(WP)CDS(M)/ICP/EPI/OOI
12 December 1988 ENGLISH ONLY
REPORT
~RKSHOP OF MANAGERS OF THE EXPANDED ~' PROGRAMME ON IMMUNIZATION
Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Manila, Philippines 27 June - 1 July 1988
WHO/WPRO LTBRAB~
.,.7IiIa
Ph~
30 MAR 1989 Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines December 1988
The view. expressed in this report are those of the participants in the Workshop of Managers of the Expanded Programme on Immunization and do not necelsarily reflect the policies of the Organization •
..
This report h.s been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Region and for the participants in the Workshop of Managers of the Expanded Programme on Immunization held in Manila, Philippines, from 27 June to 1 July 1988.
CONTENTS
1.
INTRODUCTION SUMMARY OF
2.
..................................................................................................... PROCEEDINGS .. ................................................................ " .... " ...... .
1 1 1
2.1 Opening remarks ........................................................................................ 2.2 Global overview ........................................................................................ 2.3 Regional overview •••••••••••••••••••••••••••••••••••••.••. : 2.3.1 2.3.2 2.3.3 2.3.4 2.3.5 2.3.6 2.3.7 2.3.8 2.3.9 2.3.10 Past developments •••••••••••••••••••••••••••••••••. Developments since first EPI managers' workshop •••• Coverage .................................................................................... ..
2 3
4 4
Ine ide nee .................................................................................. .. Training ............................................ "...................................... .. Cold chain and logistics ••••••••••••••••••••••••••• Vaccine production/procurement •••••••••••••••••••••
Hepstitis B vaccine production/procurement ••••••••• Surveillance - control and elimination ••••••••••••• Progra1l'lllle reviews ••••••••••••••••••••••••••••••••••
12 12 12 13 13 13 14 14 14
2.4 Analysis of EPI target disease incidence and immunization coverage trends in the Western Pacific Region •••••••••••••• 2.4.1 2.4.2 2.4.3 2.4.4 2.4.5 2.4.6 Tuberculosis ••••••••••••••••••••••••••••••••••••••• Diphtheria ••••••••••••••••••••••••••••••••••••••••• Pertussis •••••••••••••••••••••••••••••••••••••••••• Tetanus Measles Poliomyelitis (please see 2.11.1)
............................................ ............................................
14 15 15 16 16 16
2.5 Hepatitis B and Japanese Encephalitis ••••••••••••••••••••••
2.5.1 2.5.2
Hepatitis B immunization programme ••••••••••••••••.•
16 17 18
Japanese encephslitis •••••••••••••••••••••.••••••••
2.6 Ersdication lessons learnt..................................
2.6.1 2.6.2 2.6.3 2.6.4 2.6.5 2.6.6 2.6.7
Commitment by WHO and nations •••••••••••••••••••••• Definition of objectives •••••.•.••••••••••.•....•.. Quality control of vaccine •••••••••••.••••••••••••• Programme management ••••••••••••••••••••••••••••••• Research ••••••••••••••••••••••••••••••••••••••••••• Confirmation of nil incidence - certification •••••• Implications to future: candidate disesse for eradication efforts ••••••••••••••••••••••••••••••••
18 18 18 19 19 19 19
ii
2.7 2.8
Experiences of poliomyelitis eradication initiative •••••••• Poliomyelitis surveillance •••••••••••••••••••••••••••••••••
20 20
2.8.1 2.8.2 2.8.3 2.8.4 2.8.5 2.8.6 2.8.7
Infection/incubation period/communicability •••••••• Epidemiological trends ••••••••••••••••••••••••••••• Epidemiological surveillance of poliomyelitis •••••• Search for additional cases . •"..•....•••.....••.••.• Identifying groups/areas at risk •.....•..••••••....~ Management of household contacts ••••••••••••••••••• Community control measures •••••••••••••••••••••••••
21 21 21 21 21 22 22
2.9 Lameness survey........................................... 2.10 Laboratory aspect of poliomyelitis......................... 2.11 Situation analysis - poliomyelitis •..•••••••••••••••••••••
23 24 25
2.11.1 2.11.2 2.11.3
Western Pacific Region ••••••••••••••••••••••••••••• Current status of poliomyelitis in the United States of America ••••••••••••••••••••••••••. Epidemiological surveillance on poliomyelitis in Japan •••••••••••••••••••••••••
25 27 28 29
3.
CONCLUSIONS ••••••••••••••••••••••••••••••••••••••••••••••••••••
ANNEX 1
AGENDA •••••••••••••••••••••••••••••••••••••••••••••••
37 39
ANNEX 2 - LIST OF PARTICIPANTS, OBSERVERS AND SECRETARIAT ••••••
1.
INTRODUCTION
The second Workshop of Managers of the Expanded Programme on Immunization (EPI) was held in Manila, Philippines, from 27 June to 1 July 1988. Thirty participants from 27 countries of the WHO Western Pacific Region attended as well as eight observers, three temporary advisers, and seventeen secretsriat members (see agenda of the workshop in Annex 1 and list of participants in Annex 2). The objectives of the workshop were: (1) to set targets and identify activities, both at national and regional level, for poliomyelitis eradication; (2) to set disease reduction targets for other EPI diseases; (3) to develop activities for the further acceleration of the expanded programme on immunization to achieve high immunization coverage; (4) to integrate hepatitis B immunization into the expanded programme on immunization where feasible; (5) to formulate draft national EPI plans of action for 1989 and 1990. The workshop was conducted in plenary and group sessions. During the plenary sessions, scientific papers were presented and discussed. During the group work, participants prepared a list of planned EPI priorities for 1988-1992.
2.
SUMMARY OF PROCEEDINGS
2.1
Opening remarks
The participants were welcomed by Dr Hiroshi Nakajima, WHO Regional Director for~he Western Pacific Region, who reiterated what he had said in his speech at the first workshop: that the larger developing countries of the Region need to put more effort into accelerating their programmes to meet the targets set, namely, that by the end of this decade immunization will have been made available to all children and significant reductions will have been achieved in morbidity and mortality from the EPI target . diseases. He also expressed his hope that elimination of poliomyelitis from the Western Pacific Region will be pursued with determination, by the allocation of adequate resources. In this endeavour, he urged UNICEF and other agen~ies to join in meeting this worthy and exciting challenge.
2
Mr Kunio Waki, Deputy Regional Director for East Asia and Pakistan, UNICEF expressed his organization's appreciation of technical support provid~d by both WHO Regional Office for the Western Pacific and WHO Headquarters for UCI/EPI (Universal Child Immunization) in the Region. He pointed out that to attain the goal of UCI there are only two years and a half left, and advocated for intensifiad efforts in carryi~ ?U~ concerted activities for the education snd motivation of mothers to m1n1m1ze dropouts; improving data base for closer monitoring of BPI; strengthening primary health care (PH?) ~ield struct~re an~ manpo~e~ to. support EPI implementation and cont1nu1ng efforts 1n soc1al mob111zat10n and fund raising. Since EPI is one component of PHC, UNICBF is making consc10us efforts to strengthen PHC in developing countries, and is concerned with the issue of sustainability from financial, management and technical viewpoints. In conclusion, he assured the meeting of UNICBF's continued support to BPI to achieve UCI by 1990 and sustain the momentum beyond into 1990s. 2.2 Global overview
Dr Ralph Henderson, Director BPI, WHO/Geneva recalled that global immunization coverage with a third dose of polio or DPT vaccines in developing countries was now at the 50% level and that immunization against measles, pertussis and (neonatal) tetanus is preventing over a million deaths from these diseases each year. Nevertheless, over three million deaths from these diseases are occurring annually, underlining the need to raise coverage rates as quickly as possible, so as to achieve the goal of Universal Child Immunization. An analysis of countries which had not yet attained a 50% coverage with polio or DPT) showed a preponderance in Africa. Nevetheless, some 44% of all unimmunized infants in developing countries reside in just four countries: China, India, Indonesia and Nigeria. A projection of expected increases in national immunization coverage suggests that a global level of "only" 70-75% will be attained by 1990, even with intensive efforts. The attainment of higher coverage remains tantalizingly close, however. Better management of the health services, particularly better supervision to assure that each contact with the health services is exploited to maximum advantage, combined with efforts to involve community leaders through social mobilizatio~, is the key. The success which has been achieved by the BPI during the past decade has shaped the agenda for the next decade. There are five major priorities to be addressed. The first is to achieve the full use of existing vaccines in all countries as soon as possible, building towards achieving worldwide coverage with comprehensive maternal and child health services by the year 2000. The second is disease control. The global BPI has established the targets of reducing measles and of eliminating neonatal tetanus by 1995. The World Health Assembly, in Hay 1988, adopted the goal of global poliomyelitis eradication by the year 2000. The third is the introduction of additional vaccines into national immunization programmes as appropriate.
3
The fou~th is the use of the BPI delive~y syetem to p~omote and delive~ other primary health care services. The BPI already combines its t~aining with diar~hoeal disease control, and is now introducing a child spacing module in its cou~ses. The p~ogramme is also promoting the adminiatration of Vitamin A fo~ child~en with measles in countries whe~e measles case-fatality ~ate. axceed 1%, and is developing approachea fo~ Vitamin A and iodine aupplementation in populations with theae deficiencies. p~evious
The fifth is ~esearch and deVElopment to support the activities in the four a~eas.
Global polio e~adication represents pe~haps the most challenging goal of all. Pu~sued approp~iately, this should se~e to st~engthen the BPI by placing a clea~ focus on disease control as the primary objective of the prog~amme and should p~omote improved su~eillance, improved laborato~y diagnostic se~ice8 and improved case-investigation and outbreak control techniques for all of the BPI target diseases. 2.3 Regional ove~iew
The Western Pacific Region is the most hete~ogenous of the WHO Regions, a unique spectrum comprising the largest and the smallest count~ie. and areas; highly industrialized countries as well a8 those among the least developed, b~oad climatic va~iation, different political ideologies and cultures; and a widely varying level of health infrastructures development. Also metropolitan powers rep~esented in this Region, through their jurisdictions are France, Portugal, United States of America and United Kingdom. ~ep~e8enting
From the point of view of the development of economiea and health infrastructures aa criteria, the Region could be divided broadly into two groups: (1) developed and (2) developing countries/areas. The developed countries with well-developed health infrastructures and delivery services with high immunization coverage supported by adequate budgetary allocations and manpower are Australia, Brunei Darussalam, Hong Kong, Japan, Macau, Nauru, New Zealand, Republic of Korea and Singapore. The developing countries again can be divided as far as health se~ices development 1s concerned in general and immunization coverage in particular, into two groups: (A) the island countries of the Pacific Basin and (B) the large Asian countries. Group (A) - The countries/areas of the Pacific Basin - American Samoa, Cook Islands, Fiji, French Polynesia, Guam, Kiribati, New Caledonia, Nauru, Niue, Samoa, Solomon Islands, Tokelau, Kingdom of Tonga, Republic of Marshall Ialands, Federated States of Micronesia, Commonwealth of Northern Mariana Islands, Republic of Palau, Papua New Guinea, Tuvalu, Vanuatu and Wallis and Futuna Islands. These countries/areas are small, with small population, scattered and comparatively isolated. The popUlation groups are Malanesians, Micronesians and Polynesians. Economically underdeveloped with inadequate health infrastructure and budgetary allocation and very limited health manpower. These are the countriea in spite of these limitations, have achieved with the support of external agencies, reasonably high coverage, as far as health services are concerned because of high community participation.
