WORLD HEALTH ORGANIZATION

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WORLD HEALTH ORGANIZATION

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ORGANISATION MONDIALE DE LA SANTE

Bm .. rhlllli ~III Miditermee Irleahll

REGIONAL COMMITTEE FOR THE EASTERN MEDITERRANEAN

Forty-sixth Session Agenda item 4(iii)

PROGRESS REPORT

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EM/RC46/INF.DOC.3

June 1999 Original: Arabic

ELIMINA TION OF TUBERCULOSIS

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EMlRC46IINF.DOC.3

CONTENTS

Page I. Introduction ... . 2. Activities undertaken in response to resolution EMlRC44IR.6 ... .

2.1 General ... " ... ... ... ... ... ... I

2.2 Programme reviews... ... 2

2.3 Development of human resources.. ... .... ... ... ... ... ... .... .... ... ... ... 2

2.4 Development of laboratory and surveillance capacity... 2

2.5 Dissemination of WHO documents and publications ... 3

2.6 Advocacy ... 3

2.7 Coordination between donors ... 3

2.8 Intersectoral collaboration for tuberculosis control... 3

2.9 Support to special initiatives... 4

3. Achievements ... .... ... ... .... ... .... .... ... ... .... ... ... ... 4

3.1 DOTS ALL OVER in the Region ... 4

3.2 Achievements in tuberculosis elimination for countries with low incidence of tuberculosis... ... 6

4. Challenges ... 8

5. Recommendations... ... ... 10

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1. INTRODUCTION

EMlRC46/INF.DOC.3 page I

The target for tuberculosis elimination is to reduce the incidence rate of new smear- positive cases of pulmonary tuberculosis to the level of the tuberculosis elimination phase', namely I per 100000 population, by 20 lOin the countries with low incidence of tuberculosis. The interim target is to reduce the incidence rate to 5 per 100000 population by 2000.

To achieve the above targets, it is very important to adopt and implement the DOTS strategy nationwide (DOTS ALL OVER) as this is the first and most important step in the control of tuberculosis. The DOTS strategy has five main components: political will, case-finding primarily by sputum smear microscopy and culture tests to identify Mycohacterium tuherCillosis, treatment of all cases using short-course chemotherapy under direct observation of treatment (DOT), regular supply of drugs and rigorous monitoring.

The DOTS strategy is a comprehensive approach to ensure the detection and cure of tuberculosis cases and is the best way to stop tuberculosis in the community.

Achieving DOTS ALL OVER by 2000 is essential for all countries in the Region, even for those with intermediate to high incidence of tuberculosis, as the first step towards tuberculosis elimination in the future.

The Regional Committee for the Eastern Mediterranean, at its Forty-fourth Session held in Teheran, Islamic Republic of Iran, 4-7 October 1997, discussed elimination and eradication of diseases and adopted resolution EM/RC44/R.6 in which it:

a) Urged Member States:

• With low incidence of tuberculosis which have not yet adopted the target of tuberculosis elimination by the year 20 to to do so;

• With intermediate to high incidence of tuberculosis to implement the strategy of DOTS ALL OVER as a prerequisite for elimination.

b) Requested the Regional Director to report regularly to the Regional Committee on progress made towards the elimination of tuberculosis.

This report is in response to that resolution.

2. ACTIVITIES UNDERTAKEN IN RESPONSE TO RESOLUTION

EMlRC44/R.6 2.1 General

Member States and the WHO Regional Office for the Eastern Mediterranean have together made substantial efforts for the accomplishment of the resolution. Accordingly, many activities have taken place in support of national tuberculosis programmes. Thesl'

I Elimination phase: a phase reached when the incidence of sputum smear-positive cases is I per 100000 population or fewer.

Elimination of tuberculosis: reduction of incidence of tuberculosis (number of new cases) to a rate of J per I 000000 population or fewer.

