| United Nations | A/50/180-E/1995/63 |
General Assembly
Economic and Social Council
Distr. GENERAL
18 May 1995
ORIGINAL:
ENGLISH
GENERAL ASSEMBLY ECONOMIC AND SOCIAL COUNCIL
Fiftieth session Substantive session of 1995
Item 12 of the preliminary list* Item 9 (d) of the provisional
REPORT OF THE ECONOMIC AND agenda**
SOCIAL COUNCIL COORDINATION QUESTIONS
Preventive action and intensification of the struggle against
malaria in developing countries, particularly in Africa
Report of the Secretary-General
Executive summary
Malaria and diarrhoeal diseases, including cholera, are major problems
that especially affect developing countries. They impede social and
economic development and degrade the quality of life of millions of
individuals, their families and their communities. They contribute to a
vicious diseasemalnutrition-poverty-disease cycle.
Urgent action is needed to prevent and control these diseases. Increased
resources from individual countries, from the United Nations system and
from other bodies are needed to apply the existing knowledge and tools and
to invest in research and development to improve them. Broader development
issues also need to be addressed in the longer term. Overall strategies
include clearly identifying the managerial and technical principles
concerned; supporting countries in capacity-building so those principles
can be adapted and appropriately applied; and securing the resources
required for programme implementation. To support these strategies,
continued efforts are needed at country level to improve government
coordination of activities supported by the United Nations system,
bilateral development agencies, non-governmental organizations and the
private sector.
________________________
* A/50/50.
** E/1995/100.
95-14918 (E) 110795/...
*9514918*
In response to requests from the General Assembly (resolution 49/135)
and the Economic and Social Council (resolution 1994/34), action plans for
the prevention and control of malaria and diarrhoeal diseases including
cholera that address these issues have been developed in collaboration with
relevant United Nations organizations, with the World Health Organization
acting as task manager. They cover goals, work plans, time-frames and
resources needed, as requested by the Council. The present report
summarizes these two action plans. It is submitted through the Council to
the General Assembly in response to the aforementioned resolutions.
CONTENTS
Paragraphs Page
I. INTRODUCTION ..........................................1 - 34
II. QUESTIONS AND CONCERNS ARISING DURING THE 1994
DELIBERATIONS OF THE ECONOMIC AND SOCIAL COUNCIL ......4 - 94
III. PLANS OF ACTION .......................................10 -515
A. Accomplishments ...................................11 - 126
B. Goals/objectives ..................................13 - 1811
C. Strategies/action plans ...........................19 - 3612
D. Resource needs ....................................37 - 5117
IV. OPTIONS TO INCREASE RESOURCES .........................52 -5621
V. CONCLUDING OBSERVATIONS ...............................57 -5922
Annexes
I. List of organizations collaborating in the preparation of this
report ...........................................................23
II. Summary of the status of malaria and diarrhoeal disease vaccines .24
III. Diarrhoeal diseases: summary of action plan 1995-1999 ...........27
IV. Summary of action plan for malaria control .......................36
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I. INTRODUCTION
1. The Secretary-General reported to the Economic and Social Council in
1993 1/ and 1994 2/ on the prevention and control of malaria and diarrhoeal
diseases, including cholera, focusing on coordinated actions being taken
within the United Nations system. After its debate in 1994, the Council
adopted resolution 1994/34, in which it decided to retain the topic on the
agenda of the general segment of its substantive session of 1995. It
requested the SecretaryGeneral to prepare a report "... that further
addresses the agreed conclusions of the 1993 coordination segment 3/ ...
and responds specifically to the questions and concerns raised during its
discussions in 1994."
2. Following the debate on the report of the Council in the Second
Committee of the General Assembly, the Assembly adopted resolution 49/135
on 19 December 1994, which is specifically directed to the control of
malaria in developing countries, particularly in Africa. This resolution
reaffirmed the 1993 agreed conclusions and, recalling resolution 1994/34,
inter alia, requested the Secretary-General to submit to the General
Assembly at its fiftieth session the report of the Director-General of the
World Health Organization, to be prepared in collaboration with other
relevant organizations, agencies, organs and programmes of the United
Nations system, on the implementation of that resolution.
3. The present report, submitted to the General Assembly through the
Council, responds to Economic and Social Council resolution 1994/34 and
General Assembly resolution 49/135. As requested, it provides "goals, work
plans, time-frames and resources needed for achieving coordination of
activities within the United Nations system and responds specifically to
the questions and concerns raised during the discussions of the Council in
1994" as well as to issues raised in General Assembly resolution 49/135.
It also presents options to enhance action on this issue and help to
mobilize funds required for this purpose. The organizations which
collaborated in the preparation of the previous two reports have also been
the major contributors to this report (see annex I), for which the World
Health Organization (WHO) has acted as task manager.
II. QUESTIONS AND CONCERNS ARISING DURING THE 1994 DELIBERATIONS
OF THE ECONOMIC AND SOCIAL COUNCIL
4. Members of the Council emphasized that malaria and diarrhoeal diseases,
including cholera, were major problems that especially affect developing
countries. They take a heavy toll in human life and suffering, accounting
for some 4 million deaths and several hundred million cases each year.
Their major impact is among infants and young children under five years of
age, pregnant women, children of school age and the men and women of the
work force. These diseases impede social and economic development,
degrading the quality of life of millions of individuals, their families
and their communities. They contribute to a vicious cycle of disease-
malnutrition-poverty-disease.
5. Members expressed concern that these problems were not receiving the
urgent attention and funding needed from individual countries and from the
United Nations system. They contrasted that fact with the mobilization of
resources for the control of human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS), also on the Council's agenda.
6. Malaria and diarrhoeal diseases were recognized as being intimately
related to social and economic development: they cannot be totally
"solved" without also addressing broader development issues. Members
affirmed that the country was the most important focus for coordination of
activities of the United Nations and other organizations in support of
national plans. Investments should be made in national capacity-building
to support the countries themselves in directing that coordination.
Efforts were also needed to strengthen the United Nations coordinator
system at the country level and coordination within the United Nations
system in general.
7. Suggestions were made that global plans of action be elaborated for the
prevention and control of malaria and diarrhoeal diseases that would
include recommendations for measures to be taken at the national level.
The malaria plan should build on the Global Malaria Control Strategy
endorsed at the Ministerial Conference on Malaria in 1992 (and subsequently
endorsed by the World Health Assembly in 1993 and by the General Assembly
in 1994). Members requested additional information on accomplishments in
the prevention and control of those diseases as well as information on
research and development, particularly with reference to the development of
vaccines.
