(WP)EPI/ICP/VID/OO I-A Report series number: RS/96/GE/04/(AUSl English 001 y
REPORT
SEVENTH MEETING OF THE TECHNICAL ADVISORY GROUP ON THE EXPANDED PROGRAMME ON IMMUNIZATION AND POLIOMYELITIS ERADICATION
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Canberra, Australia 9-13 April 1996
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines January 1997
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NOTE
The views expressed in this report are those of the participants of the seventh Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization.
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for the participants in the seventh meeting of the Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication in the Western Pacific Region, which was held in Canberra, Australia, from 9 to 13 April 1996.
CONTENTS
SUMMARY 1. INTRODUCTION ...................................................................................... 1 1.1 Objectives .......................................................................................... 1 1.2 Organization ........................................................................................ 1 1.3 Opening ceremony ............................................................................... 2 2. PROCEEDINGS 2.1 2.2 2.3 2.4 2.5 2.6 2.7 3
Global EPI overview ..................................................................... , ....... 3 Regional EPllpoliomyelitis eradication overview .......................................... 3 Regional laboratory overview ................................................................ 15 Regional operational issues ................................................................... 20 Country reports ................................................................................. 24 Progress in poliomyelitis eradication in SEARO ......................................... 38 Reclassification of AFP cases: Changing from clinical to virological case definition ..................................................................... 39 2.8 Measles surveillance and control ................................................... ; ........ 45 2.9 Measuring progress towards neonatal tetanus elimination in the Western Pacific Region ................................................................ 48
3.
CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC .................... ., ............................................... 51 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Criteria for certification ....................................................................... Current status of certification ................................................................ Surveillance activities and certification standards ........................................ Surveillance activities in non-poliomyelitis-endemic countries ........................ Additional surveillance activities for the Pacific island Subregion ................... Documentation required from each country for certification ........................... Role of the WHO secretariat in the certification of poliomyelitis eradication ...... 51 52 53 53 54 54 55
4.
MEETING OF THE REGIONAL INTERAGENCY COORDINATING COMMITTEE (ICC) ................................................................................. 55 4.1 Opening .......................................................................................... 55 4.2 Reports by ICC members ..................................................................... 55
Keywords: Immunization I Poliomyelitis - prevention and control I Western Pacific I Australia
5.
CONCLUSIONS AND RECOMMENDATIONS ............................................. 57 5.1 Progress since the last TAG meeting ....................................................... 57 5.2 Major issues and recommendations ......................................................... 58
6.
ACKNOWLEDGEMENTS ......................................................................... 63 MAPS: MAP I MAP2 MAP 3 TABLES: TABLE I TABLE 2 TABLE 3 - EPI ANTIGEN COVERAGE IN POLIOMYELITIS-ENDEMIC COUNTRIES OF THE WESTERN PACIFIC REGION, 1994-1995 .... 4 TOTAL AFP CASES REPORTED, CONFIRMED POLIOMYELITIS CASES AND WILD VIRUS-ASSOCIATED CASES, 1992-1995 ....... 6 NATIONAL IMMUNIZATION DAYS IN THE WESTERN PACIFIC REGION, 1992-1996 (AS AT I APRIL 1996) ........................................................... 9 - DISTRIBUTION OF REPORTED AFP CASES IN WPR 1995 .......... 5 DISTRIBUTION OF REPORTED POLIOMYELITIS CASES IN WPR 1995 ........................................................................ 6 - DISTRIBUTION OF REPORTED WILD POLIOVIRUS CASES IN WPR 1995 ........................................................................ 7
TABLE 4
- AFP SURVEILLANCE PERFORMANCE INDICATORS, WESTERN PACIFIC REGION, 1994 AND 1995, CASE INVESTIGA TlON COMPLETENESS AND TIMELINESS IN PERCENT (%) OF REPORTED AFP BY COUNTRy .............. II - AFP SURVEILLANCE PERFORMANCE INDICATORS, WESTERN PACIFIC REGION, 1994 AND 1995, LABORATORY SPECIMEN COMPLETENESS AND TIMELINESS IN PERCENT (%) OF REPORTED AFP, BY COUNTRy .................................................................... II - REPORTED NUMBER OF MEASLES CASES IN PRE-VACCINE ERA AND IN 1995 SELECTED COUNTRIES OF THE WESTERN PACIFIC REGION ................................................ \3 - LABORATORY RESULTS ON AFP CASES WITH STOOL SPECIMENS, 1995 .............................................................. 17 - INTRATYPIC DIFFERENTIATION OF POLIOMYELITIS ISOLATES FROM AFP CASES WITH SPECIMENS RECEIVED IN 1995............................................................. 17 - SUMMARY OF PROFICIENCY TEST SCORES FOR NATIONAL POLIOMYELITIS LABORATORIES, 1992-1994 ........ 18
TABLE 5
TABLE 6
TABLE 7 TABLE 8
TABLE 9
TABLE 10 - LABORATORY PROFICIENCY FOR NATIONAL LABORATORIES-NPEV ISOLATION RATES AND LABORATORY TIMELINESS ........................................ ········ 18 TABLE 11 - LABORATORY PROFICIENCY FOR CHINESE PROVINCIAL LABORATORIES - NPEV ISOLATION RATES AND LABORATORY TIMELINESS ............................................... 19 TABLE 12 NUMBER OF CLINICALLY CONFIRMED POLIOMYELITIS CASES AND VACCINATION STATUS OF CASES, CHINA, 1993-1995 ................................................................ 27
TABLE 13 - SUMMARY OF SELECTED AFP SURVEILLANCE INDICATORS, 1995, CHINA ................................................. 28 TABLE 14 REPORTED AFP RATE PER 100 000 CHILDREN UNDER 15 YEARS, SEARO .................................................. 38
TABLE 15 - CURRENT POLIOMYELITIS SITUATION IN SEARO COUNTRIES ...................................................................... 39 TABLE 16 GROUPING OF COUNTRIES IN THE WESTERN PACIFIC REGION BY CURRENT STATUS OF MEASLES CONTROL.. .................. 46
TABLE 17 - SURVEILLANCE AND IMMUNIZATION ACTIVITIES DURING 1996 TO 1998, BY COUNTRY GROUP, WESTERN PACIFIC REGION ................................................ 47 TABLE 18 FIGURES; FIGURE I - IMMUNIZATION COVERAGE, 1984-1995 ................................. 4 FIGURE 2 - WESTERN PACIFIC REGION REPORTED POLIOMYELITIS CASES AND OPV3 COVERAGE 1980-1995 ................................ 8 FIGURE 3 FIGURE 4 FIGURE 5 STATUS OF AFP CASE INVESTIGATION IN THE WESTERN PACIFIC REGION 1995 ........................................... 9 - REPORTED AFP, CONFIRMED POLIOMYELITIS AND WILD POLIOVIRUS WESTERN PACIFIC REGION 1992-1995 ..... 10 - PARTNER SUPPORT FOR OPV REQUIREMENT ...................... 12 INDICATORS FOR MONITORING PROGRESS TOWARDS NEONATAL TETANUS ELIMINATION .................................. 50
FIGURE 6 - CLINICAL CASE CLASSIFICATION CRITERIA ....................... 40 FIGURE 7 FIGURE 8 VIROLOGICAL CASE CLASSIFICATION OF AFP CASES .......... 41
- ESTIMATING "POLIOMYELITIS-COMPATIBLE" CASES FOR A POPULATION OF 20 MILLION ................................... 43
FIGURE 9 FIGURE 10FIGURE 11-
VIROLOGICAL CLASSIFICATION OF AFP CASES IN VIET NAM .................................................................... 44 VIROLOGICAL CLASSIFICATION OF AFP CASES IN CHINA .............................................................................. 44 ORGANIZATION OF CERTIFICATION PROCESS IN WPR ......... 52
ANNEXES: ANNEX I ANNEX 2 - TIMET ABLE ...................................................................... 65 PROVISIONAL LIST OF TAG MEMBERS, EPI NATIONAL MANAGERS, OTHER HEALTH-RELATED PROFESSIONALS, OBSERVERS/REPRESENTATIVES, AND SECRETARIAT .......... 67 WESTERN PACIFIC REGION: EPI COVERAGE DATA 1994/1995 .......................................................................... 77 REPORTED CASES OF MEASLES AND NEONATAL TETANUS WESTERN PACIFIC REGION 1994-1995 .................. 79 DETAILED FLOW CHART OF AFP SURVEILLANCE 1995 ........ 81 PROGRESS MADE IN NEONATAL TETANUS ELIMINATION IN WESTERN PACIFIC COUNTRIES 1993 TO 1995 .................. 83
ANNEX 3 -
ANNEX 4 ANNEX 5 ANNEX 6
SUMMARY
The seventh meeting of the Technical Advisory Group (TAG) on the Expanded Programme on Immunization (EPI) and Poliomyelitis Eradication was ~ttended ~y 115 participants and observers. Thes~ includ~ five members of the T~c~mcal A~vlsory ~roup, EPI managers within the Western Pacific RegIOn fwm seven poliomyelitis-endemic co~ntnes.and two non-poliomyelitis-endemic countries, an EPI mana~er ~rom tho: South-Eas~ A~la RegIOn, representatives from the Regional ~eference Laboraton~, Int~rnatlO.n~1 orga.mz~tIons, WHO Regional Office for South-East ASia and other partners In poliomyelitiS eradication, and a secretariat. The purpose of the meeting was to review progress in the EPI and poliomyelitis eradication in order to make recommendations for 1996, to disseminate information on the latest EPI developments, to coordinate technical support, to improve coordination among present and potential EPI partners and national governments, and to exchange epidemiological information and promote interregional cooperation with the South-East Asia Regiun. Regional immunization coverage for infants was maintained at over 90% in 1995, and there were significant increases in coverage in Cambodia and in the Lao People's Democratic RepUblic. Surveillance for neonatal tetanus indicates that the disease has been reduced to below one case per thousand live births per year in almost all countries and areas in the Region. Measles morbidity has declined by at least 90% compared with the pre-immunization era. Countries and areas are progressively implementing national plans of action for safe sterilization and injection practices, and for EPI cold chain and logistics. Progress has also been made in implementing the Regional plan of action for vaccine self-sufticiency. At the end of 1995, the Region was very close to achieving the 1995 Regional goal for the eradication of poliomyelitis. Only 426 clinically contirmed cases had been reported by 22 March 1996, half the total for 1994 of which only 19 were wild poliovirus-associated cases. Only one imported wild poliovirus-associated case was detected in China in 1995, despite the fact that over 5600 AFP cases were reported in 1995 in the Region, with specimens taken from 90% of cases. With greatly improved surveillance fllf AFP (acute tlaccid paralysis) and poliovirus in the Region, the TAG currently believes that the last focal points of wild poliovirus transmission are the Mekong Delta Region of Viet Nam and Cambodia, and the border between Myanmar and China. By the end of 1995, China and Viet Nam had achieved the level of surveillance quality required for the adoption of the virological case c1assitication criteria. The Regional Interagency Coordinating Committee met for the sixth time during the TAG meeting, receiving funding commitments for OPV (oral poliovirus vaccine) costs for national immunization days (NIDs) and subnational immunization days (SNIDs) for the winter season of 199611997. Despite the improvements in AFP surveillance quality, efforts and resources are still needed to sustain surveillance systems, and in particular for the continued development of the laboratory network.
1. INTRODUCTION
In September 1988, tbe Regional Committee for tbe Western Pacific adopted a resolution calling for poliomyelitis eradication in tbe Region by 1995, witbin tbe context of strengtbening tbe overall Expanded Programme on Immunization (EPI) and as a major step on tbe way to achieving tbe goal of global poliomyelitis eradication by tbe year 2000. The first meeting of tbe Technical Advisory Group (fAG) on EPI and poliomyelitis eradication in tbe Western Pacific Region (WPR) was held in Tokyo, Japan in April 1991. The next five TAG meetings were held in tbe Philippines (Cebu and Manila), China (Beijing), Viet Nam (Ho Chi Minh City) and Cambodia (phnom Penh). The TAG meetings have focused on priority areas of EPI and poliomyelitis eradication including AFP surveillance, national immunization days, strengtbening tbe laboratory network, and certification of poliomyelitis eradication, reflecting tbe progress of tbe programme.
1.1
Objectives
The TAG held its seventh meeting in Canberra, Australia from 9 to 13 April 1996, with the following objectives: (1) to review tbe EPI and poliomyelitis eradication situation in tbe Western Pacific Region; (2) to make furtber recommendations for action on EPI and otber disease initiatives, based upon a review of progress made since tbe sixtb TAG meeting, particularly in tbe area of laboratory surveillance; (3) to disseminate information on the latest EPI developments, including neonatal tetanus elimination, and measles control; (4) to review supplementary immunization activities for 1996 and beyond; (5) to propose a plan of action, budget and criteria to be used by tbe Regional Certification Commission; and (6) to ensure furtber progress in vaccine self-sufficiency in countries of the Region. 1.2 Organization
The meeting was attended by 115 participants and observers. These included five members of tbe Technical Advisory Group, EPI managers within the Western Pacific Region from seven poliomyelitis-endemic countries and two non-poliomyelitis-endemic countries, an EPI manager from tbe Soutb-East Asia Region, representatives from the Regional Reference Laboratories, international organizations, WHO Regional Office for South-East Asia and otber partners in poliomyelitis eradication, and a secretariat. Annex 1 shows tbe timetable of tbe meeting, and Annex 2 contains tbe list of participants.
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1.3
Opening ceremony
Dr S.T. Han, Regional Director, WHO Regional Office for the Western Pacific, opened the meeting and noted the great progress made towards eradicating poliomyelitis from the Region in the last leVen years, with only 19 wild poliovirus-associated cases reported in the Region in 1995. He thanked the international partners for their continuous support, noting that the Government of Australia, through AusAID, was one of earliest partners and continued to provide valuable support, making it fitting that the seventh TAG meeting was being held in Canberra. Dr Han noted the great efforts to successfully conduct national immunization days and to establish the surveillance and laboratory systems necessary for poliomyelitis eradication and certification. Dr Han emphasized that continued improvements in the qual ity of supplementary immunization activities will be required. He noted that the first meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region would be held following the TAG meeting and expressed his hope that all countries will establish national committees without delay. Dr Han noted that along with progress in poliomyelitis eradication, there has also been continued progress towards the goals of the elimination of neonatal tetanus and control of measles as well as improvements in the quality and coverage of immunization services, particularly ensuring safe injections. Looking to the future, Dr Han 'noted the progress towards poliomyelitis eradication being made by the South-East Asia Region providing confidence that the global goal of the year 2000 will be reached on schedule. Dr Michael Wooldridge, Commonwealth Minister of Health and Family Services, addressed the meeting and expressed his pleasure at having this TAG meeting in Australia. He expressed excitement at the prospect of global eradication of another disease, noting the pride that Australia took in being part of the international poliomyelitis eradication and EPI efforts. Dr Wooldridge stated that Australia would continue to provide as much help as possible. The following TAG members were appointed to serve as officers for the meeting: Chairman Vice-chairman Rapporteur Dr Isao Arita Dr Kenneth Bart Dr Robert Hall
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2. PROCEEDINGS
2.1
Global EPI overview
National EPI programmes have demonstrated a capacity to sustain high levels of immunization coverage since the peak levels attained in 1990. The optimism generated by this achievement provides confidence to expand efforts in other areas, such as disease surveillance, and the quality of vaccine delivery systems and programmes. However, there is clearly room for improvement in routine EPI coverage. This is especially true for some countries in the African and Eastern Mediterranean Regions, and in hard-to-reach popUlations in other countries. In the Western Pacific Region, the overall coverage levels in 1995 continued to exceed global levels for all infant EPI antigens. Generally high coverage levels, together with supplementary activities, have resulted in a continuing decline in the global incidence of poliomyelitis, neonatal tetanus, and measles. National immunization days (NlDs) have been important to this process, particularly for poliomyelitis. NlDs have been conducted or are planned in 88 countries in 1996, up from 62 countries in 1995, and 19 countries in 1992. Contributing further to the decline in cases are the focused interventions made possible by improved surveillance. On the other hand, 1995 saw a progression of the serious diphtheria epidemic of the last few years in the Russian Federation and Newly Independent States, and also the continued poor reporting of some EPI diseases, especially neonatal tetanus. The high and sustained coverage levels in most routine EPI programmes allow a new emphasis on such issues as the development of better injection equipment, the safety of injection practices, the monitoring of adverse events, and the introduction of vaccine vial monitors. These initiatives are being supported by continued attention to the training needs of health care workers. The EPI is further promoting case-based surveillance, through improved clinical recognition and reporting, and expanded laboratory capabilities. This can provide the information needed for targeted neonatal tetanus interventions, for the prediction and prevention of measles outbreaks, and for the continued pursuit and eradication of wild polioviruses.· Substantial challenges still remain, in 1996 and beyond, in the effort to achieve effective surveillance and disease control. Progress on other fronts in the EPI programme includes the incorporation of hepatitis B vaccine into national immunization programmes, which is now a policy in 75 countries; and the continued development of new, improved vaccines. 2.2 Regional EPilnoliomyelitis eradication overview
This paper provides a progress report on the expanded programme on immunization and the disease control initiatives within the EPI in the Western Pacific Region: poliomyelitis eradication, neonatal tetanus elimination, and measles control. The EPI was initiated in 1976 and the Regional Committee resolved in 1988 to eradicate poliomyelitis in the Region by 1995. The initiative for neonatal tetanus elimination bas a goal of less than one case per thousand live births at the district level by 1995, and for measles control a decline of 95% in measles mortality, and 90% in measles morbidity, compared with the pre-immunization era, by 1995.
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2.2.1
Immunization coverage
In 1995, the Regional coverage for EPI antigens was 94% for BeG, 92% for DPTJ, 93% for OPV3, and 89% for measles (see Annex 3 and Figure I). The calculated Regional coverage for tetanus toxoid for pregnant women remains low, at 17'J1i, despite increased neonatal tetanus elimination activities, as some countries only implement immunization of pregnant women in high-risk areas. Most countries have sustained a high level of coverage for EPI antigens, and there have been increases in coverage in at least two countries since 1994 (see Table I). Figure 1. Immunization coverage, 1984 - 1995 (children < 1 year and pregnant women for 112) Western Pacific Region 100
80
60 40
20
o BeG OPT 3
OPV 3
MEASLES
TT 2 (Preg. women)
"1984 "1988 "1990 "1991 "1992 "1993 CJ1994 .. 1995 O.I.IrOM WPRO eElS II 0122 ... tell lI.e WP.COV8W.PIIS
Table 1.
EPI Antigen coverage in poliomyelitis-endemic countries of the Western Pacific Region 1994-1995 (in rants and pregnant women)· BCG 1994 1995 78 95 94 69 91 91 95 94 94 59 94 91 96
COUNTRY Cambodia
DPTJ 1994 1995 53 79 93 48 66
OPV3 1994 1995 54 80 94 58 66
MEASLES 1994 1995 53 75 89 73 84 86 96 89 89 68 85 86 96 89
1Tl+" 1994 26 ...
1995 36 11
China Lao PDR Papua New
93 54 61 86 74 92
94 64
34 41 39 79 16
35 55 48 82 17
68 86 94 93
GuinN Philippines
85 94 92
81 94 93
Viet Nom REGIONAL COVERAGE
94
* Coverage (or at least two doses of tetanus toxoid for pregnant women Data from WPRO eElS as of 22 March 1996.
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2.2.2
Impact of EPI on target diseases Poliomyelitis is now very near to eradication (see section 2.2.3).
The total number of reported cases of EPJ target diseases contioues to decline 88 • rlllU1t of sustained high immunization coverage. An outbreak of diphtberia occurred in Mongolia In 1995, which was controlled by two national immunization campaigns In 1996 with combined diphtheria and tetanus vaccine (the first for children three to 15 years of age, the second for adults 16 to 40 years of age).
Despite high BCG coverage, tuberculosis remains a major problem In many countries, but the majority of cases are among adults. Measles outbreaks continue to occur in most countries, though at a much lesser magnitude in comparison with the pre-immunization era. Most outbreaks are usually associated with localized areas of low measles immunization coverage, or in highly popUlated urban centres. Although neonatal tetanus Is stili underreported, there were Improvements In surveiliance in 1995. As a result, countries were able to define high-risk areas more precisely, and to focus
on tetanus toxoid immunization activities in the communities where the disease still occurs (Annex 4). 2.2.3 (1) Poliomyelitis erad ication Present epidemiological situation
The Region is now essentially free of poliomyelitis as the circulation of wild poliovirus is confined to the Mekong Delta region of Cambodia and Viet Nam, though there is stili a risk of importation across borders with other Regions. As of 22 March 1996, over 5600 AFP cases have been investigated in the Region during 1995 (see Map I) and only 19 cases of poliomyelitis have been confirmed by wild poliovirus isolation under conditions of high quality surveillance (see Map 3 and Table 2). Eighteen of the 19 wild poliovirus cases were from the Mekong Delta region of Cambodia and Viet Nam, and one case was reported from the border between China and Myanmar and is classified as having been imported into China. Map 1. Distrib.tioD 0' reported AFP eues iD WPR 1995
."
AFP 1995 5,640 .. of n MardI 1996
. . \J
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Although 426 of the AFP cases reported in 1995 were confirmed as poliomyelitis by clinical criteria (see Table 2 and Map 2), most of the cases, especially in China, are not true poliomyelitis, but are due to diseases that resemble poliomyelitis. Indigenous wild poliovirus has not been r~ from China, the Lao People's Democratic Republic, Papua New Guinea, the Philippines;" the Northern region of Viet Nam in 1995. Table 2. Total AFP cases reported, confirmed poliomyelitis cases and wild vIrus-associated cases, 1992·1995 TotaIAfP ..... country Cambodle Chino LaoPDR Malaysia
reported
Conftrmed iI. polio ( lnCIIor.llnlc..,
WIld IIinII II 111 185 11 0 0 0
tI 146 2,468 10 0
n 135 1,818
84 301 3,096 11 17
81 178 4.802 19 7 0
82 146 1.191 7 3 1 0
83 135 538
84
2116 281 6 0 0
" 0 0 0 0
.~
.........,. II
..
