Cablegate: Italian Actions to Fight Tuberculosis

DE RUEHRO #0263/01 0641238
R 041238Z MAR 08





E.O. 12958: N/A

REFTEL: A) STATE 6989, B) 07 Rome 2436

1. Summary. A GOI action plan pre-dating the Berlin
Declaration on Tuberculosis (TB) is advancing the
implementation of most of ItalyQs commitments under
paragraph five of the Declaration. Italy also has
significantly increased its contributions to the Global
Fund to Fight AIDS, Tuberculosis and Malaria and to the
World Health Organization (WHO) in recent months. In
addition, Italy will be making a separate 1.5 million Euro
contribution to the WHO-directed anti-TB efforts in
Afghanistan. Domestically, Italy has a fairly significant
problem of TB incidence among legal and illegal immigrant
populations. The GOI action plan is supposed to better
measure the incidence of TB among immigrant groups and
improve TB-related health care services. End summary.

2. On January 28, Post queried the Health MinistryQs
International Affairs Office and the Italian National
Institute of Health re: ref a) request for information. On
February 7, Dr. Maria Grazia Pompa, responsible for
Infectious Disease Surveillance in the MOH Center for
Disease Control, provided Post the Italian action plan to
combat tuberculosis, called QStop TB in Italy,Q and issued
in 2006. The action plan essentially paraphrases the World
Health OrganizationQs (WHOQs) QStop TBQ plan. As such, it
addresses almost all of the commitments mentioned in
paragraph five of the Berlin Declaration on Tuberculosis,
both at the national and the international level.

3. According to the planQs introduction, a 2001 Italian
survey revealed great differences between ItalyQs northern
and southern regions regarding TB monitoring, treatment and
follow-up capabilities. Moreover, it continues, although
TB incidence in the native Italian population is very low
(7 cases per 100,000 inhabitants in 2004), the trend has
not been decreasing in the last 10 years as has happened in
the U.S. where Q according to the introduction Q action
plans have been implemented effectively. For these
reasons, the plan explains, the GOI decided to implement a
TB action plan aimed at developing effective guidelines and
increasing the quality and quantity of TB assistance in
4. The 17-page plan mentions all of the commitments
included in paragraph 5 of the Berlin Declaration, except
for the issues of Qinvolving civil societyQ and Qempowering
people with TB and their communities, and removing stigma.
(Since the plan is at the policy level, the different
therapeutic options, such as the preference for short-
course rather than normal therapy, also are not mentioned.)
The plan underscores the GOIQs intention to strengthen
public health and social services systems in order to
enhance TB surveillance and monitoring, in both quality and
quantity; to increase collaboration between TB and HIV
programs; and to promote research and development of new
diagnostics, drugs and vaccines, as well as program-based
operational research. Moreover, the issues of monitoring
and surveillance of high-risk populations, as well as
addressing multi-drug-resistant TB, and HIV-related TB, are
particularly stressed in the action plan.
5. In order to implement the action plan, in 2006 the MOH
funded two national projects dedicated to TB
epidemiological surveillance and TB drug resistance,
allocating 130,000 and 100,000 euros to them respectively.
Both projects aim at better standardization of TB
monitoring and reporting across Italy. They also support a
study called SMIRA (Multicentric Study of Italian Drug-
Resistant Tuberculosis), begun in 1995. One of the long-
term objectives is the creation of a national TB database,
which would contribute to the European surveillance system.
6. The TB action plan states that in order to improve
assistance, all TB-related health-care services will be
provided for free to all patients, including immigrants.
According to the plan, TB incidence has more than doubled
in young immigrants (those 25-34 years old) since 1999,
reaching 70 cases per 100,000 immigrants in 2004. That
represents roughly 40 percent of ItalyQs total TB cases,
and is ten times greater than the rate of TB incidence
among the Italian population. Note: The real rate of
incidence is difficult to establish, since it could be
overestimated (the overall immigrant population is likely
larger than that described in official figures, which donQt
include illegal immigrants) or underestimated, due to
incomplete TB survey data. However, it is worthy of note
that according to 2004 WHO data, TB incidence in the
countries providing the largest numbers of immigrants to
Italy is: 110 per 100,000 in Morocco, 146 per 100,000 in

ROME 00000263 002 OF 002

Romania, and 101 per 100,000 in China. TB incidence in
countries sending fewer immigrants to Italy ranges from 293
per 100,000 in the Philippines to 22 per 100,000 in Albania
and Tunisia. End note.
7. The plan calls for specific measures to monitor TB
among high-risk immigrant populations, and to increase
awareness among high-risk populations through outreach and
educational materials. Apart from taking into
consideration TB prevalence in the country of origin, the
plan notes that TB screening should be performed over the
first two years after immigrants arrive, since almost half
of the immigrants who develop TB do so after they arrive in
Italy, due primarily to over-crowding and poor living
conditions. GOI outreach to high-risk populations occurs
more through government channels, e.g., at out-patient care
centers and through the newly-created National Immigration
Medicine Institute, than through civil society
8. According to a 2006 MOH report on QTB and Immigration:
Control Strategies,Q while some regional health authorities
(e.g. Siracusa in Sicily and Treviso near Venice) rely on
TB testing only of immigrants who visit public health
facilities, others (Bari and Lecce in Puglia, and Brescia,
Genoa, Milan, Reggio Emilia, and Turin in northern Italy)
conduct active outreach efforts. These efforts include
screening tests of immigrants recruited from worker
dormitories, schools, assistance centers for newly-arrived
immigrants, communities with large immigrant populations,
prisons, and government offices where immigrants obtain
work permits. Health authorities have studied
characteristics of different immigrant groups (Chinese,
African, Eastern European) to better target outreach
efforts. One key need they identified is for more cultural
mediators/interpreters: in 2006 only four of eleven centers
studied had one or more of such employees. The out-patient
care center in Reggio Emilia is the only one exclusively
dedicated to monitoring TB in immigrant populations. The
only non-governmental association mentioned in the report
is the NAGA immigrant health and advocacy group in Milan,
which currently provides health-care services to 100,000
immigrants Qwithout residence permitsQ per year.
9. On the international level, on December 20, 2007 Italy
became the first donor to pay its 2008 pledge to the Global
Fund to Fight AIDS, Tuberculosis and Malaria. ItalyQs 130-
million-Euro contribution to the Global Fund was made
possible in part by the so-called Qtesoretto,Q extra
government revenue resulting from more effective tax
enforcement, additional taxes, and economic growth. Per
ref b), Italy also is contributing 16 million Euros to the
World Health Organization (WHO) in 2008, a significant
increase over ItalyQs 2007 donation of 9 million Euros and
over the 4 million Euros allocated in 2006. Like the
Global Fund contribution, the 2008 WHO funding benefited
from the tesoretto. In addition, Ministry of Foreign
Affairs Afghan Assistance Expert Walter Zucconi told
Econoff on February 27 that Italy will be making a separate
contribution to the WHO of 1.5 million Euros earmarked for
the fight against TB in Afghanistan. This money will be in
addition to the Global Fund contribution. However, given
the current economic slowdown, the Finance Ministry has
already warned that anticipated revenues for the 2008
tesoretto will come in under projection. It is unclear at
this time whether this shortfall will impact funding in
2008 or in out years.

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