8. Issues and concerns similar to those raised by the Council also feature
in resolution 49/135. They are addressed in the subsequent section of the
present report, which summarizes global plans of action for the prevention
and control of malaria and diarrhoeal diseases. These plans now serve as
major instruments for fostering intensified action in these fields,
including action to improve coordination within the United Nations system
itself.
9. As the previous reports of the Secretary-General to the Council, 1/, 2/
provided details of coordinated activities of the United Nations system
that support the prevention and control of malaria and diarrhoeal diseases,
including cholera, this information is not repeated herein.
III. PLANS OF ACTION
10. This section summarizes the detailed plans of action that have been
developed during the course of the past year in response to the requests of
the Council and the General Assembly with the collaboration of the United
Nations organizations shown in annex I. The actual plans are available on
request for review.
A. Accomplishments
Malaria
11. Since the adoption of the Global Malaria Control Strategy at the
Ministerial Conference on Malaria in 1992, efforts have been directed
towards supporting countries in implementing that strategy and towards
mobilizing the additional resources required. The latter include
mobilization of relevant parts of the United Nations system to coordinate
their support for national malaria control efforts. Accomplishments
include:
(a) Development of global and regional objectives and targets based on
recommendations of three interregional meetings of national programme
managers and partners in malaria control, a process by which the Global
Strategy was developed;
(b) Provision of guidelines and standards for the implementation of the
Global Strategy including:
(i)Implementation of the Global Malaria Control Strategy: report of a
study group (WHO, Geneva 1993);
(ii)The role of artemisinin and its derivatives in the current treatment
of malaria (1994-1995): report of an informal consultation (WHO, Geneva
1993);
(iii)Guidelines for selective vector control: report of a study group on
vector control for malaria and other mosquito-borne diseases (WHO, Geneva,
1993);
(iv)Information systems for the evaluation of malaria control programmes:
a practical guide (WHO, Brazzaville, 1994);
(v)Antimalarial drug policies: data requirements, treatment of
uncomplicated malaria and management of malaria in pregnancy: report of an
informal consultation (WHO, Geneva 1994);
(vi)A standard protocol for assessing the proportion of children
presenting with febrile disease who suffer from malarial disease (WHO,
Geneva, 1994);
(vii)Management of childhood illness: draft guidelines produced by five
WHO divisions/programmes currently being field-tested in collaboration with
the United Nations Children's Fund (UNICEF) and the United States Agency
for International Development (USAID);
(viii)Guidelines for cost-effectiveness analysis of vector control:
guidelines produced by the Panel of Experts on Environmental Management for
Vector Control: in collaboration with the Food and Agriculture
Organization of the United Nations (FAO), the United Nations Environment
Programme (UNEP) and the United Nations Centre for Human Settlements
(Habitat) (UNCHS) (WHO, Geneva 1993).
The guidelines described above are being incorporated into training
modules and teaching aids; considerable progress has been made in their
development as interactive teaching programmes, particularly in the context
of the Managing Tropical Diseases Through Education and Understanding
(MANTEAU) Initiative involving the European Union, the United Nations
Development Programme (UNDP) and national research institutes;
(c) Development of global and regional estimates for training for the
period 1993-1997, according priority to:
(i)Planning and implementing malaria control, particularly at district
level;
(ii)Strengthening diagnostic facilities;
(iii)Improvement of self-treatment in the community;
(iv)Selective vector control;
(d) Provision of technical and financial support to countries to develop
and implement national plans of action for malaria control in close
collaboration with other relevant partners such as UNDP, UNICEF, the United
Nations Industrial Development Organization (UNIDO), the World Bank, the
European Union, bilateral agencies, WHO collaborating centres and national
institutes with the result that:
(i)All 45 endemic countries of the WHO Africa region (now including
Eritrea and South Africa) have received financial support and, by the end
of 1994, 25 of them had completed the preparation of plans of action and 10
had already started to implement them;
(ii)Ten countries in the Americas and five in the Eastern Mediterranean
Region of WHO (where progress is seriously hampered by political
instability) have completed their plans of action;
(iii)Reorientation is in progress in all nine countries of the WHO South-
East Asia region; in the WHO Western Pacific region all nine malarious
countries have defined their objectives, targets and strategies, and eight
are in the process of implementing an accelerated programme of malaria
control activities;
(e) Provision of technical assistance to countries facing epidemic and
emergency situations;
(f) Establishment of research programmes at the global, regional and
national levels and strengthening of national research capabilities
oriented to the development of new tools for diagnosis, treatment and
prevention and to the application of existing ones by the health services
and in the community, implemented in close collaboration with the
UNDP/World Bank/WHO Special Programme for Research and Training in Tropical
Diseases;
(g) Extensive testing of the vaccine SPf66, developed by Dr. M.
Patarroyo in Colombia against P. falciparum, in trials in South America and
more recently in Africa and South-East Asia; recent results in Tanzanian
children under 5 years old show that the vaccine is safe, induces
antibodies, and reduces by about 30 per cent the risk of developing
clinical malaria in this group; these observations, taken together with the
results from South America, confirm the potential of the vaccine to confer
partial protection in areas of high as well as low transmission; other
candidate vaccines have been identified and are under development (see
annex II), including several being studied by the International Centre for
Genetic Engineering and Biotechnology supported by UNIDO;
(h) Development of indicators for epidemiological monitoring and for
management information systems;
(i) Reinforcement of collaboration for malaria control within the United
Nations system, involving particularly UNDP, the United Nations
Educational, Scientific and Cultural Organization (UNESCO), the Office of
the United Nations High Commissioner for Refugees (UNHCR), UNICEF, the
World Bank and WHO, including support for integrative programmes relating
to the Healthy Women's Counselling Guide (directed by the Special Programme
for Research and Training in Tropical Diseases with the collaboration of
the United Nations International Drug Control Programme (UNIDCP) and
several bilateral agencies), the Sick Child Initiative (in collaboration
with UNICEF and USAID) and the Safe Motherhood Initiative (in collaboration
with UNDP, UNICEF, the World Bank, several non-governmental organizations
(NGOs) and bilateral agencies).
