01.COMMUNICABLE DISEASES PREVENTION AND CONTROL

Transcription

1 II AREAS OF WORK This section contains, for each of the 38 thematic Areas of Work, the Issues and Challenges, Objectives, Strategies, Expected Results, and Indicators, and is representative of the work across the entire Organization. While the Issues and Challenges outline the principle concerns of what needs to be addressed, the PAHO Objectives and region-wide expected results incorporate the combined commitments of Member States and the Secretariat (country offices, regional units, and centers). Furthermore, the region-wide expected results form the basis for costing and estimating resource requirements over the twoyear period. Performance indicators are made explicit, and baselines and targets have been added to allow measurement of achievements in implementing the program budget.

2 Communicable Diseases 01.COMMUNICABLE DISEASES PREVENTION AND CONTROL ISSUES AND CHALLENGES Communicable diseases disproportionably affect poor and marginalized populations of the countries of Latin America and the Caribbean. Global strategies are generally available to address the most important of these, although effective technical cooperation programs must be adapted not only to meet the financial, social, and cultural conditions of the country but also the specific characteristics of this most affected population. Dengue is a disease with great epidemiological, social and economic impact. It constitutes a growing global public health problem, particularly in the Americas. In 2004 the American Region provided the greatest number of reports to the World Health Organization. The circulation of the four serotypes of dengue virus, the lack of a vaccine and of an effective chemoprophylaxis and specific treatment for the disease, are reasons why dengue is of great concern at this time. PAHO/WHO resolutions adopted by Member Countries emphasized the importance of addressing dengue through an integrated management based strategy for its prevention and control. PAHO needs to give priority to the neglected diseases. These are a group of parasitic and other infectious diseases which, because of the tyranny of national averages remain in pockets of the poorest populations. The neglected diseases to be given priority in this biennium are lymphatic filariasis, onchocerciasis, intestinal helminthiasis, and schistosomiasis. PAHO/WHO estimates that 20-30% of Latin Americans are infected with intestinal helminthes and/or schistosomiasis, while the figures for intestinal helminthiasis alone often reach 50% in slum-dwellers and up to 95% in some Amerindian tribes. Children and pregnant women are at particular risk of morbidity. Schistosomiasis (S. mansoni) still affects at least 8 countries in the Region, with Brazil carrying the largest burden with approximately 2.5 million people estimated to be infected and 6 million at risk. Lymphatic filariasis affects over a half-million people in the Region with up to 6-8 million at risk (conservatively), principally in Haiti but also in Guyana, Dominican Republic and NE Brazil. Onchocerciasis puts about a half-million people at risk in the Region. Its most problematic focus encompasses an extensive region of remote Amerindian communities on the border of southern Venezuela with northern Brazil. PAHO/WHO Resolutions call for the elimination of onchocerciasis and lymphatic filariasis as public health problems by 2007 and 2020 respectively, and the improved control of geohelminths and schistosomiasis by There has been steady progress in achieving these goals; however, global resources are scarce, sustainability of the programs depends on the political will, and significant advocacy is required. To interrupt transmission of onchocerciasis, the target is treatment coverage of no less than 85% must be maintained over a period of 12 to 14 years, while treatment coverage above 80% over a period of five years is critical to interrupting the transmission of lymphatic filariasis in endemic countries. For geohelminths and schistosomiasis the global target is that at least 75% of school-age children living in areas of risk for these diseases need access to regular chemotherapy by 2010, as identified in WHA Resolution (2001). WHO is currently developing new integrated, intersectoral and interprogrammatic strategies to address the environmental determinants and other risk factors for neglected diseases that lie beyond the health sector. A multi-disease and integrated approach to management of these diseases is desirable due to the synergies, logistical efficiencies, and potential cost-savings to be realized in both prevention activities and case management (patient care). Cost-effectiveness data are lacking, and need to be developed for both singleand multi-disease interventions, by piloting studies which incorporate cost and cost-effectiveness analyses. Infestation rates of T. infestans, the principal vector of Chagas disease in the Southern Cone, have been drastically reduced in the last 10 years. However, subregional initiatives are still being developed by the Central American and Andean countries to eliminate transmission of T. cruzi. Chagas disease surveillance and leprosy diagnosis and treatment must be integrated into health services. 75% of the new diseases that have affected humans over the past 10 years have been caused by pathogens originating from an animal or from products of animal origin. The intersectoral approach between heath and agriculture is very important for effective to understand and act in the prevention and control of many of the zoonotic disease that are considered potential threat for public health, for example, avian flu, BSE