II 11 1· 0 0 0 0 0 0
4 101 0 0 0 0
33 0 0 0 0 0 0
Mongolia
... ... ... 73 47 0 653
9 1
7 0
2 0 15 0 452 0
1 0 6 0
PNG PhUippI_ South Pacific
16 86 0
13 128 1 353 1 3.91'
13 153 3 465 0 &.640
2 10 0
13 0 557 0 1,918
4 0
7 0
VIetnam Others
807 1 2.871
124 0
135 0
0
28 0 31
157 0
35 0
7 0
. WPR
3.417
1,149
619
428
28'
74
l'
Latest _ _ data from WPRO AFP Suoveiliance System • China wild vIruo Imported. data 22 March 1996 ••• no data
Map 1. Distribution of reported poliomyelitis cue. in WPR In 1995
(j' .
p. D. A .'
.,~ Polio 1995 ,...----------, N........fpollo ..... :
~\
426 u
.r 11 Mueh 1996
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e .. .~ i
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Surveillance for AFP has improved to the extent that almost 90% of the AFP cases reported in 1995 had at least one stool sample analysed. On the national level, survelIlance is now reliable eDOII,Ib in China and Viet Nam to enable those two countries to confirm as .,se AFP cases that are associated with isolarion of wild poliovirus. poliomyelitis
0..,
The laboratory network has made impressive gains in Improving the reliability and timeliness of virological surveillance, particularly after a meeting which was held in Manila in October 1995 to discuss the laboratory situation, and to set guidelines for future progress. The performance indicators of each laboratory are routinely monitored and the indicators are published together with the weekly AFP surveillance report. (2) Immunization (a) Routine OPV coverage
During 1995, routine immunization coverage for OPV3 was maintained at over 90% in the Region (Figure 2), but increased from 58% to 64% in the Lao People's Democratic Republic and from 54% to 80% in Cambodia compared with 1994 (fable 1).
Figure 2. Western Pacific Region Reported Poliomyelitis Cases and OPV3 Coverage Polio ea.... OPV3 Co.....ge ('Mo) 100 ________________________________________ ~ ~ ~ ' ,
.....
94
93
92
13
93
93
-
• • " a a M U • " • • • "
"'".
....
n
U
--..... M
-.,
...
'"'
- ...
Yea,
• prowi5lonal data bIIsed on ..... uaI trends and informlltion (MIilabie as of 22 MAR [)reg, Source: WHOrIWPRO CBS and WPRO Polio SU......lance
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Table 3.
National immunization days in the Western PaeIne Region 1992-1996 (as at 1 April 1996) TOTAL SNIDS I I 2 0 0 0 I 5 TOTAL N1DS 2 Co.,. .ge 95"" >80% 80% 9'"
Country Cambodia China LaoPDR Mon2olia PNG Philippines Viet Nam REGION TOTAL (b)
Other And2ens Vit A
Number .Inununlzed 1.9 million 83 million 650,000 424000 NA 9.9 million 9.7 million
3 3 2 0
Measles DPT, Vit A Diphtheria tetanus
-
Vit A IT Measles Vit A IT Measles
3 3
94% 99%
16
lOS million
Supplementary OPV immunization
Supplementary immunization with OPV during national immunization days has been instrumental in eliminating the circulation of wild poliovirus. A total of 16 NIDs have been conducted in the Region from 1992 to 1995. In the 199511996 winter season, countries made great efforts to ensure high quality NIDs by focusing on areas and age groups at high risk for ongoing poliovirus transmission, and by improving social mobilization. It is worth noting that Cambodia has reduced its burden of poliomyelitis by almost two-thirds (from 296 cases to III cases) after just one year of national immunization days, while simultaneously greatly improving surveillance. (3) Poliomyelitis surveillance indicators
In 1995, over 5600 cases of AFP (see Map I) were reported throughout the Region which was an almost 50% increase over the 1994 total. Almost 100% of these AFP cases were investigated (Figure 3), and 90% had at least one stool sample sent for analysis, 70% bad two stool samples within 14 days of onset. Figure 3. Status or AFP case investigation in the Western Pacine Region 1995 Reported as AFP 5,940
• 0 0 0 0
Not investigated 16
Investigated 5,924
~--------------------
AFP 5,640
Not AFP 300
Poliomyelitis ("confirmed") 426
NOll-polio AFP ("discarded") 5,068
Pending 146
Latest available data from WPRO AFP Surveillance ,yotem •• of22 March 1996.
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Only 426 cases of AFP were clinically confirmed as poliomyelitis (see Map 2 and Annex 5), a decrease of 40" compared to 1994's total of 700 cases. Only 19 of the 1995 AFP cases were contimlld as poliomyelitis by wild virus isolation (see Map 3). All six COIIIIIHes currently reporting poliomyelitis have well established national AFP surveillance .ystems. The Improvements in completeness and timeliness of AFP surveillance in each country since 1994 are shown in Tables 4 and 5. Figure 4 shows how AFP surveillance has improved while the total number of poliomyelitis cases and those confirmed by wild poliovirus isolation has diminished.
Ftgure 4. Reported AFP, confirmed poliomyelitis and wild poliovirus Western Pacific Region 1992-1995
Theusan4s ..........• WId\llrus
7 6
ElConfinred Pdio [JAfP reported
5 <4
3
2
~~~~~ 1992
1993
1994
1995
Table 4.
AFP surveillance perrormance indicators, Western Pacific Region, 1994 and 1995Case investigation completeness and timeliness in per cent (%) or reported AFP, by country ••••••
Cambodia
China
Lao
PNG
Philippines
Viet Nam
Performance Indicator .
1994 37 10 37 37
1995 99
1994 100 86 95 100
1995 100 87 86 90
1994 100 91
1995 100 95 60
1994 99
1995 100 54 75
1994 99
1995 92 55 30 49
1994 100 81 54 63
1995 100 80 69 76
I. Case Investigation completeness
1.1 AFP investigated 1.2 follow up after 60 davs 2. Case Investigation timeliness 2.1 within 48 hours 2.2 within 7 days
81 86 95
69 6 17
75 29 50
... -'--':'-'
-
93
_JL
Table 5.
AFP 5u"eillance performance indicators, Western Pacific Region, 1994 and 1995Laboratory specimen completeness and timeliness in per cent (%) or reported AFP, by country
Philippines
Cambodia PerCormance. Indicator
China
Lao
PNG
Viet Nam
1994 1. Laboratory completeness 1. I at least one stool specimen 1.2 two stool specimens or more 2. Laboratory timeliness 2.1 at least one specimen within 14 days 2.2 two stool specilll~ns within 14 days_ 17 12 11
1995 49 47 33 30
1994 77 66
1995 92
1994 63 46
1995 79 63 47 32
1994 17 17 33
1995 85 54 85 36
1994 69 62 40
1995 77
1994 74 59 65
1995 81 72
88 80 75
71
7
58 51
18
..
..
30
41 32
74 66
51
• LaIeot available data from WPRO eElS as of 22 March 1996.
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(4)
Partner support
Although the lovernments of the countries concerned provide the major part of the resources required !br the EPI and poliomyelitis eradication, international support has been instrumental in the .uccessful implementation of poliomyelitis eradication activities in the Region. (i)
Vaccine
From 1992 to 1996, a total of US$ 32.2 million has been provided by international partners for the purchase of oral poliovirus vaccines for supplementary immunization (Figure 5). Figure S. Partner support Cor OPV requirement Poliomyelitis eradication, Western Pacific Region 1992-1996
Total: US$32.2 million
.......... (ii)
As al l. AprII996 ; Includes committed as wei as rIICieved finis
Non-OPV support
In addition to the provision of vaccine, since 1992, a total of US$ 11 million has been committed by partners, for staff, supplies and equipment, and operational costs for surveillance and NlDs. 2.2.4 Neonatal tetanus elimination (NTE)
The six countries in the Region that have recently reported neonatal tetanus (NT) are: Cambodia, China, the Lao People's Democratic Republic, Papua New Guinea, the Philippines, and Viet Nam . These countries have made much progress in 1995 with the improvement of surveillance and increase in tetanus toxoid coverage for pregnant women (Annex 6). China conducted tetanus toxoid immunization campaigns at the end of 1995 in over 200 counties that had been identified as high risk, while the Philippines incorporated tetanus toxoid immunization for women of child-bearing age in NlDs in all areas, and Viet Nam in selected
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high-risk areas. Cambodia, the Lao People's Democratic Republic and Papua New Guinea have made steady progress with routine tetanus toxoid immunization. By the end of 1995, China had reduced the incidence of NT to below one case per thousand births at the county level, while the Philippines and Viet Nam had similarly reduced NT incidence to below one case per thousand births at the province level. These countries will continue to use surveillance data to identify high-risk districts where routine tetanus toxoid immunization should be offered to pregnant women and non-pregnant women of child-bearing age. 2.2.5 Measles control
In many countries and areas of the Region, measles cases and deaths are underreported. However, surveillance has improved over the years and measles reporting in most countries is more complete now than ten years ago. Available reports show (fable 6) that most WPR countries and areas have attained the 1995 goal of 90'JI. disease reduction. The great reduction in reported cases is directly attributable to good routine coverage with measles vaccine.
Table 6. Reported number or measles cases in pre-vaccine era Dnd in 1995 Selected countries or the Western Pacific Region
country
Cambodia China Malavsia Mongolia Philippines PNG Viet Nam
Number of measles cases reported % reduction In cases by 1995 1995 Pre-vaccine era (1982) 95% 57,605 2,867 (1978) 76,20496% 2,377.776 372(1982) 9,268 96% (1972) 23,702 555 98% (1983) 43,648 90% 3,913 (1981) 78% 16,519 3,578 (1977) 6,171 95% 122,558
Most recent Immunization coverage 75% 89% 80% 85% 86% 85% 96%
WPRO CEIS as of 22 March 1996. -Indicates 1994 data (China) 1992 (Malaysia)
Countries have made efforts to increase measles immunization coverage by including measles vaccine in NIDs. This has had the particular advantage of enabling remote districts to be reached with measles immunization. 2.2.6 Introduction of other antigens
There have been greater efforts to include hepatitis B vaccine into routine infant immunization schedules in countries and areas throughout the Region. The greatest success has been in the Pacific island countries, where hepatitis B surface antigen carriage has a high prevalence. With the collaboration of international partners, many countries have been assured the continuity of supply of hepatitis B vaccine. The problem is greater in more highly populated countries due to the high cost of the vaccine, though several countries are providing higher coverage than before in urban areas. Vitamin A has been used with great success during NIDs for poliomyelitis eradication in Cambodia, the Philippines and Viet Nam.
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2.2.7
Safe sterilization and injection practices
Plans to eliminate unsafe sterilization and injection practices have been developed In Cambodia, Chilli Ite Lao People's Dell\Ocratic Republic, tbe Philippines, and Viet NIDI. The plans are based UfCID tbe regular replacement of stocks of supplies and equipment, whether reusable or disposable equipment is used. In developing tbe plans, much emphasis hIS been made on adequate planoin. based upon population size and session frequency. In tbe implementation of tbe plans, tbe focus has been on regular distribution to tbe peripheral level, and tbe II\Onitoring of indicators of appropriate use of tbe equipment. The safe destruction of used supplies and equipment will be given greater attention in tbe future.
2.2.8
Logistics and cold chain
There have been major distributions of new cold chain equipment in several countries, witb tbe support of international partner organizations and governments, including tbe Government of Japan, and tbe World Bank. Vaccine vialll\Onitors (VVM) are now in use on a trial basis in Viet Nam, but will soon be distributed tbroughout tbe Region on internationally procured OPV vials, where tbey are expected to extend tbe duration of use of vaccine vials, and decrease vaccine wastage. Non-chlorofluorocarbon refrigerants are now being supplied witb cold chain equipment in accordance witb tbe Montreal protocol.
2.2.9
Vaccine self-sufficiency
The Regional Office is actively collaborating witb centres of excellence for vaccine production and quality control. Technical support is being provided to several countries. In 1996 tbe major focus will be on tbe strengtbening of national quality control autborities.
2.2.10 (I)
Constraints and problems
Surveillance and laboratory some poliovirus laboratories have lower performance indicators: delays in specimen processing and in coordinating witb AFP surveillance; AFP surveillance is still at low levels in some recently endemic countries; funding for surveillance must be assured for tbe future.
(2)
Supplementary immunization children In high-risk groups such as mobile populations, etbnic minorities, and tbose in remote areas, are sometimes missed by NIDs; cross-border coordination between countries and WHO Regions needs to be improved.
(3)
Routine EPI some districts 8tlll have relatively low coverage.
(4)
Neonatal tetanus surveillance for NT is still incomplete; tetanus toxoid coverage estimates are unreliable.
- 15 -
(5)
Measles control surveillance for measles is incomplete; there is still low measles Immunization coverage in remote areas and some urban areas.
(6)
Sterilization and injection practices there are delays in regular distribution of new supplies and equipment; the monitoring of sterilization and injection indicators is not yet well developed.
2.2.11
Conclusions
The EPI continues to maintain a high level of coverage in the Western Pacific, and there has been a notable improvement in the quality of services. The improvements in the routine EPI have occurred simultaneously with rapid progress in poliomyelitis eradication. At the end of 1995, poliomyelitis incidence was on the verge of eradication. However, the Region prepares to enter the stage of certification of poliomyelitis eradication. Countries should ensure that AFP and poliovirus surveillance are kept at high levels of quality, and no children under five years are missed during national and subnational immunization days. Neonatal tetanus has reached very low incidence levels, and will continue to decline as countries focus on routine immunization activities in high-risk areas. Measles has been greatly reduced as a public health problem, but will benefit from improved surveillance as countries integrate measles with AFP surveillance. International partners continue to provide a high level of support for the EPI and disease control initiatives in the Western Pacific Region, while governments have successfully used the resources available to provide immunization services in all areas, including remote districts of the Region. 2.3 2.3.1 Regional laboratory overview Development of the laboratory network
With the focus of the poliomyelitis eradication programme shifting from establishing the framework for poliomyelitis eradication to establishing the framework for certification of poliomyelitis-free status, the role of the laboratory network becomes paramount. Since the establishment of a multitiered laboratory network in the Western Pacific Region in 1992, there has been a remarkable amount of progress in turning more than 40 individual laboratories into a functioning, well-coordinated network. The major areas of progress since the sixth meeting of the Technical Advisory Group include the following: . I. Data management and reporting. In many countries communications between laboratory and epidemiology staff remained poor. Essential case investigation information was not being supplied to the laboratories, and laboratories were not providing feedback to the epidemiologists. The laboratory data key variables and computerized data management system, developed in 1994, were not being used in several laboratories. To ameliorate this situation, all laboratories were required to report their results on a monthly basis to WHO WPRO. These reports have been used to prepare weekly laboratory results and performance reports that are distributed throughout the Region. The monthly reports have also been used to prepare detailed monthly results and performance reports that are distribllted to all laboratories in the network. With the instigation of these feedback mechanisms, the quantity and quality of laboratory data management and results reporting has improved dramatically.
- 16 -
2. Laboratory funding. In the 12 months between April 1995 and March 1996, approxi?lately US$ 1 million of international partner support funds, particularly from Rotary Intern~t1onal and from the Government of Japan, have been spent on equipping, supplying and financmg the ~yelitis laboratory network in the Region. The majority of laboratory equipment needs ftIt the network have now been met, and systems for the transport of stool specimens and virus isolates are in place. 3. Standardization. Since the Manual/or the vir%glcallnvestigation o/pollomyelltls was prepared in 1990, new techniques for the identification of polioviruses have been introduced. In addition, increased workload and changed expectations have prompted many laboratories to modify recommended procedures. In order to standardize these new techniques and procedures, sections of the manual were reviewed, following discussions during the first meeting on Laboratory Surveillance for Poliomyelitis Eradication in the Western Pacific Region (Manila, October 1995), and copies were distributed to all poliomyelitis laboratories in the Region. 4. Laboratory staff Iraining. With a high turn-{)ver of laboratory staff throughout the Region, there is a continuous need for training in basic tissue culture, virus isolation, and virus identification techniques. This need for training is now being addressed by sending laboratory experts to laboratories that demonstrate a need for staff training, by holding annual and semiannual laboratory meetings, and by arranging for WHO Training Fellowships for selected laboratory staff. Laboratory staff training in more advanced aspects of virus identification and characterization continues to be provided by the National Institute of Health, Tokyo, Japan, and by the Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. 2.3.2 Current status of the laboratory network: laboratory results for 1995
More than 10000 stool specimens from AFP cases were examined in 1995. This represents a 100% increase over the number examined in 1994. The number of polioviruspositive specimens continued to decline, to less than 5% of all specimens received. This confirms the decline in reported cases of clinically confirmed poliomyelitis. The percentage of specimens positive for non-poliomyelitis enteroviruses (NPEVs) increased from nine to 12%, indicating an overall increase in laboratory sensitivity (see also 2.3.3.2). After intratypic differentiation of all poliovirus isolates, wild poliovirus was detected in only 19 of the more than 5600 AFP cases examined, a further decrease from the 74 detected in 1994. With one exception, all wild poliovirus-associated cases were from the Mekong Delta area of Cambodia and southern Viet Nam. The only exception was a case reported in the Chinese province of Yunnan, which is believed to have been imported from the neighbouring country of Myanmar. All wild poliovirus isolates from 1995 were type I. Tables 7 and 8 provide more details.
- 17 -
Table 7. Laboratory results on AFP cases with stool specimens, 1995 NIIionaI~
\Au..... 1-bO'i MrtI 0Iy
QuDy COM
aDriIIad1985
........ Ifi'v.iIh 83 191 218 EB8
Ifi' 1IfP_......b: C8S
%Ifi'
VlNIS
PI 9 4 4 52
I-BIi Rot. lID
VlNIN O-N
BaUd< ~~
lJIO MAl.. M:n F'lC R'G
11ariR_
FaiIfieId R'GI~
R'lMMria ToIa!
FH.. Oh.
12 15 0 3 11 116 0 5215
0 0 0 0 0 1 0 70
P2 2 0 0 79 0 3 0 0 1 0 0 85
..., 0 0 3 31
~
nix 0 0 1 31
~. 0 0 0 18 0 0 0 0 0 0 0 18
pnq 1m 4
.22 12 8 13 0 0 :J! 4
1 9 68
pOIitiw IIIpUIItid fclrJlFElf WlHn21 13 21 9 29 31
..... %aI 77 29
Dallal ... n!pDIt
1 0 0 0 0 1 0 :J!
0 0 0 0 0 0 0 29
0 0 0 0 1 3 0 1!6
11MX!196 11MX!196 2WWJ 2WWJ 1W11!l6 ~
100 0 12 15
01IID'!II lPIIl2I!II 2)m98
19WI!B In'IB'$
0 12
Table 8. Intratypic differentiation or polio Isolates rrom AFP cases with specimens received in 1995 MPwItIt wild AagIonaI
MPwI polio
Intr_~
....1ts Pallo 3 ~
Pallo 1
Pallo 2
Country
virus
I..,.....,. aubmltted
Tobli Wild Tobli Wild Tobli Wild PendI...
Aefatei lOll Labaralory
In 1994
toref.l_
In 1995 NIH Tokyo CAM
33
11 12 1 0 247
11 9
11 7
0 0 0 0 72
0 0 0 0 0 0 0 0
0
0 0 0 0 0 0 0 0
0 7
VTN LAOS MOG CAPM Beiiina
35 0 0
1 1 0 <16
0 0 53
0 0
0 0 30
CHN
6 0 0 0
1 0 0 0
Fairfield, AlIs.
PNG PH. PIC
1 2
0
1 0 0
0
0 0 0
1 0
1 0
0
· 18·
2.3.3 2.3.3.1
Laboratory proficiency Proflcllllcy testing
Tw~ proftollecy testing exercises for national poliomyelitis laboratories in the Region were earned out In 1994. The results, which varied significantly between laboratories, are shown in Table 9. Table 9. Summary or proftciency test scores ror National Poliomyelitis Laboratories,
1992 -1994 1992 OVERAll AVERAGE SCORE ('*0) NON·ENDEMIC COUNTRIES AVERAGE ENDEMIC COUNTRIES AVERAGE
1993
1994
85
87 83
88 91
79
80
74 84
Similar proficiency testings have been carried out with the provincial poliomyelitis laboratories in China since 1992. In 1995 all 30 provincial laboratories were tested, and all achieved the minimum of at least 80% proficiency. 2.3.3.2 Routine proficiency monitoring
(1) Timeliness: The WPR indicator of routine laboratory timeliness (i.e., the time interval between receipt of the specimen and reporting of the results. calculated for each specimen received) is that at least 80% of the specimens should have a result reported within 28 days. While in 1995 progress has been made towards achieving this goal, it remains difficult to reach for many laboratories. An interim indicator, that 80% of the specimens should have a result reported within 42 days, was introduced at the beginning of 1995. All but one laboratory in China reached the interim indicator. (2) NPEV isolation rates: The WPR indicator is that NPEVs should be isolated from at least 10% of all specimens from AFP cases. There remains considerable variation in the results, both from national laboratories and the Chinese provincial laboratories (see Tables 10 and II). Table 10: Laboratory proficiency ror national laboratories - NPEV Isolation rates and laboratory timeliness Number apecimenl from AFP 1995 1994 105
0'
NPEV Isolation not. Reported within 28 Reported within 42 dop('IIo) dop ('110) ('110) 1994 7 2 12 18 27 0 1995 11 10 1994 8 10 28 37 NA NA 1995 21 29 28 1994 19 45 82 72 NA NA 1995 39 611
Laboratory Ho Chi Minh City Hanoi
Countly CAM VTN (S) VTN (N) CHN LAO MAL MOG PIC PNG PHL Oth.
