WP/EPIIlCPNID/OOI Report series no.; RS/96/GE/14f(FUl English only
~ORT EXPAN~D PROGRAMME ON IMMUNIZATION AND
WHO/UNICEF WORKSHOP ON THE
CONTROL OF VACCINE-PREVENTABLE DISEASES IN PACIFIC ISLAND COUNTRIES AND AREAS
Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC WORLD HEALTH ORGANIZATION and UNITED NATIONS CHILDRENS FUND (UNICEF) Nadi. Fiji 26-30 August 1996
Not for sale Printed and distributed by the Regional Office for the Western Pacific World Health Organization Manila, Philippines February 1997
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NOTE The views expressed in this report are those of the participants in the WHOfUNICEF Workshop on the Expanded Programme on Immunization and Control of Vaccine-Preventable Diseases in Pacific island countries and areas and do not necessarily reflect the policies of the Organization.
This report has been prepared by the Regional Oftice for the Western Pacitic of the World Health Organization for governments of Member States in the Region and for the participants in the WHOfUNICEF Workshop on Expanded Programme on Immunization and Control of VaccinePreventable Diseases in Pacific Island Countries and Areas held in Nadi, Fiji, from 26 to 30 August 1996.
CONTENTS
SUMMARY 1. INTRODUCTION ...................................................................................... I 1.1 Objectives .......................................................................................... I 1. 2 Organization ....................................................................................... I 1. 3 Opening ceremony ............................................................................... I 2. PROCEEDINGS ........................................................................................ 2 2.1 Regional overview ................................................................................ 2 3. 4. COUNTRY PRESENTATIONS ..................................................................... 4 CONTROL OF HEPATITIS B IN PACIFIC ISLAND COUNTRIES ....................... 5 4.1 4.2 4.3 4.4 5. Current situation of hepatitis B control in Pacific island countries ..................... 5 Operational issues for hepatitis B immunization ........................................... 5 Open vial policy .................................................................................. 6 Evaluation .......................................................................................... 6
SAFE STERILIZATION AND INJECTION ISSUES .......................................... 6 5.1 5.2 5.3 5.4 Introduction ........................................................................................ 6 Current status of injection practices in the EPI.. ........................................... 7 Developing plans to ensure safe injection practices ........................................ 7 Proposed indicators to monitor injection practices and supplies ........................ 7
6. 7.
GOVERNMENT OF JAPAN COLD CHAIN PROJECT ...................................... 8 IMPROVING ESTIMATION OF VACCINE REQUIREMENTS ............................ 8 7.1 Current situation .................................................................................. 8 7.2 Methods of calculating requirements ......................................................... 8 7.3 Possible actions to improve vaccine requirements estimations in Pacific island countries ....................................................................... 9
Keywords: Immunization I Hepatitis 8 vaccines I Poliomyelitis - prevention and control I Poliovirus vaccine. Oral I Pacific Islands I Fiji
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8.
PROGRESS TOWARDS CERTIFICATION OF POLIOMYELITIS ERADICATION .. 9 8.1 8.2 8.3 Background ......... , ...................................... , ..................... , ....... " .. ", .. 9 Criteria for the certitication of regional poliovirus eradication ...................... 10 The strategy for the certitication of poliomyelitis eradication in the Western Pacitic Region .............................................................. 10 8.4 Regional Certification Commission for the Western Pacific .......................... II 8.5 National Certification Committees ........... , ..... , .... , ................................. , II 8.6 Subregional Certification Committee for the Pacific islands ................ , ......... 12 8.7 Surveillance activities and standards required for certification....................... 12 8.8 Documentation required from each country for certification ......................... 13 8.9 Role of the WHO Secretariat in the certification of poliomyelitis eradication., .. , 14 8.10 Progress in poliomyelitis eradication in Pacific island countries ..................... 14 IMPROVING EPI SURVEILLANCE IN PACIFIC ISLAND COUNTRIES ............. 15 9.1 9.2 9.3 9.4 9,5 9.6 9.7 Purpose of improving surveillance .... , ................................................... , Surveillance for poliomyelitis eradication in the Western Pacitic Region, ......... Why do Pacific island countries need AFP surveillance? ................ , ........... , Improving SUI veillance for EPI diseases: ................................................. Proposed approaches for surveillance in Pacific island countries ................ , ... Case investigation of acute tlaccid paralysis cases ...................................... Group discussions: preparation of country plans of action ............................ IS IS 16 16 18 19 20
9.