3 Communicable diseases 01. Communicable diseases prevention and control and others zoonotic disease. There is a need to adapt foot-and mouth disease and zoonosis control programs to the municipal level in accordance with the decentralization policies adopted by Member States which emphasize capacity building in small communities. Special efforts are required to reach control targets set for the regional programs for the control of foot-and-mouth disease and rabies. With respect to the latter, as the program focuses on the two countries still at significant risk for these diseases Bolivia and Haiti - the new challenge is to implement strategies to prevent human rabies transmitted by wildlife, particularly by vampire bats. In the last two years several outbreaks have been were reported in South America. More research is needed to better understand the pathogens known and emerging, disease manifestation, their mechanisms of transmissions, as well as to find adequate ways of preventing, controlling and treating communicable diseases. A cadre of nationals need to be developed, especially in the key countries, where communicable diseases is responsible for a high burden of disease. GOAL PAHO OBJECTIVE STRATEGIC APPROACHES Eliminate the neglected diseases and reduce morbidity, mortality, and disability due to new and emerging communicable diseases. Assist countries to strengthen prevention, control and, where appropriate, eradication or elimination of communicable diseases and achieve the key program indicator agreed globally. Promoting evidence-based strategies; capacity building for formulation of integrated, multidisease-, interprogrammatic-, and intersectoral- based disease-prevention, control, and elimination strategies. Cooperating with the Member States to mobilize resources for the elimination, prevention, and control of targeted diseases and promoting cooperation among countries. Partnering with technical counterparts as well as collaborating extensively with complementary service providers as an integral part of communicable disease technical cooperation, especially in countries facing epidemiological emergencies or at high risk of exposure to complex emergencies. Developing strategies in communicable diseases prevention, control, and/or elimination to strengthen national health infrastructure and services in order to expand their coverage. Adopting and encouraging implementation of an innovative information- and knowledge-sharing strategy in accordance with current global and regional challenges and PAHO s new vision on information management, sharing, and knowledge exchange, while maintaining existing outbreak information and surveillance systems and networks. Linking communicable disease subregional mechanisms (e.g. subregional meetings of technical counterparts) to existing subregional institutions, such as MERCOSUR, OTCA, CARICOM, RESSCAD, RIMSA, COHEFA, among others. Defining the most critical areas of research for improving implementation of communicable disease prevention and control, programs, in collaboration with UNICEF/UNDP/World Bank/WHO Special Program for Research and Training in Tropical Diseases. REGION WIDE EXPECTED RESULTS INDICATORS BASELINES TARGETS 1. Increased capacity to plan, implement and monitor programs for prevention and control of dengue especially in key countries.. Number of countries adopting and implementing an integrated dengue prevention and control strategy; with recommendations towards health promotion activities

4 Communicable diseases 01. Communicable diseases prevention and control 2. Countries yet to eliminate lymphatic filariasis, and onchocerciasis, supported to accelerate efforts towards agreed regional goals. Number of countries where an external evaluation of the national plan for dengue prevention and control based on an integrated strategy has undertaken in collaboration with PAHO.. Number of countries in the Region that have participated in training activities on the COMBI (communication for behavioural impact on dengue) methodology. Behaviours that will lead to the elimination of vector breeding sites). Number of countries where a COMBI plan has been implemented. Number of countries where the processing of epidemiological information has been standardized to generate uniform data on dengue statistics reporting to DENGUE NET. Number of countries at risk where national programs for the elimination of lymphatic filariasis have launched the full Mass Drug Administration (MDA) component according to WHO s guidelines and with technical cooperation from PAHO. Number of countries where national programs for the elimination of lymphatic filariasis have launched a comprehensive morbidity component with technical cooperation from PAHO. Number of PAHO-sponsored validation exercises of tools to verify interruption of transmission in lymphatic filariasis, completed for the Region. Number of onchocerciasis endemic countries attaining required treatment coverage rates of 85% for a minimum of 6 years, stemming from technical cooperation with PAHO and other global partners. Number of countries where PAHO/WHO sponsored or cosponsored external evaluations of the program to eliminate onchocerciasis have taken place (2)

5 Communicable diseases 01. Communicable diseases prevention and control 3. Conditions will be created to carry out integrated health management/care, and multi-disease based strategies to control geohelminthiasis and schistosomiasis. 4. Activities to eliminate leprosy as a public health problem, as well as the consolidation and sustainability of those activities, will be promoted and evaluated. 5. Areas of interruption of the transmission of Chagas by T. infestans in the Southern Cone and by Rhodnius prolixus in Central America will be expanded and consolidated, and the initiatives of Mexico, the Andean countries, and the Amazon basin will be fully operational, with control results. In compliance with the Millennium s Objective 6 and Goal 8 reducing the incidence/prevalence, morbidity and mortality of Chagas' disease.. Number of countries where integrated, multi-disease based plans of action to control geohelminths and/or schistosomiasis have been prepared with technical cooperation from PAHO. Number of countries where PAHO has co-developed or co-financed integrated, multi-disease-based pilot interventions to control geohelminths and schistosomiasis. Number of priority countries that will have implemented the Global Strategy for the reduction of leprosy disease burden and sustainability of the leprosy control activities.. Number of municipalities in Brazil where adequate logistics to implement multidrug therapy (MDT), achieving 100% treatment coverage of cases will be in place. Number of countries contributing to regional leprosy surveillance program. Number of external program evaluations sponsored or cosponsored by PAHO in the biennium.. Number of countries where interruption of transmission by T. infestans is feasible and has been achieved.. Number of countries where interruption of transmission by T. infestans is not feasible but where transmission has been reduced. Number of countries where interruption of transmission by R. prolixus is feasible and has been achieved ,557 4, Number of countries where interruption of transmission by R. prolixus and other vectors is not feasible, but where transmission has been reduced.. Number of functional subregional initiatives with national control and/or surveillance results. Number of countries recording an increase in the coverage and quality of blood bank screenings for Chagas