4
Group (8) - Large Asian countries - China. Kampuchea. Lao People's Democratic Republic, Malaysia. Philippines and Viet Nam. These are the developing countries with large population mass, have limited health infrastructure. inadequate budgetary allocation and manpower. Varying degrees of political problems and insurgency playing part in poor delivery of services. All these countries have in the past two to three years initiated acceleration activities for EPI with full political endorsement at highest level. To support these acc.~leration, large input hils been re'1uireil and has been forthcoming from external agencies. Malaysia is an exception and has not sought any external financial support. Varying degree of· success is being achieved. 2.3.1 Past developments
The WHO project was formed in 1976 to develop and support the national EPI. The project's activities concerned with promotion of national EPIs and most of the resources available to the regional programme were allocated towards this end. The important activities of the project has been to participate in reviewing of ongoing programmes, preparation of plan of operations, training, evaluation, and development of cold chain and logistics for the countries of the Region. The project also continueil to have close collaboration with other UN agencies. particularly UNICEF as well as with non-governmental organizations interested to support immunization services in the countries within the Region. The staff resources available for the project support is from intercountry team based in Manila, intercountry team based in Suva, country-based staff and consultants. 2.3.2 Developments since first EPI managers' workshop
Greater progress has been achieved in all the countries of the Region. The countries.which have strengthened the acceleration activities are China, Kampuchea, Lao People's Democratic Republic, Papua New Guinea, Philippines and Viet Nam. 2.3.2.1 China
In order to protect children from infectious diseases, the Chinese Govermnent has formulated the policy of "prevention first". Since 1980 •. EPI activities have been strengthened by the establishment of complete EPI network at all levels in China. According to the schedule of immunization, children are immunized with EPI vaccines and therefore, the incidence of those infectious diseases have dropped considerably in the past few years. It is one of the targets to achieve 85% coverage rates during the Seventh Five-year Plan on National Economic and Social Development. There are two steps to reach this goal: first, the coverage rates should reach 85% in all provinces before the end of 1988; second, the coverage rates
5
should reach 85% in all counties by 1990. According to the 20 province.' sample survey in the first half of 1988, 12 provinces have reached the target. China will join the programme of eradication of poliomyelitis as proposed by WHO Western Pacific Region. A national conference was held in Yichang City in June for the summarizing of experiences in EPI programme and submitting a brief plan on eradication of poliomyletis in China. Hepatitie B will be added to EPI. There is a cooperative experimental pilot nroject between WHO and China in Guangxi Zhuang Autonomous Region on bringing Hepatitis B vaccine into immunization programme. The experience will be spread in the areas where hepatitis B ia rampant. Morbidity of four reported infectious diseases are shown in the "chart below:
Polio Year Cases Rate
Measles Cases Rate
Whooping Cough Cases Rate
Diphtheria Cases Rate
1985 1986 1987
1 537 I 844 969
0.15 0.18 0.09
418 159 198 738 104 925
40.37 18.97 9.90
147 298 83 979 59 543
14.22 8.02 5.62
1 423 787 427
0.14 0.08 0.04
Although EPI work has been developed quickly snd great economic and social achievement has been obtained. many problems are still being faced. Twenty per c~nt of the population are not covered by cold chain. For example. in the north--west and south--west minority areas of China, the population density is very low, the transportation is not convenient, economic, culture and education are very backward, medical workere lack modern technology and are of low quality. The lack of vehicles for vaccine transportation nationwide is another problem. An accelerated EPI programme has been organized last winter and spring in order to achieve the first goal. Mobile immunization teams were organized in the remote and minority areal. The remote and minority areas will be the focus of the EPI work in the near future because tho.e areas are the key for achieving the goal of 85% immunization coverage in China by 1990.
6
2.3.2.2
Lao Peoples' Democratic Republic
The EPI programme in Lao People's Democratic Republic was formally launched in 1982. The programme was rather to strengthen and increase accessibility of EPI from 2 provinces and 10 districts with the immuni~ation coverage of about 2.0% in 1982 to all the 17 provinces and to selected 70 districts in 1988 aiming to benefit approximately 2 010 178 people covering 51% of the country's population. Special efforts on EPI were made in 1986 and increased in 1987 but the immunization coverage still continued to remain'very low in the country as a whole: 10% for DPT3 and OPV3, 15% for BCG and Measles vaccine, and 6% for TT2 for pregnant women. The low result is caused by the limited sccessibility of the immunizstion services due to logistic problems, lack of communication, insufficient road system, etc. However, the immunization coverage for infants below one year old in the areas with access to EPI services was quite satisfactory in 1987 such as: 40% for DPT3 and OPV3, 60% for BCG and measles vaccine, 23% for TT2 for pregnant women. There is a strong commitment from the Government of the Lao People's Democratic Republic in achieving the UCI goal by 1990. This is reflected by the establishment of the National Commission for UCI. The EPl commi •• ioRS were also established at provincial and district level in all 17 provinces in the country. The WHO recommended immunization schedule is now applied, the minimum age for DPT and OPV is six weeks instead of three months. Social mobilization and health education The programme has a high political support. The president of the national commission for UCI is a member of political buro, Vice President of the Council of Ministers and President of State Planning Commission. The Lao Women's Union involvement for each vaccination session in the villages, has become a determining factor for the success of the intensive acceleration,programme. A total of 504 health education meetings in the Municipality of Vientiane with 46 250 participants were carried out. The other mass organizations: Youth Syndicates were also crucial to the success of the programme. Series of posters were distributed to all districts. Coverage achieved In February 1988, an actual immunization coverage survey with WHO assistance' for five districts out of 8 districts, which had completed their sessions of immunization in Vientiane Municipality was conducted. The coverage achieved: BCG • 70% Measles vaccine a 67% DPT3 and OPV3 - 34% TT2 - 47%
7
Three months after that, when all 8 districts had coapleted their immunization sessions on May 1988, the coverage achieved was as follows: BeG 77%
Heasles vaccine - 70% DPT3 and OPV3 a 71% TT2 - 62% Problems and obstacles The intensive acceleration programme is the first of its kind in Lao People's Democratic Republic. EPI at national and provincial level have not much experiences in this fieldwork. Public transportation in Keneral is not reliable or is irregular. For the acceleration of EPI, the cold chain requires improvement. 2.3.2.3 Papua flew Guinea
The stated goal of the EPI as expressed in the National Health Plan 1986-1990 is to reduce morbidity and mortality due to immunization preventable diseases. To do this. an objective has been established to increase vaccination coverage of the target groups by 5% each year for each vaccine, starting from the 1985 performance. The main target Kroup for immunization is all children less than one year of age. However, children between one and two are frequently vaccinated. Tetanus immunization is also carried out for women, during their first and fourth pregnancies. (1) Sabin Vaccine (OPV):
In 1987, 91% of the target group received their first dose. However, the figure dropped to 84% for the second dose, and to 76% for third dose. In 1987, only 44% received their third dose of OPV vaccine before their first birthday. Another 32% got it thereafter. (2) Triple Antigen (DPT):
Vacci~ation coverage is more or less similar to that of OPV as regards the various doses as well as the distribution before and after one year of age.
(3)
Measles vaccine
Although measles vaccine was introduced in the EPI in 1981, no data are available for 1981 and 1982. In 1987, 65% were vaccinated against measles, between 9 and 24 months of age, 37% before and 27% after the first birthday.
8
(4)
B.C.G. vaccine
In 1987. BeG covered 74% of the children less than one year old. As a matter of fact. data regarding BeG above one year include booater doaes administered to children at school-entry. and school-leaving. Data for doses administered during the second year of life is not available separately. (5) Pigbel vaccine
According to the National BPI Policy Docume"nt. target population for Pigbel immunization is children from age two months up to five years old in the Highlands. Children at school entry age should alao receive Pigbel vaccine if they have no previous history of Pigbel vaccination. Problem of "dropouts" Sabin vaccine was taken as an indicator for dropouts in the series of vaccinations. Dropouta between dose-l and dose-3 in Sabin vaccination shows that although the problem of dropouts is high in 1987. there is a general trend of improvement over the last nine years. The need for better performance in the different provinces is apparent. Proper supervision. monitoring. and follow up from the different administrative levels is helpful. 2.3.2.4 Philippines
In April 1986. an BPI comprehensive programme review was conducted. Cluster survey for coverage was a component of the review; it showed that only 21.3% of the children surveyed were fully immunized. The survey included reasons for immunization failures. Table 1: BPI Coverage by Antigen Cluster Survey Philippines April 1986 Antigen BCG DTP3 OPV3 Measles Fully Immunized Tetanus Toxoid Strateg~es
% Coverage 62.2 45.8 47.6 43.2 21.3 18.5
for Acceleration:
Strengthening of the immunization activities was the earliest approach implemented. This includes revision of the immunization schedule of 3-14 months old children to an earlier schedule from birth - 11 months. In order to give opportunities to infants to be fully immunized. a monthly or even more frequent immunization sessions were adopted instead of
quarterly immunization rounds.
9
An EPI manual was developed in order to standardize and streamline operations. EPI newsletter was developed and distributed. This is one way of updating knowledge, sharing of experiencea and dissemination of new guidelines at all levela. Improvement of the .onitoring aystem has been started in 1987 Feedback of programme reviews haa been done periodically during the national, regional, provincial and municipal staff meetings. The problem among the cities i. largely due to administrative reasons as they are under the direct surveillance of city local government. Such improvement in the monitoring aystem haa been achieved due to computerization of reports, standardization of format and timetable for reporting. Better communication with the beneficiaries - parents of infants through mass media is now undergoing through experimentation under a health communication scheme supervised by the Public Information Health Education service of the Department of Health. Preliminary results have been very encouraging. Periodic/continuou8 training of EPI managers and peripheral workers is an important strategy in our EPI acceleration. Workshops for these managers are conducted twice a year to discuss problems/solutions, strengths/weaknesses, formulate operational plans and recommend policies. In the reorganization, the National EPI Staff unit of 2 staff was increased to twelve staff membera. Unfortunately, up to this time, we have not recruited the key officials for this program. Social mobilization campaigns were done in selected urban areas. These were joint efforts of Rotary Clubs, UNICEF, local government and other non-governmental organizations. 1987 Achievements: The 1987 achievement of the Philippine Immunization Program showed (Table II) that.we have increased our fully immunized children from 21.3% to 62%. Table II EPI Coverage by Antigen Philippines, 1987 Antigen Bro M~
Coverage of Infants % 92% 73% 73% 68% 62%
OPV3 Heasles Fully Immunized
lO -
Evaluation of Achievements: The Philippines is far from eliminating its problems: Improvem~nt of the cold chain system has been steadily built up but there 18 no read1ly responsive scheme to detect breakdowns and instigate immediate measures for repairs/maintenance.
