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
/...  A/50/180
  E/1995/63
  English
  Page
A/50/180
E/1995/63
English
Page
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.

/...  A/50/180
  E/1995/63
  English
  Page
A/50/180
E/1995/63
English
Page
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.


/...  A/50/180
  E/1995/63
  English
  Page

A/50/180
E/1995/63
English
Page

/...A/50/180
E/1995/63
English
Page
A/50/180
E/1995/63
English
Page
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


 

This document has been posted online by the United Nations Department of Economic and Social Affairs (DESA). Reproduction and dissemination of the document - in electronic and/or printed format - is encouraged, provided acknowledgement is made of the role of the United Nations in making it available.

Date last posted: 18 December 1999 16:30:10
Comments and suggestions: esa@un.org