6 Communicable diseases 01. Communicable diseases prevention and control 6. Conditions will be fostered for eradicating foot-and-mouth disease FMD, protecting free areas, and keeping the Region free of mad cow disease (bovine spongiform encephalopathy BSE).. Number of countries/zones of the Southern Cone and Brazil (except for Amazon region) free of foot-andmouth disease.. Number of countries with epidemiological surveillance systems for vesicular disease that will be sustained throughout the Region Human rabies transmitted by dogs will be almost eliminated; sylvatic rabies will be epidemiologically monitored; and countries will be supported in the implementation of control programs concerning bovine tuberculosis, and echinoccocosis. 8. Guidelines will be provided for prevention and control of plagues leishmaniasis and rickeittsiosis. Latin America and the Caribbean will maintain BSE-free status. Number of countries where foot-andmouth disease programs have been audited. Reduction in the number of countries that have yet to eliminate human rabies transmitted by dogs. Number of countries in Latin America with rabies surveillance systems reporting regularly to PAHO. Number of countries in Latin America and the Caribbean with received PAHO technical cooperation to control bovine tuberculosis and echinoccocosis.. Number of countries. Provided with a technical orientation and basis for policy decision for plagues leishmaniasis and rickeittsiosis New knowledge applied to improve effectiveness of CD programs 10. Support provided for strengthening the capacity for research and its application in endemic countries. Number of new, significant and relevant scientific advances in the biomedical, social, economic and public health sciences.. Number of new and improved intervention methods validated for prevention, diagnosis, treatment of rehabilitation, for the population affected by infectious diseases.. Number of new and improved strategies and policies validated and recommended to use. Number of institutions in Key Countries with developed capacity to propose and implement relevant research activity

7 Communicable diseases 01. Communicable diseases prevention and control RESOURCES (US$) Regular Budget Other Sources Total ,031,300 13,147,000 31,178, ,969,600 16,226,000 33,195,600 Of which: Country 5,405,000 6,344,700 11,749,700 Subregional 1,426, ,800 2,006,800 Regional 10,138,600 9,300,500 19,439,

8 02. COMMUNICABLE DISEASES RESEARCH SELECTED ISSUES AND INTERVENTIONS PREVIOUSLY IN THE AREA OF WORK 02. COMMUNICABLE DISEASES RESEARCH (CRD) HAVE BEEN CONSOLIDATED WITH AREA OF WORK 01. COMMUNICABLE DISEASES PREVENTION AND CONTROL (CPC) PLEASE NOTE THAT ALTHOUGH THIS AREA OF WORK HAS BEEN CONSOLIDATED INTO AREA OF WORK 01, THE NUMBERING SEQUENCE HAS BEEN MAINTAINED FOR COMPARABILITY

9 June

10 Communicable diseases 03. EPIDEMIC ALERT AND RESPONSE ISSUES AND CHALLENGES In the past 25 years, new, emerging, and re-emerging infectious diseases have continued to pose a considerable challenge to the public health services of the American Region. Several factors contributing to their emergence are human behaviour and activities such as expansion of agricultural frontiers, increase in population mobilization across borders, and trade in food products. Some new infections exhibit a focal geographic distribution, whereas others are widely dispersed and, in some cases, are global in their extent. It is should be noted, that most emerging pathogens affecting man are zoonotic. Two recent events call for the acceleration and improvement of technical cooperation activities on preparedness, alert and response to epidemic-prone diseases. First, the International Health Regulations, adopted in May 2005, provide a powerful tool for harmonizing public health action among Member States, and a framework for the identification, reporting and response to public health emergencies of international concern. Second, the emergence of a new highly pathogenic strain of avian influenza that threatens human health given its potential for human to human transmission is an alert for the possible emergence of a new pandemic strain. Easy access to intercontinental transportation, densely populated urbanized areas, a rising aging population and an increase in immuno-compromised and chronically ill populations are factors that can contribute to its dissemination. Thus, it is imperative for the countries to be adequately prepared to handle a public health emergency caused by a pandemic influenza. Until now, only two countries in our Region have complete pandemic preparedness plans. With regard to other public health threats, early detection of cases such as yellow fever and other hemorrhagic fevers is crucial to timely outbreak control and appropriate patient-care management. Also, the dissemination of West Nile virus to Central America and the Caribbean sub-regions emphasizes the importance of developing local capabilities to detect and respond to outbreaks due to arboviruses that cause neuroinvasive diseases in humans. In addition, the increase in the resistance to antibiotics among a range of bacteria and the ever-changing pattern of resistance are of serious concern. A broad range of strengths and weaknesses related to the management of emergencies caused by epidemic infectious diseases were identified as a result of the response to the SARS epidemic. Among the latter one: inadequate capacity for epidemiologic investigation, difficulties with timely access to laboratory testing and results, and lack of protocols for data or information sharing, infection control and biosafety. Major challenges for the biennium are: Prospects for controlling a pandemic influenza are limited. Despite the progress made in vaccine development, a shortage of vaccine is anticipated during the first wave of the pandemic. The use of antiviral agents will be constrained by high costs and limited supplies. Given this scenario, all countries need to develop national influenza pandemic preparedness plans to reduce the expected impact on the population, the health care services and their economies. Stockpiling of vaccines and antivirals is a key component of the plan and represents a major difficulty to overcome. Maintaining pandemic influenza preparedness as a high national political priority: The pandemic influenza preparedness competes in priority with many other current public health issues. Therefore, PAHO needs to provide support to the countries for the mobilization of internal and external funds and other resources. Strengthening national preparedness and response: Preparedness is critical to improving health security. National public health infrastructure for alert and response needs to be strengthened so that countries can detect and intervene in epidemic events at the local level. Acquiring these core capacities is a continuous process that may require expansion of the existing infrastructure and this process can be accelerated through external support