Diarrhoeal diseases, including cholera
12. UNICEF and WHO have been fostering national diarrhoeal prevention and
control programmes and supporting the coordination of national and external
activities relating to them for over 15 years. Progress in these
programmes has contributed to the number of deaths among children under 5
in developing countries declining by 17 per cent from 117 per 1,000 live
births in 1985 to 97 in 1993, representing 1.1 million fewer deaths. Other
selected achievements include:
(a) Issuance of technical guidelines relating to case management and
prevention;
(b) Social mobilization, networking and involvement of the media at the
national and local levels to promote preventive measures and oral
rehydration therapy (ORT);
(c) Issuance of management support guidelines relating to planning,
training, monitoring and evaluation in the areas of case management of
diarrhoea, nutrition, food safety, rural and urban water supply and
sanitation services; a set of participatory tools for sanitation and
hygiene improvement have been developed by WHO and the UNDP/World Bank
Regional Water and Sanitation Group - East Africa;
(d) Annual production of 400 million packets of oral rehydration salts
(ORS), two thirds in developing countries and 85 per cent corresponding to
the WHO/UNICEF formula;
(e) Implementation by the end of 1994 by over 100 countries of plans of
action for the control of diarrhoeal diseases in children based on the
policies promoted by UNICEF and WHO;
(f) Incorporation of strategies to prevent and control contamination of
food and drinking water throughout the production/distribution chain into
the national plans of action on nutrition prepared by member countries with
technical assistance of FAO and other United Nations organizations;
(g) Implementation during 1990-1994 of 37 health facility surveys, 69
household surveys and 17 focused programme reviews using WHO/UNICEF
methodology;
(h) Training of 42 per cent of health staff with supervisory
responsibilities in supervisory skills and about one third of doctors and
other health workers in standard diarrhoea case management, participation
of staff from 128 medical schools in 20 countries and from 55 paramedical
schools in some 20 countries in workshops to assist them in strengthening
teaching related to diarrhoeal diseases;
(i) Establishment of more than 420 diarrhoea training units in 85
countries;
(j) Preparation of technical guidelines by WHO on the application of
environmental sanitation measures for the control of cholera and other
epidemic diarrhoeal diseases;
(k) Establishment of technical, sociocultural and operational research
programmes at the global, regional and national levels and strengthening of
national research capacities, priority being given to case management in
health facilities, case management in the home and diarrhoea prevention as
well as to the study of the safety and efficacy of vitamin A
supplementation in young infants and studies of ways to increase the
proportion of mothers who breastfeed;
(l) Field testing of methods to identify hazardous behaviour leading to
food contamination and transmission of diarrhoeal diseases, including
cholera; development of training materials on food safety assurance and
food inspection;
(m) Completion of initial trials of vaccines against diarrhoeal disease-
causing organisms, including:
(i)Studies of rotavirus vaccine in Peru and Brazil showing the vaccine to
afford 25 to 50 per cent protection against all episodes of rotavirus
diarrhoea for one year and 50 to 75 per cent protection against episodes
that are clinically severe and potentially life-threatening; a 10-fold
higher dose of vaccine has produced 80 per cent protection against severe
rotavirus diarrhoea in the United States and the manufacturer is proceeding
with plans to develop the vaccine for marketing;
(ii)Studies of vaccines against Enterotoxigenic Escherichia coli
(ETEC: a disease caused by members of the E. coli group of intestinal
bacteria) among adults in Sweden have shown that an oral vaccine composed
of killed ETEC and the purified non-toxic B subunit of cholera toxin is
safe and immunogenic, with some 80 per cent of volunteers developing
intestinal antibody responses after two doses; further studies are
continuing;
(iii)Field trials in Bangladesh and Peru of a killed cholera vaccine
given in two or three doses have shown it to be safe and to provide 85 per
cent protection for 4 to 6 months, declining to some 50 per cent in all age
groups for three years. Studies to determine the long-term efficacy of the
vaccine and to evaluate the benefit of a booster dose given after one year
are under way in Peru; studies of a live oral vaccine in volunteers have
shown it to be safe and highly protective as early as eight days after a
single dose and further studies are being pursued;
(iv) Completion of a small efficacy trial of a parenteral Shigella
sonnei polysaccharide-protein conjugate vaccine (against a common form of
dysentery) conducted among adults in Israel has suggested that it is
protective, at least for several months and these results are supported by
other studies using similar antigens; further studies using a variety of
antigens are being pursued;
(n) Maintenance of communications with health workers of all categories
through the WHO newsletter Environmental Health and fact sheet Infant
Feeding and the quarterly newsletter Diarrhoea Dialogue, produced with
support from UNICEF and WHO;
(o) Agreement with the Swiss Disaster Relief Corps to provide technical,
managerial and financial assistance in epidemic diarrhoea control and the
establishment of special collaboration with the International Federation of
Red Cross and Red Crescent Societies for the control of diarrhoeal
diseases, including cholera, in the newly independent States of Eastern
Europe and Central Asia;
(p) Establishment of close inter-agency coordination between UNICEF and
WHO in the areas of diarrhoeal diseases, nutrition and water supply, and
between FAO and WHO in the area of nutrition, with the respective agencies
meeting at least twice a year at global level to develop joint approaches
and to coordinate activities; establishment of the AFRICA 2000 initiative
for water supply and sanitation, which promotes partnerships between
countries, agencies and NGOs; collaboration with UNDP, UNICEF and several
bilateral development agencies in support of the International Centre for
Diarrhoeal Disease Research, Bangladesh; and coordination activities with a
number of United Nations and bilateral development agencies at the country
level, with examples including UNICEF/WHO coordination in most countries,
coordination with the World Bank in Bangladesh and with UNEP in Brazil.
B. Goals/objectives
Malaria
13. The goal for malaria control is to prevent malaria-induced mortality
and to reduce morbidity and social and economic loss through the
progressive improvement and strengthening of local and national
capabilities for malaria control.
14. Within this goal two global objectives have been set:
(a) By the year 1997, at least 90 per cent of countries affected by
malaria will implement appropriate malaria control programmes;
(b) By the year 2000, malaria morbidity will have been reduced by at
least 20 per cent compared to 1995 in at least 75 per cent of affected
countries.
15. In support of these goals and objectives, the "milestone" targets have
been set including:
(a) By the year 1995, 50 per cent of malaria-affected countries are
implementing national plans of action for malaria control;
(b) By the year 1997:
(i)At least 50 per cent of countries affected by malaria will have
developed epidemiological and managerial information systems according to
regional guidelines;
(ii)By the year 1998, entomological staff will have been trained in
selective vector control in at least 80 per cent of malaria-affected
countries;
(iii)At least 80 per cent of malaria-affected countries have implemented
national antimalarial drug policies;
(iv)At least 80 per cent of malaria-affected countries have implemented
plans for the prevention and control of epidemics.
Diarrhoeal diseases, including cholera
16. Goals for the prevention and control of diarrhoeal diseases by the
year 2000 in children under the age of 5 years were endorsed in 1990 at the
World Summit for Children:
(a) Reduction by 50 per cent in deaths due to diarrhoea; and
(b) Reduction by 25 per cent in episodes of diarrhoea.
