WHO Action Plan

Introduction | Components | Timeframe |Objectives | Immediate action  | Medium-term action | Long-term action | References

Introduction

At the first meeting of the Intergovernmental Negotiating Committee (INC) for an international legally binding instrument for implementing international action on certain Persistent Organic Pollutants (POPs), the World Health Organization, mandated by World Health Assembly Resolution WHA50.13 (annex 1), proposed the development of an Action Plan to support its Member States in making informed decisions concerning the effect on disease transmission of a reduction and/or elimination of DDT, under a future POPs Convention. Such a WHO Action Plan would aim to increase public health staff awareness of the INC process. Ultimately, the Action Plan would assist Member States in their efforts to reduce their reliance on DDT use for public health purposes without jeopardizing the level of protection offered by their vector control programmes.

The Action Plan for the Reduction of Reliance on DDT in Disease Vector Control presented in this document emerged from an expert consultation held from 16 to18 June 1999 at WHO, Geneva (see Annex 2 for the report of the consultation).

Three strategic principles have served as the basis for developing and formulating the Action Plan. They are: involvement of countries concerned, early identification of funding mechanisms and advocacy.

The most recent recommendations concerning DDT use for indoor residual spraying against malaria vectors date back to 1993. They list well-defined conditions and a number of precautions (WHO, TRS 857, 1995). DDT is also used at times for the control of kala-azar (visceral leishmaniasis), plague and tick-borne encephalitis, but is not formally recommended by WHO for these purposes. In malaria control, it is used in routine spraying operations, for prevention of disease transmission and in epidemic situations. Some countries reserve the right to maintain stockpiles of DDT for emergencies.

Preliminary data show that at least 24 countries use DDT for vector control. Yet, there is a great deal of variability in the intensity of its use. There is also a disparity between the geographical distribution of DDT use for malaria control and the areas of the world where the malaria burden weighs the heaviest.

The use of adulticides, including DDT, for indoor residual house spraying to control vectors is just one of several possible components of integrated vector management (IVM). In turn, IVM is just one component of integrated disease management. The strategy for the prevention and control of vector-borne disease places vector control in the context of disease management and aims to seek tailor-made, flexible solutions to local malaria problems. In addition to its main objective of reducing disease transmission risks, another major goal of IVM is to reduce the use of insecticides whenever possible. It promotes decision-making criteria and management procedures that ensure the best local mix of alternatives at a given place and time.

For the purpose of this Action Plan, alternatives are defined as:

The concept of integrated vector management (IVM) as a sub-component of disease management will provide the decision-making framework for vector control in the future, including decisions on the use of DDT or other adulticides. This management approach has been highly successful in agriculture in the sustainable control of pests and in the reduction of reliance on insecticides.

The three main instruments for achieving the goals of the Action Plan are:

It is recognised that there are several countries that continue to rely on DDT for public health purposes and that these countries should be allowed to do so until safe, effective and affordable alternatives are available and operational.

 This is in line with recommendations made at the 20th Malaria Expert Committee meeting in October 1998 which, inter alia, state: It is anticipated for some time to come that there will continue to be a role for DDT in combating malaria, particularly amongst the poorest endemic countries. Restrictions on DDT for public health use contained in a future POPs Convention should therefore be accompanied by technical and financial mechanisms to ensure that effective malaria control is maintained, at least at the same level, through vector control methods that depend less on pesticides in general, and on DDT in particular." (WHO, TSR 892, 2000).

It has, therefore, been a fundamental principle in the development of this Action Plan that any possible deadline in the POPs Convention should relate not to the phase-out of DDT, but rather to the time at which the financial, technical, and administrative tools are in place to begin a transition from DDT to an integrated deployment of alternatives, without any jeopardy to disease transmission risk. Thus, the original IFCS requirement of reduction and/or elimination of DDT at no cost to public health is fulfilled. In the final text of the Convention no such deadline is included.