11 Communicable diseases 03. Epidemic alert and response Sustaining and strengthening sub-regional surveillance networks: Country initiatives are complemented by sub-regional surveillance networks set up to provide reliable laboratory diagnostic support and information exchange as a prerequisite for effective and prompt response to any outbreak. Lack of funding for subregional surveillance networks is a major obstacle to their active and effective operation. Improving PAHO s internal and external coordination mechanisms for regional alert and response activities. GOAL PAHO OBJECTIVE STRATEGIC APPROACHES Contribute to improve social and economic well-being of all people of the Region and global health security through action to reduce the impact of communicable disease epidemics on health. To strengthen Member States capacities to detect, identify and respond rapidly to threats at all levels from epidemic-prone and emerging infectious diseases of known and unknown aetiology and are prepared to respond to a national influenza pandemic.. Supporting development of national infrastructure core capacities for epidemic alert and response in accordance with the IHR-2005 and for influenza pandemic preparedness.. Strengthening regional/subregional surveillance networks for emerging and re-emerging infectious diseases (EID), including FluNet and resistance to antimicrobials.. Setting up appropriate mechanisms to coordinate regional alert and response activities to comply with the revised International Health Regulations.. Sustaining and expanding information and knowledge sharing to uphold regional interest and commitment for epidemic alert and response. REGIONWIDE EXPECTED RESULTS INDICATORS BASELINES TARGETS 1. Technical cooperation provided for the strengthening of core capacities to detect epidemic-prone diseases and enhance response-readiness as indicated in the IHR, which includes: neuroinvasive diseases caused by arboviruses, viral hemorrhagic fevers, SARS, respiratory diseases, and other emerging zoonotic diseases.. Number of guidelines produced and disseminated (smallpox, influenza, SARS, polio).. Number of country assessments of core capacities and national plans of action.. Number of subregional workshops for development of technical capacity on epidemic prone diseases Latin American and CAREC member countries supported to develop and implement National Influenza Pandemic Preparedness Plans (NIPPP).. Number of countries that received PAHO technical cooperation to complete the development of NIPPP.. Number of countries that have disseminated and implemented the NIPPP to the local level

12 Communicable diseases 03. Epidemic alert and response 3. All Latin American and CAREC member countries reporting to FluNet and sending influenza isolates for characterization. Number of countries implementing influenza surveillance and reporting data to FluNet in accordance to established guidelines.. Number of National Influenza Centers sending influenza isolates for characterization to the PAHO/WHO Collaborating Center Systems will be structured for surveillance and response preparedness in animal Influenza (poultry).. Number of countries with operational animal Influenza Prevention Plans Effective partnerships sustained through active sub-regional Emerging Infectious Diseases (EID) alert and response networks and adequate resources mobilized to support them.. Number of existing sub-regional EID alert and response networks established by PAHO.. Number of networks financially supported for annual meetings and the exchange of resources such as training, mobilization of investigative teams, laboratory Procedures established in PAHO for appropriate coordination of alert and response to public health emergencies of regional concern and management of implementation of the revised International Health Regulations.. Task Force on Epidemic Alert and Response operations with procedures and responsibilities for IHR implementation spelled out.. Number of countries having received technical cooperation for implementation of required core capacities for compliance with the Regulations Percentage of reported outbreaks that is verified and followed-up through collaboration between Member States, the Secretariat, and partners of the Subregional EID networks. 60% 90%