235 296 4347 15 5 0 0
Prov.labo Bangkok IMR.Kl
160 J4S 421 8966
22 12 9 0 0
sa 91 . 100 NA 100
n 29 NA 100
22 24 0 6 12
Utaanbataar Fairfield PNGIMR RITM, Manila Totals
17
ln 0 5197
206 0 10162
0 4 14
JJ 5 12
70 18
0 12 7S
85 J8 69
17 31 89
J5
- 19 -
Table
n.
Laboratory proficiency ror Chinese provincial laboratories - NPEV Isolatloo rates and laboratory timeliness. High-risk provinces shown In bold type R_ _ 28 Number 0'
opeclrnoo't AFP
'nom
NPEVIoollllon ....
R_ _ 42
('"
cIoys('"
cloys ('"
PruvInce FUJIAN GUIZHOII HAINAN HUBEI
1984 71 321 12 44 H
111115
HUNAN JlANGXI QINGHAI SICHUAN XINJIANG YUNNAN ANHUI BEWING GANSU GUANGXI HEBEl HEILONGJIAN HENAN JIANGSU JILIN LIAONING NEIMONGOL NINGXIA SHAANXI SHANDONG SHANGHAI SHANXI TIANJIN ZHEJIANG Totals
111 31
. I
197 120 111 14 310 313 302 41 141
1984 0 14 2 2& 2. 3& 10 0 I II
1l1li5 1 11 7 22 23 23
1984 2t 1. 41 43 II 72
1l1li5 17
• 0
. II
1984 7. 71
1995 17 II
II
17 H 73
12 13 I
• •
32
123 243
27 33
•
70 72 II
n
II
. .... 11
71
. II
n 0
II
34
eo
41 280 48
2 25
71 98
12 73
.
14 17
47 349
379 68 158 446
411 58
m
619 240 847 349 262
293 59 98
84 48
189 121 43
19 0 4 31 11 28 5 0 11 23
52 859
249 I_ 44
71 0 I
24 73 \I
0 22
97 4347
168 42 391 8966
27 3 16
11 3 3 9 14 5 19 13 2 2 3 0 13 12 5 17 7 8 12
28 25
98
100 80
100 45 1fT
100 99
12 21 12 53 44 20 1fT
68 85
89 92
30
87 80 98 94 99 85 115 73
100 94 44
100 90 99
85 33
93 100 57 30
4 19 71 58 31 17 0 37
67 71 76 68 68
32 87 92 53
100 100 97 100 91 79 100 94 115 99
n
100 10 72
91
The extremes reported in 1994, however, have been replaced by a greater proportion of laboratories reporting rates within the expected 10% to 20% range. Laboratories that continue to achieve lower than expected NPEV isolation rates in 1996 will be the focus of increased attention from WHO and its partner agencies. 2.3.4 Constraints
(I) While specimen transport systems are now in place and basic equipment needs have largely been met (see above), ongoing funding, at approximately USS 500 000 per year, will be required to cover costs for specimen transport, supplies, laboratory staff training, and network communications. This funding will be required until global certification of poliomyelitis eradication has been achieved. (2) Ongoing national and local authority support will be required to continue the prograntme. A renewed effort must be made to secure this support, especially where the successes of the prograntme and competing interests have reduced the priority of poliomyelitis eradication activities. (3) Training of laboratory staff in basic virological techniques is another ongoing need, especially in view of the high turnover of staff. This will not only require more resources, both organizational and financial, but, given the current limited Regional training capacity, may necessitate the use of training facilities in neighbouring WHO regions.
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2.3.5
Conclusions
An effectlVlllld reliable poliomyelitis laboratory network has now been established in the Western Paclflo IiIIion. A laboratory data management and reporting system is in place and is being used to provl8e feedback information on AFP cases and results to laboratories, EPI managers, governments and international agencies. The system is also being used to monitor laboratory results and performance, and to focus attention on those laboratories which continue to experience problems. With increased AFP surveillance activity, laboratory workload has increased dramatically. In spite of this increasing workload, laboratory performance has continued to show improvement, with the Region overall achieving the established WHO laboratory performance indicators. Variation continues to exist between laboratories, however, and those laboratories which fail to reach expected performance levels are under increasing scrutiny from WHO and its partner agencies. With the change to a virological case definition of poliomyelitis, confidence in the ability of the laboratory network to detect and correctly identify wild polioviruses is essential. Maintaining confidence in the ability of the laboratories will be the major task of the poliomyelitis eradication programme in the years leading to certification of poliomyelitis-free status. Within the past year, approximately USS I million of international partner support funds have been spent on equipping, supplying and financing the poliomyelitis laboratory network in this Region. The majority of laboratory equipment needs of the network have now been met, and systems for the transport of stool specimens and virus isolates are in place. More funding will be required, however, to ensure that the network is maintained until certification of poliomyelitis-free status is achieved. Additional support will also be required to meet the increasing demand for training of laboratory staff. With the change from a clinical to a virological confirmation of poliomyelitis cases, maintaining a high level of national and international confidence in the laboratory network is essential to the poliomyelitis eradication programme in this Region. Linked to this is the ability of all laboratories to fully document their activities and their results. This becomes particularly important as the Region establishes the requirements for certification of poliomyelitis-free status. 2.4 2.4.1 Regional operational issues Regional overview of sterilization and injection safety
A Regional plan of action on safe EPI sterilization and injection practices was endorsed by the fourth TAG. The 1994 TECH NET recommended that the Western Pacific Region goal of eliminating incorrect EPI sterilization and injection practices by the year 2000 be adopted globally. An EPI Update on safe injections has been issued and an article on this subject has appeared in the WHO Bulletin. Safe EPI injections is now accorded a high priority at the global level. Since 1993, good progress has been made in most countries of the Region in improving EPI sterilization and injection practices. National plans of action to eliminate incorrect EPI sterilization and injection practices have been ratified in Cambodia and the Lao People's Democratic Republic, and draft national plans have been prepared in Mongolia, the Philippines, and Viet Nam. The main points covered by these national plans are: the establishment of standard acceptable quantities of steril ization and injection equipment at health-facility level;
- 21 -
the adoption of a minimum replacement period for both sterilization and reusable injection equipment; appropriate training for staff involved in the EPI at all levels; the calculation and costing of annual national requirements on the basis of these two standards. In China, safe injections have been identified as one of the highest priority issues for EPI both at national level and in many provinces. A locally produced double-rack portable medical stearn sterilizer, costing about USS 30, has been successfully field tested. A World Bank loan will fund adequate quantities of stearn sterilizers, and reusable syringes and needles in 10 provinces with a popUlation of about 400 million. In about 300 other counties, adequate quantities of stearn sterilizers, and needles and syringes have been purchased for mass IT campaigns, as part of neonatal tetanus elimination activities, with funds from AusAID, UNICEF, and WHO. In urban areas, EPI sterilization and injection practices are already of high qUality. Autoclaves are used to sterilize reusable syringes and needles or disposable syringes and needles are used. Guidelines and training materials on safe injections have been drafted as part of preparations for the mass IT campaigns, A national plan of action is expected to be drafted later in 1996 with some provinces also expected to prepare plans of action. Additional funds have been allocated or are being sought in all the above countries as well as others. While most countries are now on target to achieve the year 2000 target for 100% safe EPI injections, some countries still need to give higher priority and to increase resources to solve this problem. Actions necessary: • National plans to eliminate incorrect EPJ sterilization and injections practices should be prepared or approved by the remaining countries which have not done so. • Strong international participation is still required to provide additional resources. • Following the example of the Philippines and Viet Nam, government funds need to be allocated at national and subnationallevels to ensure safe injections. • Systems for monitoring the supply and distribution of sterilization and injection equipment still need to be established in many countries. 2.4.2 Cold chain
Several countries have now prepared detailed cold chain and logistics plans for the EPJ, which include minimum equipment standards and equipment of choice, ideal equipment levels, armual replacement requirements, and the costs of upgrading the cold chain and regularly replacing equipment. These countries include Cambodia, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines, and Viet Nam. In China, plans have been prepared at the prOVincial level for the ten provinces involved in the joint Government of China - World Bank project, one of the aims of which is to improve the infrastructure of the EPl. Along with the development of detailed plans, considerable support has been provided for upgrading EPI infrastructure both by governments themselves and by partner agencies, most notably the Government of Japan for Cambodia, the Lao People's Democratic Republic, and Viet Nam; the Government of Germany for the Philippines; the World Bank and Government of Luxembourg for China; and the Government of Australia for Papua New Guinea. Due to the support provided in 1995 and expected in 1996, major cold chain requirements in most countries have been met for the medium-term.
- 22-
2.4.3
Vaccine vial monitors (VVMs) and open-vial policy
A field trill of vaccine vial monitors on vials of oral poliovirus vaccine is currently being conducted in V"~, Although the trial is not due for completion until April 1996, early data suggest that .... VVMs are well understood by field workers. The trial also suggests that in areas of low vaccine wastage, the VVM may not reduce wastage further. The trial will probably be extended to assess the impact of the VVMs in extending vaccine use in remote areas where access is difficult. The policy of EPIIWPRO remains that open-vial policies will only be encouraged when VVMs are introduced on all vaccine vials. Apart from vaccine wastage, the impact of VVMs will be felt in extending the use of vaccines in situations where the cold chain is not strong, particularly in remote areas. The ways in which this can be done will be explored in the field in Viet Nam and hopefully in other countries in 1996. 2.4.4 Integration of hepatitis B vaccine Further progress has been made since the sixth TAG Meeting. (a> A collaborative project between the Government of Australia, with the technical support of WHO and UNICEF, and ten Pacific island countries has ensured vaccine supplies for a three-year period from 1996, with two years of partial funding subsequently to allow for a gradual assumption of responsibility by the governments themselves or other partner agencies. The project aims at the solid integration of hepatitis B immunization in the EPI in these ten countries. Currently all Pacific island countries and areas have a reliable source of hepatitis B vaccine. (b) Viet Nam is continuing local production of hepatitis B vaccine and will commence hepatitis B immunization as part of the EPI for all infants in Hanoi and Ho Chi Minh City in 1996, with a view to expanding the programme of immunization in 1997.
(c) The joint Government of China - World Bank project is exploring ways of increasing the coverage of infants with hepatitis B vaccine in rural areas in the ten provinces of China covered by the project. The current status of integration of hepatitis B vaccine in the EPI can be summarized as follows: the Western Pacific Region is the most advanced in the world with respect to integration of hepatitis B vaccine in the EPI; all countries and areas in the Region except Cambodia and the Lao People's Democratic Republic, have now integrated hepatitis B vaccine to some degree in immunization programmes; coverage is good where adequate vaccine supplies are available; constraints to full integration: The main constraint is cost of purchase or production of vaccine which is currently high and likely to remain high.
- 23-
Actions necessary: • Every effon must be made to ensure continued reliable supplies of hepatitis B vaccine to hepatitis-endemic countries (p&nicularly Pacific island countries). • If EPI programmes in Cambodia and the Lao People's Democratic Republic continue to improve, gradual integration of hepatitis B vaccine will be encouraged (tentative stan date 1998). • WHO will strongly suppon activities under the Government of China-World Bank project to ensure integration of hepatitis B vaccine with the EPI in rural areas. • All avenues for vaccine supplies for Viet Nam will be explored, including local production and partner agency suppon. 2.4.5 Vaccine self-sufficiency
Progress with the implementation of the Regional plan of action for vaccine self-sufficiency since the sixth TAG meeting is reported below. (a) The existing system for coordinating centres of excellence (such as Therapeutic Goods Administration, Australia and Biken, Japan) has been strengthened through various means, including memoranda of understanding and establishment of a list of individual expertise available within the Region. (b) Information collection and dissemination: The database on vaccine production, control and supply within the Region has been further expanded.
(c) National vaccine procurement and supply systems have been strengthened: Comprehensive EPI vaccine requirement calculations have been undenaken for Cambodia, the Lao People's Democratic Republic, Mongolia, and Papua New Guinea, in conjunction with the government and where possible with UNICEF offices in the respective countries. These calculations should form the basis of government planning and can be used in negotiations with partner agencies where necessary, to ensure adequate vaccine supplies in the medium-term. (d) Vaccine production has been improved in selected countries: OPV production in Viet Nam. In 1995, in support of POLIOVAC the Government of Japan provided another batch of seed virus, and provided training in production techniques for OPV production. Further staff training at National Institute of Health, Japan of staff from POLIOVAC in specific production and quality control procedures will take place in 1996, and a filling machine will be provided and in operation by the end of the year. POLIOV AC has undertaken to supply 20 million doses of OPV for use in supplementary immunization activities in \996, and should be capable of providing the full national requirement by 1997. (e) Strengthening of national quality control authorities: Viet Nam. In July 1995 a mission of experts from TGA Australia to the National Centre for Control of Biological Products (NCCBP) in Viet Nam took place. The experts advised on specific control procedures for tetanus toxoid (TTl and diphtheria, pertussis and tetanus (OPT) vaccines, and collaborated with both NCCBP staff and staff of the vaccine production facility at Nha Trang (IVAC) on quality assurance procedures. A follow up mission will take place In the first half of 1996, and It Is planned that staff of the NCCBP will go to TGA Austral ia for training in the second hal f of the year. . China. The national control authority has agreed to a consultancy which will take place in 1996.
- 24-
Actions necessary: • Technical support will continue to be provided to enable the Government of the Philippines to . . 111 informed decision on the continuation of vaccine production. • Support WIll continue to be provided to national control authorities in China, the Philippines, and Viet Nam. • A workshop for national control authorities in countries in the Region will be organized, with the aim of identifying solutions to constraints and sharing experience. • The possibility of national workshops on quality control, to bring together staff of both NCAs and producers, will be explored in the above three countries. 2.4.6. TECH NET meeting recommendations
The 1996 TECHNET Consultation which met in Manila 12-16 February 1996, made recommendations on the following areas: (1) (2) (3) (4) (5) (6) Further progress in the use and evaluation of vaccine vial monitors. The preparation of standard guidelines on the safe handling, disposal and destruction of used injection equipment. The development of national plans of action to achieve 100% safe injections in the EPI by 2000. The replacement of ageing cold chain equipment with CFC free models over the next five years. The use of computer software for EPI stock control. The operational and resource implications associated with the addition of other antigens to poliomyelitis NlDs.
A full report of the TECH NET consultation will be published separately by GPV/HQ. 2.5 2.5.1 Country reports Cambodia
Achievements in relation (1)
to recommendations from the sixth TAG meeting
Routine EPI
In 1995, the programme objective was to achieve 80% full infant immunization coverage in 12 populous provinces containing almost 85% of the national population. This objective was achieved. The national coverage at the end of 1995 was 95% for BCG, 80% for OPV3, 79% for DPTI and 75% for measles. By the end of 1995, 36% of pregnant women had received at least two doses of tetanus toxoid. (2) Neonatal tetanus elimination
While there is not yet an official neonatal tetanus elimination initiative in Cambodia, there is steady progress in increasing IT coverage for pregnant women and in the number of vaccinations being given to other women of child-bearing age. The percentage of pregnant women with two or more IT vaccinations was 36% in 1995, compared to 26% in 1994. The number of non-pregnant women of child-bearing age with two or more IT vaccinations was
- 25-
277634 in 1995, compared to 200 148 in 1994. Surveillance for NNT is still unreliable in most areas of the country. (3) Measles
Coverage of target-age children through routine EPI services improved to 75" in 1995. Surveillance for measles is still unreliable in most areas of the country. (4) Injection safety in the EPI
A national plan of action to improve steriliution and injection practices was drafted and adopted during 1995. The plan provides a mandate and blueprint for bringing sterilization and injection practices throughout the country to the desired standard. Supplies of steriliution and injection equipment have been increased and regular schedules for replacing syringes, needles and sterilization equipment have been put in place. Generally there are now adequate supplies of injection and sterilization equipment in the country to make safe steriliution and injection practices possible. Continued training and improved monitoring will be required to assure that all EPI injections are safe. The issue of safe destruction and disposal of used injection material requires more attention. (5) NlDs
Cambodia successfully conducted its first national immunization days in 1995. On II February and II March 1996, Cambodia conducted its second NlDs. The number of target-age children (children aged zero to 59 months) vaccinated with OPV during the first round of the 1996 NlDs was 1.78 million. The number vaccinated during the second round was 1.81 million target-age children. These totals are about the same as in 1995. Estimated coverage of target-age children nationally was about 90%. Cambodia plans to conduct NlDs again in 1997 and 1998. Special immunization activities will be undertaken as needed. During the 1996 NlDs, special government-supported efforts were made to reach mobile and remote populations. This was much more successfully done than in 1995 and much was learned from the efforts made. Lessons learned from these efforts will be applied in the 1997 and 1998 NlDs so that even greater success reaching these populations can be achieved. (6) AFP surveillance
Improving surveillance for acute flaccid paralysis was a poliomyelitis eradication initiative priority for 1995. With external support for funding it was possible to successfully extend active AFP surveillance from a primarily national hospital-based system to a system encompassing all provincial health facilities, as well as health facilities in many districts. Provincial staff were trained in case investigation methods and central-level staff travelled extensively to the provinces to ensure that the system of case classification was consistent with TAG recommendations. The result of these activities has been a much improved system for detecting, reporting and investigating AFP cases in Cambodia. Prior to August 1995, 70% of all AFP reports were being generated by the national hospitals in Phnom Penh. From August to December 1995,70% of the reported cases of AFP were generated by the provinces. All surveillance indicators for 1995 are greatly improved over 1994 performance levels. Greatest improvement was registered for percentage of AFP reports investigated, percentage of AFP reports investigated within 14 days of onset, percentage of AFP cases with at least one stool specimen taken, and percentage of AFP cases for which 6O-day follow up investigations are conducted. One area of AFP surveillance in Cambodia still in need of major attention is specimen collection and transport. This will be a 1996 programme priority.
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Major ProbleJ!!& (1) Routine
and constraints
BI\
MaintenaJ'&f routine EPI coverage at its current high level will require considerable external support for lOme time to come. Needs for 1997 appear to be assured, but programme officials will have to project programme needs several years in advance and make these needs known to partner agencies In order to assure that resource requirements are available without interruption. (2) Poliomyelitis eradication
Poliomyelitis eradication efforts, both supplementary immunization and AFP surveillance activities, face the same need for external support as those of the routine EPI. This constraint must be addressed in the same way as for the routine EPI. Mobile and remote populations continue to be a programme concern. Higher coverage among target-age children in mobile populations along the Mekong River must be achieved to assure the complete interruption of wild poliovirus transmission. Stool specimen collection and transport was much improved during 1995 but is not yet up to standard. The sensitivity and efficiency of the AFP surveillance must be further Improved. Stool specimens are sent to Ho Chi Minh City for analysis. This increases logistics difficulties for the programme, but is being dealt with as well as transportation facilities permit. Late receipt of laboratory results has been a programme constraint, but by the end of 1995 was greatly improved. At this stage of poliomyelitis eradication in Cambodia, the timely notification of wild poliovirus Isolation from stool specimens is critical for effective programme management. (3) Measles and neonatal tetanus
Cambodia is probably not ready to embark upon special initiatives for these diseases, but further improvements in immunization coverage, especially TI for pregnant women, is needed. Surveillance information for both diseases is not reliable enough at present to provide useful programme information. 2.5.2 China
Immunization coveraell In 1995, routine Immunization coverage (by 12 months of age) was 94% for BCG, 93% for DPT3, 89% for OPY3, 94% for measles. Coverage figures have been relatively stable since 1993. The 1995 fi&Ures are based on a newly introduced reporting system and may be over-estimates of the true coverage-levels. Per province, analysis shows that Jiansu, Guangdong and Xianjiang were below the mean (96.0%) for OPY3 coverage, and Guandong and Guizhou below the mean (95.8%) for measles coverage. 63.6% of the counties reported > 80% OPY3 coverage in the routine immunization programme. Two rounds of NIDs were organized in 1995/1 996, targeting all children zero to 47 months old in all 2865 counties in 29 provinces. Coverage was 95.5% and 96.4%, respectively. Subnational immunization days are currently planned for several high-risk provinces during the winter season in China (December 1996/January 1997). Two rounds of tetanus toxoid immunization campaigns were held for women of child-bearing age in 256 counties. Coverage was reported as > 80% for these two rounds ofTI.
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EPI Cases reported to the national routine reporting system for notifiable diseases in China Data indicate that the number of reported cases has decreased for each of the vaccine preventable diseases in 1995, when compared to 1994. However, it must be noted that most provinces do not report through this system. (1) Poliomyelitis
Table 12 summarizes the most important data related to poliomyelitis reporting through the routine system. It must be noted that this system is completely different from the AFP system developed for pOliomyelitis eradication. Table 12. Number or clinically confirmed poliomyelitis cases and vaccination status or cases, China, 1993-1995.
Number of poliomyelitis cases Proportion of zero-dose children among poliomyelitis cases
1993 538 35%
1994 261 13.4%
1995 165 18.2%
The table does not reflect the "floating" or unregistered children in China, who represent a cohort of high-risk children who have been difficult to register on the provincial EPI system for routine and supplemental immunization services. Also, the system is not representative for China, since most provinces do not report cases through this system. In November 1995, the only case of poliomyelitis caused by wild poliovirus that year was reported in a 16-month old boy (without previous OPV immunizations) from Myanmar. The boy's family resides in northern Myanmar; after onset of paralysis on I I November 1995, the parents took the child across the border to Tunnan province, China, to use the hospital facilities in DeHong Prefecture. The National Laboratory in Beijing confirmed wild poliovirus type 1 in a stool specimen from the case. NIH in Japan performed genetic sequence analysis and reported a > 17% difference between this isolate and previous Chinese poliovirus isolates. (2) Measles
The number of reported measles cases decreased to 57 28 I in 1995 (= 4494 per 100 000) from 76 204 in 1994, but reporting may be incomplete. (3) Neonatal tetanus
NT surveillance is still incomplete, although improving. Reported cases of NT have fallen over the last few years to 4228 cases in 1994. No figures are available for 1995. Oual ity of EPI Services (I)
Improvements and problems with the quality of services
Ongoing training programmes and the implementation of routine administrative reporting of immunization coverage have contributed to an improvement of the quality of EPI services. Further improvement can be expected in ten provinces under a current World Bank funded health project. In 1996, a national evaluation of the EPI will be done, using Lot Quality Assessment methodology in selected townships, to ascertain if the third national EPI target of 85% coverage at the township level has been achieved. The survey will also look at management issues and quality of services, and will provide useful information to further improve services.