EPI newsletters cannot be produced on time because of the lack of manpower and problems with printing press. Disease surveillance is still a problem as field reports are most often delayed and incomplete. Reports of epidemics are more timely because of the awareness of local government/media and other agencies. Sentinel surveillance sites are now undergoing careful development. The strategies used have been built and adapted with the existing systems of the Philippines. The process can almost be equated to just making the plans and system more functional and more efficient to programme "needs. These strategies are very easy to sustain. 2.3.2.5 Viet Nam The Progress of EPI acceleration strategies in 1987-1988 (a) Political leaderships are involved as chief EPt steering Committee at all levels. They are in charge of EPt activities in their localities. (b) 42 930 points of vaccination were set for 7 358 communes in the whole country on an average one point of vaccination per one commune established implemented regular vaccination. - The immunization schedule
*
Basic immunization for children under one year 1 month 2 months 3 months
Under
4 months 9 months
BCG, Polio DPT, Polio DPT, Polio DPT, Polio Measles
.* Booster dose for: Children 12-23 months Children 24-35 months DPT and Polio Po lio
Obstetrics guides are also involved to vaccinate BCG and polio for children at birth (c) Vaccinators follow up strictly children who are not g1ven friar to vaccination sessions, mothers are informed in vaccines at vaccination sessions.
details dates and places of vaccination;
11
The purpose of immunization, dates of return and the necessity to return are informed to mothers when they are present at vaccination sessions with their children. The invitation cards are included in the above mentioned information. Recently, incorporation of the growth chart is applied as pilots in certain localities. (d) Chsnneling and identifying of children in need of immunization were achieved by health workers, leaders of working group, members of Women's Union and Red Cross Society. (e) Vaccination Day (from 25th to 30th monthly) i8 organized in the whole country. The permanent vaccination (weekly) is run in Some urban areas. (f) The World Health Day, 7 April 1987 "bnunization - A chance for every child" used for promotion of the programme among political leadership. The Day (7th April 1987) was taken to launch EPI acceleration in the entire country.
Training 19 557 peripheral health workers/leaders were trained for acceleration Mobilization of political will and social mobilization for UCI/EPI Since 1985, the Chairman of the Minister's Council, Chairman or Vice-Chairman of Provincial (districts) People's Committee, participate as leaders of EPI Steering Committee from national to communal and districts level. Finance, electricity supply, manpower, communication propaganda, social mobilization etc. are given priority for EPI activities - and has resulted in good achievements of the goal UCI/EPI 1986-1987. Health information system in EPl EPI informa~ion from provinces were reported quarterly but sometimes delayed and incomplete. From now, EPI information will be conducted monthly. Improvement of immunization services to disadvantaged, in urban areas: (a)
seven surveys were performed in such areas in 1987. poor response from population and routine reporting system not satisfactory. were noted.
Regular vaccinations are implemented in the entire urban areas. The Steering Committees are established from provincial level to communal level in both urban and rural areas.
12
The urban surveillance system for EPI target diseases has started in Hanoi in 1988. It should be carried out in Ho Chi Minh City and in the other large cities such as Da Nang, Hai Phong. 2.3.3 Coverage
Wide variation in the immunization programme development and its implementation is noticeable because of varying degree of coverage by health services.
Overall regional coverage has reached BCG - 68%, DPT3 - 61%, TOPV3 75.1%, measles - 60%. Dropout rate still plagues many of the countries which are achieving over 80% coverage for 1st dose of DPT and TOPV. The efforts to achieve the goal of 1990 is perceived by some as an end. This is not so. In fact, it is really the beginning of the consolidation and maintenance of 1990 goal for the forseeable future. 2.3.4 Incidence
Incidence of EPI target diseases, i.e. poliomyelitis, diphtheria, whooping cough and tetanus, has shown definite downward trend. Downward trend in incidence of measles is seen only in countries where immunization coverage is high. Downward trend in incidence of tuberculous meningitis and disseminated tuberculosis in children under five years is certainly noticeable in several of the countries, which hsve achieved high BCG coverage. However, overall incidence of all forms of tuberculosis is not ,showing clear decreasing trends. 2.3.5 Training
Training has continued to form one of the main components of the programme. Specific training courses were conducted for programme planners, supervisors and peripheral health workers. Such courses were conducted in China, Fiji, Lao People's Democratic Republic, Papua New Guinea, Philippines"Samoa, Solomon Islands, Tonga, Viet Nam and Malaysia. Training in repair and maintenance of cold chain equipment and in logistics are becoming increasingly important, as equipment are getting older. Such training courses were conducted in China, Philippines, Viet ,Ham, Papua New Guinea and an intercountry course in Fiji for the South Pacific Island countries. To improve the training of medical students, nurses and allied health professionals, WHO initiated the incorporation of the current principles of expanded programme on immunization into the existing curricula of the medical and nursing schools in the Philippines and Papua New Guinea.
13
2.3.6
Cold chain and logistics
Three of the largest countries in the region - China, Philippines and Viet Nam hsve finalized the selection of the equipment for the cold chain. Mos~ of the countries have received majority of the vaccine storage equ1pment as planned and have distributed them to the central, intermediate and peripheral levels of the health services. WHO contributed organization in China, countries in the South -facilitate the conduct to the strengthening of repair facilities and their Papua New Guinea, Philippines, Viet Nam and the Pacific by providing staff and training materials to of national workshops.
Field trials on the use of solar powered refrigerators for the vaccine storage were completed in the Philippines, Solomon Islands and Vanuatu. The results of the trials were discouraging. WHO will continue to pursue the trials as the new and improved solar powered refrigeration systems become available. 2.3.7 Vaccine prOduction/procurement The EPI vaccine production in the developing countries is limited. China which produces all the EPI vaccines has been technically supported by WHO to upgrade production facilities. World Bank funding for the building of new plants in China is still under negotiation. In the meantime, UNICEF has provided substantial financial and equipment support to upgrade the quality of vaccines in six institutes to practice good manufacturing practices. Viet Nam is producing its own oral po~iomyelitis vaccine, although it is not yet up to the WHO standards. Technical support i. being provided to upgrade production facilities. A test run on the new DPT production facilities was conducted snd efforts to improve and increase BCG production is being supported. A feasibility study for the production of measles vaccine has been initiated. The Philippines is self-sufficient in the production of BCG and tetanus toxoid, both of which meet the national quality control standards which are similar to WHO standards. Evaluation to improve the DPT production was conducted and recommendations were submitted to the Government. It will take sometime before this vaccine will be produced in the Philippines, in spite of almost 10 years of input by WHO/UNICEF and Philippine Government. UNICEF has played an important part in the promotion of EPI programme and has been ~ major provider of the vaccines and cold chain equipment to Aost of the smaller and large countries of the Region. 2.3.8 Hepatitis B vaccine prOduction/procurement
The technology, expertise and equipment for the large scale production of hepatitis B vaccine have been auccessfully transferred to China through WHO collaboration with Japan. China produced over nine million doses of the vaccine in 1986 and 17 million in 1987 and initiated immunization of infants in the highly endemic rural areas and big cities.
14
WHO also collab orate d with Fiji, Tonga and Weste rn Samoa in the estab lishm ent of labor atory facil ities and traini ng of perso ident ificat ion of high- titre carri ers of hepa titis B surfa nnel. for ce antlg ens and colle ction , proce ssing and conce ntrati on of plas~. :he conce ntrate d plasm a will be proce ssed into vacci ne in Japan and vaCClne wlll be return ed to the count ries for the immu nizati on of infan ts in 1988- 1989. 2.3.9 Surve illanc e - contr ol and elimi natio n
The weake st component in the EPI programme is the surve illanc e of the EPI targe t disea ses. As count ries are appro achin g a high level of immu nizati on cover age, case inves tigati on of EPI targe t disea ses need to be given high prior ity. This activ ity has been initia ted in 1986 i~ sever al of the South Pacif ic Island count ries. However, a major effor t WLll be neede d to maint ain high immu nizati on cover age, promp t inves tigati on of possi ble cases , and taking appro priate conta inmen t measu res. 2.3.1 0 Programme review s WHO also partic ipate d in compr ehens ive programme review s of natio nal programmes in China , Lao Peopl e's Demo cratic Repub lic, Papua New Guine a, Philip pines , Weste rn Samoa, Solomon Islan ds, Tonga and Viet Nam. Simil arly, speci fic review s were under taken of the exist ing cold chain and logis tics for EPI at vario us level s. 2.4. 2.4.1 Analy sis of EPI targe t disea se incide nce and immu nizati on cover age trend s in the Weste rn Pacif ic Regio n Tuber culos is
The gener al trend of all forms of tuber culos is haa shown modes t decre ase; from 32 per 100 000 popul ation in 1980 to 23 in 1985. The disea se is wides pread , with varia ble incide nce rate and is being repor ted from every count ry. Analy zing the trend s of incid ence- rate, based on avail able inform ation, it is possi ble to categ orize them as follow s: decre asing , witho ut chang e, incre asing , irreg ular. The decre asing trend s have been seen in Japan , Austr alia, Brune i Darus salam , Guam, New Zeala nd, New Caled onia, Singa pore, Cook Islan ds, Macau, Malay sia, Repub lic of Korea , Walli s and Futun a. No notic eable chang e in tuber culos is incid ence- rate is repor ted from Fiji, Frenc h Polyn esia, Papua New Guine a. Samoa, Solomons Islan ds, Tonga ,Tuva lu, Vanua tu.