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EMlRC46IINF.DOC.3 page 2

include programme reviews. human resources development. support to laboratory and surveillance activities. distribution of relevant documents. advocacy and promotion of intersectoral collaboration. Also. special initiatives within the Region and with other WHO regions have been actively pursued.

2.2 Programme reviews

At their annual meetings. organized by the Regional Office and of which there have been two since 1997. national managers of tuberculosis programmes in the countries of the Region reviewed the progress and constraints in the promotion of the DOTS strategy. This annual review provides the national managers with a clear view as to their current situation with regard to tuberculosis control and the actions necessary to accomplish the targets set by the resolution.

The Regional Office organized visits by WHO staff and consultants to on-going DOTS projects to review their activities and ensure proper implementation. In addition to these DOTS project reviews. the Regional Office collaborated with the national authorities in Egypt and the Islamic Republic of Iran in the conduct of in-depth reviews of the national tuberculosis programmes. aiming to evaluate all aspects of tuberculosis control and promote organizational. technical and administrative improvement. Similar in-depth reviews are planned for tuberculosis control programmes in Sudan and the Republic of Yemen. and possibly other countries, in 1999.

2.3 Development of human resources

The Regional Office continued to support the development of strong national technical leadership in tuberculosis control. Three regional training courses on tuberculosis control were held in the Islamic Republic of Iran (1997). Pakistan (1998) and the Syrian Arab Republic (1998). The course lasted two weeks in the Islamic Republic of Iran and one week each in Pakistan and the Syrian Arab Republic. A total of 55 participants attended these courses from 15 countries of the Region. The Regional Office also continued to support national training activities. In addition. several tuberculosis experts in the Region were awarded WHO training fellowships in tuberculosis control. Another way of developing a regional core of experts in tuberculosis was through including national tuberculosis managers in WHO missions to receive on-the-joh practical training.

In order to further strengthen WHO support to national programmes. tuberculosis experts were recruited at regional and national levels. This included recruitment of one more full-time tuberculosis officer at the Regional Office. a full-time tuberculosis expert in Somalia and an infectious disease officer in Afghanistan. National experts on tuberculosis were also recruited in Pakistan and Somalia. .

2.4 Development of laboratory and surveillance capacity

In order to establish a laboratory network with a system of quality control. WHO laboratory consultants visited several countries. As a result of the visits. surveillance on anti-tuberculosis drug resistance was also started in the Islamic Republic of Iran. Morocco and Oman, in line with the strategy of the WHO global project.

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EMIRC46IINF.DOC.3 page 3

Information on tuberculosis control is collected regularly from all countries and is summarized in the WHO report on tuberculosis control published annually. In addition, in order to closely monitor the implementation of the strategy of DOTS ALL OVER in the Region, a new reporting system called DOTS quarterly fax was started at the end of 1998 whereby information from all countries is published every 3 months and sent by fax to all countries of the Region. The countries make their returns on a form included in the same fax.

2.5 Dissemination of WHO documents and publications

The Regional Office continued to disseminate essential information on tuberculosis control throughout the Region. This included publication of original documents by the Regional Office, translation and publication of WHO headquarters publications into Arabic and posting of information on the Regional Office Website.

2.6 Advocacy

World Tuberculosis Day, 24 March, is commemorated widely throughout the Region every year. Activities have included meetings, mass media campaigns and press conferences. The campaigns have succeeded in raising public awareness and inducing greater support from decision-makers.

The Regional Office, in collaboration with the Royal Tropical Institute in the Netherlands, started a research project to assess the costs, effects and cost-effectiveness of DOTS projects in Egypt and the Syrian Arab Republic. The objective is to assess the effectiveness of DOTS projects in economic terms with a view to attracting greater political and financial support. This is the first such study to be conducted in the Region.