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(2)
Safe injections
A nation~ for safe sterilization and injection practices has been drafted, but needs further work bJinalization. Availability of steam sterilizers and funding from the World Bank for reusabl. ~ection equipment in ten provinces should lead to further improvements. Steam sterilizers and reusable syringes and needles were provided for IT campaigns in 1995, and will be used for routine EPI activities in the future. Health workers in high-risk areas have been trained in safe injections for IT campaigns. A subprovincial plan will be field-tested in one high-risk province in 1996, and will, if successful, be extended to the entire province. (3) Planning and implementing vaccine supply and logistics
A system exists for monitoring vaccine logistics, but emphasis has not always been on efficient use of vaccines. With vaccine prices raising and demand for vaccines reaching a plateau, it will become important to avoid wastage due to expiration of vaccine. A shortage of IT vaccine occurred, and quality of vaccine does not always meet WHO standards, but it is expected that with increased prices in the next years, most of these problems will disappear. However, additional resources will need to be identified to procure the expected higher priced vaccines in the future. Shortfalls of OPV for SNlDs are expected to be about 100 million doses for the 1996/1997 SNlDs in selected provinces, costing about US$ 2.5 million (at the new, higher price of US$ 0.025 per dose). (4) Cold chain equipment
Cold chain equipment, procured in the mid-1980s is starting to break down, resulting in shortages. The World Bank and the Government of Luxembourg will provide support for the replacement of equipment in ten provinces. A newly established, and WHO-certified, national cold chain testing centre will add to China's capability to produce a wide range of good quality cold chain equipment. Disease reduction activities (I) Poliomyelitis eradication: surveillance
In 1995, many of the AFP surveillance indicators increased to nearly 80% or near certification levels. Data management for both AFP and laboratory surveillance needs further improvements at the provincial level. There was one case of wild poliovirus detected with onset in 1995 (see above for details). Table 13 summarizes selected AFP surveillance indicators for 1995 (data as of 22 March 1995). Table 13. Summary of selected AFP surveillance indicators, 1995, China. 1995 4802 1.511100,000 1.46/100 000 84% 86% 92% 80%
Total AFP cases AFP Rate «15 yearoldl Non polio AFP Rate «15 years old) % of AFP cases reported within 14 days of onset % of AFP cases investiaated within 48h of report % of AFP cases with at least one stool specimen collected % of AFP cases with at least one stool specimen collected within 14 days after onset of paralysis
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In 1995, 4802 AFP cases were investigated in China. There were 165 clinically 21 lost to follow-up, two died, one wild poliovirus). All these cases are located in only 62" of the provinces (and only 5" of the counties). Four thousand one hundred eighty six (4186) cases were discarded as non-poliomyelitis AFP, while 21 cases were still pending as of 22 March 1996. ~nfirmt;d poliomyelitis cases (135 with residual paralysis,
Applying the new WPRO virological case definition, there was only one case confirmed (through wild poliovirus isolation), 613 cases were classified as "compatible", and 4186 cases were discarded as non-poliomyelitis AFP. While the reliability of the laboratories has greatly improved in three provinces, non-poliomyelitis enterovirus isolation rates were below the expected 12" in some laboratories. (2) Poliomyelitis eradication: supplementary immunization
Additional rounds of supplemental immunizations were held in five prefectures in YUMan in March and April 1996, after a wild poliovirus case was detected in Yunnan. Problems and constraints in disease reduction initiatives in 1995 (1) Poliomyelitis eradication The major problems encountered in China include: (a) data management (incomplete and/or late data entry, cleaning data sets); (b) importation of wild poliovirus (or continued circulation of wild poliovirus), especially in the border areas;
(c) development of effective strategies to address the complex problems in improving surveillance and supplementary immunization activities in high-risk areas; (d) effectively reaching special populations, such as children in minority and migrant ("floating") populations who have never or only partially been immunized; (e) how to overcome the problem of "NID fatigue" in certain areas where many rounds of supplementary immunization have been conducted; (f)
limited resources and competing priorities for public health funding and the need for support to ensure improved AFP and laboratory surveillance and to implement successful SNlDs.
Planned solutions include: (a) to continue to improve the quality of AFP surveillance: intensify active surveillance, do active case search, especially in vulnerable, high-risk areas. Continue to improve laboratory surveillance (to improve sensitivity/specificity), especially with the new viral case classification in effect; (b) to address the high-risk provinces and populations: a Poliomyelitis Eradication Review is planned in ten high-risk provinces in May 1996 with international participation. Particular strategies are to be developed to reach special populations for more effective social mobilization;
(c) improve cross-border coordination with neighbouring countries;
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(d) SNlDs are planned for December 1996 and January 1997. The review is expected to help develop plans for these SNlDs. Routine immunizations Is to be maintained and improv.... especially for areas not included in the SNlDs; ·i,,"
(e) stron,fMlticai support is needed until certification. especially since the programme is facing a shortfall of funds for OPV for the upcoming SNlDs in 1996/1997. Also. continuous international support will be needed to deal with importation cases. (2) Neonatal tetanus elimination (NTE)
A national plan for NTE was adopted. Surveillance of neonatal tetanus (NT) was greatly improved after NT was made a Class B notifiable disease. i.e .• to be reported within one month by law. Although reporting is still incomplete. the number of reported cases is failing every year. Ninety per cent of the counties have reportedly achieved the NTE goal of less than one NT case per 1000 live births. IT campaigns were conducted in 256 high-risk counties in 1995. immunizing about 14 million women (coverage over 80%). Problems with NTE include lack of funding (for personnel. equipment, TI), lack of social mobilization, and lack of coordination between various departments. (3) Measles control
Measles continues to be a major cause of EPI morbidity and mortality in China. There is a need to develop a national surveillance plan, based on the AFP model. Currently, several provinces may be ready to establish measles surveillance programmes and accelerated control activities. 2.5.3 Lao People's Democratic Republic
Achievements in relation to recommendations from the sixth TAG meeting
In 1995, the EPI programme in the Lao People's Democratic Republic continued to improve. The strong political commitment and good community participation were sustained. The nationwide immunization coverage sustained the level of record high achieved in 1994. The NlDs of 1995/1996 were conducted in January and February 1996 and reached all provinces and districts, particularly most of the remote and difficult to access villages. Great efforts were made for the improvement of AFP surveillance activities. Progress was made gradually. Routine immunization activities Despite the heavy rains and the flooding throughout the country which severely hampered the 1995 programme implementation, immunization services were provided at least four times a year in approximately II 600 villages (92 %) for the first time in the country. The reported coverage, although not yet reflecting final figures, was 64% for OPV3, 54% for DPT3, 59% for BCG and 68% for measles. The coverage ofTT2+ reached 35',11, among pregnant women and 50% among women of child-bearing age. The OPV3 coverage among children under 12 months of age was over 50',11, in 13 provinces and measles coverage among children nine to 23 months of age was over 50% in 16 provinces. However, the coverage of OPV3 was under 50% in three provinces. The IEC (Information, Education and Communication) Subcommittee composed of representatives from National Institute of Hygiene and Epidemiology (NIHE), Centre for Education and Information for Health (CIEH), WHO, UNICEF and Japan International Cooperation Agency (JlCA) developed a more appropriate workplan focusing on production of
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more lEe materials. Training of village headmen and Lao Women's Union (LWU) members on EPI promotion was conducted in many provinces. The training activities at different levels contributed substantially to Improve the quality of services. Supplies and equipment were adequately provided to operational levels. The village health workers were mobilized and trained to solve the lack of staff at grass-roots level. Standard charts for EPI coverage monitoring were developed, distributed and used in many provinces and districts. There has been a major effort to improve sterilization and injection practices in the EPI in 1995. Policy on safe sterilization and injection practices was developed based on the experiences learned from the past years and from WHO guidelines, and adopted by the Ministry of Health. The consistent training of peripheral health staff in basic immunization skills ensured that health staff knew how to sterilize syringes and needles properly. The infrastructure of the EPI was developed with a reliable and functioning cold chain and logistic system. Data on the current status of cold chain equipment was collected and used as the basis for the planing of replacement in the future. The routine recording and regular reporting on vaccine stock were improved. Policy on cold chain and logistics including standards for provincial, district and subdistrict levels was prepared. Supplementary immunization activities National immunization days were conducted in all districts (133) in January and February 1995 with a five-week interval between each round. The preliminary result of the first round NIDs from IS out of a total of 18 provinces showed a good success and more than 80% of children under five years old were immunized with OPV. The second round of NIDs is also expected to achieve high coverage. Measles and OPT vaccines were also given where the transportation, supplies and equipment did not cause any obstacles. For the first time Vitamin A was included in the NIDs and given to children of one to four years of age. The NIDs stimulated the mothers to receive immunizations for themselves and their children through successful social mobilization activities. The major improvements made in this year's NIDs were as follows: (I) the NIDs commenced on the 3rd of January and 10th of February throughout the
country. Opening ceremonies in selected districts in every province were organized; (2) NID promotion and preparation visits were made to the weakest provinces by central-level and international staff, prior to the NIDs. Technical support for planning and training was provided; (3) supervision visits were conducted during each round of NIDs in order to determine and solve the problems during implementation. Surveillance The AFP surveillance system was improved significantly In 1995. Active surveillance and weekly hospital visits, for AFP and measles cases, commenced in September 1995 in Vientiane municipality. Active surveillance activities were well performed and resulted in the detection and investigation of five cases of AFP within a short period of time of introduction of the system. Based on the experience of Vientiane municipality, the active surveillance was expanded to eight provinces covering 75 % of the total population of the country by February 1996 and further expanded to 13 provinces covering 87 % of the population by the end of March 1996.
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There were II poliomyelitis cases confirmed by residual paralysis at 6O-day follow up in 1995. These reported from 11 districts of six provinces. Six po1i~1 cases under five years old received at least one OPV dose and unon, those three cases"ved three or more doses. Forty per cent and 50'1 of cases received OPV doses in 1993 and 1994, respectively. There has been 110 wild poliovirus isolated in the country since 1992, a1thouJh the AFP surveillance and stool specimen collection and laboratory analysis have been improved in the past three years particularly since 1995. There were no new AFP cases found though active search activities took place in both 1994 and 1995. Constraints
and problema
active surveillance began late and there is no active surveillance at district level; low non-poliomyelitis AFP reporting rate indicated the low quality of the surveillance performance in 1995. This was the major problem in determining the circulation of wild poliovirus if any, as well as the certification of poliomyelitis eradication; the reporting from district to province was very weak due to inadequate training, lack of operational funds from provincial health departments, and lack of communication planning; the identification of high-risk areas of NNT is still pending due to the weak surveillance; investigation of outbreak of measles does not exist and limited available data is not adequate to guide the measles control programme; lack of transportation particularly in the most remote areas; vaccine and logistics management were inadequate in some districts; heavy rainy season resulted in disruption or delay of the implementation EPI programme in five provinces. 2.5.4 Malaysia
Based on a 'background rate' of non-poliomyelitis AFP, at least 60 cases of non-poliomyelitis AFP would be expected in Malaysia annually even in the absence of ongoing circulation of wild poliovirus transmission. Until last year, very few cases of AFP were reported annually from Malaysia, indicating that AFP surveillance had not been established widely in the country. In 1994, only 17 AFP cases were reported, with stool specimens taken from only three cases with long delays after onset. The number of AFP cases reported in 1995 has increased significantly to seven cases. Thirteen cases had two stool specimens taken. Information about the actual timing of specimen collection is incomplete, but stool collection seems to have been within two weeks of onset in about 50% of AFP cases. Thus, there has been a significant increase in the number of AFP cases reported. While this is a welcome development, the majority of cases are still reported from several large hospitals (university hospitals, other academic centres) in only two areas - Selangor state (i.e., around the capital Kuala Lumpur) and Kelantan state (north-east peninsular Malaysia). No AFP cases were reported from several other important states with large populations (especially Trengganu and lohor state in peninsular Malaysia, and, Sabah and Sarawak in eastern Malaysia), leaving AFP surveillance still unrepresentative for the nation as a whole.
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. Thro~gh. its good working relationship with all large medical centres in the country, the nallo~a1 ~hovlrus laboratory at the Institute ~or Medical Research (IMR) has been successfully coordmallng many aspects of both AFP and virological surveillance. To further Improve AFP surveillance, the Ministry of Health is planning to give more support to the IMR to conduct integrated surveillance activities for AFP and wild poliovirus, and also plans a workshop in mid-1996 to retrain state epidemiologists and chief clinicians of state hospitals in all aspects of active surveillance for AFP. Malaysia also reported that supplementary immunization activities with OPV. targeting children under five years had been done in 52 out of 113 districts. with high reported coverage. There are plans to conduct focused immunization activities in 75 % of districts again in 1996. Routine EPI immunization coverage. including hepatitis B vaccination. was maintained at high levels for all antigens during 1995. 2.5.5 (1) Mongolia Routine EPI activities
In 1995 Mongolia continued to show improved immunization rates after the dramatic drop in coverage reported in 1992. Reported coverage rates for OPV3 in 1995 were 86% (up from 77% in 1994), while measles coverage increased to 85% (from 80% in 1994). Vaccine requirements for 1995 were met by UNICEF and WHO, and no shortfall in requirements is anticipated for 1996. Vaccine supplies are stored in the central cold store in Ulaanbataar, and distribution to aimags (provinces) takes place two or three times each year according to the vaccine distribution plan. Distribution of vaccine from aimag to somon (district) and from somon to bag (subdistrict) remains a problem in some areas due to lack of transport. Maintenance of vaccines at somon level also remains a problem, due to lack of suitable cold chain equipment. (2) Disease surveillance
Disease surveillance has been carried out in Mongolia for many years, and is well established. In January 1996 a weekly AFP reporting system, using telephone communication from aimag to central-level, was established throughout the country. With the exception of diphtheria, the reported incidence of EPI diseases remains low. There were 128 reported cases of diphtheria, with 21 deaths, in 1995. In response to this epidemic the Government of Mongolia. in collaboration with WHO, UNICEF and the Government of Japan, carried out a mass immunization campaign in November 1995 In which more than 1.5 million people aged 16 to 40 years were vaccinated against diphtheria and tetanus. Despite the increased coverage with measles vaccine, the reported number of measles cases rose from 0.78 per 10 000 population in 1994 to 2.45 per 10000 population in 1995. The increase was particularly noted in Ulaanbataar and other urban areas, and was seen to be mainly affecting children two to ten years of age. In response to this situation the Government is planning to conduct a mass immunization campaign against measles in May 1996. The target group will be all children aged nine months to ten years. (3) Supplementary immunization
Mongolia carried out its first NID in 1994, reaching 60% of the targeted children aged two to five years. A second NID was carried out in 1995, when 97% of all children under eight
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years of age received OPV. The th ird NID Is planned for the last ten days of May 1996. with the second round In the last ten days of June. (4)
Problema 4wnstraints
Major problema Include the lack of suitable cold chain equipment at somon level. and the lack of equipment and essential supplies In the national poliomyelitis laboratory. Communication difficulties at somon and bag level continue to present obstacles to rapid reporting of disease. 2.5.6 (I) Papua New Guinea Routine EPI activities
Reported coverage figures for EPI vaccines in 1995 showed an increase over 1994 figures, with OPV3 coverage rising to 68 % and measles coverage rising to 85 %. A major part in the continued improvement of coverage has been played by the Child Survival Programme, which conducted three rounds of immunization patrols in II provinces during 1995. Although there has been marked improvement in all provinces, there remain at least four provinces with low coverage rates. (2) Disease surveillance
Thirteen cases of AFP were reported in 1995. From one of these a vaccine-related poliovirus type 2 was isolated. Measles outbreaks were reported in several provinces, but the total number of reported cases decreased to 3730 in 1995, compared with 6821 in 1994. Reported cases of pertussis continued to increase, to 2814 in 1995. Tuberculosis continues to be a major health problem in Papua New Guinea, and the prevalence rate has risen steadily over the past few years. The prevalence of TB among children, in whom it often manifests as extrapulmonary TB, is of particular concern. (3) Supplementary immunization
In September 1995 one round of supplementary immunization was carried out in Morobe province. OPV and measles vaccine were given to children below seven years of age, and tetanus toxoid was given to pregnant women and women with children less than one year of age. Outbreak immunizations were conducted in response to measles epidemics in Northern Capital District, and Central, Madang and Eastern Highlands provinces. (4)
Problems and constraints
Major problems continue to be encountered in overall management of EPI and disease control activities following decentralization of health services. This has been exacerbated hy the chronic shortage of funds, following on from the national financial crisis which started in 1992. 2.5.7 The Philippines
National immunization days in the Philippines were the first NlDs conducted in the Region. NlDs in the Philippines were considered to be very successful, with very high reported coverage for children under five years of age. The Philippines is now the first country in the Region to conduct a fourth NID.
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However, a1thougb there were some improvements in AFP surveillance in 1995 progress in surveillance bas been slow in the Pbilippines compared to other recently endemic a:untries in the Region. Of 153 AFP reports in 1995 (1994:126), four cases bave been confirmed as poliomyelitis on clinical grounds, 51 cases bave been discarded and 92 cases are still pending fmal c1l1;SSification. Althougb ~ large proportion of cases bave not been finally classified, the non-poho AFP rate for 1995 Will be at most 0.6 per 100 000 population under 15 years of age. Of all 153 AFP cases, 17 % bad at least one stool specimen taken. However, there was no progress regarding completeness and timeliness of stool collection, with only 32 % of AFP cases baving two specimens taken within 14 days of onset (1994: 34%). This is significant not only because the percentage is low compared to other countries, but also because it is a percentage based on an already low rate of AFP reporting. AFP reporting has been variable by administrative Region. Fortunately, AFP rates have been better than average (i.e., 0.8 to 1 per 100 000 population) in the most important higb-risk areas where wild poliovirus bad been isolated most recently, mainly in Metropolitan Manila and Metropolitan Cebu. However, several densely populated, important areas remain (north-west, central and southern Luzon, western and eastern Visayas) in wbicb reported AFP rates are too low. Surveillance quality was affected by problems both in field AFP surveillance as well as problems in laboratory workup of stool specimens. The recent decentralization of bealth services bas bad overall negative effects on all reporting systems of the Department of Health (DOH). Only the 15 regional bealth offices are still directly linked to the DOH central office, and it bas become very difficult to get any surveillance reports from provincial and municipal health offices. Also, the approacb of active surveillance at bospitals, which bas been very successful in identifying AFP cases in Metro Manila and Metro Cebu, is not yet used enough at regional and provincial regions. Several regional offices report that not enougb staff time is available to conduct routine active surveillance visits. Quality indicators of laboratory performance indicate that the national poliomyelitis laboratory also had problems in virus isolation and timeliness of processing. The laboratory found non-poliomyelitis enteroviruses (NPEV) in only 4% of specimens (expected NPEV rate 10-20%), and only 31 % of results were available within 42 days of receipt of the specimen in the laboratory. As a result, the TAG could not yet recommend to the Philippines to start using virological case classification criteria, since the surveillance quality indicators agreed upon at the 1995 TAG meeting in Phnom Penh have not been reached (i.e., AFP rate of I per 100 000 population, with two adequate specimens taken from at least 60% of AFP cases). The DOH has begun to take action to address both surveillance problems. Five new poliomyelitis surveillance officers, tasked to conduct active surveillance at key regional and provincial hospitals, have been hired and placed in the most problematic regions, where AFP reporting for the first quarter of 1996 has already increased compared to 1995. A revision of existing training material, as well as training courses, is planned for 1996. To address the perceived weakness of the national laboratory, a WHO consultant spent two weeks working with staff in the laboratory in March 1996. The TAG also recommended that as of now, a1iquots from all specimens submitted to the national laboratory should be sent to one of the Regional reference laboratories. Based on the low performance of AFP surveillance, which did not allow sufficient confidence that transmission of wild poliovirus had actually been interrupted, the Department of Health decided to conduct a fourth round of national immunization days for poliomyelitis eradication in 1996, instead of focusing only on high-risk areas as originally planned.