Other supporting goals for the year 2000 adopted by the Summit include:
(a) Empowerment of all women to breastfeed their children exclusively
for four to six months and to continue breastfeeding, with complementary
food, well into the second year;
(b) Reduction by 50 per cent in severe as well as moderate malnutrition
in children under 5 years;
(c) Reduction in the rate of low birth weight (2.5 kg or less) to less
than 10 per cent;
(d) Virtual eradication of vitamin A deficiency;
(e) Universal access to safe drinking water;
(f) Universal access to sanitary means of excreta disposal; and
(g) Reduction by 95 per cent of measles deaths and reduction by 90 per
cent of measles cases by 1995.
17. In addition to these goals, UNICEF and WHO adopted in 1993 selected
goals to be achieved by 1995 as stepping stones to the year 2000 goals.
For diarrhoeal diseases, these include 80 per cent use of ORT and continued
feeding for children with diarrhoea, 80 per cent of mothers knowing 3 rules
of home case management of diarrhoea and 80 per cent of the population
having access to ORS.
18. The goals for cholera and epidemic dysentery are to limit the spread
of these infections, to reduce morbidity and to prevent mortality. The
operational objective is to ensure that by the year 2000 all countries at
risk of outbreaks of epidemic diarrhoea have in place plans and mechanisms
to respond rapidly to epidemics so as to minimize mortality and socio-
economic loss.
C. Strategies/action plans
19. While the strategies below relate separately to malaria and diarrhoeal
diseases, including cholera, their common elements include clearly
identifying the managerial and technical principles concerned, supporting
countries in capacity-building so those principles can be adapted and
appropriately applied and securing the resources required for programme
implementation. To support these strategies, continued efforts are needed
at the country level to improve government coordination of activities
supported by the United Nations system, bilateral development agencies,
NGOs and the private sector. Improved coordination of development efforts
also remains a need at the international level.
20. The strategies and action plans summarized below by and large reflect
WHO's contributions. Other organizations of the United Nations family have
collaborated in their development and provide support within their own
sectors according to their own comparative advantages and perspectives.
UNICEF is a particularly close WHO partner in programme development and
implementation and complements WHO's activities through its special
strengths in advocacy, community mobilization and operational support to
national programmes.
Malaria
21. The malaria control strategy was developed through a process of
thorough consultation and on the basis of experience gained in addressing
the problems of the last two decades in making the transition from a
programme goal of eradication to one of control. It was endorsed by the
Ministerial Conference on Malaria in 1992, by the World Health Assembly in
1993 and by the General Assembly in 1994.
22. In setting priorities for the implementation of the strategy, the
following major problems faced by malaria control programmes were
recognized:
(a) In most countries of sub-Saharan Africa, the quality and coverage of
disease management by existing health services are still inadequate and
most treatments for malaria occur in the community, not in the health
services;
(b) Many control programmes lack the managerial and epidemiological
capability to adapt their activities to the local malaria situation;
(c) Many countries lack the financial and technical resources for
implementing their malaria programmes.
23. The strategy has four technical elements:
(a) To provide early diagnosis and treatment;
(b) To plan and implement selective and sustainable preventive measures,
including vector control;
(c) To detect early, contain or prevent epidemics;
(d) To strengthen local capacities in basic and applied research to
permit and promote the regular assessment of a country's malaria situation,
in particular the ecological, social and economic determinants of the
disease.
24. The strategy places emphasis on the strengthening of local and
national capabilities to analyse different malaria situations, to mobilize
and guide partners, to plan and implement control interventions, to monitor
and evaluate progress, to identify and solve problems, to adapt to change
and to contribute to overall health development in the context of primary
health care.
25. Training is being used as the main instrument to achieve such
capability strengthening. The training of district health teams, which has
already been implemented in 15 countries in Africa, will be extended in
1995 to a further 11 countries in Africa and 6 in Asia and the Americas.
With the support of the United Kingdom, a special effort is being made to
strengthen district health services in epidemic-prone areas of India and
Nepal. Education, the dissemination of health information and the
preparation of operational guidelines for different levels of health
services and other partners are being used to complement training
activities.
26. The malaria action plan supports the malaria control strategy by
placing priority in the following interrelated areas:
(a) Strengthening national capability for:
(i)Development, implementation, monitoring and evaluation of
appropriate national plans of action for malaria control;
(ii)Disease management by the development of antimalarial drug
policies, the strengthening of diagnostic and treatment facilities and,
especially, the improvement of self-treatment in the community;
(iii)Early detection, containment and prevention of epidemics and the
timely reaction to emergency situations;
(iv)Programme management and surveillance to assist countries with the
establishment of new epidemiological and managerial information systems and
the evaluation of existing ones in order to provide control programmes and
the international community with up-to-date, relevant information on the
status of malaria control in the world;
(b) Research and development oriented to solving local operational
problems in the control of malaria; the development and introduction of
selective and sustainable preventive measures, including vector control,
vaccines and the protection of pregnant women from malaria; and the
development of new antimalarial drugs;
(c) Coordination to stimulate both the mobilization of financial
resources and multisectoral partnership of all interested parties in
integrated malaria control activities and to ensure the implementation of
common policies, continuity of action and optimal use of resources at the
international and national levels. Initiatives include inter-agency
agreements on the 1995-2000 Plan of Action for Malaria Control,
collaboration with the World Bank and regional development banks (such as
those for Africa and the Americas) in malaria control projects in at least
five countries and joint policy agreements for malaria control with other
international and regional organizations. The major challenge will be to
ensure the political will for inter-agency and intersectoral coordination
at the national level and the development of a basic framework to ensure
its implementation. The activities of the Panel of Experts on
Environmental Management for Vector Control, comprising representatives
from FAO, UNEP, UNCHS and WHO, as demonstrated in certain countries of the
Eastern Mediterranean region of WHO, has proved helpful in this regard.
27. During 1993-1994, priority was given globally to providing national
control programme support to malaria endemic countries in sub-Saharan
Africa. Based on this experience and that in other regions that have
identified constraints for the implementation of the Strategy, and in order
to utilize the limited resources available more effectively, two or three
countries in each region will now be selected globally for receiving more
intensified support to acquire and document experience that could guide
other countries in the process of implementing the Global Strategy. This
support will be consistent with the development of the countries' health
services and will aim at sustainable results, which should be applicable
and accessible to other countries in similar circumstances.
28. The criteria for selecting these countries include:
(a) Government commitment to lead and support malaria control by a plan
of action in line with the Global Strategy;
(b) Government collaboration and coordination with WHO, as well as other
international and bilateral agencies, NGOs and other institutions involved
in malaria and its control;
(c) Sufficient institutional and human resources to support the plan of
action for control;
(d) Malaria control considered one of the critical steps in health
development in the country;
(e) Existing or potential collaboration with national research
institutions;
(f) Adequate conditions for both national intra- and intercountry
training.