Furthermore, support for the Action Plan or for the assistance to countries to make a successful transition to alternatives to DDT should not be at the expense of financial resources earmarked for other priority public health issues.

Taking into consideration the conclusions and recommendations of the group of experts, WHO has developed the following Action Plan.

Components of the Action Plan

Based on the outcome of the expert consultation (Annex 2), five areas of major importance for the implementation of the Action Plan were identified. They include:

  1. Country needs assessment,
  2. Safe management of DDT stockpiles,
  3. Institutional research networks,
  4. Monitoring, and
  5. Advocacy.

Objectives and activities for each of these are presented below. In addition, each activity has been earmarked as a immediate, medium- or long-term action. The time frame does not foresee action for all areas of importance under each time horizon.

Timeframe

The proposed endpoints for the activities are as follows:

 Objectives

Country Needs Assessment

Safe Management of DDT Stockpiles

Institutional Research Network

Monitoring

- Human exposure to DDT.

- Public health outcomes of DDT reduction.

- Production, storage and usage of DDT.

- Efficacy and appropriateness of DDT in areas where it continues to be used.

- Efficacy and appropriateness of alternatives to DDT, including integrated vector management (IVM).

Advocacy

Immediate Action

Country Needs Assessment

Prepare an inventory of current use, trends and regulatory status of DDT

To better understand what support Member States may need in order to reduce their reliance on DDT in vector control programmes, it will be necessary to review and update current information on the use of DDT in vector control. This will be done through the activities of WHO, FAO, and Global Crop Protection Federation (GCPF). The main categories of DTT use are:

Promotion of and incentives for the development of national action plans for the reduction and/or elimination of DDT

Country needs to facilitate a successful transition to a situation of reduced reliance on DDT in vector control should be assessed through Member State consultations at the WHO regional level or in different eco-epidemiological settings. 

Safe Management of DDT Stockpiles

Co-operate with concerned organizations (FAO, UNEP) and non-governmental partners including the GCPF

A review, update and expnasion of inventories of DDT stocks should be combined with efforts to encourage corporate partnerships that aid and fund proper storage and disposal of DDT. 

Monitoring

Ensure a global program of monitoring exposure of DDT in humans

WHO, through the International Programme on Chemical Safety (IPCS) should promulgate standards, and identify regional laboratories to perform clinical and environmental sampling and analyses. 

Advocacy

Furnish the appropriate information to the health sector to allow for balanced decisions based on "informed consent"

The provision and dissemination of appropriate information consists of the following elements:

WHO, the Secretariat of the Convention and industry through GCPF all have a role to play in this activity. Appropriate information should also be made available to NGOs.

 Provide the health sector with the opportunity to have its views represented in the INC process and after

Firstly, participation of health ministries in the INC process should be encouraged through provision of information as described above, and the use of Notes Verbales of the WHO Director General and/or Roll Back Malaria to Member States.

In addition, it can be propose to national governments and/or Convention negotiating blocs (the WHO Regional Office for Africa, CRULAC, G77, etc.) that they adopt a joint position on DDT reduction. Action should also be undertaken to facilitate cooperation between NGOs and ministries of health and/or Convention negotiating blocs.

The DDT issue in the context of the POPs negotiations should be made a topic for internal discussions at WHO Regional Offices. 

Medium-term Action

Country Needs Assessment

Inventory of current use, trends and regulatory status of DDT

The inventory of actual current DDT usage prepared under Immediate Action should be expanded, taking into account the results of the review of the indications of use. The following elements should be taken into consideration:

Modalities for preparing the inventory should include a review of the presently used DDT reporting systems provided by country vector control programmes. Member States can furthermore be assisted in the development of DDT inventory questionnaires through

Promotion and incentives for the development of national action plans for the reduction and/or elimination of DDT

This activity will entail the identification and promotion of incentives for the development of national action plans. It will also provide guidance and technical assistance to Member States for the development of national integrated disease control action plans.