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Routine EPI coverage in the Philippines has been maintained at good levels in 1995, except for tetanus toxoid Immunization of pregnant and child-bearing age women. Reported coverage with twqpr more doses ofTT for pregnant women in 1995 was only 45')(,. Th~s . decrease in ~~erage ill attributed to the ongoing controversy around alleged abortIfacIent properties oft . toxoid. 2.5.8 Viet Nam
Main achievements in relation to the recommendations of the sixth TAO meetin& Routine immunization coverage of > 90')(, nationwide has been maintained for the third consecutive year. Overall coverage of pregnant women with TT2+ was raised from 79')(, in 1994 to 82')(, in 1995 and a national plan of action for safe sterilization and injection practices has been implemented. Completeness and timeliness of monthly reporting and AFP case investigation, including stool specimen collection and follow-up visits, continued to improve. Active searches for unreported AFP cases have been implemented in most provinces. NIDs were conducted for the third time in the whole country during November to December 1995, targeting children under five years of age. Twenty million doses of locally-produced OPV were used during this campaign. National immunization days are planned for the fourth time for the 1996-1997 winter season. DiSease reduction initiatives (1)
Poliomyelitis
In 1995, 465 AFP cases were reported, and 135 were confirmed as poliomyelitis, including seven with wild poliovirus isolated. In 1995, of 465 persons reported with AFP, at least one stool specimen was collected for 376 (81')(,), two stool specimens were collected for 335 cases (72')(,), and two stool specimens were collected within zero to 14 days of the onset of paralysis for 304 cases (66')(,); poliomyelitis was confirmed by clinical criteria in 135 cases (29')(,). Wild poliovirus type I was isolated from seven persons, all in the Southern region (Mekong Delta). As of 15 March 1996, the last person with wild poliovirus isolated in the Northern region had an onset of symptoms on 8 November 1993. No wild poliovirus was isolated in 1995 from AFP patients in the northern region and from AFP patients in the central region. A total of 333 AFP cases were determined not to be poliomyelitis (1.12 AFP cases per 100 000 children aged < IS years of age). Active searches for AFP cases have been conducted in the medical records of provincial hospitals and selected district hospitals, in all provinces. This activity has been instrumental in further raising awareness ahout AFP surveillance among clinicians, in improving the sensitivity of case detection and collection of stool specimens, and in identifying weaknesses in the surveillance system. National immunization days were conducted on 11-13 November 1995 and 16-18 December 1995, with two doses of OPV administered, five weeks apart, to all children in the country aged < five years. According to reports of doses administered, ten million children received two doses of OPV. Mobile immunization teams active in the south of Viet Nam reached many previously unimmunized children. (2) Measles
Measles remains a serious cause of morbidity and mortality, resulting mostly from low coverage or delayed immunization in remote areas. In 1995, reported nationwide coverage with measles vaccine was ahout 95')(,. Six thousand one hundred seventy one (6171) measles cases and nine measles deaths were reported, compared with II 853 measles cases and 54 measles
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deaths in 1994. The majority of cases were in remote districts. Provincial plans of action have been implemented to increase coverage in selected remote areas. (3) Neonatal tetanus elimination
Coverage of pregnant women with two doses of tetanus toxoid vaccine (Tf2) rose from 79% in 1994 to 82% in 1995. Estimated coverage of women of child-bearing age with 1T2 in 210 selected high-risk districts was 94%. Lack of injection and reusable sterilization eqUipment, resulting in unsafe injection practices, remains a substantial cause for concern. A national plan of action for safe sterilization and injection practices has been adopted and is being implemented. This plan includes stocktaking of equipment at district, provincial, regional and national levels and effective distribution of reusable injection equipment and steam sterilizers. Surveillance for neonatal deaths and neonatal tetanus is improving in selected high-risk districts, but neonatal tetanus is still widely underreported. The number of high-risk districts has been increased to 210 in 1995 (from 140 in 1994). Constraints and problems (a) Local production of OPV is expected to deliver 20 million doses in 1996. The remaining needs of the programme (total annual requirement: 36 million doses) are expected to be met from contributions by partner organizations. There is a need for continued collaboration with the local manufacturer (pOLlOVAC), particularly in the area of staff training and quality control. (b) Planning for the activities of mobile immunization teams needs to be strengthened to better reach children aged < one year of age, and unregistered and mobile children, particularly in the Mekong Delta area.
(c) Further improvement in poliomyelitis surveillance must emphasize the quality of investigation, stool collection and follow-up; monitoring of zero-reporting at the district level, including active searches for AFP cases in low incidence areas; and support to laboratories for isolation of poliovirus and intratypic characterization of poliovirus isolates. (d) Full immunization coverage should be raised to > 80 % for children under one year of age in mountainous districts and provinces, with special efforts to provide measles vaccine to all children as soon as possible after nine months of age, and to unimmunized children nine to 23 months of age during NIDs in mountainous districts. (e) Neonatal deaths and neonatal tetanus surveillance, as well as measles surveillance, needs to be improved. (f) Injection and sterilization equipment should be supplied to mountainous districts and provinces.
2.5.9
Australia
Australia is the only industrialized country in the Region which has begun to develop surveillance for AFP. AFP surveillance is conducted through the Australian Paediatric Surveillance Unit (APSU), which sends every paediatrician a monthly pre-paid report card, asking whether they have seen any cases of a list of rare childhood illnesses, including AFP. The response rate is around 90%. For AFP cases, the paediatricians are asked to also report any cases by phone. Since the AFP surveillance was implemented in March 1995, 35 cases have been reported in the first II months, which is consistent with the expectation of 40 cases annually. Very few cases, however, have been reported by telephone.
- 38 -
Clinical information is available on 23 of the cases. Thirteen (57") of these were Guillain Barre. Thirteen (57") had residual paralysis after 60 days. Only five cases had adequate stool~.g done, although 22 cases (95") were hospita!ized. ~s a .result ?~thls lack ofstool t igbt out of the 23 cases (36") would be classified as pollomyehtls compatible". No d poliovirus has been isolated in Australia for more than ten years. Problems with the AFP surveillance system include slow responses, ineffective telephone reporting, and inadequate collection of stool specimens. Non-responders are considered to be only a minor problem. Solutions envisaged include more information distribution to paediatricians and laboratories (through letters, journals, professional societies). If needs be, an expert committee could be formed to examine case reports and to advise on the likelihood of poliomyelitis. In summary, AFP surveillance in Australia has been functioning for one year. The incidence of reported cases is as expected for a poliomyelitis-free country but some more work needs to be done to definitely exclude poliomyelitis in all cases. 2.6 Progress in poliomyelitis eradication in SEARO
Despite an OPV coverage in SEA Region of over 80% (coverage maintained since 1990), the countries in South-East Asia continue to account 57% of the world's reported poliomyelitis cases. Among these, India, Bangladesh, Myanmar and Nepal account for 99.9% of all the cases reported in SEA. The "poliomyelitis-population-belt" of SEA runs through northern India, Bangladesh, and Myanmar. Nevertheless, there has been a reduction in cases by at least 80% as compared to 1987, i.e., from 29 756 cases in 1987 to 5112 in 1994, and tentatively about 4000 cases in 1995. AFP surveillance is inadequate in all poliomyelitis-endemic countries, with the possible exception of Sri Lanka, which estimates that sensitivity of its surveillance system is 90%. Only Sri Lanka and Thailand consistently evaluate AFP and poliomyelitis surveillance. India, Bangladesh and Indonesia have also implemented various forms of AFP surveillance systems. In India, where mandatory AFP surveillance just started in 1995, it is estimated that only 30% to 40% of the poliomyelitis cases are reported. India, Bangladesh, Myanmar, Nepal, and Indonesia are the priority countries to improve surveillance and to sustain NlDs. Development of adequate surveillance systems however will require a similar commitment from donoragencies as is already the case for NlDs. Poor surveillance of AFP in SEAR is a potential constraint to achieving the eradication goal by the year 2000. Table 14. Reported AFP rate per 100 000 children under 15 years, SEARO
An overview of the poliovirus circulation in SEAR suggests that wild poliovirus infection appears in at least seven of the ten SEAR countries. The epidemiological situation in Myanmar, India and Bangladesh indicates that these countries pose a special threat to WPRO member countries. In detail, the situation can be summarized as follows:
- 39 -
Table IS. Current poliomyelitis situation In SEARO countries India Nepal Indonesia Thailand Maldives DPR Korea Bangladesh Bhutan Mvanmar Sri Lanka Type 1 2 3 wild polio multiple transmission chains At least endemic for typtl_1 wild poliovirus At least endemic for type 1 wild poliovirus At least endemic for type 1, 3 wild poliovirus No endemic circulation· 1 imported poliomyelitis case in 1994 No cases reported. Needs further Investigation No current data to describe chains of transmission No current data to describe chains of transmission No current data to describe chains of transmission No current data to describe chains of transmission
There is a critical need to expand and improve SEAR's capacity to provide adequate public health laboratory services for poliomyelitis eradication in the Region. Virological surveillance must be strengthened by increasing the percentage of AFP cases with adequate stool samples (two samples within two weeks of onset). In India, only 14% of the reported cases have stools collected. A country network of five poliomyelitis laboratories is currently operating, but will need expansion to eight or nine laboratories. In India, the Government has announced that the NIDs should be expanded to include the age groups zero to five years, instead of the zero to three years group. This implies that the target group will increase from 75 million children to 125-140 million children in 1996/1997 onwards. This will drastically increase vaccine resource requirements for the next NIDs in India. Due to a very limited budget for activities under the WHO regular budget, most of the regional and country poliomyelitis/general EPI activities have to be supplemented with extrabudgetary funds. Vaccine requirements for NIDs are approximately US$ 50 million per year in SEAR. Interested donors such as Rotary, UNICEF, DANIDA, JICA, CDC/USA ODA, and other partners as well as concerned governments are encouraged to support this initiative, not only in the provision of OPV, but also the provision of cold chain, vehicles, and laboratory equipment. To meet such vaccine demand, WHO and the member countries must promote regional self-sufficiency in the production and distribution of high-quality vaccines among themselves as decided by the Ministers of Health during their meeting in Colombo in September 1995. NIDs/SNIDs were conducted in 1995 in seven countries in SEAR, costing minimally about US$ 57 million (an increase of 1325% compared to 1994, reflecting the increased number of NIDs). It is equally important to improve intercountry and interregional collaboration in poliomyelitis eradication activities. For NIDs, "epidemiological blocks" should be considered for greatest impact, as was done previously in Central America and in Eastern Europe, the Middle East, and Central Asia. Collaboration can also be organized in such a way that support from SEARO and ASEAN can be mobilized. India, Nepal, Myanmar, Sri Lanka, Nepal (and Pakistan) have planned to conduct almost simultaneous NlDs in the months of NovemberlDecember (1996) and January (1997). 2.7 2.7.1 Reclassification of AFP cases; Changing from clinical to virological case definition Introduction
Surveillance quality in countries of the Western Pacific Region improved rapidly from 1992 to 1995. Despite these improvements in surveillance quality, no wild poliovirus was found in most areas, and it is likely that the transmission of wild poliovirus has been interrupted in most of the Region.
- 40-
Many reported AFP cases continue to be confirmed as poliomyelitis, however, bued on the clinical case confirmation criteria adopted by all countries at the beginning of the eradication initiative. Th~majOrity of these cases are confirmed because residual paralysis wu found . p examination. However, residual paralysis can also be caused by other at the 6O-day specific for paralytic poliomyelitis only. As the incidence of paralytic conditions and II poliomyelitis decreases, It becomes less likely that residual paralysis Is caused by poliomyelitis. up to 25" of non-poliomyelitis AFP cases (GBS, other causes) will improve but may still show residual paralysis/weakness 60 days after onset. Thus, using the clinical classification criteria for poliomyelitis may result in misclassification of AFP cues as poliomyelitis, unless classification criteria are made more specific.
2.1.2
Surveillance quality needed before virological classification criteria can be used
Confirming as poliomyelitis only those AFP cases associated with wild poliovirus will effectively raise the specificity of the case classification criteria, and will avoid misclassification. these 'virological' case classification criteria should only be used where surveillance quality is sufficiently high. If surveillance quality is not at a high-level there Is a substantial risk of missing true poliomyelitis cases; surveillance quality should have reached the following level before countries can switch to the virological case classification criteria: the non-poliomyelitis AFP rate is one per 100 000 population under 15 years of age; at least 60% of AFP have two adequate specimens taken 24 hours apart, within 14 days of onset of paralysis; at least 60% of AFP cases are investigated within 48 hours of report; 80" of reporting units provide zero-reports on time. 2.7.3 Clinical and virological case classification criteria All countries are currently using the following clinical case classification criteria.
Flgure 6. Clinical case c1usslncatlon criteria Clinical case classification crlterlo; "Acute flaccid pan-lysis cases in children under 15 yean
ainicat classification of AFP caws Oed or loot 10 foll"""p
of age are confirmed al poliomyelitis for any !.'!m: of the following:
• • pooiti", for
-ann -ann 6 .... nn
- wild poliovirus isolated from a .tool .pecimen - res1dual paralysis at 60 days after onset - death before follow-up at 60 day. - case lost to follo ..-up. All other AFP Cales arc discarded as non-poliomyelitis AFP."
/ AFP
... WaJ panI)'i.
'"
FoIl_upal 60 days
,
/
noresiWai ponI)'i.
/
\\'1
.Idpol..
1000niS
_
• di.....u
- 41 -
Countries where AFP surveillance has reached the quality levels described above should adopt the following virological case classification criteria:
Flgure 7. Virological c1assIncation or AFP cases Ylrolosisal s- C ......llcMtOl criteria
________________
~.
auWm
II,
iIoIdioD ..IcquKy of IkIoI ~ .... follow-.., DiIearded _ _-polio
01 APr C_..-, ... _ willi poliovirul wida
rea--
Wild poliavirus of
......e)
- AFP _ wida 2 ~ 1I0oI ~ .... DO willi poIiovu- iIoI.IioD. or - AFP _ with ~ . . . . . . DO wild poIiovina . . . . . . QI) . . . . ..a panIp. . . . 'diKudcd' by .. upe:rt ..........
/
DO wiW poliovirw i.ol.tioa but iBId...... 1Ioo11pOCne... (-'-' lhene W_ 110 raid" .,....1yW &lid the cae ... 'dilcarded' by .. cqtCrt c;ommiaec)
AFP _
,..lWe
widt,
(DeWIou ol.deguate .J!!:t'bnftlS: two apedm_ c:oUected witlWl 14 . .". 01 ODMI
ice pnMlIII. la COIIlaiaer)
0' par",,_ reachIDa the laboratol')' with
"'" odt>plte - - - - - - , dis:md
Poliomyelitis-compatible cases should be considered as an indicator of weak surveillance, because adequate samples were not COllected, and poliomyelitis could not be excluded with the same certainty as for the other cases. AFP cases not classified as 'confirmed' or 'poliomyelitis-compatible' can be discarded; that includes cases for whom 'adequate' specimens tested negative, regardless of whether or not there was residual paralysis. 2.7.4 Operational aspects of classifYing cases
All of the surveillance data available for a case should be reviewed as soon as it is available; the decision on how to classifY should be made only when all data on a case is completely assembled. The following are important operational aspects of case classification: final classification should be done at national level; final classification should await the completion of all data to be collected on each case, including case investigation results, final laboratory results and follow-up examination; expert groups should be formed at national level (provincial level in China) to review and facilitate final classification of unclear cases. One of the problems in applying the clinical case definition has been that complete, accurate virological, epidemiological, and clinical data are needed to accurately classifY cases. While much emphasis has been on the laboratory results. clinical case classification also relies on the results of the follow-up examination, since cases with residual paralysis (or no follow-up) are confirmed as poliomyelitis. It is clear that the accuracy of the follow-up examination varies greatly depending on the expertise of the person examining the case. Often, this task is done by people who are not very experienced in clinical examination.
- 42-
Although clinical assessments will not be used to confirm cases using the virological case classification, the result of the follow-up examination is still is the main basis for classifying cases as poliomy"jtls-compatible. Expert advice will be needed for an accurate classification of these doubtful . . . Countries (provinces in China) should establish expert groups, composed of epidemiologists, virologists, paediatricians and paediatric neurologists. These groups should be responsible for the determination of final status, based on the best available data for each case.
2.1.S
Key variables for classification The key variables needed to determine the adequacy of specimens are: the date of collection of stool specimens; number of specimens collected, and date of onset of paralysis. Also needed for virological case classification are: final result of the laboratory analysis (including the result of intratypic differentiation for cases in whom poliovirus was isolated at country/province level), and whether or not a follow-up examination was done, the date of this examination, and its result (I.e., whether there is residual paralysis or not).
The virological criteria place even more importance on the result of the laboratory examination of stool specimens, however, the clinical assessment at follow-up is still important to determine whether a case can be discarded or is classified as poliomyelitis-compatible. 2.1.6 How to best use the virological case classification criteria
Countries switching to the virological case classification criteria should initially tabulate AFP surveillance data using both cI inical and virological criteria to allow a comparison between the two classification systems. This will be the best way to explain to health workers why a virological classification system is being used and to point out similarities and differences between the two classification systems. regions and provinces should be aware that they are responsible to provide the national level with timely, accurate and complete data, without which an accurate final classification cannot be made. 2.1.1 Significance of poliomyelitis-compatible cases
Cases with no or inadequate specimens and residual paralysis will be classified as poliomyelitis-compatible. There has been some confusion about the significance of poliomyelitis-compatible cases, and it is important to remember the following facts. it is unlikely that J!!! AFP cases will have two adequate specimens collected, which means that a certain number of AFP cases will become compatible cases every year; compatible cases shouid carefully be examined to assess the probability of whether or not a true poliomyelitis case was missed.
- 43 -
This would include: carefully and completely documenting each compatible case; for each compatible case, the reason for this classification must be clearly established; this would include establishing the most likely alternate clinical Dx of all compatible cases; examining the geographical location of these cases (mapping) to look for clustering in a specific area; if clustering of compatibles is found, to establish the most likely reason for this (I.e., population density, missing data in crucial fields, etc.). There are two main factors determining the proportion of AFP which wlIl be poliomyelitis-compatible: the completeness and timeliness of collecting adequate stools, and the proportion of non-poliomyelitis AFP with residual paralysis at 60 days. Once AFP surveillance Figure 8. &t1matlng 'poJlomyelitis-compatible' cases ror a qual ity has reached population or 20 million certification levels (i.e., AFP rate of > = 1 per 1()() ()()() population, adequate T"'" """",aim: specimens from at least 80% 20tnillim of AFP, and at least 80% of cases followed up), the I proportion of AFP classified Elcpcokd ""'1>'1;' AfP: as compatible can be roughly 10 .... predicted. The model assumes a country with a total 20%(20_1_ 10%(60 _es) with population of 20 million, with odocpk ...... ~1tooI.' eight million children under 15 years of age; also, it assumes that wild poliovirus 25%(Y2IlI_ ""'(IY2ll1 ..;..... 1 transmission has already been ra'''' ,..-.J>-iI .... r......... interrupted, and that 25% of I non-poliomyelitis AFP will be E.,........, ,..., reported as having residual paralysis at 60 days after onset
...... .....,..
5_(7·5%·(8°1 ....... With these assumptions, a ·poI........IWe· minimum of 7.5% of cases would be expected in the 'compatible' category. In add ition, some of the 15 cases without adequate stools and without residual paralysis might become compatible after expert review.
"'............
... ~
-_
I
- 44-
2.7.8
Reclassifying 1995 AFP data from China and Viet Nam
Using t h e . current 1995 datasets available to WHO, the virological case definition was applied to AFP data from both China and Viet Nam. For both countries, specimens were considered adequate if there were two specimens collected within 14 days of onset of paralysis. The additional criteria for 'adequacy ofspecimens', such as 'ice present on llTival in laboratory' and 'stools collected at least 24 hours apart' were not available or very incomplete, and were not used in this analysis to define 'adequate' specimens. 'Compatible' cases have not yet been mapped for this preliminary analysis; also, no more detailed analysis of compatible cases (i.e., assigning the most likely alternative diagnosis) was performed. This should be done as soon as possible in order to assess the probability of whether or not true poliomyelitis cases may have been missed. In Viet Nam, 66'Ai (307/458) of AFP cases without
Figure 9. Virological classification or AFP cases In Viet Nam
wild poliovirus isolation in 1995 had two adequate specimens taken. A minimum of 58 cases of 465 (12 'Ai) AFP cases reported overall would have become compatible (residual paralysis: 33, death before follow-up: 15, lost to follow-up: 10). Expert group assessments are not yet available for the 93 cases with inadequate specimens but no residual paralysis; thus, a small number of these 93 cases may also be classified as compatible.
:::: 7
~:
__________________
~.
0M&m
7 58
< NDWiId
-.,{7 ,.,..,...
-._ cHed or lost to
m<
""7s7- No__ _ < -1..3 J ~ NY,",
. c."'
''5
93
--
------------.. - - 30
In 1995, 76'Ai of reported Figure 10. Virological c1usincatlon or AFP cases In China AFP cases in Ch ina had two specimens collected within 14 days of onset (3667/4800). _.IIvo: ~ 1 Wild poliovirus was found in 1 only one case, a child from Myanmar who had come across . "'-_., =:;'" .,1000.. co", ''''''' 128 the border into Yunnan province 4800 to seek health care. ......_ \ 128 /1113
AFP:(
--------------------.,
Of the 613 cases with no or inadequate specimens, 128 cases would be compatible because they had documented residual paralysis (125), died (one) or were lost to follow-up (two). Four hundred eighty five (485) cases had no residual paralysis documented at follow-up.
7'~ \
No_
/
... .....--,.,
1_spekINns
::.,;.___ (-"}485 485 _low
DIsc...
- - - - - - - - - - DIsc"':
41811
4186
- 45 -
2.7.9
Conclusions
AFP surveillance quality In countries of the Western Pacific Region has continued to improve and has reached quality levels in several countries which allow them to switch from clinical to virological case classification criteria. In both China and Viet Nam, more than I per 100 000 non-poliomyelitis AFP cases were reported in 1995, with two specimens taken within 14 days of onset from more than 60% of AFP cases. A reclassification of 1995 AFP cases from both countries showed that only a relatively small proportion of reported AFP cases would have been labelled compatible. China and Viet Nam should begin to use virological case classification criteria to classify AFP cases reported in 1996. As a result, only AFP cases associated with wild poliovirus will be confirmed, eliminating the risk of falsely labelling non-poliomyelitis AFP cases as poliomyelitis. However, using virological case classification criteria will require both countries to maintain and further improve surveillance quality. Other poliomyelitis-endemic countries should attempt to raise AFP surveillance quality in 1996 to the level required for switching to the virological classification criteria. 2.8 2.8.1 Measles surveillance and control" Introduction
Although great progress has been made in reducing the global burden of measles, it remains a major cause of sickness and death. It is estimated that 45 million cases and one million measles related deaths occur annually throughout the world. In developing countries, measles accounts for approximately 10% of the estimated 12.2 million deaths that occur annually in children under five years of age. 2.8.2 Status of measles control in WPR in 1995
Surveillance for measles has improved in WPR countries over the last decade. Most countries in the Region have attained the 1995 goal of a 90% reduction in the number of cases. This reduction is directly attributable to good routine coverage with measles vaccine. Despite this progress, measles is still the most significant EPI target disease in the WPR. There are an estimated one million to 1.5 million cases each year. Case fatality rates vary from a low of 0.1 % in developed countries to around 5%, mostly in South-east Asia, the Philippines and Papua New Guinea. Between 26 000 children and 39 000 children die annually in the Region due to measles and its complications. These deaths continue to occur for several reasons: vaccination coverage is not evenly distributed. Outbreaks occur in areas, both rural and urban, where coverage is low; in areas of high vaccination coverage, some children remain susceptible, because a) not all children are immunized and b) vaccine efficacy is only around 85%. 2.8.3 Accelerated measles control in the Americas
There has been considerable progress towards the elimination of measles in the Americas through the use of mass immunization campaigns targeting children from nine months to 14 years of age. These campaigns were originally used to pre-empt outbreaks, which could be predicted from coverage and surveillance data. The results have been dramatic. Chile did not report any confirmed measles cases in 1994 and 1995, following a mass campaign in 1992.