The finalization of the selection of the particular countries and their
exact number will be determined during regional meetings on malaria
control. This initiative will not detract from efforts to support and
strengthen malaria control in all countries, ensuring that, by the year
2000, all persons at risk have access to affordable and adequate treatment.
29. A summary of the malaria action-plan is provided in annex III. This
includes targets that have been developed at regional meetings of national
programme managers. These activities will be reviewed and updated in the
light of experience and new technological developments.
Diarrhoeal diseases, including cholera
30. The strategy for reducing mortality from diarrhoeal diseases has been
evolved by WHO and UNICEF during some 15 years of work in supporting
national programmes. It was endorsed by the World Health Assembly in
resolutions WHA31.44 (1978), WHA35.22 (1982) and WHA40.34 (1987). The
UNICEF Executive Board, at its session of 2 to 6 May 1994, approved the
policies and the mediumterm plan for UNICEF's action to control diarrhoeal
diseases.
31. The strategy focuses on correct case management. This comprises:
(a) Prevention of dehydration by treating diarrhoea early in the home,
using home prepared fluids;
(b) Treatment of dehydration using ORS;
(c) Appropriate feeding during and after diarrhoea;
(d) Selective use of intravenous fluids for severely dehydrated cases;
(e) For persistent diarrhoea, use of ORS, continued feeding with full
caloric intake and treatment of any associated infection.
32. Strategies to prevent diarrhoea require multisectoral coordination at
the country level to promote good nutrition (in particular breastfeeding),
food safety, education on hygienic behaviours (handwashing, proper disposal
of faeces, maintenance of drinking water free from faecal contamination)
and adequate water supply and sanitation.
33. Measles frequently leads to diarrhoea in children in developing
countries and is accompanied by a high fatality rate. In addition,
children remain susceptible to diarrhoea for long periods after measles
itself has subsided. Prevention of measles also forms part of the strategy
and is being addressed successfully through the Expanded Programme on
Immunization (EPI), which receives widespread national and international
support with particularly close collaboration between UNICEF and WHO.
34. The goals of preventing diarrhoea cases and deaths can be achieved
more rapidly and at lower cost if all major causes of childhood illness are
approached in an integrated way. It is estimated, for example, that in
developing countries nearly three quarters of deaths in children under 5
years are attributable to diarrhoea, acute respiratory infections (ARI),
measles, malaria and malnutrition. WHO and UNICEF have defined the
technical policies on the integrated case management of the sick child and
are supporting countries in implementing them. The current management
support materials oriented towards diarrhoea and other specific diseases
are being replaced by materials addressing integrated case management.
35. The strategies for preventing and controlling epidemic diarrhoea
(cholera and dysentery) are similar to those for non-epidemic acute
diarrhoea, although epidemic diarrhoea primarily affects adults. A rapid
response to cholera outbreaks is required to minimize loss of life and to
control the spread of the epidemic. Water purification, sewage treatment,
promotion of food safety and education on hygienic practices are effective.
Travel and trade restrictions are not. For dysentery, mortality can be
reduced by prompt recognition of the illness and treatment. Because of
widespread resistance to standard, low-cost antibiotics in both cholera and
dysentery, the current policy is to reserve antibiotic treatment for those
patients at risk of dying if antibiotic treatment is not administered.
36. The action plan for the prevention and control of diarrhoeal diseases
supports the strategy through the following programme elements:
(a) Definition of technical policies that provide the content of the
strategies;
(b) Planning sound national programmes focusing on priority activities
and on selected areas and high-risk population groups that offer the
greatest potential for mortality and morbidity reduction, bearing in mind
data from programme reviews and a realistic estimate of human and material
resources;
(c) Training, supervision and logistics, oriented towards increasing
the access of the population to trained health-care providers and health
services offering counselling contributing to prevention, such as that
related to breastfeeding, to the need for measles immunization, to safe
food and to water and sanitation;
(d) Communication and education, oriented to improving home prevention
and care, the appropriate use of health facilities and preventive services
and the increased use of safe food and water and sanitation facilities;
(e) Monitoring and evaluation, designed to provide the means for timely
evolution of strategies to ensure that goals and targets are being met;
(f) Research and development, oriented towards the better application of
existing tools and the development of new or improved tools, including work
to develop, test and introduce new vaccines;
(g) Coordination, emphasizing a multisectoral and integrated approach
using existing mechanisms to strengthen country capacities to coordinate
activities at the national and subnational levels (including support for
the United Nations Resident Coordinator system and use of the Country
Strategy Note); the collaboration of the different organizations at the
global level in the implementation and evaluation of the action plan
(including that between FAO and WHO in the implementation of the Plan of
Action on Nutrition adopted by the 1992 International Conference on
Nutrition); the annual WHO Meeting of Interested Parties, in which United
Nations organizations, bilateral development agencies, NGOs and
representatives from national programmes participate; and use of existing
permanent coordinating mechanisms, including the Economic and Social
Council, the Administrative Committee on Coordination (ACC) Subcommittee
for Water Resources, the Water Supply and Sanitation Collaborative Council,
the Codex Alimentarius Commission and the UNICEF/WHO Joint Committee on
Health Policy; and regional coordination committees.
A summary of the diarrhoeal diseases action plan for the period 1995-1999
is provided in annex IV.
D. Resource needs
37. In the estimates provided below, resource needs have been narrowly
defined within the health sector. This is because a great deal can be
accomplished with the limited resources that have been identified and
because the full needs of the health sector that could contribute to the
prevention and control of these diseases, let alone the needs in sectors
relating to areas such as education, water and sanitation, food hygiene and
environmental management, are large and merge without clear distinction
into the needs required for combating underdevelopment in general. There
are certainly countries or areas within countries where such general
developmental support is a precondition for efforts to prevent and control
these diseases. One example that has been cited in previous reports is the
lack of adequate water and sanitation in rural schools in many parts of
sub-Saharan Africa. Little improvement in the success of primary school
educational efforts can be expected until actions are taken by schools,
communities and Governments to improve environmental health conditions and
to reduce the prevalence of common health problems, including malaria and
diarrhoeal diseases. More frequently, however, an essential core of
infrastructure exists on which the investments identified below can build
and make a difference. Nevertheless, without the resources needed for more
general development, optimal prevention and control of these diseases will
be hindered, and hindered most in the countries in which they are most
prevalent.