Irreg ular trend s are obser ved in Kirib ati, Laos, Niue, Philip pines ,
The BCG cover age in the Regio n as a whole has been good; reach ing in s?me count ries over 90%. In 1986 - seven count ries repor ted cover age fLgur es, above 50% (Macau reach ed 100%, Papua new Guine a and Philip pines 73% and 72% cover age, respe ctive ly, Viet Nam - 57%)
15
2.4.2
Diphtheria
Starting from 1978 and particularly from 1980 there is clear downward trend of diphtheria incidence-rate in the Region as a whole, from 1.16 per 100 000 population in 1980 to 0.22 in 1986. Epidemiological situation in the countries differs considerably. Eighteen countries have reported zero cases of diphtheria in 1986, 15 of them, for the last 13 years. These 15 countries are located in the South Pacific. In addition there are countries reporting sporadic cases of the disease, most probably importations: Brunei Darussalam, Hong Kong, Japan, Macau, New Zealand, Samoa, Republic of Korea, Singapore. Steady and regular decrease of diphtheria incidence-rate is reported from China. Irregular trend is observed in the Philippines with years of high incidence-rates, alternating with years of low incidence rates. High incidence-rates are still reported from Democratic Kampuchea, Laos, Viet Nam. Vaccination coverage against diphtheria for the whole Region is around 60%. In countries reporting zero incidence (Cook Islands, Fiji, French Polynesia, Guam, New Caledonia, Samoa, Tonga, Wallis and Futuna) immunization coverage have exceeded 70%. It is reported by several studies that with immunization coverage against diphtheria at 70-80% its incidence decreases to 0.1 or less per 100 000 population. The low coverage in Viet Nam: 45.0% in 1987, - correlates well with continuous transmission of the infection at high level. Further efforts should be undertaken to upgrade the coversge in Viet Nam. Special attention also should be paid to countries reporting high incidence (Democratic Kampuchea, Laos) or irregular incidence of diphtheria (Philippines). 2.4.3 Pertussis
In the Region as a whole pertussis incidence has fluctuated around 20-30 per 100 000 population. It is more widespread than diphtheria. Only 12 countries aid not report pertussis in 1986, and some of them for several years (American Samos, Cook Islands, Guam, Nauru, New Zealand, Niue, Samoa, Singapore, Tokelau, Tuvalu.) Steady decrease of the disease is reported from Fiji (1982), Japan (1979), Republic of Korea (1984), Tonga (1982), Tuvalu (zero reports since 1981, Viet Nam (1983). Since 1980 decreasing trend in incidence is notable in Kampuchea. Immunization coverage against pertussis in the Region remained in the
range of 50 to 60%, which is not enough to see its effect on the incidence-rate. In some countries with higher coverage, 70 to 90% the decreasing trend is seen: Guam (97% in 1985 - no cases of pertussis), Hong Kong (80% and higher coverage - single cases of the disease), Japan (81-98%
16
coverage - steady decrease of incidence), Macau (80-83% coverage - single case of pertussis), Samoa (80-99% coverage - no cases since 1982), Singapore (76-91% coverage - no cases since 1983). Kiribati, Papua New Guinea, Philippines, Vanuatu, Viet Nam, and Democratic Kampuchea with low immunization coverage do show continuing pertussis transmission at fairly
high level. 2.4.4 Tetanus
The tetanus incidence-rate in the Region has been 0.18 per 100 000 population (1986). In 1986 only 9 countries did not report incidence of the disease, 4 countries (Australia, Japan, New Zealand, Republic of Korea) reported incidence rate below 0.1 per 100 000 population. Incidence rate of 0.1-1.0 was reported from Brunei Darussalam, Fiji, Hong Kong,Laos, Vanuatu. Five countries reported incidence rate over 1: French Polynesia (1.2), Kiribati (1.6), Papua New Guinea (2.3), Philippines (1.6), Viet Nam (2.5). 2.4.5 Measles
During epidemic years, high incidence-rates in some of the South Pacific Island countries were noted: 1818 per 100 000 population in Cook Islands in 1980; 2361 in Kiribati in 1984; 800 in Nauru in 1977; 5090 in Tuvalu in 1980; The acceleration in the measles immunization coverage is priority in most of the countries of the Region. 2.4.6 2.5 2.5.1 Poliomyelitis - Please see 2.11.1 Hepatitis B and Japanese Encephalitis Hepatitis B immunization programme
Infections with hepatitis B virus (HBV) occurs at varying rates throughout the world. In general, the endemicity of HBV infection among countries in the Western Pacific Region is high (infection rate = 70-90%, chronic carrier rate - 8-15%). In several countries (Australia, New Zealand) the endemicity of HBV infection is low (infection rate=2-6%; chronic carrier rate~O.l%). However, within these countries reside indigenous populations having high rates of infection. The objective of hepatitis B programme is to prevent chronic infection with the virus and thus the late sequel such as chronic liver disease and hepatocellular carcinoma. Studies in Taiwan by Dr Palmer Beasley and colleagues have demonstrated that men who are chronic HBs Ag carriers have a risk of death from hepatocellular carcinema that is almost 500 times greater that HBsAg negative men. In the Western Pacific, approximately 50% of the HBV infections occur during the first five years of life. Infants born to chronically infected mothers who are HBs Ag positive become asymptomatically infected and have a 70% chance of becoming chronic HBV carriers. Children acquiring chronic HBV infection due to perinatal transmission account for at least 30% of the chronic HBV carriers in the Region's population and represent an important target for immunization programmes. Children not infected during
17
the first five years of life have aproximately a 40% chance of becoming chronic HBV carriers. Introduction of HB prevention progammes should be considered a high public health priority in those countries where the chronic carrier rate is greater than 7%. In countries not aware of their rates of HBV infection, serologic surveys should be undertaken to determine overall rates of infection, rates of chronic infection, and the contribution of perinatal infection to the overall rates. The main activities included supporting the local production of hepatitis B vaccine and diagnostic reagents through technology transfer. There are two model systems for the transfer of vaccine production technology. One is concerned with technology transfer for the large-scale production of plasma-derived hepatitis B vaccine in China; the other main activity is the high-titre HBsAg plasma collection scheme, in countries where local production of HB vaccine is not feasible. The WHO Technical Advisory Group on Viral Hepatitis and Expanded Programme on Immunization (EPI) recommend that HB immunization be integrated into the EPI programme as soon as possible in highly endemic areas. A pilot project to determine the feasibility of integrating HB immunization into the EPI has started in Long An County, Guanxi Province, China. The following countries or areas have already initiated the use of hepatitis B vaccine; American Samoa, Australia, Brunei Darussalam, China, Guam, Japan, Macao, Nauru, New Zealand, Niue, the Republic of Korea and Singapore. Fiji, Papua New Guinea, Samoa and Tonga will be introducing hepatitis B vaccine in 1988, and plans are in preparation for the remaining South Pacific island countries, including Cook Islands and Vanuatu to administer the vaccine before 1990. As HB Immunization programmes are beginning, efforts should be directed at determining rates of vaccine coverage in the target population. The objective of HB Vaccine programmes is to prevent chronic childhood infections and chronic liver disease and hepatocellular carcinoma which occur 40-50 years later. However, the serologic demonstration of age-specific reduction of chronic HBV infection once high rates of vaccine coverage are achieved is a means of evaluating the success of the programme.
2.5.2
Japanese Encephalitis
Japanese encephalitis is endemic or periOdically epidemic in China, Japan, the Republic of Korea, Northern Thailand, India, Viet Nam, Cambodia, Laos, Burma and Nepal. Sporadic cases occur in other countries of the Western Pacific and South East Asia Regions. In endemic areas, it is mainly children who are afflicted. The annual incidence is 0.1-5.0/100 000. Although control of mosquitoes by pesticides snd vaccination of pigs are important control measures, mass vaccination of humans is the most
reliable and cost effective preventive measure. be immunized as early in life 88
Children at risk ought to
possible since case occur already during
the first year of life.
18
The currently marketed mouse brain JE vaccine varies in cost from US$l.OO to $2.40. A less costly vaccine is needed. In addition, countries should maintain surveillance of JE cases and JE virus in mosquitoes, so that 'reliable data can be reported through the EPI Global Surveillance System. Potential approaches include research on less costly means of production and application, as well as joint purchasing coordinated by WII0/UNICEF. 2.6 Eradication lessons learnt
"The global eradication of poliomyelitis by the year 2000 is an appropriate gift, together with the eradication of smallpox from the twentieth to twenty-first century." It was so noted by the 41st WHA when the commencement of the eradication of poliomyelitis was adopted. The eradication of smallpox was declared by WHA in 1980 and comprehensive account of the programme performance entitled "Smallpox And Its Eradication" was published by WHO in 1988. It would be worth reviewing the lessons learned from this programme when the initiative for polio eradication has just started on the global bases. 2.6.1 Commitment by WHO and nations
Disease eradication is unquestionably an attractive goal, but difficulty in its achievement should not be underestimated. Smallpox eradication, when its intensified programme was initiated in 1967, had been perhaps at the most favourable position for the eradication efforts as compared with any other diseases. There was no animals reservoir, no subclinical infection and the availability of stable freeze-dried vaccine which gave virtually 100% protection. Almost two-thirds of the geographical areas on the earth were free of endemic smallpox. 2.6.2 Definition of objectives
The smallpox eradication programme had the clear definition of objectives, namely"zero smallpox case". The advantage of this was that everyone including the programme personel, finance officers, politicians, etc. could undertand clearly what their target was. Once it showed a good feasibility, it helped greatly collecting the funds and making useful propagandas through media. Incidentally, the smallpox eradication programme employed special information officer who assisted in the propagation of smallpox success story worldwide. On the other hand, if there was an apparent failure, such as reintroduction of epidemics in Bangladesh as the results of Indo-Pakistan War, there was uproar of media criticizing the WHO's "gamble" for the eradication. Whatever, it is good to have a simple' target with which we know clearly the success or failure of the programme. 2.6.3 Quality control of vaccine
One of the important lessons learned from the smallpox eradication programme was that the quality of freeze-dried smallpox vaccine was extremely poor at the beginning of the programme.