- 46-
Virtually all central and south American countries have adopted the strategy of Initial mass campaigns for children nine months to under IS years of age, followed by campaigns which are held~. three to five years for children under five years of age. PAHO has resolved to eI~ measles from the western hemisphere by the year 2000. 2.8.4
Accelerated measles control In the Western Pacific Region
Most countries In the Region have high routine immunization and a well-developed EPI infrastructure. Accelerated measles control will be built upon strategies used in the poliomyelitis eradication efforts, namely, sustained high routine Immunization coverage, Itrong disease surveillance (I inked to the active surveillance system for AFP) and supplementary immunization activities. The control activities are designed to: predict and prevent outbreaks or epidemics of measles In countries of the Region; further reduce indigenous transmission of measles virus; improve the timeliness and completeness of measles surveillance In the Region. WPRO may adopt a country-specific approach, with countries being grouped depending on the current status of measles control, based on epidemiology, immunization coverage and status of surveillance systems (fable \6). The initial stage Is to ensure that there are no pockets of poor coverage for routine EPI, including measles, and that reliable surveillance systems (linked to AFP surveillance) are in place, to maximize detection of transmission. This may. be followed by supplementary immunization campaigns. A three-year plan for surveillance and immunization activities is outlined in Table 17. Table 16. Grouping of countries In the Western Pacific Region by current status of measles control
'.'a"', Epidemiology Of Measles
Group t: MOII(IOIIa, Paclflc Industr. countries
Group 2: PhilippInes, VIet Nam, ChIna, MalaysIa Measles endemic in highly populated urban areas, frequent outbreaks in rural areas Some districts have high mortality rates. Routine coverage 80'14090'140, some districts have lower coverage
Group 3: CambodIa, Lao PDR, Papua New GuInea Measles endemic, high mortality rates
Periodic outbreaks of measles. Low mortality rates.
Immunization Coverage Surveillance
Routine coverage 80'14090'140 (lower in some industrialized countries) Reliable surveillance
Routine coverage tor measles under 80'140 Unreliable. much underreporting
Under-reporting, though surveillance can show trends
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Table 17.
Surveillance and Immunization activities during 1996 to 1998, by country group, Western PacinI! Region Group 1: Mongol/a, PaclDc Islands, Industr. CountrillS Group 2: Phll'pp'nlls, Villt Ham, China, Malal.sla Group 3: Cambodia, Lso POR, Papua Hllw Gulnlla -Adapt_ .... doIInItIon lor _ -E_"~'" ,.--,-,monIhIy
Surveillance activHies
1996
1997
- EstabIIIh . . . . . ~CIIY confirmation for Index cae 01 auIbreak -1_llOIjIiIaInoconIlng Ind reporting of ......... .._ I n d _ - Inwstlpatlon of !'!!IY caM -Introduce mo.. . . - monitoring IndIcatora - AI _ _ 10 be Job.
-Adapt--_In_ dellnltlon for ......... -Include
"'-forAFP - Outbreak ....1IIIgaIIon
- 1 _ hoopItoI recording Ind reporting of mo...... anddeaths
-Include
_lorAFP
_In_
-E_ .........
-1~laI_
confirmed
Ilbon1tory corn"'" l,taUon for • Introduce measles
Index case of outbreak surveillance monitoring IndIcatora -Aa .............. ahouIdbe conflnned by IabonltCIIY • Ca.. investigation of IIV&J'f case
1998
_mao. . _ . Ind_ -Introduce mo.• Eotablish _ IabonltCIIY conllrmotlon lor Indo. caoe of auIbreak - R_ _ immunization coverage lor all onttgons
Immunization actlvHies
1996
-
- MongolII ond Poc. Island countries to conduct NIDa lor _ 1 0 prewnt p<edlcted -Impr... routine_ coverage lor Inlanls
• Identify high rIoIc d _ with low immunization
coverage -P........ _ t o l o w coverage dlotr1cla to enable them to ral.. coverage to 9O'J(,
1997
- Identify high rIoIc oms with low ImmUniZation coverage
- Conduct NIDa lor to reduce suoceptIbIeo
moa_
• Identify high rIoIc wtth low immuniZation
dI_
coverage • P........ nosour_1o low c.....ge district. to enable them to raise coveragolo 9O'J(,
1998
- Conduct NIDalor...- to reduce auscop!!bIes
- Conduct NIDa for _ _ 10 reduce suscepl!bIes
The main strategies are: (I) (2) (3) Achieve and maintain routine Immunization coverage of 90% for infants, with one dose of measles vaccine given as soon as possible after nine months of age. Identify low-coverage areas, high-risk districts, and ensure 90% routine measles immunization coverage. Establish a reliable surveillance system for measles, to include a simple case definition, rapid reporting, outbreak Investigation and laboratory confirmation. Supplemental activities to be considered in the future Include: (a) (b)
Conduct supplementary measles immunization initially for ali children aged nine months to under 15 years of age, regardless of Immunization status. Conduct follow-up campaigns according to epidemiological situation.
- 48-
2.8.5
Conclusions
Measles II .... most significant of the EPI target diseases In the WPR. While there haa been significant -"'vement in the control of this disease, it still causes substantial death and sickness. Outbreaks occur in almost all countries in the Region, and case fataJity is high. Accelerated measles control is needed to secure further improvement in this situation. 2.8.6 Recommendations
All countries in the Region should develop plans for accelerated measles control, based on the current status of measles control (epidemiology, immunization coverage and status of surveillance systems). initial control activities should include maintenance of high routine EPI coverage in all areas; targeting of high-risk areas; strengthening of surveillance, including simple case definitions, rapid reporting, outbreak investigations and laboratory confirmation; consideration should be given to supplementary immunization activities, initially in children nine months to under IS years of age; then subsequently in children nine months to under five years of age, every three to five years, depending on the local measles situation. 2.9 2.9.1 Measuring progress towards neonatal tetanus elimination in the Western Pacific Region Introduction
Neonatal tetanus elimination is defined as less than one case of neonatal tetanus per 1000 live births per district per year. In 1996, all countries should document the progress made towards neonatal tetanus elimination. By the end of 1995, all countries had made considerable progress with NTE. Tetanus is a disease that will never be eradicated, as the causative organism Qostrldium tetani exists freely in the environment. Therefore, some kind of control measures to protect newborn infants against NT must continue indefinitely. However, as clean deliveries and routine TT immunization become more common, and the successive cohorts of children fully immunized with DPT become adults, the disease will be much less of a problem, and countries will not have to carry out large scale immunization activities to control it. At previous meetings, the TAG has recommended that countries focus their efforts on high-risk areas by Incorporating tetanus toxoid (IT) immunization into routine immunizations for pregnant women, and developing reliable surveillance based upon existing AFP surveillance systems. 2.9.2 Purpose of measuring progress towards neonatal tetanus elimination
Having successfully immunized a high proportion of women of chlld-bearlng age with tetanus toxoid (both when pregnant and not-pregnant), the main purpose of measuring a country's progress is to improve and sustain NT control where it is still needed. A district that had no NT cases in 1995 may claim to have eliminated NT, but may have cases In 1996 unless surveillance and TT immunization are maintained at high levels.
- 49 -
The challenge for 1996 and beyond is to use sel1l(.1ed indicators (see below) to Identify those areas (high-risk areas) where sufficient progress has not yet occurred, and to provide these areas with the support and resources needed to continue and to Improve control measures against NT. The purpose of measuring progress towards NTE may be summarized as follows: (a) to sustain and improve control activities for NT in countries or areas of a country where the disease remains a problem; (h) to monitor the incidence of neonatal tetanus; (c) to monitor the quality of surveillance for NT; (d) to monitor tetanus toxoid immunization activities; (e) to monitor the control measures implemented in response to the report of a NT case;
(f) 2.9.3
to identify the high-risk areas where control measures must now be focused. Use of indicators to measure progress towards neonatal tetanus elimination
To fully document the progress that has occurred in each country, a set of indicators Is recommended (see Table 18). These indicators include surveillance for NT, immunization coverage, immunization activities, clean deliveries, and case response to NT. Indicators should be monitored in all countries that reported NT cases at any time in the last three years. Such reporting should be done in two steps: (I) Measure the NTE indicators over three years by units of population of approximately one million (province in most countries; county in China). (2) If data are available, measure the NTE indicators over three years at the next lower administrative level (district). This will identify areas where continued efforts are required beyond 1995. 2.9.4 Procedure for progress report
(I) At national EPI meeting, introduce guidelines and protocols to regional and provincial EPI managers and surveillance staff; (2) Distribute guidelines and protocols to every province and request completion of data within three to six months; (3) Follow up with provincial visits to assist health managers to complete data collection; (4) Hold national EPI or NT elimination workshop to review and analyse data, finalize indicators and produce national report, Including specific recommendations resulting from the progress report.
TABLE SURVEILLANCE I. lDcideace of NT per I000 live births per year.
18. Indicators for monitoring progress towards neonatal tetanus elimination IMMUNIZATION COVERAGE IMMUNIZATION ACTIVITIES CASE RESPONSE I. "of NT .,.. which bave ' ieapood.od to by iDmllmj,.tiOll of cbildCLEAN DELIVERY
I. " iDfmts protected from NT It birth
1. " _ where routiDe IT is offered to pregaaat WOmal
I. "of .....li.... .w;--. tIuIt lab pIKe ill '-lib &cilitia
the_ 2. "of iepoiliiiJl aaia Jq>Orting NT. including zero Jq>Orts 011 time.
beiIriDJ . . -
in
em- (IT2 +) for pregJWit women.
2. T _ toxoid " COY....., It leat
two
2." _where SUJIP~laJy IT i. offered to aU WOmal of child-bearing age. 3. " _
3. " of neonatalletallus cases that have Uildergoae minimum level of case investigUion to determine the jmmllnjzation status of the mother. 4. "of province or district hospitals which have bad a review of hoopital records to ~ for NT cases.
3. Tetanus toxoid" coverage. It leat two em- (IT2 + ) for womea of child bearing age.
where booster
em- of IT are offered to children over 12 iIIOIItbs of age (i.e. before. or during school) o '"
S. "of provinces with hip risk districts identified. -I.
iafuuprWclOd .. birIh -' aay ti.- i. tho piIIt.. ~
t!!!m
w.... _
.............: _ _ oflTi.Ihe .... P.......,. _ofwloich_inlhe .... _ , .
ot_ ..... _of .. _ _ _
eITr
l. 4. 5. 6. 7. S.
2.
~ CONnp TIl+
- two or more doIN olTr f_ preaaIIIl ...... _ _ - _ _ 28da,10rbirlh.
N..-.I _ _ . . . - ....... lUCk .... cry .. _ . " - with ... lrd ... 2Iob <Ioy.""'...ny within 28 doyI ofbirlh. IaveICipIed NT cue - NT c. . . dial have IIIIdeIJo- ........m lnel of CMI i........... 10 'eiwian - . . ordlellllOtber. locideace of ~ - number of NT reported cue. per 1000 live bitda, per year. Hip rUt diltrict ... any dillrict wilb oue 01' more NT CUM reponed, or home detivetiu >30 •• «Tn+ coverqe <50~. Action laUn '"" reapouc to NT by immunizaioo of cruld'""-rirll ap women in the area.
kioI--
't .........
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2.9.5
Conclusions
All countries in the Region that have recendy reported neonatal tetanus had, by the end of 1995, made significant progress towards neonatal tetanus elimination. China, the Philippines and Viet Nam have succeeded in eliminating the disease to a rate of less than one case per thousand live births per year at the province leVel. where a province is defined as an administrative unit of approximately one million population. The review of progress towards NTE should be used to identify specific areas and determine specific activities where elimination efforts will be required in the future. However, despite the progress that has been made towards the NTE goal, and as tetanus will never be completely eradicated, surveillance and immunization activities for NTE should continue indefinitely.
2.9.6
Recommendations
(1) All countries that have reported NT in the last three years should document progress towards NTE using indicators of surveillance for NT, immunization coverage, immunization activities, clean deliveries, and case response to NT. (2) All countries should use data collected by a review of progress and surveillance information to identify remaining high-risk populations in order to take action by immunizing with tetanus toxoid. (3) Given the high coverage that has now been achieved with tetanus toxoid for women of child-bearing age, tetanus toxoid coverage should be measured by using children protected from NT at birth as the denominator. (Infants may be considered as protected at birth if the mother has received at least two doses of IT during pregnancy or a total of at least three doses of IT at any time in the past).
3. CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC
3.1
Criteria for certification
At its first meeting, the Regional Commission for the Certification of the Eradication of Poliomyelitis set criteria, strategies and a plan of action for certification. For the WPR to be certified as poliomyelitis-free it is essential that all countries in the Region meet the following criteria: there is no evidence of indigenous wild poliovirus transmission detected for a period of three years in which surveillance has been maintained at the level of performance needed for certification; a National Certification Committee in each country has validated and submitted the certification documentation required by the Regional Commission; appropriate measures are in place to detect and respond to importations of wild poliovirus.
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3.2
Current stahls of certification
Countries have been divided into groups: Poliomyelitis-endemic countries (Cambodia, China, the Lao _Ie's Democratic Republic, Malaysia, Mongolia, Papua New GuInea, the Philippines, Viet N"1m); countries non-endemic for> five years (Australia, Brunei Darussalam, Hong Kong, Japan, Macau, Republic of Korea, New Zealand, Singapore). National Certification Committees will be formed in each country. The Committee members should have a background in public health, epidemiology, virology, neurology or other related disciplines. All countries that are reporting zero cases of poliomyelitis should appoint a National Certification Committee by December 1996. Other countries should establish committees by the end of 1997. The non-poliomyelitis-endemic countries should review their plan of action and report proposed activities to the Regional Commission by the end of 1997. These countries should submit documentation by 1998, while all poliomyelitis-endemic countries should submit documentation by 1999. Pacific island countries will be considered as a single epidemiological block due to the unique epidemiological sihlation, and will be represented by a five-member Subregional Certification Committee, which will coordinate activities normally performed by national committees. The Subregional Committee will be appointed by December 1996. Certification for the Pacific island countries may proceed relatively rapidly. Their first briefing report is expected in 1997. Countries in the Pacific island group are American Samoa, Cook Islands, Fiji, French Polynesia, Guam, Kiribati, Marshall Islands, Micronesia, Nauru, New Caledonia, Niue, Northern Mariana Islands, Palau, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu, Vanuahl, Wallis and Futuna.
Figure II. Organization of certification process In WPR
Global Commission Regional Commission " -
/~~
/
National Committees
Sub-Regional Conuni for the Pacific Islands
National EPI & Surveillance
National EPI & Surveillance
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3.3
Surveillance activities and certification standards
The Global Commission has listed six indicators for demonstrating that an AFP surveillance system meets the level of performance required for certification. In the WPR national surveillance systems should meet the specified performance level for a minimum ~f 12 months prior to certification. The indicators are: (i) At least 80% of expected routine AFP surveillance reports shoUld be received on time and the distribution of reporting sites should be representative of the geography and demography of the country. (Ii) The AFP surveillance system should detect a non-poliomyelitis AFP rate of per 100 000 population aged less than 15 years.
> one case
(iii) At least 80% of reported AFP cases should be investigated within 48 hours of being reported to the level which is responsible for case investigation.
(iv) All AFP cases should have a full clinical investigation, with at least 80% of AFP cases having an examination of two adequate stool specimens in an accredited laboratory and a followup examination for residual paralysis at 60 days after the onset of the paralysis. (v) All virus isolation tests, including negative results, must be performed by accredited laboratories. (vi) At least 80% of the specimens from AFP cases must be suitable for analysis upon arrival in the laboratory. In addition, active surveillance must be conducted in high-risk areas, such as: border areas with countries known to be poliomyelitis-endemic; large minority populations which have frequent contacts with similar populations in poliomyelitis-endemic countries; areas with underdeveloped health care services, low immunization coverage and incomplete disease reporting; areas with recent laboratory confirmed cases. Active surveillance consists of regular (e.g., weekly) visits to health care facilities to identify and investigate unreported cases of AFP. At a minimum, this should Include paediatric hospitals, infectious diseases hospitals, and referral hospitals with paediatric wards. Additional surveillance activities to demonstrate the absence of wild poliovirus may include collection of stool specimens from contacts of AFP cases, (where adequate samples cannot be collected from the AFP case), and stool surveys in areas where AFP reporting and investigation is unreliable, and there are known contacts with poliomyelitis-endemic areas. 3.4 Surveillance activities in non-poliomyelitis-endemic countries
Some non-poliomyelitis-endemic countries which have been poliomyelitis-free for many years may not be able to establish routine AFP surveillance systems which meet the requirements for certification. In some cases, the Regional Commission may approve data from sources, such as Paralytic Poliomyelitis Surveillance (a mandatory poliomyelitis reporting system including vaccine-associated poliomyelitis); Poliovirus Surveillance (systematic monitoring of enteroviruses isolated from patients with neurological syndromes, and related data
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from public health and hospital laboratories); High Level of Population Immunity to Polioviruses (immunization data which demonstrates very high coverage with at least three doses of poliovu:...yaccine among the general population and high-risk groups, plus serological studies which dllllilatrate a very high level of population immunity). Special studies will be required to complete certification in these cases, including surveillance for AFP cases through sentinel reponing sites, and serological studies and/or stool sampling in high-risk areas/populations to demonstrate high levels of Immunity and absence of wild poliovirus. 3.5 Additional surveillance activities for the Pacific island subregion
Innovative surveillance activities are needed to demonstrate the absence of wild poliovirus circulation from the countries and areas of the Pacific island subregion. Due to the limited population size of these islands, one of the most important indicators of AFP surveillance performance, the non-poliomyelitis AFP rate, is not a useful gauge of the standard of surveillance on an individual island (although it will be used to evaluate the overall sensitivity of AFP reponing in the Pacific island countries). Therefore, there should be full investigation of the limited number of AFP cases which do occur, documentation of high routine immunization coverage in all areas and among all populations of each Pacific island country and area, and supplementary OPY immunization in those geographical areas or among those populations where OPY3 coverage is less than 80%. In addition to this standard documentation the Regional Commission may require periodic retrospective hospital record reviews for childhood paralysis. The record reviews should be conducted at a minimum of every six months and cover at least the three-year period immediately prior to certification. All previously unreported AFP cases which are detected through record reviews should be classified by an expert committee. Stool surveys may be required in areas where immunization coverage is low, where there is clustering of poliomyelitis-compatible cases from record reviews, or where there is known contact with poliomyelitis-endemic countries, to demonstrate the absence of wild poliovirus circulation. 3.6 Documentation required from each country for certification
The Pacific islands Subregional Committee and each National Certification Committee must provide the appropriate documentation to demonstrate that the subregion or country is poliomyelitis-free and that wild poliovirus importations would be readily detected. The documentation must cover five general subject areas: (1) Country background information: demography, geography and organization of health services relevant to poliomyelitis eradication and its certification. (2) Structure of the poliomyelitis eradication initiative (immunization, surveillance and laboratory services). (3) Poliomyelitis immunization activities showing high routine poliomyelitis immunization coverage and, where appropriate, that supplementary immunization activities have been implemented. (4) Surveillance for paralytic poliomyelitis and polioviruses, to demonstrate that disease surveillance is of a sufficient standard to detect any cases of paralysis due to either indigenous or imported wild poliovirus.
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(5) Laboratory services for poliomyelitis eradication to demonstrate that the poliovirus laboratory could isolate and identify wild polioviruses. 3.7 Role of the WHO secretariat in the certification of poliomyelitis eradication
The WHO EPI secretariat will assist with the implementation of the certification strategy at the national and subregional level and, when appropriate, act as a liaison between the committees and the Regional Commission. The WHO EPI secretariat will be responsible for identifying the unmet resources requirements for the certification process.
4. MEETING OF THE REGIONAL INTERAGENCY COORDINATING COMMITTEE (ICC)
4.1
OJ)enin~
Chairman Brian Knowles of Rotary International opened the meeting by recognizing the continuing progress towards poliomyelitis eradication and the achievement of other EPI objectives, as evidenced by the proceedings of the TAG. 4.2 4.2.1 Reports by ICC members Australian Agency for International Development (AusAID)
Mr Alan March stated that AusAID was committed to a philosophy of development which focused on capacity-building and long-term sustainability. Recent AusAID public health assistance in the Region has focused on malaria, poliomyelitis eradication, neonatal tetanus control, and HIV/AIDS. Mr March stated that AusAID had a particular interest in development projects in Cambodia, China, Indonesia, the Lao People's Democratic Republic, Papua New Guinea, and Viet Nam. Mr March stated that because of the recent change of the Australian Government, new AusAID policies had not been articulated. However, it was expected that AusAID would continue to be interested in EPI and poliomyelitis eradication activities . 4.2.2 Centers for Disease Control and Prevention (CDC), Atlanta, USA
Mr Robert Keegan reaffirmed CDC's continuing support for the global and Regional partnerships which have developed to eradicate poliomyelitis and to achieve other EPI disease control elimination objectives. Mr Keegan stated that the United States Government, through CDC, had increased its global contributions for poliomyelitis eradication to US$ 27 million in 1996, of which 80% would go for grants to UNICEF and WHO for poliovirus vaccine and technical support. Mr Keegan expressed CDC's continuing commitment to support for WPRO's poliomyelitis eradication efforts, and for participation in the initiative to accelerate measles control. 4.2.3 Japan International Cooperation Agency (JlCA)
Dr S. Taira stated that the Government of Japan had an interest in providing support to countries of the Asia-Pacific Region, and that Cambodia, China, the Lao People's Democratic Republic and Viet Nam were priority countries. Dr Taira summarized recent support from the Government of Japan, through JlCA, for provision of vaccine, cold chain equipment and technical support.
