of TB under proper case management conditions, including direct observation of treatment, and Recording and reporting system enabling outcome assessment of each and every patient and assessment of the overall programme performance. Road map for Global targets of 85% treatment success and 70% case detection will be achieved and sustained in all countries. System will be established to measure progress towards achieving MDGs: 50% reduction in TB prevalence and deaths by Plans for sustainable financing will be developed for each country. Malaria Present situation and future challenges During the past two decades, despite a declining trend in the reported cases of malaria (about 2 million cases per year at present, the proportion of Plasmodium falciparum malaria has increased from 12% to more than 45% (see Fig. 5). While India reports the largest proportion of cases in the Region, Myanmar reports the most deaths from malaria. Increasing resistance to the first and second line antimalarial drugs has necessitated a policy change that would require the use of a combination

30 Figure 5: Trend of P. falciparum in SEA Region, treatment. According to WHO estimates, based on the loss of 1.87 million DALYs in the SEA Region, the economic losses are about US $ 3 billion every year. Malaria is a deterrent to investment and tourism that adds to the economic burden. Focal epidemics are common and if these are not controlled promptly and effectively, malaria becomes endemic and reverses the gains achieved. Recent developments in the control of malaria include the availability of rapid diagnostic tests, artemisinin-based combination treatment, pre-packaged drugs, long-lasting insecticide-treated bednets, tools to test the quality of antimalarials, Health Mapper and information technology. The challenges include resource gap, occurrence of malaria as several different eco epidemiological subtypes that require the use of stratified strategies, inadequate capacity in WHO and Member States for scaling up control efforts, and gaps in timeliness and quality of information on malaria. Cross-border problems and evidence of drug resistance have necessitated a policy change. Strategies and activities The goal is to reduce malaria morbidity by 50% and mortality by 75% by 2010 (with 2000 as the baseline) and to further halt the incidence

31 of malaria by 2015, in accordance with the MDGs, by progressively implementing self-reliant malaria control programmes, which will focus on the following aspects: Advocating for the application of effective preventive measures against malaria for populations at risk, Promoting and facilitating access of populations at risk to effective treatment of malaria, Supporting countries to build capacity for malaria control, and Strengthening malaria surveillance systems and monitoring and evaluation of malaria control. Based on past experiences, WHO/SEARO has revised malaria control strategy, which now reflect multi-sectoral approach, based on evidence, and in line with the ecological, environmental, and behavioural dimensions of the health problem. The revised strategy will be used as a framework for: Provision of technical support to countries to review and revise policy and strategic plans, Sustaining intersectoral partnerships and bringing malaria control to the mainstream in line with other departments in the health sector, Developing a consensus on the use of evidence-based interventions, tools and products using a stratified approach to deal with different eco-epidemiological sub-types of malaria, Reducing malaria burden through scaling-up of the programme, Supporting capacity-building in malaria research in the countries, Enhancing evidence base for drug resistance through stronger surveillance and by monitoring quality of drugs, and Monitoring progress towards the achievement of the stated goals and targets

32 Activities: WHO has assisted countries in preparing applications for funding by GFATM. Funding (US $ 150 million) for nine countries has been approved. Tools and guidelines have been made available for programme management at district level, treatment of uncomplicated malaria, management of severe P. falciparum malaria at level I and level II health facilities, external programme review, and regional strategic framework. Therapeutic efficacy monitoring network has been established. This is helping to revise the national policy on antimalarials. Based on the key indicators for monitoring and evaluation, formats and guidelines have been prepared for information on malaria. The tools developed include those for health facility assessment and for conducting household surveys. Malaria control programme is supporting assessment of the problems of malaria in pregnancy, quality of drugs, use of pesticides in public health, and integrated disease surveillance. Progress has been made in cross-border collaboration in the Mekong sub-region, and work has started in the South Asian countries. Road map for New/Revised malaria control strategy will be adopted by countries and plans will be prepared based on this strategy. Targets for scaling up insecticide treated bednets (ITN) and indoor residual spray (IRS) will be set and a system to measure these will be accepted by countries. Partnerships with donors, including the World Bank, will be fostered and strengthened for malaria control activities in the Region

33 4.3 Objective Three: Eradicating and eliminating communicable diseases (ECD) The regional priorities in this portfolio are the elimination of leprosy, lymphatic filariasis, kala-azar and yaws. While funding for leprosy is considered satisfactory to achieve the targets, efforts have to be intensified for the elimination of lymphatic filariasis, kala-azar and yaws. Leprosy Present situation and future challenges South-East Asia Region achieved the goal of leprosy elimination in December 2005; the regional prevalence being 0.86/ population (Fig. 6). Of 11 countries, 9 including India have declared achievement of leprosy elimination. The priorities now include integration of leprosy into the general health care system, building capacity of the general services to provide quality leprosy services ensuring social integration of cured/disabled leprosy patients into the community, and sustaining advocacy and information, education, and communication (IEC) activities to increase awareness and decrease the stigma attached to the disease. Figure 6: Leprosy Prevalence Rate per , South-East Asia Region and India,