13 Communicable diseases 03. Epidemic alert and response 7. Programs for surveillance and containment of resistance to antimicrobial drugs and nosocomial infections will be promoted and supported.. Number of countries that have plans in place to contain antimicrobial resistance. Number of countries with national norms for nosocomial infection control Number of studies on cost of hospital infections. Number of countries with at least two health care institutions that follow defined clinical guidelines for treatment with antibiotics RESOURCES (US$) Regular Budget Other Sources Total ,292,000 5,000,000 6,292, ,608,900 5,422,000 8,030,900 Of which: Country 1,235,400 1,897,700 3,133,100 Subregional Regional 1,373,500 3,024,300 4,397,

14 Communicable diseases 04. MALARIA ISSUES AND CHALLENGES Malaria is endemic in 21 countries of the Region. During the past decade, approximately 1 million cases were reported annually. The disease represents an important social and economic burden to the population at risk, primarily those in the poorer communities. Plasmodium falciparum resistance to antimalarials has been reported. The Region faces the need to strengthen countries capabilities to detect and monitor the resistance phenomenon. In countries where transmission has been interrupted, there is need to maintain surveillance to prevent reintroduction. All 21 endemic countries adopted the Roll Back Malaria initiative launched in 1998 and are implementing the Global Malaria Control Strategy. One of the targets of the United Nations Millennium Summit is to combat malaria, and the decade has been declared the decade to Roll Back Malaria in Developing Countries. While funding is available for qualifying countries from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, some countries need support in preparing proposals for these resources. Technical coordination and cooperation is also needed so that resources, once available, can be effectively and efficiently implemented. In order to make better progress, the feasibility of expanding the scope of the Global Malaria Control Strategy also needs to be determined in order to synergize the present scope of work with other on-going or planned interventions, such as integrated vector management (IVM). GOAL PAHO OBJECTIVE STRATEGIC APPROACHES Halve the burden of malaria by 2010 and reduce it further by 2015 (Millennium Development Goal): halt and begin to reverse the incidence of malaria. To consolidate, strengthen and intensify the malaria control strategy in the Americas, specifically in the 21 malaria endemic countries and prevent the reintroduction of transmission in nations where transmission has been interrupted. Identify and fill gaps in the current implementation of regional, subregional and country programs. Provide relevant technical assistance to the endemic countries in the area of surveillance systems improvement and in program monitoring and evaluation. Strengthen advocacy, resource-mobilization and capacity-building capabilities in the various levels of the malaria program regional, sub-regional, and national. Optimize the efficiency and effectiveness of programs through the use of the inter-programmatic approach. REGIONWIDE EXPECTED RESULTS INDICATORS BASELINES TARGETS 1. Malaria prevention and control strategy implemented and expanded in endemic countries.. Of 21 malaria endemic countries, number implementing all components of the Global Malaria control strategy within the context of the Roll Back Malaria Initiative Number of countries undertaking joint activities in areas of common epidemiological interest. Of 21 malaria endemic countries, number which have reduced malaria burden by 50% or more in comparison with

15 Communicable diseases Malaria 2. System of surveillance and routine monitoring of malaria and control measures functioning in all malaria endemic countries.. Number of countries with high P. falciparum burden implementing antimalarial treatment policies based on evidence of efficacy. Number of endemic countries using epidemiologic indicators for monitoring and evaluating disease burden Increase advocacy on importance of malaria and efforts to increase resources available for its control. 4. Increased involvement in inter sectoral efforts. Of the countries where malaria transmission has been interrupted, number undertaking surveillance and reporting information on imported malaria cases.. Number of endemic countries providing annual information on morbidity, mortality, progress, and outcomes.. Number of eligible malariaendemic countries with approved proposals to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.. Number of malaria endemiccountries supported by the Amazon Network for the Surveillance of Antimalarial Drug Resistance (RAVREDA/Amazon Malaria Initiative). Number of endemic countries with malaria efforts that are carried out with and alongside other programs and sectors (eg, environmental sanitation) in malaria control activities RESOURCES (US$) Regular Budget Other Sources Total ,700 12,606,000 13,510, ,296,500 12,909,000 14,205,500 Of which: Country 119,000 8,668,900 8,787,900 Subregional Regional 1,177,500 4,240,100 5,417,