2.7 Coordination between donors

The Regional Office continued to play an active role as coordinator between donors and countries in order to secure support for national tuberculosis control programmes. In Iraq, the Regional Office coordinated with the Japan Anti-Tuberculosis Association and the International Union Against Tuberculosis and Lung Disease (IUATLD) to obtain the support necessary for the start of a DOTS demonstration project. The Regional Office also coordinated with the Government of the Netherlands in Egypt, the Japan International Cooperation Agency in the Republic of Yemen and the Norwegian Lung and Heart Association and IUATLD in Sudan.

2.8 Intersectoral collaboration for tuberculosis control

At the national level several agencies, including national tuberculosis control programmes of ministries of health, government health care institutions run by ministries other than the ministries of health, the private health care sector and nongovernmental organizations such as anti-tuberculosis associations, carry out tuberculosis control in many countries of the Region. The Regional Office was therefore active in promoting intersectoral collaboration so that all partners implement the strategy of DOTS ALL OVER. To facilitate this collaboration, in the meeting of national managers of tuberculosis control programmes in the Region in September 1998, national tuberculosis managers and representatives of the private health sector and nongovernmental organizations jointly prepared a protocol for intersectoral collaboration. In the protocol, establishment of a national board representing all partners in tuberculosis control and formulation of national

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EMlRC46/INF. DOe. 3 page 4

tuberculosis guidelines, with the involvement all partners In these processes, were recognized as the important prerequisites.

2.9 Support to special initiatives

2.9.1 Support to the tuberculosis elimination initiative in Member States with low incidence

The eliminaticn initiative adopted in 1996 by the six Member States of the Gulf Cooperation Council (GCC), namely Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates, is progressing well in close collaboration with WHO. The target of the initiative is to reduce incidence rates of smear-positive pulmonary tuberculosis to I per 100 000 population by 20 I 0, as stated in resolution EM/RC44/R.6. National tuberculosis control programmes in these countries prepared comprehensive plans of action for the launch of the initiative. The plans clearly illustrate steps that must be taken for the initiative, giving the highest priority to DOTS ALL OVER. With the help of WHO, annual meetings on the tuberculosis elimination initiative are held to review the progress and update action plans.

2.9.2 Support to other regional and inter-regional tuherculosis control initiatives

At present there are three initiatives in addition to the tuberculosis elimination initiative in the Member States of the GCe. These are the Horn of Africa tuberculosis control initiative, the Near East tuberculosis control initiative and the Maghreb tuberculosis control initiative. The latter is expected to start in 1999.

Seven countries in the Horn of Africa, namely Djibouti, Somalia and Sudan from the Eastern Mediterranean Region and Eritrea, Ethiopia, Kenya and Uganda from the African Region. are involved, with the support of WHO, in the Horn of Africa tuberculosis control initiative (HATCI) which began in 1996. The initiative aims to strengthen cross- border tuberculosis control activities. Since its start, the national managers of these countries have met annually to review progress and prepare plans of action accordingly.

Six countries in the Near East, namely Cyprus, Iraq, Jordan, Lebanon, Palestine and Syrian Arab Republic are involved. with the support of WHO. in the Near East tuberculosis control initiative (NETCI). At the first meeting of the initiative in May 1998, the participants identified several areas for collaboration such as joint human resources development. exchange of experiences and joint laboratory activities.

3. ACHIEVEMENTS

3.1 DOTS ALL OVER in the Region

At the end of 1998. seven countries (Bahrain, Cyprus, Djibouti. Jordan, Morocco.

Oman and Qatar) had achieved DOTS ALL OVER with high treatment success rates.

Kuwait is in the final stage of accomplishing DOTS ALL OVER.

Three countries have achieved more than 50% DOTS coverage: Sudan (65%).

Syrian Arab Republic (55%) and Republic of Yemen (54%). Three countries have achieved 25% to 50% DOTS coverage: Somalia (48%). Saudi Arabia (40%) and Islamic Republic of Iran (28%). Egypt has expanded its DOTS projects. achieving 19% coverage.

Four countries (Iraq. Lebanon. Pakistan and Tunisia) have started DOTS demonstration projects covering less than 10% of the total population.