34 The progress made so far is as follows: Since the inception of MDT, more than 12.8 million cases of leprosy have been treated in the Region. Resources for elimination of leprosy have been mobilized in a sustained manner. From March 2002 to December 2005, the regional prevalence declined from 2.6/ to 0.86/ population and the prevalence rate in India has declined from 4.2/ to 0.95/ WHO supported monitoring and supervision, advocacy and IEC, and capacity building of general health staff, and organized leprosy management training at all levels in the countries for the final push towards elimination. WHO provided technical assistance in conducting leprosy elimination monitoring (LEM) exercises in Bhutan, India, Nepal and Thailand and a case validation study in India. The system of monitoring has been simplified. MDT has been supplied free of cost in user-friendly blister packs in collaboration with partners. Strategies and activities With the overall vision of eliminating the scourge of leprosy from the countries of the Region, our collective goal for 2005 was to achieve elimination of leprosy as a public health problem, i.e. to attain a prevalence rate of less than one case per population at regional and national levels and to provide quality services in a sustained manner. Surveillance activities will be continued to enhance the success of elimination efforts. Elements of these efforts include: detection of all cases of leprosy, reduction of over-diagnosis, treatment of cases with MDT and achievement of high cure rates, through capacity building of general health services, advocacy and IEC, and promoting partnerships. The WHO activities include providing technical support to countries: To strengthen leprosy integration into the general health services and build the capacity of general health workers to provide quality leprosy services,

35 To ensure timely case detection, prompt treatment with MDT and achievement of high cure rates, and To ensure effective monitoring and supervision. In addition to providing technical inputs and guidance in planning, implementation and monitoring of the programme, WHO will also provide free supply of MDT, advocate for sustaining political commitment and resource mobilization and provide limited funding for critical activities. Road map for Leprosy elimination will be achieved in all countries, progressively moving towards sustainability and quality of services. Lymphatic filariasis Present situation and future challenges About 700 million people in nine endemic countries in the Region are at risk of LF. They constitute 64% of the global estimate of 1.2 billion people at risk. The current situation in the Region is as follows: All countries have accepted the LF elimination initiative; national task forces have been formed in all countries and LF elimination is a national goal in each country. A Regional Programme Review Group (RPRG) consisting of independent LF experts meet regularly to review country plans and make recommendations for free supply of albendazole for mass drug administration (MDA). India, Maldives, Sri Lanka, Thailand and Timor-Leste are implementing MDA in the entire endemic population; Indonesia, Myanmar and Nepal are implementing MDA in some areas, with plans for annual scale-up. Coverage levels of >80% of the targeted population have been achieved in most places. By 2005, the Region covered 12% of the population at risk with DEC + albendazole through MDA

36 An intercountry workshop on morbidity management was held by WHO followed by training at national level. Major issues and challenges include: lack of new data regarding geographical distribution of LF; poor planning of the implementation strategy; insufficient funds, which prevents successful mapping of endemic areas; scale-up of MDA; and disability alleviation and nonadoption of the two-drug strategy (DEC+albendazole) for MDA in India, except as a pilot in a few districts. Strategies and activities Our vision is that LF will no longer be a major public health problem in the Region by 2020 and visible disability related to the disease will become non-existent over the next 20-year period. Our goal is to achieve elimination of LF as a public health problem by Our objectives to this end are to reduce and ultimately interrupt the transmission of LF, and to prevent and reduce disability in affected people. Mass drug administration (MDA) of two drugs - DEC and albendazole - to the entire population at risk once a year for five years in the endemic areas is the main strategy for control. To be effective, the programme needs to be adequately backed up by advocacy and IEC. At the same time, home-based self-care measures for disability prevention and alleviation will be promoted. Monitoring, research and partnerships are necessary for the success of MDA. Mobilization of resources is a prerequisite for sustaining elimination efforts. WHO has developed and disseminated tools, guidelines and advocacy materials, assisted in mapping endemic populations and facilitated free supply of albendazole. Beside technical inputs and guidance in planning, implementation and monitoring of the programme, WHO will continue to provide free supply of albendazole in collaboration with Glaxo-Smith-Kline (who have pledged a free donation of the drug till 2020). It will also advocate for sustained political commitment and resource mobilization, and provide limited funding for critical activities

37 Road map for Indicators MDA scale-up will cover at least 200 million people in endemic countries, and will bring about a policy change in favour of MDA in all countries. Mapping to determine geographic distribution of endemicity will be completed in all countries. Community-based disability alleviation programme will be implemented in all countries. Kala-azar Present situation and future challenges Three bordering countries in the Region (Bangladesh, India and Nepal) account for an estimated 20% of the global burden of kala-azar in 96 districts with over 147 million people at risk (Fig. 7). There are an estimated cases leading to a loss of about DALYs each year. Its maximal impact is on poor people. If untreated, mortality from kala-azar is high. Elimination of kala-azar has become a priority because of the political commitment and increasing concern about its link with HIV/AIDS. Elimination is possible since only humans are responsible for its transmission, insecticides (including DDT) are highly effective against the vector, screening of cases can be done easily with the rapid test rk 39 and miltefosine, an oral drug, is safe and effective (in more than 95% cases). However, even though a political commitment has been made, resource constraints are likely to impede elimination efforts. Miltefosine is not likely to reduce cases of post-kala-azar dermal lesions (PKDL) and this phenomenon can lead to persistence of foci of the disease. The capacity to implement and supervise indoor residual spraying (IRS) is weak in kala-azar-endemic districts. Because kala-azar is a disease predominantly of the poor, their access to health facilities is weak, resulting in few cases being treated adequately. There is a wide gap between reported cases and estimated cases

38 Figure 1.7: Kala-azar distribution in the SEAR, 2005* *Affected areas shown in colour The following new developments create a condition conducive to kala-azar elimination: The health ministers of the affected countries have endorsed the elimination of kala-azar through intensified cross-border collaboration. Research coordinated by the Special Programme for Research and Training in Tropical Diseases (TDR) with Indian Council of Medical Research (ICMR) and pharmaceutical industry has helped in the discovery of the effective and safe oral drug, miltefosine. The drug has been registered for use in India. The usefulness of rk 39 as a screening diagnostic test is supported by research carried out in the countries of the Region. The use of effective insecticides has helped many states/ provinces to remain kala-azar free. A regional strategic plan has been prepared and India has developed a plan of action. Strategies and activities