16 Communicable diseases Malaria

17 Communicable diseases 05. TUBERCULOSIS ISSUES AND CHALLENGES Despite well known interventions, tuberculosis (TB) continues to be a major public health problem in the Region, with 230,000 reported cases annually. The internationally recommended tuberculosiscontrol strategy, DOTS (Directly Observed Treatment, Short-course Drug Therapy), has been successfully implemented in several countries of the Region, and its application is expanding in others. However, this process must be accelerated to improve coverage and quality in the application of the strategy in order to raise both detection and cure rates. Furthermore, special efforts are needed to improve access for neglected and hard-to-reach populations, including individuals deprived of their liberty and indigenous groups. Two interventions in the expanded DOTS framework are improving the quality of care and services to TB patients: 1) The Practical Approach to Lung Health initiative (PAL), which introduces standardized actions to provide a satisfactory, cost-effective response to the demand generated by respiratory illnesses in primary care, helping to increase early detection and quality in TB diagnosis; 2) The Public-Private Mix for DOTS initiative (PPM), designed to integrate all health service providers, public and private, into tuberculosis control policies. The two initiatives are beginning to be implemented in the Region. The Stop TB Initiative is a partnership among technical and financial institutions, with USAID and the Global Fund to Fight AIDS, Tuberculosis, and Malaria the main partners in the Region. The focus of the initiative is on priority countries those with high TB incidence and prevalence rates and weak epidemiological surveillance systems that impede adequate monitoring of DOTS execution. Social mobilization is needed to tackle TB in high-prevalence countries. Technical support is also needed to ensure the effective and efficient use of the existing resources, and to promote other countries access to financial support. Successful response to control the illness in the long-term depends on financial and political commitment, greater access to quality laboratory services, uninterrupted drug supplies, high patient adherence to extended treatment regimens, and effective reporting/follow-up systems. The effective expansion of DOTS demands a multi-sectoral and sustained response to address the social and environmental factors that increase the risk of developing TB. This requires TB control to be viewed broadly, as a component of international, national, and local strategies to alleviate poverty, with due consideration given to the right of every TB patient to have access to diagnosis and treatment (universal standards of care). Above and beyond the historical challenges of tuberculosis, the recent emergence of the dual TB-HIV epidemic together with multidrug-resistant TB (MDR-TB) has added to the complexity of TB control, making new strategies necessary. Tackling the challenge of TB-HIV coinfection requires closer collaboration with HIV/AIDS programs. For MDR-TB, expansion of the DOTS Plus strategy is proposed (DOTS Plus is a strategy within DOTS that requires organization of the health services, the application of treatment guidelines, the procurement of drugs at competitive prices through the Green Light Committee, special monitoring and evaluation of patients, etc.). Many countries in the Region are currently providing treatment to MDR-TB patients outside the precepts of the DOTS Plus strategy. In response to this increased burden, tuberculosis figures prominently among the Millennium Development Goals targets, with specific indicators established for prevalence, death rates, detection, and patients cured. Timely measurement of the degree to which these Millennium Development Goals have been achieved calls for an accurate, reliable epidemiological surveillance system that will help WHO/PAHO monitor progress toward reaching these indicators. GOAL To assist all countries in reaching the global control targets of 70% detection and 85% treatment success rates and to sustain this achievement in order to halve the prevalence and death rates associated with tuberculosis by

18 Communicable diseases 5. Tuberculosis PAHO OBJECTIVE STRATEGIC APPROACHES To introduce and accelerate sustainable DOTS expansion, especially in neglected populations.. Closely monitoring DOTS coverage throughout the Region to facilitate its maintenance or expansion.. Promoting the formation of Stop TB in the countries and national mobilization campaigns to sustain political commitment and secure financial resources.. Promoting innovative strategies, such as PAL (Practical Approach to Lung Health) and PPM (Public Private Mix for DOTS) and developing new policies and strategies to deal with the issue of TB-HIV coinfections.. Expansion of the DOTS-Plus strategy in selected countries with multidrug-resistant tuberculosis. REGIONWIDE EXPECTED RESULTS INDICATORS BASELINES 1 TARGETS 1. Expanded DOTS coverage and improvement in the quality of its application throughout the Region. 2. Access to treatment for neglected populations, and TB-HIV and MDR- TB patients will have increased.. Percentage of population covered by DOTS throughout the Region. 78% 90%. TB case detection rate 50% 70%. Treatment success rate under DOTS. Number of countries implementing PAL. Number of countries implementing PPM. Number of countries with plans of action for prison populations. Number of countries with active programs for persons deprived of their liberty. Number of countries with plans of action targeting TB-HIV patients. Number of countries with active programs targeting TB-HIV patients. Number of countries with national plans of action targeting indigenous populations. Number of countries with active programs targeting indigenous populations. Number of countries applying DOTS-Plus strategy 81% % Data referring to result 1 - DOTS indicators, as of 2003; data referring to new initiatives and result 2, as of

19 Communicable diseases 5. Tuberculosis 3. Improved surveillance and program evaluation systems in place.. Proportion of countries submitting accurate annual epidemiological surveillance reports. Proportion of countries submitting monitoring reports concerning HIV in TB patients. Proportion of countries presenting financial reports regarding TB programs 90% 98% 10% 40% 10% 50% RESOURCES (US$) Regular Budget Other Sources Total ,282,400 5,832,000 7,114, ,390,100 5,973,000 7,363,100 Of which: Country 442,900 2,987,000 3,429,900 Subregional Regional 947,200 2,986,000 3,933,