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EMlRC46I1NF.DOC.3 page 5

Afghanistan, Libyan Arab Jamahiriya, Palestine and United Arab Emirates had not started DOTS projects by the end of 1998, although the United Arab Emirates was expected to start projects in early 1999.

All the DOTS projects in the Region have achieved successful results in terms of smear conversion rates at the end of third month of treatment and treatment success rates (Table I). DOTS areas have shown better activities than non-DOTS areas (Tables 2 and 3).

In the field of diagnosis, the proportion of smear-positive cases among all cases of pulmonary tuberculosis was as high as 79% in DOTS areas while it was only 48% in non- DOTS areas. The cure rate in DOTS areas was as high as 81 % while it was only 58% in non-DOTS areas.

Taking these results into account, it is clear it is clear that the DOTS strategy is implementable in many different situations in the Region and can achieve good results. It is recognized that the presence of effective political commitment and strong technical leadership is absolutely essential.

Table 1. DOTS implementation status in the Eastern Mediterranean Region, 1998

DOTS Country DOTS coverage Smear Treatment

coverage ^(%)' conversion rate success rate

category ^(%) ^(%)

DOTS ALL Bahrain^b 100 70' 59'

OYER Cyprus,·11 ₁₀₀ ₃₃^h NA

( 100'7.-) Djibouti 100 96' 75'

lordan^l^' I ()() 94h NA

Morocco 100 85' 83'

Oman 100 93' 91'

Qatar 100 92' 92'

50lk-99o/c Kuwait^e 90 RO' 73'

Sudan 65 ^94~ 75^a

Repuhlic of Yemen 60 87' 7S^a

Syrian Arab Republic 55 91' 92³

100/('-49% Somalia 48 82' 89'

Saudi Arabia^l^" 40 NA NA

Islamic Republic of Iran 28 99' 87'

Egypt 19 93' 90'

<IOo/r Iraq" 9 94h NA

Lebanon<: 9 NA NA

Pakistan R 66' 74ⁱ

Tunisia 5 ItJO' 93ⁱ

Not yet started Afghanistan

Libyan Arab Jamahiriya Palestine

United Arab Emirates

Sources: Regional tuberculosis surveillance. DOTS quarlerlyjax, the meeting of national managers of tuberculosis control programmes in the Eastern Mediterranean Region. September 1998 and the subregional meeting for the tuberculosis elimination initiative in the Member States of the Gulf Cooperation Council. November 1998.

NA = not available

~ As al 31 December 1998 blntormation on nationals only

~ As these countries started DOTS projects in 1998. information on smear conversion and treatment outcome is not fully available as yet

J Three smear-positive cases were registered during the 2nd quarter of 1998 and one case became smear-negative at the end of the third month of treatment

<' Of 73 cases registered in 1997. 13 cases (18%) left the country during the treatment

Note. Information was collected for the following periods: 'I st half of 1998. '1997. h2nd quarter of 1998. 11 st half of 1997.

'1996

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EMlRC46/INF.DOC.3 page 6

Table 2. Case finding in DOTS areas and non-DOTS areas in the Region

Pulmonarl: Extra· Total Smear positive!

Smear~positive Smear- pulmonary Pulmonary

New Relapse negative

(A) (B) (C) (D) (E) [(A)+(B)]/[(A)+(B)+(C))

DOTS areas 29756 1402 8295 17380 56653 79%

52.5% 2.5% 14.6% 30.7% 100.0%

Non-DOTS areas 17410 519 19092 10929 48774 48%

35.7% 1.1% 39.lo/c 22.4% 100.0%

Total 47172 1921 27 387 28309 105427 64%

44.70/, 1.80/, 26.0% 26.9% 100.0%

Source: Meeting of national managers of tuberculosis control programmes in the Region. 1998