Malaria
38. Detailed estimates of global resource needs for malaria control have
been developed and are available in the complete Action Plan for Malaria
Control 1995-2000. 4/ Estimates contained in the action plan indicate that
US$ 46 to 61 million per year is required in new external support. Some
explanations of these estimates are provided below.
39. In Africa, the scarcity of national resources has meant that most
countries must seek external resources in order to mount effective control
programmes. Recent examples of countries that have been able to mobilize
external support include Ethiopia (US$ 8-11 million in 1994), Ghana (US$ 5-
8 million), Namibia (US$ 2-4 million) and Zimbabwe (US$ 6 million).
40. At present, most endemic countries of sub-Saharan Africa are not
involved at the national level with vector control and rely on disease
management and community-based preventive activities. National government
expenditure on malaria represents an average of 10 per cent of the total
public expenditure on health. This cost covers primarily the payment of
salaries for national staff involved in disease management and for a
limited supply of antimalarial drugs. Since the coverage of public services
is as low as 40 per cent in many countries, many malaria patients obtain
treatment outside the formal health services with an expenditure that
exceeds that of the public services. This is being addressed in some areas
through the Bamako Initiative, in which communities are supported in
establishing revolving funds permitting the purchase of antimalarial and
other drugs.
41. For the endemic countries of sub-Saharan Africa, the cost of a basic
package of training and management-support activities amounts to some US$
300,000 per year per country, or a total cost of US$ 14 million per year.
An additional US$ 12 million per year is needed for control, including
epidemic control. These costs do not include short-term technical
assistance or the training of specialized staff in international courses.
This total of US$ 26 million could be channelled through bilateral or
multilateral arrangements. WHO will provide technical support to receiving
countries as required in accordance with the resources at its disposal.
42. The total population at risk outside Africa (predominantly in Asia and
the Americas) is approximately 1,750 million persons. It is estimated that
the present public costs of specific malaria control programmes in these
populations is between US$ 0.10-0.20 per person per year or between US$ 175
to 350 million per year. This cost should decrease during the coming
decade as a result of:
(a) Increased financing by individuals and communities;
(b) Reduced malaria risk as a result of social and environmental
stabilization;
(c) Better targeting and selection of vector-control activities.
A precondition for the first and third of these events is reorientation and
strengthening of national programmes. This will require capacity-building
and external investments beyond the current external support, which is
mainly used to acquire commodities. Such new external investments should
be approximately 10 per cent of the current public expenditures or US$ 20
to 25 million per year.
43. Although the resource requirements for country support for malaria
control described above include costs of country-specific operational
research, they do not include the broader costs for priority research and
development conducted under the auspices of the Special Programme for
Research and Training in Tropical Diseases in support of the Global
Strategy.
44. TDR goals for the period 1995-1998 include:
(a) Completion of field trials of the Colombian SPf66 malaria vaccine;
(b) Initiation of human clinical and field trials on other candidate
malaria vaccines including new asexual blood stage and transmission
blocking vaccines;
(c) Identification and development of promising new antimalarial drugs;
(d) Development of strategies to improve health-seeking behaviour and
encourage safe home treatment in Africa;
(e) Determination of appropriate and most cost-effective use of
impregnated bed-nets in Africa;
(f) Development of strategies to prevent the development of drug
resistance in South-East Asia through the unregulated supply of
antimalarial drugs, particularly those derived from artemisinin (a new
therapeutic agent purified from a traditional Chinese remedy);
(g) Determination of a strategy for the diagnosis and treatment of
childhood malaria as part of the WHO/UNICEF integrated strategy for sick
children.
45. At present, the Special Programme has a yearly budget for malaria
research of approximately US$ 7.5 million. At this level of funding, not
all the currently promising approaches to achieving the above goals can be
pursued and evaluated. It is estimated that an additional US$ 5 million
per year would be required for the Special Programme to accelerate the
development and field testing of available tools and strategies to meet the
global goals and targets set for control of malaria. The Special
Programme's co-sponsors (UNDP, the World Bank and WHO) are urging that
contributions to this programme be increased.
Diarrhoeal diseases, including cholera
46. Global resource needs for diarrhoeal disease control (CDD) can be
estimated based on the 1995-1999 action plan for diarrhoeal diseases.
Resources will be needed to support the strengthening of case management
for non-epidemic diarrhoea within the context of the integrated management
of the sick child; for prevention activities including improvements in food
safety, water supplies and sanitation; for improved preparedness for and
control of epidemic cholera and dysentery; and for a minimum package of
essential research. Estimates based on the 1995-1999 action plan indicate
that US$ 59 million per year will be required in new external support.
Brief explanations of these figures are provided below.
47. Owing to the difficulties and expense of preventing diarrhoeal
diseases, most countries have focused on improving the quality of diarrhoea
case management in health facilities and in the community. This can be
accomplished most efficiently through an approach that combines management
of diarrhoeal diseases, ARIs, measles, malaria and severe malnutrition into
an integrated process. The annual costs of providing integrated clinical
care have been estimated at US$ 8 per case, or US$ 1.1 per capita, for low-
and middle-income countries. In addition to the recurrent costs of WHO's
CDD activities, reorientation and strengthening of national capacity will
be needed to support the move to integrated management.
48. The basic package of CDD programme activities designed to support and
improve case management (including planning, training and supervision,
logistics, communications and monitoring and evaluation) requires
approximately US$ 360,000 per country per year, with an additional US$
40,000 required to support the reorientation of these activities to
integrated management. These costs represent US$ 16 million for low-income
economies and US$ 17.2 million for lower-middle-income economies. The
costs of developing and disseminating the technical content of integrated
management relevant to diarrhoeal diseases will require an additional US$ 1
million per year. These costs do not include short-term technical
assistance or specialized external training for national staff.
49. Essential preventive activities include the development and adoption
by countries and communities of food safety policies and legislation,
improved water supply and sanitation systems, effective breastfeeding
promotion programmes and community education programmes targeting hygienic
food and water practices. National courses on breastfeeding, food and
water will cost an average of US$ 120,000 per year per country, and
regional workshops on water-related issues will add an additional US$
50,000. Estimated costs of these activities in low- and lower-middle-
income countries, including development and dissemination of technical and
training guidelines, are US$ 10 million per year.
50. Preparedness and response for epidemic diarrhoea (cholera and
dysentery) must be improved through training of central- and district-level
staff in at-risk countries, through improved communication to the public in
preparation for and during the early stages of an epidemic, through the
refinement of rapid alert systems for epidemics and through swift and
effective response by national and international staff. Estimated costs
for continued improvement of district, national and international response
capability are US$ 10 million per year.