 Capacity building to promote, utilise, and evaluate alternative methods for vector control

In a comprehensive way, this activity will:

Validation of effectiveness of different vector control interventions and analysis of their cost effectiveness

Past and present vector control programmes will be reviewed as to their (cost-) effectiveness and sustainability. Alternative disease and integrated vector management strategies will be designed, implemented and evaluated. In the context of comparative studies, cost-effectiveness analysis of DDT and alternatives in different settings will be conducted. 

Safe Management of DDT Stockpiles

Safety measures - co-operation with organizations concerned (FAO, UNEP) to provide assistance to Member States

Based on the inventory preparation and partnership promotion under Immediate Action, this are of activity will now see action to assure safe containment of stockpiled DDT.

Evaluation will take place of security of local stockpile management in order to prevent illegal diversion. Designation of stockpile management responsibility to appropriate organizations will be pursued. 

Co-operation with organizations concerned (FAO, UNEP) to review and/ or develop the criteria if there is to be disposal of a stockpile of DDT: (i.e. FAO Pesticide disposal series No.4, 1996) along the following categories:

Institutional Research Network

Research on the use of alternative vector control methods and strategies should be promoted through inter-institutional co-operation. Primary research should be dedicated to:

In addition, research should be promoted on

 Monitoring

Human exposure to DDT - assist in the development of a global program of monitoring exposure of DDT in humans.

Under the aegis of IPCS, this area of activity will see revision, updating and standardization of protocols for analyses and data reporting. 

Public health outcomes of DDT reduction - ensure that DDT reduction is not causing adverse impacts on the health status.

A number of activities are foreseen under this heading:

Monitor the efficacy and appropriateness of DDT in areas where it continues to be used. Ensure that continuing the use of DDT is bringing positive public health gains.

WHO, together with minstries of health and where appropriate the Secretariat of the POPs Convention, will work towards the development of a comprehensive approach to evaluating the use of DDT for vector-borne disease control, including:

Monitor efficacy and appropriateness of alternatives to DDT, including IVM.

Firstly, this activity will ensure that information is gathered on the performance of DDT alternatives, in order to make decisions on whether to substitute DDT with these alternatives. It will further provide assistance in the development of standard methods for governments to document the cost of deploying alternatives, disseminate these costing methods through national malaria control capacity building programmes, include training exercises to teach trainers how to educate others on the use of costing methods, as part of vector-borne disease control capacity building , and finally, collect information on the cost increment of alternatives (i.e. the cost margin over and above the cost of DDT), for purposes of subsidizing the cost increment through a financial mechanism.

Advocacy

Develop methods for a full economic evaluations of the impact of the reduction or elimination of DDT use on malaria, including potential mortality and morbidity.

Communicate with industry to promote further collaboration in the area of IVM. 

Long-term Action 

Country Needs Assessment

Capacity building needed to promote, utilise and evaluate alternatives for vector control

This will entail the strengthening of both institutions responsible for implementing and evaluating integrated disease programs and of country epidemiological and managerial information systems.

 Validation of effectiveness of different vector control interventions and analysis of their cost-effectiveness

Studies on cost-effectiveness of alternatives to DDT will be continued and the

applicability and reproducibility of alternative strategies to other locations, regions, and under different eco-epidemiological situations will be determined.

 Institutional Research Network

Evaluate integrated vector management schemes. Compare their cost-effectiveness and sustainability with single method approaches

 Advocacy

 Expeditiously disseminate ongoing results of the WHO Action Plan to all interested parties. In particular, distribute the scientific results of alternative strategy implementation and IVM projects 

References

WHO, 1995. Vector control for malaria and other mosquito-borne diseases. Report of a WHO Study Group, WHO Technical Report Series 857, World Health Organization, Geneva

WHO, 2000. Twenthieth report of the WHO Expert Committee on Malaria, WHO Technical Report Series 892, World Health Organization, Geneva

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Action plan for the reduction of reliance on DDT in disease vector control, WHO/SDE/WSH/01.5