10. ACCELERATED SURVEILLANCE AND CONTROL OF MEASLES .................. 20 10.1 10.2 10.3 10.4 10.5 Measles control and elimination in the Western Pacific Region ...................... Epidemiology of measles in Pacitic island countries ................................... Strategies for measles elimination .......................................................... Phasing in of measles elimination strategies ............................................. Measles elimination in the Americas ...................................................... 20 20 22 22 23
II. CONCLUSIONS ...................................................................................... 24 TABLES: TABLE I SELECTED EPIINDICATORS 199511996 PACIFIC ISLAND COUNTRIES FROM 18 COUNTRIES PRESENT AT THE WORKSHOP ........................................................................ 5 DISPATCH OF STOOL SPECIMENS TO REFERENCE LABORATORy .................. , ............................. 20 DISTRIBUTION OF MEASLES OUTBREAKS BY COUNTRY AND YEAR, PACIFIC ISLANDS 1980-1995 ............................. 21
TABLE 2 TABLE 3 TABLE 4
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- SURVEILLANCE AND IMMUNIZATION ACTIVITIES 1996 TO 1998 ..................................................................... 23
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FIGURES; FIGURE 1 FIGURE 2 FIGURE 3 CERTIFICATION PROCESS IN THE WESTERN PACIFIC REGION ................................................ II REPORTED AFP, CONFIRMED POLIOMYELITIS AND WILD POLIOVIRUS WESTERN PACIFIC REGION 1992-1995 .............. 16 REPORTED MEASLES CASES, PACIFIC ISLAND GROUPS 1973-1995 .......................................................................... 21
ANNEXES; ANNEX 1 ANNEX 2 EPI INDICATORS BY COUNTRY FOR 1995 ............................ 27 SUMMARY OF PROCEEDINGS OF DISCUSSIONS ON THE GOVERNMENT OF JAPAN PROJECT FOR SUPPORT FOR THE EPI IN PACIFIC ISLAND COUNTRIES 1996-2000 ............................... 29 ACTIVE SURVEILLANCE VISIT SUMMARY FORM ................. 31 STANDARD CASE DEFINITIONS .......................................... 33 FORM FOR MONITORING COMPLETENESS AND TIMELINESS OF REPORTS (INCLUDING ZERO REPORTS) FROM REPORTING SITES ............................................................. 35 RECORD SEARCH DATA COLLECTION FORM AND REPORT OF RECORD SEARCH ............................................ 37
ANNEX 3 ANNEX 4 ANNEX 5 -
ANNEX 6 -
SUMMARY
The WHO/UNICEF workshop on the Expanded Programme on Immunization (EPI) and Control of Vaccine-Preventable Diseases in Paciric Island Countries and Areas was held from 26 to 30 August 1996 in Nadi, Fiji. Eighteen Pacific island countries and areas were represented at the meeting, together with eight observers from AusAID, Centers of Disease Control, United States of America, Departments of Health of Australia, New Zealand and Vanuatu, Japan International Cooperation Agency, the South Pacific Commission, and eight secretariat members from WHO and UNICEF. The workshop reviewed progress made since the last workshop in 1992 on a wide range of EPI issues, including routine immunization coverage, hepatitis B control, safe sterilization and injection, cold chain and logistics, certification of poliomyelitis eradication, disease surveillance, and measles control. During the workshop, the participants reviewed national vaccine requirement estimates using a system recommended by WPRO, and tinalized proposals for cold chain equipment through the Government of Japan cold chain project. In addition, the participants prepared draft plans of action for improving surveillance to meet the requirements of the certification of poliomyelitis eradicatioll. The standard of presentations by the participants, and output of group work was much higher than in the previous workshop in 1992. Pacitic island countries and areas are now making sufficient progress in the EPI to take a leading role in the poliomyelitis certification process, and hepatitis B control in the Western Pacitic Region.