20 Communicable diseases 06. HIV/AIDS ISSUES AND CHALLENGES More than 2 million people are living with HIV/AIDS in the Region of the Americas. The spread of the HIV epidemic is increasing; an estimated of around 290,000 persons contracted the infection during About half of these infections are acquired by young people, most of them in the range years. Geographically, countries in Central America, the English-speaking Caribbean, and the Island of Hispaniola (Dominican Republic and Haiti) are the most affected by the epidemic. Various epidemiological patterns can be observed throughout LAC, but most infections are due to unprotected sexual intercourse. Injection drug use is a significant and growing factor in HIV transmission in several countries. Other sexually transmitted infections, in addition to being a public health problem per se, contribute to the transmission and further dissemination of HIV. Whereas the reduction of new infections remains a paramount component of national plans and programs, the increasing access to treatments that are effective in reducing morbidity and mortality, the continuous increase in the number of people living with HIV/AIDS, and concerns about global health equity have created a demand for services intended to meet the medical, social, and economic needs of people living with HIV/AIDS (PLWHA) and their families and caregivers. All these services configure the framework of the approach known as comprehensive care. Within this framework, STI control becomes a major preventive strategy to reduce HIV transmission. As the Millennium Development Goals were adopted by 191 governments in September 2000, HIV/AIDS was recognized as a specific problem that required special attention globally; and in June 2001, the Secretary-General of the United Nations a Special Session of the General Assembly (UNGASS) convened to urge all governments to heighten their responses to HIV/AIDS. In September 2003 a followup session was held at which progress on the UNGASS commitments was evaluated. Heightened political commitment in the Americas was conspicuous at a Special Summit held in Monterrey, Mexico, in January 2004, in which attending Heads of State pledged that their countries would provide universal treatment to all those in need, or treatment of at least 600,000 people by the end of Likewise, the WHO 3 by 5 initiative, has provided important opportunities for a more focused response on the part of PAHO, and for linking HIV/AIDS to health systems strengthening. Increased financial resources available to most countries through the Global Fund to Fight AIDS, TB, and Malaria and the existence of successful interventions to control HIV transmission, have set the stage for rapidly scaling-up comprehensive care and treatment, as well as for rekindling primary prevention efforts, in the AMRO Region. Nevertheless, despite significant progress in many countries, overall progress in reducing the growth and impact of HIV/AIDS has not been as effective as expected. Renewed and better coordinated efforts are urgently required, especially in the areas of sustained prevention efforts, reduction of discriminatory practices, and greater access to comprehensive care, support, and treatment. GOAL To halt or have begun to reverse the spread of HIV/AIDS by PAHO OBJECTIVE STRATEGIC APPROACHES To improve and expand the national and intercountry technical and managerial capacity to prevent and control HIV/AIDS/STI.. Supporting the development of strategic and sectoral plans, as well as extrabudgetary initiatives for the prevention and control of HIV/AIDS/STI, at the regional, subregional, country, intercountry, and local levels.. Placing special emphasis on groups with increased vulnerability.. Working with partners and stakeholders, such as the Global Fund to Fight AIDS, TB, and Malaria and the United States President's Emergency Plan for HIV/AIDS Relief (PEPFAR) on areas of care and treatment. Promoting improved and simplified methods and tools that can be implemented at the community level in a decentralized manner. Using STI services as entry points for HIV/AIDS. Integrating maternal syphilis screening within prevention of mother-to-child transmission (PMTCT) programs, as a first step towards elimination of congenital syphilis. Seeking to enhance the quality of

21 Communicable diseases 06. HIV/AIDS training programs for the delivery of ART, the accreditation of training institutions, and the continued supply of well-trained human resources at all levels.. Working with partners to reduce prices of second-line medicines through the use of cost-effective mechanisms, such as the Revolving Fund for Strategic Public Health Supplies.. Supporting the implementation of the Central American Second-Generation Surveillance Plan for HIV/AIDS through training and technical cooperation in collaboration with other partners, including the World Bank, Centers for Disease Control, and United States Agency for International Development.. Providing high-quality technical guidance to national HIV/AIDS programs and to PAHO focal points at the country level through the work of the Technical Advisory Committee on HIV/AIDS, founded in Supporting resource mobilization efforts for HIV/AIDS programs in countries. REGIONWIDE EXPECTED RESULTS INDICATORS BASELINES TARGETS 1. Visible leadership and commitment to urgent action to reach the goal of universal access to antiretroviral therapy (ART) at national and regional levels.. Number of countries that have in place legislation and/or policies that have been developed with PAHO support to reduce stigma and discrimination against people living with HIV/AIDS Health systems/services strengthening, including the adaptation and application of appropriate tools, supported.. Number of countries assisted by PAHO to implement innovative HIV/AIDS communications strategies. Number of countries that with PAHO support have integrated a gender approach into HIV/AIDS programs. Number of consultations with United Nations, development partners, and other regional bodies in which PAHO leads deliberations on comprehensive care and treatment of HIV/AIDS. Number of countries assisted by PAHO to implement operational scaling-up plans. Number of countries assisted by PAHO to integrate care and treatment into primary care services and with other health services, including antenatal services, MCH, TB, etc