51. Any estimation of resource needs must also include support for
essential research needed to reduce diarrhoea-related morbidity and
mortality. These questions include the efficacy and effectiveness of
alternative treatment regimens (including ORS formulations, zinc
supplementation for persistent diarrhoea, vaccines for rotavirus, cholera,
and Shigella, and the efficacy of specific antibiotic regimens for cholera
and dysentery), the efficacy and effectiveness of behavioural interventions
designed to improve family responses to diarrhoeal diseases and the
effectiveness of interventions to prevent the contamination of food. A
minimum annual estimate of the support needed for research is US$ 5.5
million.
IV. OPTIONS TO INCREASE RESOURCES
52. Paragraph 5 above refers to the dissatisfaction expressed by members
of the Economic and Social Council with the current level of resources
being invested in the prevention and control of malaria and diarrhoeal
diseases. The Council deplored the fact that these conditions, whose
causes and cures are so well known, remain major public health problems.
They also recognized that these diseases represent symptoms of a larger
problem: inadequate investments for sustainable human development.
53. While solutions to this larger problem are being sought, actions can
be, and are being, pursued to increase these resources. In part this
requires working more efficiently: doing more with less. In part it
requires mobilizing additional resources freed by reducing investments,
both within and outside of the health sector, in less productive
activities. The plans of action for malaria and CDD summarized above
include both of these approaches. It will be important to continue to
evolve these plans, guided by the results of monitoring and evaluation
activities.
54. Better coordination remains a central strategy for improving
efficiency; doing more with less. As emphasized in previous reports and in
comments by the Council itself, the most important focus for coordination
is at the country level. It is in the long-term interest of all
development partners to strengthen the coordination capacities of the host
Government itself.
55. In many countries, ministries concerned with the social sector need
support to ensure that development projects do not promote disease
transmission through alterations in the physical environment or through
displacements of migrant populations that bring them into contact with
diseases to which they are susceptible, such as malaria. Well-conducted
environmental impact assessments should be supported by the international
community and should be a prerequisite for support to major infrastructure
development projects. Existing intersectoral coordinating mechanisms (such
as the Panel of Experts on Environmental Management for Vector Control) and
initiatives (such as the AFRICA 2000 initiative for water supply and
sanitation) should also be fully exploited.
56. It is hoped that the debate of these issues in both the Council and
the General Assembly will serve to remind representatives of the
seriousness of these problems and of the need to mobilize additional
resources both from within countries where these diseases are prevalent and
from the international community. Benefits from prevention and control
accrue to the individuals, families and communities at risk, but also to an
individual country's development efforts, themselves a stimulus to
international trade, and to reduced risks of infection from exportation to
non-endemic countries.
V. CONCLUDING OBSERVATIONS
57. Malaria and diarrhoeal diseases are diseases of social and economic
underdevelopment. Yet substantial progress in their prevention and control
can be accomplished with better application of the resources now available
at the community, national and international levels. Progress will depend
primarily on the commitments of national Governments, as reflected in the
allocation of national resources, to achieving the goals and targets that
they have set. Their actions, supported by coordinated efforts of the
United Nations system, bilateral development agencies, NGOs and the private
sector, can reduce mortality among children from these and related causes,
freeing parents from attending to sick children and giving them confidence
in the benefits of family planning. These efforts also spur social and
economic progress by reducing time lost from school and work.
58. While current prevention and control tools work, better tools would
permit even more cost-effective strategies to be implemented, making
continued investment in basic research a worthwhile investment. Continued
support is also needed for applied research to ensure that the current
tools are being appropriately adapted to the communities in which they are
being employed.
59. Successes in preventing and controlling malaria and diarrhoeal
diseases provide indices of the success of current development policies.
Progress in achieving their prevention and control should continue to be
monitored at the national and international levels. With concerted
efforts, the world can enter the next century having made significant
advances in conquering these diseases and having reaffirmed the efficacy of
coordinated United Nations action in support of Member States.
Notes
1/ E/1993/68.
2/ E/1994/60.
3/ Official Records of the General Assembly, Forty-eighth Session,
Supplement No. 3 (A/48/3/Rev.1), chap. III, sect. B, agreed
conclusions/1993/2.
4/ Available from WHO on request.
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Annex I
LIST OF ORGANIZATIONS COLLABORATING IN THE
PREPARATION OF THIS REPORT
Department of Humanitarian Affairs of the United Nations Secretariat
Department for Policy Coordination and Sustainable Development of the
United
Nations Secretariat
United Nations Children's Fund (UNICEF)
United Nations Development Programme (UNDP)
United Nations Environment Programme (UNEP)
World Food Programme (WFP)
Office of the United Nations High Commissioner for Refugees (UNHCR)
International Labour Organization (ILO)
Food and Agriculture Organization of the United Nations (FAO)
United Nations Educational, Scientific and Cultural Organization (UNESCO)
World Health Organization (WHO)
World Bank
United Nations Industrial Development Organization (UNIDO)
Annex II
SUMMARY OF THE STATUS OF MALARIA AND DIARRHOEAL
DISEASE VACCINES
I. MALARIA
1. Two main types of vaccine are currently under development: one that
prevents disease (based on pre-erythrocytic (including liver stage) and
asexual blood stage antigens) and one that blocks transmission, aiming to
arrest the development of the parasite in the mosquito. Several of these
have advanced to the point of human trials for safety, immunogenicity and
efficacy.
2. The UNDP/World Bank/WHO Special Programme for Research and Training in
Tropical Diseases is supporting work to develop both types, with priority
accorded to the disease-prevention vaccines, aiming specifically at
reducing both severe and complicated malaria and mortality in children
under 5 years old, a high risk group, especially in Africa.
3. Many candidate disease prevention antigens based on the asexual blood
stage have been proposed for vaccine development. Recently, the Special
Programme sponsored a task force to review and promote the accelerated
development of the most advanced candidates. Together with the task force
and USAID, the European Union has established a malaria antigen database
for use globally via the Internet. In addition, collaborative efforts are
under way in the United States of America to scale up and purify, according
to Good Manufacturing Practice (GMP), sufficient amounts of an antigen
found on the surface of blood-stage merozoites, merozoite surface protein 1
(MSP-1), which has been shown to protect monkeys from infection. Plans for
phase I and II clinical trials using this material could be completed by
mid-1995. Phase I trials of two other leading recombinant candidate
vaccine antigens, serine rich antigen (SERA) and an apical membrane antigen
(AMA-1) could begin in 1996.
4. One synthetic cocktail vaccine for P. falciparum, called SPf66 and
developed by Dr. M. Patarroyo in Colombia, has been tested extensively in
trials in South America and more recently in Africa and South-East Asia.