19
2.6.4. Programme management The smallpox eradication programme promoted the flexible approach for the programme development. For example, the Jet injector, which was thought to be the main tool for the eradication efforts, was abandoned just two years after its introduction and replaced with the bifurcated needle. For the surveillance, a postcard showing smallpox patient was used to let villagers know what disease the surveillance team was seeking. For the personnel recruitment, we were extremely lucky that excellent co-workers or colleagues joined the programme. However, it should be • recognized that those who did not meet the requirements had to go, a rare incident in WHO. 2.6.5 Research
At the beginning, we ourselves thought that a great deal of research would not be required for the programme. The fact turned out otherwise. There had been enormous needs to develop the practical technology and virological study. 2.6.6 Confirmation of nil incidence - Certification
The smallpox eradication programme had to organize the work for certification of smallpox eradication in order that all the nations approved the success of the programme to stop the smallpox vaccination. It was again a difficult period for the programme .ince the finance ministry wanted to withdraw the smallpox funds as soon as the crisis of the epidemic were over. The thirteen years smallpox eradication programme costed 5300 million, and with the stoppage of the vaccine programme the world had been saving each year 51000 million from its health budget. When the global poliomyelitis eradication is certified, the immunization programme will not be required. 2.6.7 Implications to future: Candidate disease for eradication efforts
Measles,appears to be a good candidate disease for eradication, but despite intensive effort being made by U.S.A. since 1978, the disease has not yet been eradicated. The speed of virus transmission is quicker than smallpox. Poliomyelitis appears to be promising since a large part of the world has become free of the wild polio virus for many yeara. The 1988 WHA resolved to proceed with the global programme. However, in addition to the difficulty in the surveillance as mentioned, there will have to be a great deal of developments particularly in research areas. For example, the current live vaccine is thermoliable requiring the persistent cold chain system and the killed vaccine is expensive. The antibody production in the tropical areas is sometimes
20
irregular. As already mentioned, surveillance methodology and the definition of poliomyelitis eradication will have to be developed. 2.7 Experiences of poliomyelitis eradication initiative
The American Region has established the goal of polio eradication by 1990 as the spearhead for the development of EPI. To help PARD implement the effort, a Technical Advisory Group (TAG) was appointed to help define strategies to achieve the goal, and to review progress and adjust the programme on a periodic basis. The strategy to achieve polio eradication as outlined by the TAG rests on three major components: 1) achieving and maintaining high vaccination coverage; 2) intensive surveillance and active case
investigation; and 3) agressive containment of outbreaks. At the national level all countries of Latin America and the Carribean developed EPI five year plans. These national plans include a narrative report which covers a five year period (1987-1991), and which states the objectives, targets, strategies and tactics of the programme a8 well as a detailed analysis of activities to be implemented in year one on the following areas of action: biologicals, cold chain, training, social communication, operational costs, supervision, epidemiological surveillance, research and evaluation. For each activity there is an expected output and a timeframe for implementation. When the EPI was launched in the Americas in 1977, coverage with OPV for children under one year of age was in the order of 30%. This coverage gradually increased to nearly 75% in the early eighties showing a slight decline to under 70% in 1985. With the establishment of the polio eradication goal, coverage started increasing again and has been maintained
at over 80% for the last two years. One of the major impacts of setting the eradication target was the development of national surveillance systems and a network of laboratories to support case diagnosis. Since the announcement of the goal to eradicate polio nearly three years ago, a Field Guide for Surveillance and Polio Eradication has been published and widely distributed. A key element of the eradication programme, in addition to early Case notification, is the organization of proper containment activities. The major impediments to the ~oal of polio eradication fall into four major categories: a) political and social will; b) managerial constraints, c) vaccine efficacy and stabilisty; and d) adequacy of surveillance and response to outbreak control. 2.8 Poliomyelitis surveillance Susceptibility is universal, independent of race; infection, followed
or not by symptoms, confers lifelong homologous immunity. Severity of illness, following infection, is age-related, in that paralytic symptoms are more frequent and more severe in older age groups.
21
Two patterns are observed: where high environmental/personal hygiene standards prevail, the oropharyngeal route of transmission is more important;
where those standards are deficient, the oral-fecal route of transmission is predominant.
2.8.1
Infection/incubation period/communicability
Irrespective of the source, man becomes infected by ingesting contaminated matter; hence, the virus undergoes a primary stage of replication in the pharynx and ileum, which are rich in lymphoid tissue. (Silent phase of the infection). Progression of the infection involves a period of viremia, associated with prodromal, non-specific, systemic symptoms. 2.8.2 Epidemiological trends
Poliomyelitis occurs worldwide. In the pre-vaccination times, the highest incidence was recorded in temperate and industrial countries, where both sporadic, endemic cases as well as epidemics would occur. In such settings, a seasonal pattern was observed, with higher frequencies in summer and early autums }though variations were wide, from year to year, and area to area}. Poliomyelitis has been characteristically a disease of children, but where socio-economic and hygiene standards have markedly improved, cases occur among older individuals. 2.8.3 Epidemiological surveillance of poliomyelitis
Although a few WPR countries report a significant number of poliomyelitis cases each year, the large majority of countries/areas in the Region have reached "nil" (or almost-nil") incidence of polio. Therefore, the occrance of one case could and should be treated as an epidemic, in most (if not all) the WPR countries/areas. While recognizing that routine investigation of endemic, sporadic poliomyelitis cases may require greater efforts. 2.8.4 Search for additional cases
Routine surveillance and reporting may not be sensitive or reliable enough to provide an accurate picture of the problem. For example, hospitals may only report cases at the end of the month/year; private health providers may not report at all. Schools, local leaders, and private clinics should be contacted frequently throughout the epidemic. 2.8.5 Identifying groups/areas at risk
Record basic information" for each case onto a line listing and a Case Investigation Form. Visit each affected household to obtain the relevant information. However, after 30 to 50 cases are recorded, primary efforts should be focused On control, unless resources and investigation objectives allow extensive home visits to be continued.
22
Mark on a map the location and number of cases at each location. precise street maps are not available, make a sketch map).
(If
Review the immunization ~tatus of the community. If poliomyelitis is. occurring in which immunization levels are not high, then emphasis should be ' placed in covering the affected area(s) with a mass immunization programme. 2.8.6 Management of household contacts
Primary or booster immunizations of polio vaccine should be given to all household contacts. Theoretically, a monovalent vaccine of the same virus type causing the epidemic could be used, if available. However, trivalent vaccines are fully effective in controlling epidemics and should be used immediately. All family members should be checked daily for illness. 2.8.7 Community control measures Immunization: this is the first priority.
All persons targeted in the affected areas should receive one dose of trivalent oral polio vaccine (OPV). Monovalent vaccine of the type causing the epidemic may also be used. It is important to assure that appropriate amounts of vaccine are on hand for the control efforts and that enough vaccine carriers exist to transport vaccine.
Control activities in the community Identify potential contacts of cases, in the community, particularly relatives, friends and schoolmates of the same age a~ the cases. If face-to face contact occurred less than 18 days ago, assure immunization and follow up for possible illness. Identify pockets of susceptibles. Conduct special immunization clinics to reach an immunize such groups. Develop a system for care and transport of cases. th~ught
If the proportion of persons in the community who are susceptible is to be high, minimize activities which may bring them into intimate contact.
Coordination of investigation and control activities. It is important to keep in frequent contact with all staff involved in the epidemic. In particular, community leaders and other involved persons should be informed as to the progress of the epidemic and its control efforts. Surveillance techniques described earlier are suitable for all situations, and particularly for countries/areas with nil/low polio incidence.
23
Follow-up investigation of the epidemic and possible channels of further spread, such ss exposed individuals living in other areas, is important in order to ensure that the epidemic has been completely controlled. The more active the surveillance system, the easier it is to conduct follow-up. Community health education is also important for this purpose, since an informed community is more likely to cooperate in control efforts and in the reporting of suspect cases. It is extremely important to evaluate the reasons why an epidemic. occurred, and to identify any mistakes which were made during the control efforts. Such information is valuable in helping to determine the effectiveness of the immunization programme, and where improvement is needed. The experience gained during an epidemic should be described and is useful for handling future epidemic of poliomyelitis or other diseases preventable by immunization. As a minimum, the report should include the following sections: 1. 2. 3. 4. 5. 6. 7. Introduction (How the epidemic was reported and investigated, etc.) Description of the epidemic (time; place; person). Analysis of the epidemic. Methods of Surveillance. Control Measures Taken. Problems Encountered. Conclusions and Recommendations.
The report should be fed back to those involved in field activities to assure that recommendations are adopted. and to assure cooperation in the future. 2.9 Lameness Survey
Since the first lameness survey carried out in Ghana in 1974 by Nicholas et a1. approximately 100 surveys to estimate the prevalence of lameness due to poliomyelitis have been conducted in more than 25 countries. The results of these surveys were a8 follows: Poliomyelitis has been endemic both in rural and urban areas; More than 90% of paralytic cases were in children under the age of three; One third of the cases were in children under the age of one; Overall prevalence was 5/1000; Overall incidence was 1/200 in children and 20/100 000 in general population; There was little clustering; Reporting completeness of cases was less than 10%.
24
2.10
Laboratory aspect of poliomyelitis
The poliovirus is an enterovirus. There are three antigenic types; I, 2, and 3; all types can cause paralysis. Type 1 - most commonly is the cause of paralysis, type 3 less frequently, and type 2 uncommonly. Host of the epidemics are due to type 1. Vaccine-associated cases are usually due to types 3 and 2. Virus isolation and poliovirus antibody surveys are important components of poliomyelitis surve·Lllance. Virus can be found in the faeces from 72 hours to 6 weeks after infection, with a higher probability in the first week, and in the throat swab from 72 hours to 7-10 days after infection. Less likely to yield virus are cerebrospinal fluid (CSF) and blood. Therefore, collection of CSF and blood specimens for the purpose of viral isolation is not recommended. Blood specimens should always be obtained for the detection of antibodies to poliovirus at anytime after onset of paralysis. Neutralizing antibodies in the serum appear early after infection and may be at high levels by the time the patient is hospitalized. Complement fixing (CF) antibodies rise later and significant titre increases may be demonstrated more easily than with neutralizing antibodies. Collection, storage and shipment of specimens; 1. If a suspected case is seen within 6 weeks after onset of paralysis, collect; Stool - two specimens should be obtained at an interval of 24-28 hours for viral isolation. If stool specimens are not available, two rectal swabs should be taken. Blood - Paired sera should be obtained in order to detect an increase in the level of antibodies. A second serum (convalescent) should be taken 5-6 weeks later. 2. If a suspected case is seen more than 6 weeks after onset of paralysis, collect; Blood - Obtain a first sample (convalescent) in order to evaluate the level of antibodies. Another sample (late convalescent) should be taken 5-6 weeks later. 3. If death occurred, collect blood and spinal cord, grey matter, medulla pons, cerebrum, payer's patches;
.
In the course of the eradication of poliomyelitis, following deserve special·attention: (1) analysis of poliovirus strains inducing paralytic poliomyelitis to elucidate whether the causative strain is vaccine-derived or
wild origin, for such differentiation, a very sensitive and precise method should be used.
;
25
(2)
If the disease was induced by wild poliovirus strains, it is very important to define whether this wild virus is a strain of local origin or imported from other areas - determination of origin of wild strains also requires very sensitive method of analysis.
Some of the virological/serological methods recently developed but not widely available are: (1) (2) (3 )
ELISA method; for typing of poliovirus and for titration of poliovirus antibodies. Use of monoclonal antibodies reliably discriminate between wild and Sabin-like poliovirus strains. Oligonucleotide fingerprinting method; by this method, it is possible to distinguish vaccine-related isolates from wild strains. Radioactively labeled DNA "probes" are able to identify viruses grown in tissue culture by nucleic acid hybridization techniques.
(4) 2.11 2.11.1
Situation analysis - poliomyelitis Western Pacific Region
Poliomyelitis incidence in the Western Pacific Region has shown decreasing tendency for the last eight years. With further acceleration of activities of the Expanded Progra_e on Immunization there is a good prospect for drastic decrease of poliomyelitis incidence and its ultimate elimination. Historically industrialized countries of the Region have introduced oral polio vaccination in early 1960& and its further expansion in developing countries in late 1970s with the inception of EPI took place. Decrease started from the year 1980, when incidence rate was 92 per 100 000 population, reaching 22 in 1986, which shows more than 4 fold decrease. Counery wise, the steady decreasing trend is reported from the Peoples Republic of China and the Republic of the Philippines; notable results are achieved in Malaysia and Republic of Korea where after steady decrease of polio incidence, zero cases are being reported for several consecutive years. The incidence trend in Viet Nam, Laos and Democratic Kampuchea is still showing epidemic pattern. As many as 17 countries in the Region have had zero cases of poliomyelitis for the last 13-14 years (48.5%) 8 countries, or additional 22.8% have not had cases for the last 4-12 years and further 4 countries have hade a single case. Only 6 countries, or 17.1% report incidence rates of poliomyelitis, which is high.