Table 3. Treatment outcome in DOTS areas and non-DOTS areas in the Region

Total number Cured Treatment Died Failure Default Transfer

of cases completed ont

DOTS areas 43261 35 III 2238 1013 572 3805 325

100% 81% 50/, 2% 1% 9% 1%

Non-DOTS areas 2858 1657 402 91 71 434 181

1000/c' 58% 14% YYr y'/r 15% 69'0

Total 46119 36768 2640 I 104 643 4239 506

100% 78% 6% 2% ^1% 9% 1%

Source: Meeting of national managers of tuberculosis control programmes in the Region. 1998

3.2

Achievements in tuberculosis elimination for countries with low incidence of tuberculosis

There are nine countries in the Region with low incidence rates of tuberculosis. Six of them (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates) are the Member States of the GCC and undertook in 1996 to eliminate tuberculosis. The remaining three countries, namely Cyprus, Jordan and Libyan Arab Jamahiriya have shown their commitment to the tuberculosis elimination strategy.

In the tuberculosis elimination initiative in the Member States of the GCC, the following progress is observed.

• achievement of strong political commitment;

• endorsement of national plans of action for the initiative;

• adoption of the strategy of tuberculosis elimination as a national policy for tuberculosis control;

• establishment of central units for tuberculosis control in ministries of health;

• commencement of full implementation of DOTS;

• designation of a national reference laboratory for tuberculosis control in all GCC countries;

• introduction of the WHO-recommended strategy of short-course chemotherapy under direct observation of treatment (DOTS);

• introduction of the WHO-recommended recording and reporting system;

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• high treatment success rates;

• incidence rates of sputum smear-positive cases of tuberculosis ranging between 4 and 7 per 100000 among nationals (the interim target was to achieve 5 per 100000 by the end of 2000).

The other three countries with low incidence of tuberculosis in the Region have made similar progress. Cyprus and Jordan achieved DOTS ALL OVER in 1998 with satisfactory smear conversion and treatment success rates.

Table 4. Tuberculosis control status among countries with low incidence of tuberculosis in the Region

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Country DOTS Incidence Information from DOTS areas Remarks

coverage rate of Third month Treatment

(%) smear- sputum success rate

positive cases conversion rate (%) (per 100000) (%)

Bahrain 100 7 70 59' • '59%: out of 27 cases. 8

cases died during

treatment of these, 7 were non-tuberculosis deaths

Cyprus 100 2" 33' NA • b2: expatriate cases are

included

• c33%-: lout of 3 converted to negative

• DOTS started in 1998 so treatment outcome is not yet available

Jordan 100 2' 94 NA • d2: expatriate cases are

included

• DOTS started in 1998 so treatment outcome is not yet available

Kuwait 90 4 92 73

Libyan Arab Not yet 22' No DOTS No DOTS _{• e22:}incidence rate of all

Jamahiriya started _fOTmsof tuberculosis and

including expatriate cases

Oman 100 7 92 91

Qatar 100 7 92 92

Saudi Arabia 43 5 NA NA • DOTS started in mid-1998

so neither sputum conversion rate nor - treatment outcome are yet

available

United Arab DOTS 7 NA NA • DOTS started in 1999 so

Emirates started neither sputum conver~ion

1/1/99 rate nor treatment

outcome are yet available NA ~ not available

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4. CHALLENGES

EMIRC46IINF. DOC. 3 page 8

With due consideration to the progress so far achieved, resolution EMIRC44/R.6 still poses an enormous challenge to the countries of the Region, as indicated in Table 5.

The seven countries that have achieved DOTS ALL OVER account for only 8% of the population of the Region, and for 6% of the total regional cases of tuberculosis. The eight countries in which DOTS is expanding account for 47% of the regional population and 32% of regional tuberculosis incidence. More important is the fact that the eight countries in which DOTS implementation is lagging account for 45% of the regional population and 62% of the regional tuberculosis incidence. Unless major efforts are made in these countries, the Region will continue to see an increase in incidence of and mortality from tuberculosis in the coming decades.

Table 5, DOTS implementation status in the Eastern Mediterranean Region

WORLD HEALTH ORGANIZATION