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4.2.4
Rotary International
Dr Gra3i'Connell expressed Rotary's commitment to being a major partner for .. ion until the objective is achieved. He noted that, although Rotary'. poliomyelitis support had prev Iy focused on supplying OPV, in the past year support had shifted emirely to AFP surveillance. Dr O'Connell announced that the second payment of USS 6S5 000 of Rotary's USS 1.7 million grant to WPRO for AFP surveillance was expected to be released imminently to support further operational costs in the poliomyelitis~ndemic countries. Rotary International also has 8 new initiative called PolioPlus Partners Programme through which funds for support of NIDs and the laboratory network can be generated from Rotary clubs worldwide. Dr O'Connell stated that the Rotary community in Japan has been especially interested in supporting poliomyelitis eradication, and had recently raised a total of USS 371 ()()() for vaccine, and operational and certification costs in Cambodia, China, Mongolia, and in the Regional Office. 4.2.5 UNICEF
Dr Tan commented that the new Executive Director of UNICEF had specifically mentioned her support for poliomyelitis eradication and other goals established for the year 2000. UNICEF spent more than USS 13.6 million in 1995 on poliomyelitis eradication and EPI activities in poliomyelitis-endemic countries of the Region. In addition to strong support for EPI, UNICEF provides support for water, sanitation, health education, and other public health projects. Dr Tan stated that UNICEF was committed to working with WHO and other partners to achieve poliomyelitis eradication and other year 2000 goals. 4.2.6 Republic of Korea
Dr Omi introduced Mr Yong Kyu Kwon who represented the Republic of Korea for the first time at the ICC. The Korean Government was recognized for providing support for the TAG meeting. 4.3 Shortfalls
Mr Chris Maher summarized projected funding shortfalls for NIDs and SNIDs for the winter campaigns in 1996-1997, including vaccine (USS 4.9 million) and operational costs (USS 370 (00). Mr Maher also summarized shortfalls for surveillance, laboratory activities and certification costs, estimated at approximately US$ 0.95 (with receipt of USS 655 ()()() from Rotary) in 1996, and US$ 1.5 million in 1997. Following this presentation, informal discussions were held among the partner organizations. Commjtments The following commitments were made: CDC: JlCA: USS 1.0 million for OPV for China SNIDs USS 0.5 million for OPV in Cambodia USS 0.5 million for OPV in China US$ 0.32 million for OPV in the Lao People's Democratic Republic USS 1.1 million for OPV in Viet Nam
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4.3.1
Rotary
~ recommendation wil.1 ~e made to the Trustees of Rotary Foundation of Rotary Internallonal that USS 0.5 mllhon be approved for surveillance in 1996 and an additional US$ 0.5 million for 1997 upon receipt of appropriate plans. The Secretariat was also encouraged to submit laboratory supply and equipment needs for 1997 to Rotary for funding consideration by PolioPlus Partners Programme. 4.3.2 UNICEF
Fund-raising activities were agreed upon by UNICEF committees in Hong Kong Netherlands and the United Kingdom In attempts to meet OPV shortfalls In China and ' Viet Nam.UNICEF also suggested that country UNICEF offices may be able to fund costs for certification activities. 4.3.2 AusAID
Although AusAID was unable to make a specific funding commitment, AusAID stated that it would welcome proposals for funding of operational coSts in Cambodia (USS 320000) and Papua New Guinea (USS 50 000). As a result of these funding commitments, the ICC expects that sufficient funds will be available for all planned NID and SNID activities for 1996-1997 winter campaigns. Although the Secretariat agreed to make efforts to reprogramme funds to meet priority surveillance activities this year, it was recognized by the ICC that some activities would have to be curtailed due to the funding shortfall. 4.4 Recommendatjons and conclusions of the ICC
(I) The ICC noted that special activities may be necessary in border areas and may require commitment of funds at short notice. The ICC recommended that these plans be prepared and forwarded to the ICC as early as possible to enhance the likelihood of funding. (2) The ICC reviewed the surveillance budget for 1996 and 1997 in detail and endorsed the need for funding for this critical activity.
5. CONCLUSIONS AND RECOMMENDATIONS
5.1
Progress since the last TAG meetin2
At the end of 1995, the Region was very close to achieving the 1995 Regional goal for the eradication of poliomyelitis. Only 426 clinically confirmed cases, of which 19 were wild poliovirus-associated, had been reported by 22 March 1996, half the total for 1994. Only one imported wild poliovirus-associated poliomyelitis case was detected in China in 1995, despite the fact that over 5600 AFP cases were reported in 1995, with specimens taken from 90% of cases. However, in view of the vast geographical area and large population of China, efforts are being intensified to continue to define the epidemiological situation. Of the 426 clinically confirmed cases in the Region in 1995, 165 were reported from China. With greatly improved surveillance for AFP and poliovirus in the Region, the TAG currently believes that the last foci of wild poliovirus transmission are the Mekong Delta Region of Viet Nam and Cambodia, and the border area between Myanmar and the Southern provinces of China.
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Regional immunization coverage for all EPI antigens was maintained at over 90% . Routine coverage increased significantly in Cambodia and in the Lao People's Democratic Republic. Surveillance for neonatal tetanus indicates that the ~isease has been reduced to ~el~w one case per th~ live births per year in almost all countnes and areas. Measles morbidity has declined by at least 90% compared with the pre-immunizatl~n. er~. Coun!r~es ~e • progressively implementing national plans of actIOn for safe stenhz!llI?n and mJ~tlon practl~es. and for EPI cold chain and logistics. Progress has also been made m Implementmg the Regional plan of action for vaccine self-sufficiency. 5.2 5.2.1 Major issues and recommendations Poliomyelitis eradication
Surveillance for poliomyelitis eradication Surveillance for AFP has improved dramatically in 1995. China and Viet Nam have now achieved the interim AFP surveillance criteria. Recommendations <I) Further progress shuuld be made towards reaching AFP surveillance quality levels necessary for certifying poliomyelitis eradication in AFP surveillance: case-finding. stool collection and transport. and laboratory performance. (2) All countries should aim to report using virological case classification criteria. China and Viet Nam should report using virological case classification criteria. with all AFP specimens tested at an accredited laboratory. (3) Countries which have not met AFP surveillance performance standards should continue to report poliomyelitis based on the cI inical case classification criteria. (4) China and Viet Nam should continue to report using both clinical and virological criteria as an interim measure. and move to a virological case definition once they have achieved the interim APP surveillance and laboratory performance criteria. (5) When the virological case classification system is adopted. all 'poliomyelitis-compatible' cases should undergo careful epidemiological review. with additional investigations as needed, to exclude the possibility of unrecognized circulation of wild poliovirus. Poliomyelitiscompatible cases with or without residual paralysis should be reviewed by an expert committee. Efforts should be made to maximize the percentage of APP cases from whom two adequate stool samples were collected and examined in accredited laboratories. This will reduce the number of cases classified as poliomyelitis-compatible. (6) Given the imminent requirements for certification of poliomyelitis eradication, nonpoliomyelitis-endemic countries should establish appropriate surveillance for paralytic poliomyelitis and polioviruses using methods such as the APP and enterovirus surveillance being established in Australia. (1) Specific efforts must be made to improve surveillance quality in those countries not yet meeting the interim criteria, particularly the Philippines. Surveillance reviews should be carried out as necessary to identify problems and develop appropriate solutions.
(8) To support the increased emphasiS on surveillance. detailed surveillance needs assessments should be prepared and detailed in budgets submitted to the Interagency Coordinating Committee.
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(9) Continued coordination will be required between national EPI, surveillance, and laboratory staff. Laboratory syste~ th~t has been developed to monitor performance. Adoption of the virological case
The TAG commends the major improvements in the laboratory network, especially In the
classlficatlon system and the demands of certification of poliovirus eradication require a sensitive AFP surveillance system and a high quality poliovirus laboratory network. The meas~res required to further improve laboratory competence are detailed in the report of the Meeting on Laboratory Surveillance for Poliomyelitis Eradication in the Western Pacific Region, 16-18 October 1995. Recommendations (10) WPRO should establish a formal system for annual accreditation of network laboratories. Accreditation will be based on performance in the following areas: use of WHO-approved laboratory protocols; use of WHO-supplied cell lines, with regular scheduled replacement; score on most recent proficiency test; specimen sensitivity from results on stool pairs; NPEV annual isolation rate; time required to report specimen results; confirmation of poliovirus typing by Reference Laboratory; consistent high level of performance. (11) Until laboratories qualify for accreditation, duplicate specimens from all AFP cases should be referred to a WHO-designated, certified laboratory for confirmation of results. (12) A virus-based classification system requires that all AFP specimens be processed or verified by a certified laboratory. (13) Laboratories should test no fewer than 150 specimens annually for virus isolation to maintain proficiency and provide a basis for assessing qualifications for accreditation. Laboratories testing < 150 specimens for virus isolation should establish a protocol for expanding testing, such as stool surveys among epidemiologically appropriate groups in high-risk areas (i.e., stools from aseptic meningitis cases). Staff from low-workload laboratories should be given the opportunity to spend time in high-workload, accredited laboratories in order to maintain their skills in virus isolation. (14) Continued support for the laboratory network is required, in the form of training, consumable, and other resources, to ensure a uniformly high standard of laboratory performance. Detailed lists of requirements, developed by EPI WPRO in conjunction with national counterparts, should be used in approaching partner agencies for support. It is essential in the final stages of poliomyelitis eradication that these needs, as detailed in the proposals submitted to partner agencies, be met.
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Cross-border coordination There haa been a well documented example of cross-border transmission of wild poliovirus betw. . Myanmar and China at the end of 1995. Recommendatioos (15) Very high priority should be given to minimizing the risk of importing wild poliovlruses across borders with poliomyelitis-endemic countries. (16)
WHO should coordinate immunization and surveillance activities in high-risk border areas in 1996.
(17) Efforts should be made by the WHO Regional Offices concerned to assure that at least one round of supplementary OPV immunization activities in Myanmar and China overlap in the winter season of 1996/1997 to ensure that all children in the border area are immunized, regardless of where they are or what country they originate from. (18) An AFP case which is suspected to have been imported from another country or province within a country, must be regarded as the responsibility of the country or province in which the case presents. Therefore every AFP case must be reported and investigated, including stool sampling by the hospital and/or surveillance team in the country in which the case presents. If the case is residing in another country at the time of follow-up, the national surveillance centre in that country should be informed of all details of the case. (19) Special strategies should be devised to target high'risk populations. These strategies should include the use of mobile teams, extra immunization posts, house-to-house immunization where appropriate, intensive social mobilization, the development of IEC materials in minority languages where necessary, and collaboration with local community leaders. Expanding the surveillance system In the Region of the Americas, adding other diseases to the AFP surveillance system has been shown to strengthen the system, especially when poliovirus circulation has been reduced to very low levels. Recommendation (20) In countries where active surveillance is well established, surveillance for other diseases, including measles and neonatal tetanus should be added to the existing system. 5.2.2 Supplementary immunization: NIDs and SNIDs
The TAG congratulates the six countries of the Region which have conducted NlDs. The TAG particularly notes that the number of confirmed poliomyelitis cases in Cambodia has been reduced by approximately 50% after the first NlDs in 1995. The success of mobile teams in Viet Nam in finding and immunizing children previously missed by the NlDs is noted by the TAG. It is important that political commitment to achieve poliomyelitis eradication through support for supplementary immunization activities and surveillance be maintained. Recommendations (21) Particular attention should be paid to improving the quality of NlDs and SNIDs, especially to ensure that high-risk groups are reached. This is particularly important in areas with recent evidence of wild poliovirus circulation, such as the southern provinces of China and the Mekong Delta area. Areas considered as high risk or in need of special attention should be
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designated, and detailed operational planning undertaken, well before NIDs or SNIDs are c?nduct~. High-ris~ groups may include mobile populations, zero-dose children, second or hIgher bIrth order children, and children incompletely immunized in the routine programme. (2~) Innovative methods shoul~ be explored and employed to identify characteristics of children not reached by conventional supplementary Immunization activities. Specific strategies to reach such groups should be based on the characteristics identified, and should be devised to target these high-risk groups during supplementary immunization activities.
(23) The TAG reaffirms recommendations 20 and 21 made by the sixth TAG meeting, which detail the guidelines for planning future immunization activities. 5.2.3 Certification of poliomyelitis eradication
The Regional Commission for the certification of poliomyelitis in the Western Pacific Region will hold its first meeting immediately after the seventh TAG meeting, setting the criteria, standards and documentation that will be required for both the currently endemic and non-endemic countries to certify poliomyelitis eradication. Recommendation (24) The recommendations of the Regional Commission should be circulated to all countries of the Region as soon as possible for action. 5.2.4 Accelerated measles control activities
Reported measles morbidity has fallen by at least 90% In the Region since the preimmunization era, concurrent with a decline of95% in reported measles mortality. However, outbreaks of measles still occur in most countries of the Region. Recommendations (25) At this stage, it is imperative not to jeopardize poliomyelitis eradication or the routine EPI. In view of the significant burden of morbidity and mortality of measles in both developing and industrialized countries of the WPR, the TAG recommends that countries of the Region should adopt strategies to accelerate measles control activities, the first of which is to improve measles surveillance. The Region should monitor experiences in other parts of the world and use epidemiological studies before undertaking widespread accelerated measles control. Only countries close to poliomyelitis eradication should consider initiating accelerated measles control. (26) The TAG recommends the implementation of a regional plan of action for measles control which includes identification of high-risk areas for improved routine measles immunization coverage, strengthening surveillance for measles, and supplementary measles immunization where appropriate and feasible. The timing of activities in the plan should be according to the current stage of measles control in each country, and to ensure that they support, and do not interfere with poliomyelitis eradication. 5.2.5 Neonatal tetanus elimination
All countries in the Region that have recently reported neonatal tetanus had, by the end of 1995, made significant progress towards neonatal tetanus elimination. China, the Philippines and Viet Nam have succeeded in eliminating the disease to below one case per thousand live births per year at the province/prefecture level.
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Recommendations (27) As the tetanUl organism will never be eradicated, long-term sustainable pl~ should ensure that surv,11I111Ce and immunization activities for NT elimill8lion are ongomg. (28) All countries should further improve NT surveillance and use surveillance information u the basis for identifying high-risk populations and areas for targeted immunization activities with tetanus toxoid. Where NT surveillance is incomplete or IIOnexistent, other indicators of NT risk, such as the number of home deliveries, or deliveries assisted by traditional birth attendants, and the occurrence of NT in hospitals, should be used to identify high-risk areas while surveillance is being established. (29) Tetanus toxoid coverage should start to be measured by determining the percentage of children that were protected from NT at birth. Infants may be considered as protected at birth if the mother had received at least two doses of TT during pregnancy or a total of at least three doses of TT at any time in the past. (30) Countries which are conducting active AFP surveillance should integrate search for unreported NT cases at the time of the regular weekly or monthly visits to health care facilities, in particular through health facility record review. (31) Countries should promote standardized investigation and response to all NT cases that are reported, including immunization of the mother, immunization of all child-bearing age women in the community and in hospitals, and promotion of clean delivery in the community. (32) Efforts should be made to ensure that adequate information, education and social mobilization activities are used in high-risk communities for NT elimination 5.2.6 Routine EPI activities
Sustainability (33) There should be a continued focus on the routine EPI coverage, especially in high-risk areas. Hepatitis B immunization (34) Member countries should continue to increase coverage of infants with hepatitis B vaccine and to further integrate hepatitis B vaccination into national EPI programmes. 5.2.7 Safe injection and sterilization
Although countries have made progress in developing and adopting national plans of action for safe EPI sterilization and injection, unsterile EPI injections are still common, and there are still many areas within countries that are not yet following the national plans. Recommendations (35) Countries should make every effort to implement fully the plans of action for safe EPt sterilization and injection, by improved monitoring and supervision of sterilization and injection practices, and the ensuring regular distribution of equipment to the peripheral-level. (36) All countries should develop guidelines for the safe destruction of used injection equipment.
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5.2.8
Vaccine vial monitors (VVMs)
Beginning in 1996, vaccine vial monitors will be provided with all OPV vials produced by the major vaccine producers. Experience to date with VVM hIS been that they are simple to understand and that they have the potential for allowing the extended use of OPV at the peripheral-level. Recommendations (37) Health workers in all countries using imported OPV should be trained in the use of VVMs. (38) Ellperience with the use of VVMs, especially in remote districts, should be evaluated and reported to promote more effective use.
6. ACKNOWLEDGEMENTS
The Technical Advisory Group of the Expanded Programme on Immunization and Poliomyelitis Eradication of the Regional Office of the Western Pacific gratefully acknowledges the Commonwealth Minister of Health and Family Services, Dr Michael Wooldridge, for inviting the World Health Organization to holding this meeting in Australia. As in all previous meetings, the TAG gratefully acknowledges the outstanding contribution and participation of all partners in poliomyelitis eradication, including the national governments of WHO member countries, the Government of Australia through AusAID, the Government of Japan through JICA, the Centers for Disease Control and Prevention, USA, Rotary International, UNICEF, and the World Bank. In addition to funds, partner agencies have generously contributed technical, management and promotional ellpertise. Large amounts of additional funds have been provided for critical areas, such as vaccine supply, operational support for NlDs and surveillance, including stool specimen collection and transport. The poliomyelitis eradication effort would not be able to make its remarkable progress without the support of the ICC partners and this support is gratefully acknowledged.
SEVENTH MEETINO OF THE TECHNICAL ADVISORV GROUP ON EXPANDED PROORAMME ON IMMUNIZATION AND POLIOMVEUTIS ERADtcATION IN THE WESTERN PACIFtc REGION Canberra, Australia
9·13 April19H TENTATIVE nMETABLE Time Tuesday, 9 April REGISTRATION 1. Opening ceremony Time Wednesday, 10 April 7. Poliomyelitis eradtcation - AFP surveillance and NIDs (a) Introduction - AFP surveillanea (b) eo..ntry p<eSOnIations ond _ : AFP surveillanc. data and indicators Surveillance problems and future plans Results of 199511996 NiCs Plans for NIDslSNIOs 199611997 Country presentations and discuaIons: Cambodia, Lao People's Democr'IItic R.pu~ic, Vtel Nam, China, MongoI __ , Australia Time Thursdav 11--ADril Time Fridav. 12 April
0800-0830 0830~'30
13. Measles control 0800~830
0800·1000
16. Oiseussions of chft conclusions, i8COi i Wi . . td8tions,
......,.,.,
0800-0810
(a) Measles suMliiance and ~ Discussion
• • • •
Opening speach Welcome spooch Seff-introdudion Etection of officers, Chairman, ViCe-Chairman and Rapporteur • Administrative announcements • Group photograph
0830-0900 0900-0.30 0,30·1000
and eomrnents
(b) Progress with men'" control in the Americas
0810-1000
Discussion
0930-1000 1000·1030
COFFEE BREAK • Address of the Chairman • Introduction
1000·1030 1030·1130
COFFEE BREAK Country presentations and discussions: Malaysia, Papua New GuiMl, Philippines 8. Progress in poliomyelitis. £ in SEARO Discussion tio; i
1000·1030
COFFEE BREAK 14. Neonatal tetanus elimination
1000·1030 1030·1200
COFFEE BREAK ICC· further discussions
1030·1115 1116-11"
1030·1200
2. Global 0V4fView 1130-11" 3. R~ EPl overview
(a) Country pntSWltations: Philippines, Viet Nam, China (b) Regional guidelines for ensuring progress towards NT eliminetion Discussion
1200·1330 1330·1430
4. Regtonlilllibcnlofy owrview LUNCH BREAK
5. Country~cns: Pragrns
._(-in ~ f't"",,_"ii. on 1 " " " ' - ' (EPI) .~(.."..-)
1141·1200 1200-1330 1330·1346
LUNCH BREAK 9. Reclassification of AFP aMI: chMging from clinical to virological case definition Discussion
1145-1200 1200-1330
LUNCH BREAK 15. lna.r.o-ICY Coordinating Commiba
1200-1330
1330·1_
1330·1_
OponingRemorks (a) Introduction
134-1480
- V .. Nan (VVM)
1_·1.15 1.15·1.,0 1~·11100
10. Laboratory proficiency issues Discussion 1 t. S~ laboratory pt....bItioi .. : China, Viet Ham, Australia
1""11508
·S-oIChoinnon&R_ (0) Pt _ _ .. 0 1 _ ...... : AusAIO, CDC, JICA, R~ 10 . . , _.., UNICEF
110
LUNCH BREAK F _ 0I"""'"*Y
... '" I
1~·11100
8. Regton.I 0V8f\Ii8w of opaiatioiwt i...... : (0) .... Ilzidloo' _ _ _
1500·1530 1530·15010 15010·15110 15110·1Il00 1100·1115 1815-1130 1830
COFFEE BREAK (b) HepIIIitis B immunization Rogional updaloo... ; m _ into EPI (0) Voccino ...· UIicioncy (VSS): Discussion (d) PI_ l U i ot NCOIihi". '
11100·1530 1530·1800 1100·1130
COFFEE BREAK 12. Regional Certification of dM It f
11100·1530 "~n 1130-1'00
COFFEE BRUoK Queations and .,....,.. (0) RogionaIl>_'_" FundinG _ _
11508·1530 1530·_
of poliomyelitis
1100·1530
R _ ... Rogional VSS _ _ IS
Quality of auveillance, dIta to be coIec:Ied, establishment of nationai cot i Ni ,ittws
1130-1700
Discussion
01 TECHNET--. DI.cu •• ion
.c._'.........• Solo injoction _ ·Voccino~
. Cpa_ .. .........· S"'-roquI.....a • VICcinI~farthe fubn
1130-1700
r
COFFEE BREAK Cwilio • otthe
, 01 """"'*Y
17.~_
R_ _ byOrS.T._
1130-1700 1900 Dinner to be hosted by Australia
Discussion
>C
. =
- 67-
ANNEX 2
PROVISIONAL LIST OF TAG MEMBERS, EPI NATIONAL MANAGERS, OTIlER HEALTH-RELATED PROFESSIONALS, OBSERVERS/REPRESENTATIVES, AND SECRETARIAT
1. TECHNICAL ADVISORY GROUP (TAG) MEMBERS
Dr Isao Arita Chainnan Agency for Cooperation in International Health 4-11-1 Higashi-machi, Kumamoto-shi Kumamoto City 862 Japan
Dr K. Shinmura Deputy Director Infectious Disease Control Ministry of Health and Welfare (JovernrnentofJapan 1-2-2, Kasumigaseki, Chiyoda-ku Tokyo Japan
1. EPI NATIONAL MANAGERS
Dr Kenneth J. Bart Associate Director for Scientific and Medical Affairs Office of International Health Department ofHeaIth and Human Services 5600 Fishers Lane Rockville, Maryland 20857 United States of America
CAMBODIA Ms LyNareth National Poliomyelitis Eradication Manager National Centre for Hygiene and Epidemiology Ministry of Health Phnom Penh
Dr Dai Zhicheng Director-General Department of Disease Control Ministry of Health 44 Hou Hai Bei Yan Beijing 100725 China
Dr Chea Kim Ly Director Expanded Programme on Immunization National Centre for Hygiene and Epidemiology Ministry of Health Phnom Penh CHINA
Dr Robert Hall National Center for Epidemiology and Population Health Australian National University Canbe!!l!. A.C.T. 0200 Australia
Dr Wang Ke-An Vice Director Chinese Academy of Preventive Medicine 27 Nanwei Road Beijing 100050
- 68Annex 2 MONGOLIA Dr Wang Zhao
==t~e~ . i_Control Ministry of th 44 Hou Hai Bei Yan Beijing 100725
Ms Dotj Narangerel EPI Manager and Officer Department of Public Health Ministry of Health U1aanbaatar-11
Dr Yu Jingjin Deputy Director EPI Division Department of Disease Control Ministry of Health Beijing
PAPUA NEW GUINEA Dr Tantirige Sathyapala Ruberu National Epidemiologist Department of Health P.O. Box 3991 Boroko, N.C.D.