26
Thus , two main POs1t1ve trends, as far as polio incidence in Western Pacific Region in concerned, are as follows: cont1nuously dropp1ng incidence in the Region as a whole from the year 1980, and increasing number of the countries without reported cases of poliomyelitis. The province-wise or region-wise information from the countries facilitates better epidemiological analysis and better understanding of what is going on in the field. For example, in 1986, in China the outbreak of poliomyelitis occurs in Guangxi and partially in neighbouring provinces. Also in Viet Nam in 1986 and 1987 poliomyelitis incidence was confined mostly to the southern and to less extent to Central Regions, compared' with the incidence in Northern Region which was five times less. Such distribution of incidence correlates well with the levels of immunization coverage both in China and in Viet Nam: provinces and regions with low coverage have higher incidence levels. The present polio situation was assessed in countries through a special questionnaire. All the respondents confirmed that poliomyelitis is a notifiable disease in their countries. And 80% indicated that a medical officer is the person who performs epidemiological investigation of every case of poliomyelitis. This information lays good foundation for further development and strengthening of polio surveillance in the Region. Some differences are observed in immunization schedules. Only three countries have accepted inununization of newborns, which is recommended for
..
. endemic countries by WHO and by recent studies. Another few countries have accepted the schedule developed by WHO,. Still another few countries practice booster doses of polio vaccine at the ages from 18 months to 4-6 years. Thus, with the inception of polio control and eradication programme it seems advisable to unify different schedules through adoption of WHO recommended one.
Much controversy exists over the contraindication policy for immunization. Only two respondents indicated that they favour no "contraindication policy". Others still have 1-4 contraindications for polio immunization, among them: diarrhoea, high fever, debilitating conditions, immune deficiency, steroid therapy, rickets, acute infections.
Thus the WIIO policy on contraindication needs reinforcement. The response to the question regarding the national target year for polio eradication was: seven have already reached the eradication stage, two put it at 1990, four - 1992, one in 1995-2000 year. Confirmation of poliomyelitis in four countries is based on clinical findings only; seven countries base their diagnosis on clinical, serological and virological findings; two countries - on clinical and serological data. The countries have identified 21 national laboratories (some of them several laboratories) either for serological, virological or for both types of confirmatlon of polio cases. Interesting fact is that four Pacific Island countries identified their referral laboratory - in CDC, Atlanta. Twelve national laboratories expressed their willingness to be nominated as WHO collaborating centres for polio programme, one (in Singapore) has already been working as such. Some preliminary results of sero-typing of polio virus is China and Viet Nam in 1986 indicate that in these countries serotype 1 is generally for paralytic case anrl corresponds with the generally accepted hypothesis.
27
Thus, the present position of polio surveillance in the Region can be characterized by the awareness in the countries to the magnitude of the problem, by the desire to undertake the steps to strengthen surveillance through improvement of laboratory services, immunization schedules, contraindication policies, through cooperation with ~IO. Routine collection of information from provinces and regions, at national level should also be strengthened and encouraged, as such routine analysis of incidence and immunization coverage failures facilitates prompt implementation of remedial action.
The vaccination coverage has upward tendency in percentage of children immuni~ed against poliomyelitis in the countries of the WPR. Some of them have already exceeded the 80% coverage level, which fact lays good background for the control of the disease in the Region with its ultimate elimination. Past seven years experience in the WPR countries shows that with the increasing immunization coverage incidence of poliomyelitis decreases and finally results in interrupt of transmission of wild polio virus; SOme of the countries with limited chances for wild polio virus importation could reach zero incidence status even with moderate levels of the immunization coverage.
Identification of the national laboratories, establishment of the network of poliomyelitis referral laboratories and strengthening of the laboratory services for polio programme and for EPI are important for reliable serological and virological confirmation of polio cases. As it has been shown in proceedings of International Symposium on Poliomyelitis Control in Washington, DC, held on 14-17 March 1983 a number of viruses (Coxsackie A and B, ECHO, other enterovirus) can produce paralytic poliomyelitis-like syndromes. 2.11.2 Current status of poliomyelitis in the United States of America
The United States of America experienced repeated epidemics of poliomyelitis of increasing magnitude during the first half of this century, culminating in a peak incidence in 1952, when more than 20 000 cases of paralytic disease were reported. The introduction of inactivated poliovirus vaccine (IPV) in 1955 was followed by a dramatic decline in reported incidence, although there was an upswing during 1958-1959. Soon after oral poliovirus vaccine (OPV) was introduced in 1961, it essentially replaced IPV as the vaccine routinely used, both in the United States and in most of the rest of the world. More than 540 million disease of trivalent OPV have been distributed in the United States since it was introduced in 1963. During the 12-year period 1975-1986, 139 cases were reported in the United States. there were 10 epidemic cases, all of which occurred in 1979. Eighty-six endemic cases occurred in persons with a history of contact with OPV, either as recipients (37), household contacts (31), or non-household contacts (17), while 13 cases were reported with isolates of vaccine-like-virus in persons discovered to have immunodeficiencies. Immunization levels in school-age children are at small time high, with approximately 97% having records indicating receipt of 3 or more doses of OPV.
28
Institute of Medicine (National Academy of Sciences) once again re-evaluated U.S. polio immunization policy in January, 1988. Based on consideration of these issues, the Institute of Medicine recommended that once enhanced potency-IPV combined with DTP is licensed (expected within 2 to 5 years), a combine IPV!OPV schedule consisting of 2 or more doses of DTP-IPV followed by OPV at 18 months and at entry to elementary school should be adopted. The rational for this sequential IPV-OPV schedule is based on several points. First, it is believed that such a schedule would reduce or even eliminate cases of vaccine-associated
paralysis in recipients of OPV and to a lesser extent in contacts. The mixed schedule provides humoral, pharyngeal, and intestinal immun1Y, thereby reducing the potential for wild virus transmission. Some secondary spread of vaccine will still occur and provide immunization for susceptible contacts although the extent of such spread should be reduced. The continual routine use of OPV would ensure its availability in case of need for epidemic control, where it is the vaccine of choice. 2.11.3 Epidemiological surveillance on poliomyelitis in Japan
In Japan, from 1951 to 1963, the nationwide campaign was organized to immunize the risk population with the oral polio vaccine. Since then, the incidence of poliomyelitis rapidly decreased. In recent years, despite the intensive surveillance, only a few cases have been discovered in each year. 2.11.3.1 Incidence
The 1961-63 campaign had resulted in the remarkable reduction of the cases during 1964 to 1969. Further reduction has occurred since 1970, reaching the yearly incidence of only one or two cases in the last 5 years. It is noted that cases were caused by the vaccine poliovirus, but since mid 1970's type 2 virus of the vaccine has been the frequent cause of the disease.
2.11.3.2
Epidemiological Surveillance
Three systems of epidemiological surveillance on poliomyelitis, have been initiated since 1962 and continued up to now. They are (1) notification and investigation of cases (2) investigation of susceptible of the population and (3) investigation of sources of infections. The later two systems have carried out as part of Japan's epidemic prediction programme. 2.11.3.3 Notification and investigation of cases
Poliomyelitis has been a notifiable disease in Japan. As the number of cases has considerably decreased, the reported cases and the specimens from suspected cases are being promptly investigated by the prefectural health services and laboratories. Vaccine-related cases - Cases meeting the following three criteria were p laced in a category of "vacc ine-re lated" cases: (1) onset of illness between 1 and 30 days following the administration of live poliovirus vaccine, (2) clinicallY classified as typical paralytic poliomyelitis, and the poliovirus isolates of miscellaneo"s origins were sent from the prefectural health laboratories to the National Institute of Health for further characterization. All isolates except one were vaccine virus. I
29
"vaccine-like"
~3) vi~ologically classified as positive for poliovirus infection with the 1solat1on of a serotype poliovirus that could be classified as ~
Discussion
Poliomyelitis appears to have been eradicated in Japan with the mass vaccination campaign, containment vaccination, when the outbreak occurred and the epidemiological surveillance. pol~omyelit~s, ~he absence of th? typical polio paralysis for the long per1~d of t~me 1n a country may indicate that the poliomyelitis has been
Although there are a number of subclinical infections in
erad1cated 1n that area. Therefore, the primary target for the surveillance sho?ld be the typicsl polio paralysis. Needless to say, it would be most des1rable to set up some trial areas to confirm this point. 3. CONCLUSIONS
During the final plenary session, the following conclusions were apprllved: 1. This was the second EPI managers' workshop to be held in the Western Pacific Re~ion. It had provided an invaluable opportunity for participants to exchange information and share experiences. Similar meetings should be organized again in 1989 and 1990. The participants reiterated the usefulness of such a workshop. They also re-endorsed the conclusions and recommendations of the first EPI Managers Workshop in 1986, which are, still valid and should be pursued and implemented.
2. This meeting had been held with the participation of the Regional Director of WHO, Deputy Regional Director of UNICEF, and observers from UNICEF, Rotary International, USAID and the South Pacific Commission. The participation of these organizations and various other organizations supporting the expanded programme on immunization is an important element in promoting their continuing close collaboration. Invitations should be sent for their continued participation in future meetings. The group also urged these organizations to continue to send their observers to ensure collaboration. 3. Steady progress has been recorded by most countries of the Region in the area of childhood immunization services. As suggested in the first meeting in 1986, several countries have initiated acceleration activity to take them nearer the target of 1990. Yet programme acceleration remains an overriding priority for some countries, and maintenance of achievements for others, if the 1990 immunization goal is to be attained. National acceleration efforts can be strengthened by the following means: (a) adopting national immunization schedules which protect children as early in the first year of life as possible and defining clear national policies on contrainidcations, in accordance with information provided by WHO, recognizing the large benefits of immunization in relation to the risks of the target diseases, reducing contra indications to a minimum;
30
(b)
. ,·...un,·za tion at every conta ct point , parti cular ly by promo ting . ' contin uing to streng then outrea ch serVi ces and.bY encourag~n~ the provi sion of immu nizati on servi ces by hospi tals and clini cs servin g sick child ren; monit oring of cover age by distr ict in order to follow progr ess, ident ify low cover age and take appro priate up actio n; mobil izing socia l action which creat es effec tive consu mer deman n and ensur es that the healt h servi ces are able to make an adequ ate respo nse to that deman d.
(c)
(d)
comm unity group s. Socia l mobi lizati on activ ities shoul organ izatio ns and d be speci ficall y includ ed in natio nal plans of opera tions, and staff with speci fic respo nsibi lities in this area should be desig nated withi n the minis try of healt h.