1. INTRODUCTION
1.1
Objectives The objectives of the workshop were: (1) to review operational issues for the Expanded Programme on Immunization (EPI) in the Pacific island countries and areas, with particular emphasis on hepatitis B vaccine, safe injection practices, and cold chain and logistics management;
(2) to review the current status of acute flaccid paralysis (AFP)/poliomyelitis surveillance and both routine and supplementary OPV (oral poliovirus vaccine) immunization in the Pacitic island countries and areas, including Australia and New Zealand; to promote progress towards poliomyelitis-free certification of the Pacific island (3) countries and industrialized nations in the Pacitic, including Australia and New Zealand; and (4) to discuss other important disease control initiatives in the Pacitic island countries and areas, including surveillance of EPI diseases and accelerated control of measles. 1.2 Organization
The WHO/UNICEF workshop on the Expanded Programme on Immunization and Control of Vaccine-Preventable Diseases in Pacitic Island Countries and Areas was held in Nadi, Fiji, from 26 to 30 August 1996. Eighteen national participants from 18 countries and areas of the South Pacific attended as well as eight observers from AusAID, United States Centers for Disease Control, Departments of Health in Australia, New Zealand and Vanuatu, Japan International Cooperation Agency (JICA), and South Pacific Commission, and eight secretariat members from WHO and UNICEF. 1.3 Onening ceremony
The participants were welcomed by Dr N. Goneyali, Director of Hospital Services, Ministry of Health and Welfare, Fiji on behalf of Dr Leo Smith, Minister of Health, who was unable to attend because of Government commitments. Dr Goneyali reminded participants that this workshop was a follow up to the workshop held for EPI managers in Suva, Fiji in 1992. He stated that immunization programmes in the Pacific had reached maturity and had commenced to focus on disease control and eradication targets after achieving satisfactory coverage tigures. Disease surveillance was critical to guide and measure the impact of disease control and eradication strategies. Dr Goneyali thanked WHO and UNICEF for their ongoing commitment to improving health of Pacific island peoples and for organizing the meeting. He also expressed his appreciation to the Governments and nongovernmental organizations which had contributed to improving immunization programmes in Pacific island countries and areas.
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Dr B.I. Rana, Immunization Officer, UNICEF, welcomed participants on behalf of Dr Jacqui Badcock, Assistant Representative, UNICEF, Pacific Programme Office who was unable to be present. Dr Rana noted that UNICEF's involvement in immunization programmes was long and important. He noted that assuring a steady and continuous supply of potent vaccine was a critical element in the immunization programme. In 1995 the 12 Pacific island countries that had been receiving vaccine free from UNICEF had begun contributing to the cost of procuring the vaccines and by 1997 would fully finance the cost of the vaccine supply through the Vaccine Independence Initiative. Dr Rana also stated that a Pacific regional project had been established in 1996 by UNICEF in collaboration with WHO and with funding from AusAID. Ten countries: Cook Islands, Fiji, Kiribati, Niue, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu, and Vanuatu would benefit through the provision of hepatitis B vaccines, support for training and evaluation. Dr S.K. Ahn, WHO Representative, South Pacific, welcomed participants on behalf of Dr S.T. Han, WHO Regional Director for the Western Pacific, who was unable to attend. Dr Abn stated that the workshop was a very important component of the disease control initiatives in the Pacific. Hepatitis B was a major public health problem in the Pacific island countries and areas, however due to the long standing collaboration with UNICEF, and governments of Australia, Japan and New Zealand much progress had been made in ensuring that every newborn infant in the Pacific island countries and areas will be protected against this disease through early immunization. Even though no Pacitic island country had reported poliomyelitis cases for several years, he stated that it would be necessary to document evidence that the wild poliovirus has been eradicated and that surveillance is of sufficient quality to detect and take action against any new case of poliomyelitis that might be imported from another country. Measles has continued to be a problem in the Pacific and the workshop would provide an opportunity to discuss strategies to further reduce the incidence of this common disease.
2. PROCEEDINGS
2. I 2. I. I
Regional overview Immunization coverage
In 1995, the Regional coverage for EPI antigens was 94% for BCG, 92% for DPT3, 93% for OPV3, and 89% for measles. The calculated Regional coverage for tetanus toxoid for pregnant women remains low at 17%, despite increased neonatal tetanus elimination activities, as some countries have only implemented immunization of pregnant women in high-risk areas. 2.1.2 Poliomyelitis eradication
The Region is now essentially free of poliomyelitis as the circulation of wild poliovirus is confined to the Mekong Delta of Cambodia and Viet Nam, though there is still a risk of importation across borders with other Regions.