22 Communicable diseases 06. HIV/AIDS 3. The effective and reliable supply of HIV-related medicines and other commodities supported. 4. The prevention of sexually transmitted HIV, with a focus on vulnerable groups supported, and the prevention of sexually transmitted infections (STI), including congenital syphilis, strengthened.. Number of countries that develop or update comprehensive care and treatment plans using guidelines elaborated, translated, and/or adapted by PAHO. Number of countries implementing models of non-conventional entry points developed in collaboration with PAHO. Number of countries that adopted and or adapted guidelines, protocols, and recommendations on care interventions and treatment schemes developed or facilitated by PAHO. Number of training centers in the Region provided with technical support to implement standardized training systems to support care and treatment. Number of laboratories assisted by PAHO to scale up treatment and monitor patient outcomes. Number of operational research studies under way to foster evidence-based interventions in health care delivery. Number of countries that with PAHO support count with updated policies to provide universal access to HIV/AIDS medicines. Number of countries implementing PAHO/WHO norms in good procurement, storage, and distribution practices. Number of new models of prevention for vulnerable groups developed and tested in countries with the support of PAHO. Number of countries trained in new models of prevention for vulnerable groups. Number of countries implementing new models of prevention of sexually transmitted HIV and STI with the support of PAHO

23 Communicable diseases 06. HIV/AIDS 5. The production of strategic information and dissemination of the lessons learned supported.. Number of countries implementing, with the support of PAHO, training plans to increase the capacity of health teams to carry out prevention activities. Number of countries that have eliminated congenital syphilis with PAHO support. Number of countries with updated policies and programs linking prevention activities to care and treatment. Number of countries and institutions that will have strengthened their surveillance systems with the support of PAHO. Number of countries that, with the support of PAHO, updated their health information systems to reflect HIV/AIDS AIDS prevalence and ART needs. Number of countries supported by PAHO for their national capacity building in the production of strategic information RESOURCES (US$) Regular Budget Other Sources Total ,041,200 29,923,000 31,964, ,081,800 35,663,000 37,744,800 Of which: Country 366,500 20,000,000 20,366,500 Subregional 0 663, ,000 Regional 1,715,300 15,000,000 16,715,

24 Non communicable diseases and reduction of risk 07. SURVEILLANCE, PREVENTION, AND MANAGEMENT OF CHRONIC DISEASES ISSUES AND CHALLENGES Non communicable disease (NCD) contributes almost 50% of the disability-adjusted life years lost (DALYS) in the countries of Latin America and the Caribbean. Of the approximately 3 million deaths which occur annually in the Region, 1.7 million are due to noncommunicable diseases. Approximately 45% of these deaths are caused by cardiovascular disease, of which ischemic heart disease and stroke are the leading causes. Cancer accounts for 20% of mortality, the majority attributed to stomach and lung cancer. Yet the incidence and mortality from cervical cancer is among the highest in the world and breast cancer incidence is increasing in almost all countries and surpassing cervical cancer in many of them. Although diabetes officially constitutes only 5% of deaths, it is underreported given that the recorded cause of death is usually one of it complications, such as cardiovascular and renal disease. The fact that cardiovascular diseases are the leading cause of premature mortality among women in the Region is noteworthy. Despite the extent of the burden of NCDs, the public health infrastructure of the Region is more suited to infectious disease and reproductive health. Successful NCD programs require an intersectoral approach and major changes to the health care system. Resources for NCDs are limited at all levels, national through global. The challenge is to develop sustainable programs with a population basis that can extend benefits to vulnerable populations. Integrated programs for noncommunicable diseases, particularly cardiovascular disease, have proven successful in several developed countries. Models are being adapted to our Region but require careful evaluation of their implementation to ensure effectiveness. Otherwise, countries may spend their scarce health resources on initiatives of unknown efficacy and effectiveness. In addition, it is important to strengthen the regulatory role of the State since actions at the policy level reach a larger segment of the population and tend to be more effective when combined with individuallevel action from health services. PAHO has sponsored the CARMEN (strategies to reduce multifactor NCDs) Network to share information on integrated NCD prevention and control, which promotes action at three levels: policy, community, and health services. Nonetheless, a major hurdle to program development is that many countries still do not have basic information on the burden that NCDs and its risk conditions, and traditional data collection methods for health statistics are not suitable to assess the magnitude for NCDs. New surveillance systems are needed as well as regular analysis of their data for decision-making, programming, and evaluation. At the level of health services, chronic diseases demand an approach that is quite different from that of acute diseases that can be resolved with limited contacts with the health care system. To address this problem a new model for care of chronic conditions has been evaluated resulting in improved care for persons living with diabetes at a very low marginal cost. The model is based on full participation and empowerment of persons living with the disease. At the same time, care is delivered as a team, in which the medical intervention is only one of the components. Technical cooperation will focus on building public health capacity to develop the various facets of integrated NCD prevention and control programs. GOAL PAHO OBJECTIVE To reduce the burden of premature mortality and morbidity related to chronic, noncommunicable diseases. To assist countries in developing a public health approach to NCD prevention and control, based on appropriate health information, and in identifying attainable outcomes leading to the reduction of the burden on NCDs