Socia l mobi lizati on can be achiev ed by seekin g the endor semen t of natio nal polit ical leade rs, makin g full and profe ssion al use of a~l relev ant chann els of comm unicat ion (inclu ding the mass media ) and by ensur ing the activ e partn ership of other minis tries, nongo vernm ental
4. Impro vemen t in the manag ement of the healt h servic es would contr ibute towar d programme accel eratio n. In addit ion to adapt ing immu nizati on sched ules and recom menda tions for contr a indic ation s to meet natio nal needs , progra mme manag ers shoul d striv e to do the follow ing: (a) reduc e clinic waitin g times ;
(b) provi de mothe rs with speci fic inform ation conce rning react ions which may be expec ted as a resul t of immu nizati on and conce rning the time and place for any return visit s neede d to compl ete the immu nizati on sched ule; (c~
recor di
use the child healt h record s( growt h chart ) as the immu nizati on
(d) promo te the use of record system s which ident ify child ren who have not appea red for a sched uled immu nizati on clinic appoi ntmen t and activ ely follow up such child ren; (e) count ries which are plann ing accel eratio n any neces sary extra vacci nes and other mater ials well effor ts shoul d order in advan ce so that routin e servi ces are not compr omise d.
These activ ities will also reduc e drop out rates . 5. Speci fic immu nizati on cover age and disea se reduc tion targe ts should be set in all natio nal progra mmes . These are impor tant not only for monit oring programme progr ess, but for provi ding adequ secur e the suppl y of vacci nes and equipm ent neede d to ate lead-t ime to achie ve the targe ts. targe ts for measl es and neona tal tetan us. II
" "
I r r
Parti cular prior ity shoul d be accord ed to settin g disea se reduc tion for incor porat ion withi n natio nal
progra mme.
~hese.dis7ases have been recommended by ~mmun1zat1on and shoul d be consid ered
the expan ded programme on
Stand ardize d case defin ition s for
• I
J
31
Cold chain and vaccines Only vaccines meeting WHO's biological requirements should be procured, and the quality of these vaccines should be maintained by appropriate storage and transport systems. In the case of countries facing difficulties with the quality of locally produced vaccines, WHO should provide the support of its prestige, expertise and, where possible, resources, in improving quality, quality control and certification procedures fer EPI vaccines. Neonatal tetanus remains generally a neglected disease in the Region. Neonatal tetanus should be made a separately reportable disease in all countries of the Region. Countries in which no cases of neonatal tetanus have come to the attention of the health authorities are not necessarily free from this disease. Specific neonatal tetanus surveys should be considered in countries which report an infant mortality rate of over 20 per 1000 live births or 20% of the deliveries attended by untrained persons. Countries in which cases are recognized should develop a specific strategy for reducing the incidence to below 1 case per 1000 live births by 1990 and eliminated it by 1995. Where national incidence is already below one case per 1000 live births, a goal of elimination by 1990 should be adopted. Strategies should include a mix of approaches which include the following: (a) efforts to immunize all women of child-bearing age with special emphasis on pregnant women, women who are approaching child-bearing age, and women who are members of high-risk groups or live in high-risk areas; identification, training and supervision of birth attendants; and strengthening surveillance of this disease, including case investigation to identify reasons for failure to immunize.
(b) (c)
A mass tetanus immunization programme for women of child-bearing age should be considered in high-incidence areas, and tetanus should be included among the antigens administered during a national or subnational immunization day, week, etc. A record of the tetanus immunization status of the mother should be included in the child's immunization record. Measles remains a problem for all the children in all the countries of the Region, owing to low immunization coverage. Immunization should be started by the age of 9 months. Efforts should be made to achieve over 90% immunization coverage by 1995. Epidemiological analysis of reported cases and outbreak investigations of cases occurring in areas which have been immunized should be carried out. The results should be used to improve the efficacy of disease control strategies. Health education efforts should be made to reduce the incidence of measles by over 90 percent by 1995.
32
Hepatitis B - Chronic infection is highly endemic in most countries in the Region and the rate of mortality and morbidity due to chronic liver diseases and hepatocellular carcinoma is very high. Several countries in the Region have started to incorporate hepatitis B immunization within their national immunization programmes. Hepatitis B immunization should be integrated within the existing EPI, as costs of this vaccine permit, with special priority given to countries with carrier rates greater than 7%. The most effective hepatitis B immunization strategy for this Region is the immunization of all infants, beginning at birth. It is crucial that the first dose of vaccine (either plasma-derived or recombinant DNA) is given soon after birth, preferably within 24 hours. A second dose is required 1-3 months after the first, and a third dose 6-12 months after the second.
The high cost of screening women for HBsAg and of hepatitis B immune glohulin (HBIG) precludes this practice in most countries of the Region. Hepatitis B vaccine given at birth is highly effective in interrupting the transmission of hepatitis B, and should be the immunization strategy of first choice in developing countries. Japanese encephalitis remains a public health problem in some of the countries of the Region. Efforts should be pursued to define an effective immunization schedule compatible with a schedule appropriate for EPI and to introduce this vaccine as rapidly as possible in endemic areas. 6. Training still remains a priority. Progress in training has been made in the course of the acceleration efforts. National programmes should develop specific training plans which will systematically provide initial and remedial in-service training to all health workers involved in the provision of immunization services. All countries should incorporate appropriate training materials in the curricula of institutions training health personnel. This applies as well to training materials which have been developed for other programmes such as diarrhoeal disease control and acute respiratory infections. 7. The national and regional health information systems need National managers often receive incomplete provisional data, strengthening.
and must wait many months before official data are available. Data are not received regularly from all countries by the Regional Office,and the official data which are received are not always consistent with data available in the national programme manager's office. EPI information at the national level should be updated Regular feedback of this information should be provided to programme staff. As a basis for updating, the Regional Office should provide each country twice a year with a copy of the "EPI country profile", which reflects the most recent data concerning the country available at the Regional Office. continuo~sly.
Computerization of the regional and global EPI information systems has already taken place. Computerization of national EPI information system will continue to be encouraged and supported.
33
8. Half the population of the world is expected to live in large urban areas by the year 2000. Immunization coverage in such areas, particularly among disadvantaged populations, is typicallY low, despite the abundance of medical and logistic resources in comparison with rural areas. in rural areas. These areas,
particularly in the case of migrant populations, often introduce infections Opportunities to improve immunization services in urban
areas should be found. (a) (b) (c) (d)
The following actions may be considered:
Identify the problem. Check coverage and disease incidence to pinpoint neighbourhoods and population groups at high risk. Improve the identification and follow-up of persons requiring immunization services. Improve the quantity and quality of static and outreach services. Pronmte the formation of urban immunization committees or include immunization in the mandate of existing committees to ensure the necessary political support for improving services. Involve voluntary and nongovernmental organizations dealing with specific health issues. Use urban programme reviews patterned after national programme reviews to highlight problems and develop consensus regarding solutions. Use urban health facilities as sentinel surveillance sites for one or more of the target diseases. Consider introducing periodic mass immunization days, weeks or months to supplement routine services in cities where
(e)
regular epidemics of one or more of the target disease persist.
Poliomyelitis eradication The goal of eradication of poliomyelitis by the year 1995 within the Region was fully endorsed. The hope was expressed that all countries would be poliomyelitis free by 1992. As a matter of priority, each country should prepare a national plan for poliomyelitis eradication. In this plan it should be reaffirmed that the eradication of poliomyelitis should be complementary to the other components of the programme and should serve to accelerate the control and elimination of the other EPI target diseases. This plan should set national policies and strategies, preferably in consultation with all major donors, and serve as a joint guide for external programme support. Oral poliomyelitis vaccine (OPV) remains the vaccine of choice and three doses of OPV are recommended, starting at six weeks of age with four weeks interval between doses. In countries or areas where poliomyelitis
remains a problem, an extra dose at birth may be considered.
The plan for poliomyelitis eradication should include guidelines for improving immunization coverage by district, for classifying the poliomyelitis status of districts, and for s-etting priorities for outbreak investigations and epidemic control activities.
34
Additional resources from both internal and external sources at national and regional level are essential to formulate plans to strengthen the immunization delivery system and to support the further development of laboratory services, epidemiological surveillance and epidemic control. High immunization coverage with polio vaccine is a precondition for eradication. This will also improve coverage of other antigens and should be achieved through general strengthening of the programme infrastructure, including training, improvement of ~upervision, elimination of missed opportunities and adoption of more efficient immunization activities. National immunization day strategies should be considered in countries where poliomyelitis remains endemic despite strenghtening of routine immunization services. They represent a complement to routine services and should include all EPI antigens. Coverage data should be analysed by district (or equivalent geopolitical unit of about one million population). Priority for outbreak investigation and epidemic control measures should be given to those districts already achieving a significant coverage. Disease surveillance needs considerable strengthening in most countries and should include classification of districts in respect of the epidemiological situation of poliomyelitis incidence. It is anticipated that the strengthening of surveillance for poliomyelitis eradication will also result in improved surveillance and control of the other EPI target diseases. Monitoring of morbidity should include zero reporting by district. The proposed classification of countries and districts in three categories as a guide for selection of control strategies was recommended, although it was realized that this classification may require changes in the future. This classification is as follows: Poliomyelitis free Zero cases for three consecutive years, high coverage (over 90 percent) with a protective course of poliomyelitis vaCC1ne and reliable reporting from health facilities: Continue high coverage and maintain active surveillance. where immunization coverage is less than optimal it should be increased.
Low incidence areas:
Less than 10 cases per year for the last three years and over 50 percent immunization coverage:
Increase the coverage of TOPV3 to over 90 percent; Review reporting completeness; Investigate each suspected case.
- 35/36 -
High incidence areas:
Ten or more cases per year or incomplete data or less than 50 percent immunization coverage:
Increase the coverage of TOPV3 to over 90 percent; Review reporting completeness; Conduct outbreak investigations and epidemic control. If immunization coverage is greater than 50 percent, this should be given urgent priority along with vaccine efficacy assessment. Case definitions are recommended as follows: Suspected case: Any case of acute flaccid paralysis (including cases of Guillain-Barre Syndrome in children less than 15 years of age) for which no other cause can be immediately identified. Suspected case with
Confirmed case:
epidemiological linkage to another confirmed case or residual paralysis 60 days after onset or laboratory confirmation or death of suspected case or lack of follow-up of the case Laboratory support is essential for the poliomyelitis eradication effort. Regional and national plans should be developed to strengthen the reference network' and to support and strengthen laboratories as required. In low incidence areas, cases should be categorized as follows: wild virus/indigenous wild virus/imported vaccine associated
unknown/others
- 37 -
ANNEX 1 ORGANISATION MONDIALE DE LA SANTE
WORLD HEALTH ORGANIZATION
IIEGIONAl OFFICE FOil. THE WESTERN PACIFIC BUREAU II.tGIONAl DU PACIFIQUE OCCIDENTAL
WORKSHOP FOR MANAGERS OF THE EXPANDED PROGRAMME ON IMMUNIZATION Manila 27 June to 1 July 1988
WPR/EPI(1)/88.1 15 June 1988 ENGLISH ONLY
PROVISIONAL AGENDA
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Registration Opening ceremony Group photograph Global overview Regional overview Introduction to acceleration and country progress reports Surveillance - EPI target dieeases and trends Hepatitis B and JE immunization Eradication-lessons learnt Experiences of polio eradication initiative Surveillance with emphasis on Lameness survey Group work Laboratory aspects of polio~elitis polio~elitis
Polio~elitie country situation analysis Polio~elitis
and TOPV and IPV experiences
Polio eradication - introduction
Annex 1
- 38 -
WPR/ID'I(1 )/88.1
Page 2
18. 19. 20. 21.