Dr Zhao Danyu Institute of Food and Safety Control and Inspection Ministry of Health Beijing
PHILIPPINES Dr Elvira Dayrit Director Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila
LAO PEOPLE'S DEMOCRATIC REPUBLIC Somthana Douangrnala Deputy Director National Institute of Hygiene and Epidemiology Ministry of Public Health Vientiane
Dr Phengta Vongprachanh Chief of Epidemiology Department National Institute of Hygiene and Epidemiology Ministry of Public Health Vientiane
DrF. Magboo Medical Officer Sentinel Surveillance System Field Epidemiology Training Program Department of Health San Lazaro Compound Sta Cruz Manila
VIETNAM Dr Do Si Hien National EPI Secretary National Institute of Hygiene and Epidemiology Ministry of Health Hanoi
MALAYSIA Dr R. Devan Principal Assistant Director of Health Communicable Disease Section Public Health Division Ministry of Health 50590 Kuala Lumpur
-69-
Annex 2
Dr Tran Van Tien National Institute of Hygiene and Epidemiology Ministry of Health Hanoi Dr Nguyen Thu Yen National Institute of Hygiene and Epidemiology Ministry of Health Hanoi
Dr S. Mangalam Division of Virology Institute for Medical Research lalan Pahang 50588 Kuala Lumpur Malaysia Dr Z. Mendsaikhan
Head Department of Virology National Center for Hygiene Epidemiology and Microbiology U1aanbaatar Mongolia Dr Tatsuo Miyamura Director Department of Laboratory II National Institute of Health 1-23-1 Toyama Shinjuku-ku Tokyo 162 Japan Dr Mark Pallansch Division of Viral and Ricketsial Diseases Centers for Disease Control and Prevention Atlanta Georgia 30333 United States of America Dr Zhang Libi Chief National Laboratory for Poliomyelitis 100 Ying Xin lie Beijing 100052 China Dr Nguyen Thi Hien Thanh Enterovirus Laboratory Institute Pasteur Hanoi VietNam Dr Phan Van Tu Poliomyelitis Surveillance Institute Pasteur Hanoi VietNam
3. OTHER HEALTH-RELATED PROFESSIONALS
Dr Mineo Arita Director Department of Viral Disease and Vaccine Control National Institute of Health Tokyo Japan Dr Ian Gust CSL Vaccines CSLLimited 45 Poplar Road Parkville Victoria Australia Dr S. Hazhizume Director-General Japan Poliomyelitis Research Institute Tokyo Japan Dr Margery Kennett Entero-respiratory Laboratory Virology Department Collaborating Centre for Virus Reference and Research Fairfield Hospital Yarra Bend Road Fairfiel!!, Victoria 3078 Australia
-70-
Annex 2
4. OBSER.PRESENTATIVES
Ms Helen Bedford Immunisation Records ACT Health OPO Box 825 Canbe!!lb ACT 2601 Australia Dr Edward O'Brien Immunisation Records ACT Health OPOBox 825 Canbe!!lb ACT 260 I Australia Ms Evonne Epping Immunisation Records ACT Health O.P.O. Box 825 Canberra, A.C.T. 2601 Australia Dr A. Herceg Medical Epidemiologist Surveillance and Epidemiology Section ACT Health OPO Box 825 Canberra, A.C.T. 2601 Australia Professor Geoff Hogg, Uni. Melb c/o Associate Professor John Ziegler Prince of Wales Children's Hospital Department of Immunology!Allergy High Street Randwick NSW 2031 Australia Professor David Isaacs, RAHC c/o Associate Professor John Ziegler Prince of Wales Children's Hospital Department of Immunology!Allergy High Street Randwick NSW 2031 Australia
AUSTRALIAN AOENCY FOR INTERNATIONAL DEVELOPMENT (AUSAID) Mr Alan March Director UNIPflOPA O.P.O. Box 887 Canbe!!lb A.C.T. 2601 Australia Ms Lindy Smith UNIPnOPA OPOBox 887 Canbe!!lb A.C.T.2601 Australia DEPARTMENT OF HEALTH AND FAMILY SERVICES Ms Pamela Brady Australian Nursing Federation 74 Harris Street Menvlands, NSW 2160 Australia Professor Margaret Burgess c/o Associate Professor John Ziegler Prince of Wales Children's Hospital Department of Immunology!Allergy High Street Randwick NSW 2031 Australia Dr Harry Nespolon Director, General Practice and Health Services Australian Medical Association PO Box EI15 Queen Victoria Terrace Parkes ACT 2600 Australia
- 71 -
Annex 2
Dr Peter Mcintyre, RAHC c/o Associate Professor John Ziegler Prince ofWaIes Children's Hospital Department of Immunology/Allergy High Street Randwick NSW 2031 Australia Dr Gavin Frost Senior Medical Advisor AIDS/Communicable Diseases Branch Department of Health and Family Services GPO Box 9848 Canberra City, 260 I ACT Australia Ms Helen McFarlane Director, Strategies Section AIDS/Conununicable Diseases Branch Department of Health and Family Services GPO Box 9848 Canberra City, 260 I ACT Australia Ms Monica Johns Assistant Director, Strategies Section AlDS/Conununicable Diseases Branch Department of Health and Family Services GPO Box 9848 Canberra City. 260 I ACT Australia Ms Anne Marie Fraser Strategies Section AIDS/Communicable Diseases Branch Department of Health and Family Services GPO Box 9848 Canberra City, 260 I ACT Australia
Mr Craig Paterson Director, Education Section AIDS/Communicable Diseases Branch Department ofHea1th and Family Services GPO Box 9848 Canberra City. 2601 ACT Australia Ms Helen Kaye Assistant Director, Education Center AIDS/Conununicable Diseases Branch Department of Health and Family Services GPO Box 9848 Canberra City. 260 I ACT Australia Ms Megan McNeill Education Section AIDS/Conununicable Diseases Branch Department of Health and Family Services GPO Box 9848 Canberra City. 260 I ACT Australia Ms Cathie Perica Disease Management Section AIDS/Conununicable Diseases Branch Department of Health and Family Services GPO Box 9848 Canberra City. 2601 ACT Australia Dr Jag Gill Director, Disease Control Public Health Service Health Western Australia PO Box 8172 Stirling St Perth WA 6849 Australia
-72 -
Annex 2
Professor ~ Smallwood Chairman; Health and Medical Relilh:h Council c/o- Department of Medicine Heidelberg Hospital, Bldg 24 Banksia St Heidelberg West VIC 3081 Australia
..-.w
Ms Anne Kempe Immunisation Coordinator Child and Youth Health South Australian Health Commission 295 South terrace Adelaide SA 5000 Australia Dr Avoer Misrachi Public Health Branch Tasmanian Department of Community Services and Health PO Box 125b Hobart TAS 700 I Australia Dr Ziatna Wallner Immunobiology Section Therapeutic Goods Administration Department of Health and Family Services PO Box 9848 Canberra. ACT 260 I Australia Michael Fisher Strategies Unit Commonwealth Department of Health and Family Services AIDS/Communicable Diseases Branch GPO Box 9848 Canberra City. 260 I ACT Australia Ms Helen Evans Assistant Secretary Commonwealth Department of Health and Family Services AIDS/Communicable Diseases Branch GPO Box 9848 Canberra City. 260 I ACT Australia
Dr John Rooney Specialist Medical Advisor AIDSllnfectious Diseases Branch New South Wales Health Locked Bag 961 North Sydney NSW 20059 Australia Dr Catherine Ealing AJg Director Communicable Diseases Branch Queensland Health 160 Mary St Brisbane OLD 4000 Australia Professor Mark Harris Royal Australian College of General Practitioners University of New South Wales School of Community Medicine Sydney NSW 2052 Australia Ms Marie McLaughlin FRCNA AJg Primary Health Services Manager Royal College of Nursing Queanbeyan District Hospitals and Health Service Collett St Oueanbeyan NSW 2620 Australia Ms lenniferRabach Royal College of Nursing Australia I Napier Close Deakin ACT 2600 Australia
-73 -
Annex 2
Ms Michaela Colebome Assistant Director, Education Section Commonwealth Department of Health and Family Services AIDS/Communicable Diseases Branch GPO Box 9848 Canberra City, 2601 ACT Australia
Dr Stephen Redd Chief, Measles Activity Centers for Disease Control and Prevention Atlanta. Georgia 30333 United States of America
Dr John Carnie Infectious Diseases Unit Victorian Department of Health and Community Services 115 Victoria Parade Fitzroy VIC 3065 Australia
BUREAU OF INTERNATIONAL COOPERATION - INTERNATIONAL MEDICAL CENTER OF JAPAN DrY. Chiba Toyama 1-21-1, Shinjuku-ku Tokyo 162 Japan
Dr Rosemary Lester Infectious Diseases Unit Victorian Department of Health and Community Services 115 Victoria Parade Fitzroy VIC 3065 Australia
Dr Matsuba Toyama 1-21-1, Shinjuku-ku Tokyo 162 Japan
Dr Kyohgoku Toyama 1-21-1, Shinjuku-ku Tokyo 162 Japan
VICTORIAN INFECTIOUS DISEASES REFERENCE LABORATORY
Keri Anne Brussen Viral Identification Laboratory Fairfield Hospital Fairfield, Australia
Dr C. Kuroiwa Toyama 1-21-1, Shinjuku-ku Tokyo 162 Japan
CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC), ATLANTA Mr Robert Keegan Polio Eradication Activity National Immunization Program Surveillance, Investigations and Research Branch Centers for Disease Control and Prevention Atlanta, Georgia 30333 United States of America
DrT. Chosa Toyama 1-21-1, Shinjuku-ku Tokyo 162 Japan
NATIONAL INSTITUTE OF HEALTH, JAPAN Dr Akio Hagiwara Chief Section of Enteroviruses Department of Virology II National Institute of Health Gakuen 4-7-1 Musashi-murayama-shi Tokyo 208 Japan
-14 Annex 2
JAPAN ~ATIONAL COOPE~ AGENCY (JICA) Dr S. Taira Medical Cooperation Department Japan International Cooperation Agency (JICA) Shibuya-ku, Tokyo Japan ROTARY INTERNATIONAL
Mr Grattan O'Connell 9 Stoneyroyd Gardens Auckland 5 Australia UNITED NATIONS CHILDREN'S FUND (UNICEF) Dr Kevin Conlan National Manager Overseas Projects UNICEF Australia Sydney NSW 2000 Australia Dr Jaime Galvez-Tan Regional Adviser on Health and Nutrition UNICEF East Asia and Pacific Regional Office P.O. Box 2-154 Bangkok Thailand Dr Riita Poutiainen EPI Project Officer UNICEF Office Phnom Penh Cambodia Mr H. Traverso UNICEF 12 Sanlitun Lu 100600 Beijing People's Republic of China Dr Phouthone Southalack Assistant National EPI Manager UNICEF P.O. Box 1080 Vientiane Lao People's Democratic Republic
Dr William Sprague 1901 Forest Shores, SE Grand Rapids, MI 49546 United States of America Dr Edward S. Trainer Manager, PolioPlus Program Rotary International 1560 Sherman Avenue Evanston, II, 6020 I United States of America Dr E.G.P. Haran Regional Advisor (Asia) Polioplus Program Rotary International New Delhi - 110029 India Mr Masami Hiraoka Regional Coordinator ASIA PolioPlus Task Force Rotary International 15-18-1 Kitabatake, Abeno-Ku Osaka 545 Japan Mr Brian Knowles 43/17 Bayview Street Runaway Bay 42160ueensland Australia
-75 -
Annex 2
Dr Bardan lung Rana UNV Immunisation Specialist UNICEF Suva Fiji Dr Alexander Malyavin Project Officer Health and Nutrition UNICEF Vientiane Lao People's Democratic Republic Dr Wilfredo Varona Project Adviser UNICEF 4th Floor NEDA sa Makati Bldg Amorsolo Streeet Legaspi Village 1229 Makati City Philippines Dr Kayode S. Oyegbite Senior Project Officer. Health UNICEF Viet Nam Country Office 72. Ly Thoang Kiet Hanoi Socialist Republic of Viet Nam Dr Nguyen Van Cuong Medical Officer National EPI Secretariat NIHE. Ministry of Health Hanoi Socialist Republic of Viet Nam
DrJ. Bilous Regional Adviser Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines MrC. Maher TechnicaJ Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr R. Sanders Scientist Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr R. Tangennann Medical Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines DrY. Sato Technical Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines
6. SECRETARIAT
DrS.Omi Director, Disease Prevention and Control WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines
-76 -
Annex 2
OrB. Ayl. ~
Expanded PftItnunmc 011 ImmunizatiOll WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Mr D. Bassett Technical Officer Expanded Programme on Immunization WHO Representative's Office House 120, Street 28 Sankat Chadomuk, Khan Daun Penh Phnom Penh Cambodia Drl. Wing Medical Officer Expanded Programme on Immunization WHO Representative's Office 9-2-151 Ta Yuan Diplomatic Compound I Xingdonglu, Dongzhirnen Wai 100600 Beijing People's Republic of China MrA. Schnur Technical Officer Expanded Programme 011 Immunization WHO Representative's Office 9-2-151 Ta Yuan Diplomatic Compound I Xingdonglu, Dongzhimen Wai 100600 Beijing People's Republic of China Dr M. O'leary Epidemiologist WHO Representative's Office 3rd Floor YWCA Building Sukuna Park Suva Fiji
COIJSultadl'~ ,.
Dr Yang Baoping Medical Officer Expanded Programme on Immunization WHO Representative's Office Quatier That Luang Vientiane Lao People's Democratic Republic DrM. Hodge Medical Officer Expanded Programme on Immunization WHO Representative's Office 24 Van Phuc Residential Quarters Hanoi Socialist Republic of Viet Nam Dr B. Melgaard Chief, EPI Global Programme for Vaccines and Immunization World Health Organization Geneva Switzerland Dr J.M. Olive Medical Officer Global Programme for Vaccines and Immunization World Health Organization Geneva Switzerland DrW. Dowdle Consultant Global Programme for Vaccines and Immunization World Health Organization Geneva Switzerland Dr I. Mochny Regional Adviser Expanded Programme on Immunization World Health Organization Regional Office for South-East Asia New Delhi - 11 0002X India
WFSrERN PACIFIC REGION: EPI COVERAGE DATA 1994/1995
118
. 78
53 93
85
85
. 54 2S 84
53 88
28
85 · 78
11
80
7S
, 28
n
11 88
0
lOll 118 118
20 S3
lOll
2V
82 82 III 34 32
.
',"
S3
84
n III 118 82 III
III
82 48 S3
71 511 S3
13 76
1._ _ la.
83 III 10
82 15 48
87 78
82 77
59
80
. tI2
80 58 83
100 54 118
100 84 85
74
"
50
118
88
100
100
118 34
34
. 10
85
84
84
100
100 76
0 71 34 811
87 0 41 84 811 tI2
0
81 lOll 87 13
100
100 83
0 83
0 84
0 ":!~
.... .... , laO:"
87
81 118 83
88
85 93 83 92
lOll
.
11 87 11
92 88
82
... .. . 87 83 83
41 38 118
. tt1
lOll 87 88
lOll 88 118
100"::' 85 118
,oo,y., 41 :
84
55 48 , :':,:
11 88
. . ..,.•.• 81 ", 13 ' 50
88 88 88
87 77
85
87 88 10 17
118
83 88
88 118
) '
• .,'"
10
" 88 118 III
74
III
78
" . . . I " " 87 14 tI2
14
53 III
82
.,'"
•
_fJl22M1n:h 1_.
... ,(
> :z: ~ ><
- 79-
ANNEX 4
REPORTED CASES OF MEASLES AND NEONATAL TETANUS WESTERN PACIFlC REGION 1994-1995 ..
Country
... 94 0
Measles,
95 0 1,198
Neonatal tetanus 94 95 0 0
American Samoa
Australia Brunei Cambodia China
NR NR 946 76,204 0 90S
NR 2,038 57,281
NR NR 147 4,228 0 0
NR NR 8
:001<1•. Fed. St. oC Micronesia Fiji French Polynesia Guam Hong Kong Japan Kiribati Laos Macao Malaysia Manhsll Island. Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Is. Palau Papua New Guinea
NR 0 414 7 0 33
NR NR 0
NR 7 228 210
NR NR 0
NR NR 0 0
NR 299 984 52
NR 4 3,114 3
NR NR 0 10 0
NR 0
6 0
NR 0 177
NR NR 555
NR 0 0
NR NR 0
NR NR 33 2 29 0 6,821 3,006 7,883 0 159 406
NR 2
NR NR 0
NR 0 0 0
NR NR NR 0 0 0 134 288
0 0 0
Philippines· Rep. oC Korea
3,730 3,913
159 336
Samoa Singapore Solomon I.land. Tokelau Tonga Tuvalu
NR NR 185 0 0
NR 0
NR NR 0 1 0
NR 0
NR NR 0 27 11,853
NR I
NR NR 0
NR 0
Vanuatu Viet Nam Wallia and Pullina ~este.rIlPacllk
0 6,171
0 422
NR 330
9
.
.
.........
Regloll ... .... ..
110,240
13 788,722
0
I ..
0 767
.
S301 .
.
...
.
I
Late. ava,a-ble data from WHO eElS •• of 5 SEPT 1996. *HoapitaisurveiUance datA.
- 81 -
ANNEXS DETAILED FLOW CHART OF AFP SURVEILLANCE 1995 BY COUNTRY AND REGION R• ....- •• AfP CAM CHN LAO
1M 5,0115 30
MM MOO PNG PIC PHI.
7 0
18 3
187
VTN
On< IlEGION
..... 0
!i03
I Not investigated CAM CHN
I Inv.lIgated 1 1
LAO MM MOO PNG PIC PHI.
0 0
VTN
on< REGION
,. ,. 0 0
0 0 0
LAO MM MOO PNG PIC PHI.
~
5:~~5 30
7
,. 0
3
153
VTN
on< REGION
i
'
......... AFP
I 178 4,802
..... I NoIAFP
503 0
LAO MM MOO PNG PIC PHI.
~~
1. 7 0
LAO MM MOO PNG PIC PHI.
~
2~. 11 0 0
VTN
13 3 153 485 0 I ....
3
,. 0
VTN
38 0
On< REGION
on<
I CAM CHN
,AFP 111 165 11 0 0 0 0
I -Ing CAM CHN LAO
CAM CHN LAO
54 4,818
'3
LAO MM MOO PNG ptC
7
MM MOO PNG PIC PHI.
PHI.
~
VTN
• 135 0 420
0
•
0 0
MM MOO PNG PIC PHI.
21 1 1 0 9
3 92 0 0
57 330 0 I ....
VTN
VTN
on< REGION
On<
Doto _ d 22 Morch 1888.
PROGRESS MADE IN NEONATAL TETANUS ELIMINATION IN WESTERN PACIFIC COUNTRIES 1993 TO 1995
COUNTRY
REPORTED NT CASES
1T2+ COVERAGE PREGNANT WOMEN
1T2+ COVERAGE CBAWOMEN
mGH-RlSK AREAS IDENTIFIED
AREAS DESIGNATED FOR SUPPLEMENTARY IMMUNIZATION WTI1I TT FOR CBA WOMEN 93 94 95
93 88 3679
94 147 4228
95 8
93 22
94 28 41
95 36
93
94 9 41·
9S 12
93
94
9S
CAMBODIA
•••
300 counties
300 counties
542 counties
,
-
200 counties
CHINA
all provinces
I" J wl /~.
LAOPDR
5 177
10
6
23
34 41 39
35
30
40
50
52
-
-
-
-
... do
,
!lg " , . PHILIPPINES
IS9 336
134 288
27 70
SS
66
58
-
52
210
all provinces
all provinces
455
VIETNAM
333
422
330
71
78
82
86
91
94
57
140
57 .. "
'-
, "
140 ..
210
,;.;..
Latest available data from WPRO CElS as of 22 March 1996. (* in high-risk countries) (- no data)
> Z Z
~
ell