This vaccine, formulated as a peptide-alum combination and given
subcutaneously, was selected for clinical studies on the basis of its
ability to protect monkeys from infection. Recent results from a field
study, cosponsored by the Special Programme and the United Kingdom,
Spanish, Swiss and Tanzanian institutes, in Tanzanian children under five
years old showed that the vaccine was safe, induced antibodies and reduced
by about 30 per cent the risk of developing clinical malaria in this group.
Taken together with the results from South America, the Tanzanian study
confirms the potential of the vaccine to confer partial protection in areas
of high as well as low transmission. Other studies in the Gambia in
toddlers aged 6 to 11 months (supported by the British Medical Research
Council) and in Thailand in children aged 2 to 15 years old (supported by
the Walter Reed Army Institute of Medical Research) will be completed by
mid-1995.
5. A "milestone meeting" to review all the available data on SPf66 and to
decide on further options for development or production and the use of the
Colombian vaccine will be organized by the Special Programme in September
1995. Depending on the conclusions of this review and on the resolution of
any outstanding issues, future development would include the design,
promotion and execution of large scale (multicentre) field trials to
determine the potential of SPf66 to reduce the level of malaria-related
mortality in African children under five years old, for which plans are
already under consideration. If a significant reduction in mortality or in
severe and complicated malaria is then observed, registration of this
vaccine would proceed.
6. With respect to transmission blocking vaccines, Pfs25 is a leading
candidate antigen found in the ookinete stage of the parasite in the
mosquito midgut. Gram amounts of GMP grade material have been produced and
a vaccine, based on the antigen formulated with alum, should go into phase
I and II clinical trials in the United States and in Africa during 1995.
7. As no single intervention tool represents a panacea, an effective
malaria vaccine is expected to be used in an integrated approach to malaria
control that includes other protective interventions and disease management
activities.
II. DIARRHOEAL DISEASES, INCLUDING CHOLERA
8. Basic research to develop new candidate vaccines for the most important
causes of diarrhoea in children is supported by the WHO Global Programme
for Vaccines and Immunization, UNIDO and UNDP. Evaluation of the most
promising of these vaccines in field trials is supported by the Programme
for Diarrhoeal and Acute Respiratory Disease Control and UNICEF.
9. Rotavirus is the most important cause of dehydrating diarrhoea in young
children world wide. An estimated 600,000 child deaths are caused by
rotavirus annually. The most promising candidate rotavirus vaccine is a
rhesus/human tetravalent vaccine that is directed against the four
important serotypes of human rotavirus. The vaccine is given by mouth in
three doses at the same time as DTP and oral polio vaccine. Studies in
Peru and Brazil have shown the vaccine to afford 25 to 50 per cent
protection against all episodes of rotavirus diarrhoea for one year and 50
to 75 per cent protection against episodes that are clinically severe and
potentially life-threatening. In an effort to improve the level and
duration of protection a tenfold higher dose of vaccine is being studied.
This has produced 80 per cent protection against severe rotavirus diarrhoea
in the United States and the manufacturer is proceeding with plans to
develop the vaccine for marketing. The same increased dose is being
evaluated in Venezuela to define its potential effect in developing
countries better. Results of the trial will be available late in 1995.
Several approaches to developing other vaccines are being supported by
UNIDO.
10. Enterotoxigenic Escherichia coli (ETEC) are the most frequent cause of
diarrhoea among children and adults in developing countries and among
travellers to those countries. Studies among adults in Sweden have shown
that an oral vaccine composed of killed ETEC and the purified non-toxic B
subunit of cholera toxin is safe and immunogenic: some 80 per cent of
volunteers develop intestinal antibody responses after two doses of the
vaccine. Studies of efficacy of the vaccine are under way in American
sailors travelling to developing countries. Preparations are also being
made for evaluation of the vaccine among infants and young children in
Egypt.
11. Cholera vaccine research aims to develop a cost-effective oral vaccine
that would protect against Vibrio cholerae 01 as well as the new V.
cholerae strain 0139, which has caused large outbreaks of cholera in South
Asia. Two approaches are being taken: a vaccine composed of killed V.
cholerae and purified recombinant B subunit of cholera toxin, and a vaccine
composed of live V. cholerae that have been made avirulent by deletion of
genes that encode the production of the A subunit of cholera toxin. Field
trials of the killed vaccine in Bangladesh and Peru, given in two or three
doses, have shown it to be safe and to provide 85 per cent protection for
four to six months. The Bangladesh study showed, however, that protection
declined after six months, averaging 50 per cent in all age groups for
three years. Studies to determine the long-term efficacy of the vaccine
and to evaluate the benefit of a booster dose given after one year are
under way in Peru. Studies of the live oral vaccine in volunteers have
shown it to be safe and highly protective as early as eight days after a
single dose. A field trial of the vaccine, given in a single dose, is
under way in Indonesia. Results from these studies are expected in one to
two years. Research is also under way to develop modified versions of each
vaccine that would protect against cholera caused by V. cholerae 0139.
12. Shigella are the most important cause of bloody diarrhoea (dysentery)
in children and adults and account for about 15 per cent of diarrhoeal
deaths among young children world wide. Disease caused by Shigella
dysenteriae type 1 is especially important as it carries a high risk of
mortality and the organism is often resistant to all locally available
antimicrobials. Several candidate shigella vaccines, including live oral
and parenteral vaccines, are being developed, with parenteral vaccines
appearing the most promising. A small efficacy trial conducted among
adults in Israel has suggested that a parenteral Shigella sonnei
polysaccharide-protein conjugate vaccine is protective, at least for
several months. This has been supported by a subsequent trial in Israel of
a parenteral vaccine based on Plesiomonas shigelloides, an organism with
capsular polysaccharide antigen identical to that of Shigella sonnei.
Although Shigella sonnei is not the most important shigella serotype in
developing countries, success with this approach would suggest that the
same method could be used to develop vaccines for the more important
serotypes of Shigella, especially Shigella dysenteriae type 1 and Shigella
flexneri.
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Annex III
DIARRHOEAL DISEASES: SUMMARY OF ACTION PLAN 1995-1999
Global goals for the year 2000:
Reduction by 50 per cent in deaths due to diarrhoea in children under
the age of 5 years
Reduction by 25 per cent of episodes of diarrhoea in children under the
age of 5 years
Universal access to safe drinking water
Universal access to sanitary means of excreta disposal
Responsible United Nations agencies
Case management strategy: UNICEF, WHO, World Bank
Preventive strategies:FAO, UNDP, UNEP, UNESCO, UNICEF, UNHCR, UNIDO,
WFP, WHO, World Bank
Work plan management: WHO
Coordination at country level: UNDP
Coordination at global level: Economic and Social Council