Group work Polio surveillance and compensation schsme in Japan Presentation b7 interested parties - UNICEF, AlDAB, . RotarT International, SCI', SPe Group presentation For.ulation ot conclusions Conclusions and finalization Closing ceremoDT
22. 23. 24.
- 39 -
ANNEX 2 ORGANISATION MONDIALE DI LA SANTI
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOil THE WESTEIlN PACIFIC IUIlEAU ltGIONAL DU PACifiQUE OCCIDENTAL
WORKSHOP FOR MANAGERS OF THE EXPANDED PROGRAMME ON IMMUHIZATION Manila 27 June to 1 July 1988
WPR/EPI(1)/IB/2 Rev.2 30 June 1988 ENGLISH ONLY
LIST OF PARTICIPANTS, OBSERVERS, TEMPORARY ADVISERS AND SECRETARIAT
1.
PARTICIPANTS
AMERICAN SAMOA
Dr Tofiga Liaiga Assistant Director for Preventive Services P.O. Box 1623 Pago-pago Dr Ian F. Cook Director Public Health Section Communicable Diseases Branch Commonwealth Depart.ent of Community Services and Health G.P.O. Box 9848 Canberra, A.C.T.·2601 Hs
AUSTRALIA
BELAU, REPUBLIC OF
Nancy Mengloi Acting Public Health Clinic Supervisor c/o Bureau of Health Services P.O. Box 100 Koror Dr K.P. Louis Acting Assistant Director (Public Health) For District of Medical and Health Services Ministry of Health Bandar.Seri Begawan Dr Rajah Intan Bite Salleh Acting Senior Medical Officer of Health c/o Ministry of Health Bandar Seri Degawan
BRUNEI
Annex 2 WPR/EPI(1)/IB/2 Rev.2 Page 2
- 40 -
CHINA
Mr Yang Huixin
Programme Officer (responsible for coordination of EPI) Division of International Organizations Bureau of Foreign Affairs Ministry of Public Health Beiling Dr Tang Baojian Programme Officer (responsible for EPI activities) Division of Acute Communicable Diseases Department of Epidemic Prevention Ministry of Public Health Beijing COOK ISLANDS Dr Roro Daniel Senior Medical Officer Ministry of Health P.O. Box 166 Rarotonga Dr L.r. Naivalulevu Acting Assistant Director Primary & Preventive Health Services (Professional) Ministry of Health Tamavua Hr Venancio Imanil, Jr. Immunization Program Coordinstor Department of Public Health and Social Services P.O. Box 2816 Agana Dr Tse Lai-Yin Medical and Health Officer Hong Kong Medical and Health Department 9th Floor, Sunning Plaza 10 Hysan Avenue Hong Kong Dr Masaharu Itoh Director Infectious Diseases Control Division Health .Service Bureau Ministry of Health & Welfare Tokyo
FIJI
GUAM
HONG KONG
JAPAN
- 41 -
Annex 2 WPR/EPI(1)/IB/2 Rev.2 Page 3
KIRIBATI
Dr Terenganuea Taaraa Principal Medical Otticer (Health) Tungaru Central Hospital Tarawa ~~
KOREA, REPUBLIC OF
Hak-Kyoon Shin Chief of Enteric Virus Division National Institute ot Health Seoul Dr Keo Vilaysack Chet service de consultation ext erne et d'urgence tormateur en sante intantile au centre provincial de toraation a Savannakhet Hopital provincial de Savannakhet Vientiane Dr Phengta Vongphrachanh
LAO PEOPLE'S DEMOCRATIC REPUBLIC
Personne responsable du PEV au service de medecine preventive a l'In8titut d'Hygiene et Epidemiologie Vientiane MALAYSIA Dr Shatie bin Ooyub Senior Medical Otticer, Health National Tuberculosis Center Kuala Lumpur Ms Totha Arelong c/o Ministry ot Health Majuro
MARSHALL ISLANDS, REPUBLIC OF THE
MICRONESIA, FEDERATED STATES OF
Mr Kidsen K. Iohp Health Program Specialist tor Communicable Diseases Department of Human Resources Kolonia, Pohnpei 96941
NEW ZEALAND
Ms Lee McCloy Assistant Executive Otticer Communicable Diseases Department ot Health P.O. Box 5013 Wellington
Annex 2 WPR/EPI(1)/IB/2 Rev.2 Page 4
- 42 -
NOR'ntERN HARIANA ISLANDS, COMMONWEALTH OF THE
Hr Lorenzo Iriarte Public Health Administrator Commonwealth of the Northern Marianes Saipan
PAPUA NEW GUINEA
Hr Hoses Sitoo'u Acting Regional Epidemiologist New Guinea Islands Regional Unit P.O. Box 8 Rabaul
PHILIPPINES
Dr Consuelo Aranas Regional Health Director Office of Public Health Services Department of Health San Lazaro Compound Rizal Avenue, Sta. Cruz Manila Dr Alcindo M. Barbosa c/o Department of Health Services Caixa Postal 473 Macau lolr Tipasa Me
PORTUGAL
SAMOA
EPI Coordinator Health Department Apia Dr Carol LIM Kah Chao Medical Officer in Charge of MCH Clinic Ministry of Health Primary Health Department 2 Mount Sinai Plain Singapore 1027 Dr Ezekiel Taranga Nukuro Undersecretary Health Improvement Ministry of Health P.O. Box 349 Honiara
SINGAPORE
SOLOMON ISLANDS
- 43 -
Annex 2
WPR/EPI(1)/IB/2 Rev.2 Page 5
TONGA
Dr Malakai 'Ake Medical Officer Communicable Diseases Ministry of Health P.O. Box 59 Nuku'alofa Mr Arnold Bani
VANUATU
Assistant National EPI Coordinator Ministry of Health P.O. Box 207 Port Vila VIET NAM Dr Le Dien Hong Director, Depart.ent of Hygiene and Epidemiology Ministry of Health Hanoi
2.
OBSERVERS
UNICEF STAFF
Mr
Kunio Waki Deputy Regional Director UNICEF East Asia and Pakistan Regional Office Bangkok Thailand Ms Shangguan Yun National Programme Officer for Health UNICEF, China OCB No. 12 Sanlitun Lu China
Mr
Walter Sitzman Programme Officer c/o UNICEF Representative P.O. Box 1080 Vientiane Lao People's Democratic Republic
Annex 2 WPR/EPI(1)/IB/2 Rev.2 Page 6
- 44 -
Me Judy Otto
Project Officer, Pacific Programme Office of the UNICEF Representative NED/. Build ing Legupi Village Makati, Metro Manila Philippines Steven Allen Senior Programme Officer c/o UNICEF Representative Viet Nam Office Khach San Hoa Binh HT 45 Hanoi SOCIalist Republic of Viet Nam Mr
Rotary International
Mr Herbert A. Pigman
Director Immunization Task Force Rotary International The Rotary Foundation One Rotary Center 1560 Sherman Avenue Evanston, Illinois 60201 United States of America South Pacific Commission Steven Terrell-Perica Health Surveys Epidemiologist South Pacific Commission P.O. Box D5 Noumea Cedex New Caledonia Mr
United States Agency for International Development
Mr Alasdair \~y1ie EPI Adviser (Resources for Child Health Project) MCH Service Department of Health San Lazaro Compound, Sta. Cruz Manila Philippines
- 45 -
Annex 2 WPR/EPI(1)/IB/2 Rev.2 Page 7
3.
TEMPORARY ADVISERS
Dr Isao Arita Director Kumamoto National Hospital 1-5. Ninomaru. Kumamoto shi Kumamoto-ken 860 Japan Dr Stephen Cochi Start Medical Epidemiologist Surveillance, Investigation and Research Branch Division ot Immunization Center tor Prevention Services Centers for Disease Control Atlanta. Georgia 30333 United States of America Dr Harold Margolis Chief Hepatitis Branch Division ot Viral Diseases Center for Infectious Diseases Centers for Disease Control Atlanta. Georgia 30333 United States of America
4.
SECRETARIA T
Dr T. Bektimirov Assistant Director-General World Health Organization Geneva Switzerland Dr Agostino Borra Medical Officer WHO Regional· Otfice for the Western Pacific Manila Philippines
- 46 -
Annex 2 WPR/EPI(1)/IB/2 Rev.2 Page 8
Dr Giuseppe Cuboni Medical Officer ICP/HST/OOl WHO/Suva FijiDr Hiroyoshi Endo Medical Officer WHO Regional Office for the Western Pacific Manila Philippines
Mr Mauno Erkkila EPI Technical Officer, Cold Chain WHO Regional Office for the Western Pacific Manila Philippines Dr R. Henderson Director Expanded Programme on Immunization World Health Organization Geneva Switzerland Dr Henrica Jansen Associate Professional Officer WHO Regional Office for the \'iestern PacifiC Manila Philippines Dr Pekka J. Jousilahti Associate Professional Officer World Health Organization Papua New Guinea Dr Ko Keja Medical Officer Expanded Programme on Immunization World Health Organization Geneva Switzerland Dr Gennady Martchenko Consultant WHO Regional Office for the Western Pacific Manila Philippines
- 47 -
Annex 2 WPR/EPI(1 )/IB/2 Rev.2 Page 9
Dr Harkishan Mehta Regional Adviser, Communicable Diseases WHO Regional Office for the Western Pacific Manila Philippines Dr Jean Marc Olive WHO Regional Office for the Americas Washington, D.C. United States of America Dr Sergio Pieche Associate Professional Officer WHO Regional Office for the Western Pacific Manila Philippines Mr Frank Rousar Field Development Officer rcp /EPI/001 WHO/Suva Fiji-Dr Akira Shimouchi Medical Officer WHO Regional Office for the Western Pacific Manila Philippines Dr Sima Huilan Regional Adviser, Health Laboratory Technology WHO Regional Office for the Western Pacific Manila Philippines Dr Takusei Umenai Director, Disease Prevention and Control WHO Regional Office for the \'Iestern Pacific Manila Philippines
r
I