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As at 22 March 1996, over 5500 AFP cases had been investigated in the Region during 1995 and only 19 cases of poliomyelitis had been contirmed by wild poliovirus isolation under conditions of high quality surveillance. Eighteen of the 19 wild poliovirus cases were from the Mekong Delta area of Cambodia and Viet Nam. One case was reported from the border between China and Myanmar and was classified as having been imported into China. Although 426 of the AFP cases reported in 1995 were confirmed as poliomyelitis by clinical examination, most of the AFP cases clinically confirmed as poliomyelitis, especially in China, are not true poliomyelitis. They are due to diseases that resemble poliomyelitis (such as Guillain-Barre Syndrome with residual paralysis). 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. The laboratory network has made impressive gains in improving the reliability and timeliness of virological surveillance. Supplementary immunization with OPV during national immunization days (NIDs) 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. Although the governments of the countries concerned provide the major part of the resources required for the EPI and poliomyelitis eradication, international support has been instrumental in the successful implementation of poliomyelitis eradication activities in the Region. 2.1.3 Neonatal tetanus elimination
The six countries in the Region that have recently reported neonatal tetanus are: Cambodia, China, the Lao People's Democratic Republic, Papua New Guinea, the Philippines, and Viet Nam. These countries made much progress in 1995 with the improvement of surveillance and an increase in tetanus toxoid coverage for pregnant women. 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. 2.1.4 Measles control
In many countries of the Region, measles morbidity and mortality 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 that most Western Pacific Region countries have attained the 1995 90% disease reduction goal. The great reduction in reported cases is directly attributable to good routine coverage with measles vaccine. Countries have made efforts to increase measles immunization coverage by including measles vaccine in NIDs. This has had the particular advantage of enabling remote areas to be reached with measles immunization. 2.1.5 Introduction of other antigens
There have been greater efforts to include hepatitis B vaccine into routine infant immunization schedules in countries 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 of 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 N1Ds for poliomyelitis eradication in Cambodia, the Philippines and Viet Nam.
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2.1.6
Safe sterilization and injection practices
Plans to eliminate unsafe sterilization and injection practices have been developed in Cambodia, China, the Lao People's Democratic Republic, the Philippines, and Viet Nam. The plans are based upon the regular replacement of stocks of supplies and equipment, whether reusable or disposable equipment is used. In developing the plans, much emphasis has been placed on adequate planning based upon population size and session frequency. In the implementation of the plans, the focus has been on regular distribution to the peripheral level, and the monitoring of indicators of appropriate use of the equipment. The safe destruction of used supplies and equipment will be given greater attention in the future. 2.1.7 Logistics and cold chain
There have been major distributions of new cold chain equipment in several countries, with the support of international partner organizations and governments, including the Government of Japan, and the World Bank. Vaccine vial monitors are now in use on a trial basis in Viet Nam, and will soon be distributed throughout the Region on internationally procured OPV vials, where they are expected to extend the duration of use of vaccine vials, and decrease vaccine wastage. Non-chlorotluoracarbon refrigerants are now being supplied with cold chain equipment in accordance with the Montreal protocol. 2.1. 8 Vaccine self-sufficiency
The Regional Office is actively collaborating with centres of excellence for vaccine production and quality control. Technical support is being provided to several countries. In 1996 the major focus will be on the strengthening of national quality control authorities.
3. COUNTRY PRESENTATIONS
Presentations were made by all 18 countries on the following topics: (I) Coverage for BCG, DPT3, OPV3, measles, hepB3, TT2+ in 1995 by local government
area; (2) Reported poliomyelitis, measles, tetanus/neonatal tetanus. pertussis, diphtheria, tuberculosis 1993-1996; and (3) Completeness of EPI disease surveillance reporting by reporting sites 1993-1996. Table 1 shows a summary of EPI indicators obtained from country presentation data, while Annex 1 shows the indicators by country.
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Table I.
Selected EPI indicators 1995/1996 Pacific island countries rrom 18 countries present at the workshop EPI INDICA TOR
NUMBER OF PACIFIC ISLAND
.................................................,..................................................................................................................................... OVER 80% COVERAGE OPV3 OVER 80% COVERAGE MEASLES OVER 80% COVERAGE HB3 OVER 80% COVERAGE Tf2+ AFP REPORTED COMPLETENESS OF REPORTING A V AILABLE RECORD SEARCHES MEASLES OUTBREAKS 199511996 14
COUNTRIES
13 II
4
3 7
7 7
4. CONTROL OF HEPATITIS B IN PACIFIC ISLAND COUNTRIES
4.1
Current situation of henatitis B ~omrol in Pacitic island ,()untries
All of the Pacitic island ~ountries and areas have a pol icy on hepatitis B immunization, and all have attempted to integrate hepatitis B immunization into the routine EPI. Good coverage of infants is now being achieved in many Pacitic island countries and areas (see Annex I). The major constraint has been the supply of vaccine, due to its relatively high price. A major step has been taken for the ten countries not suppl ied with vaccine by the French or United States Governments. A joint Pacific regional hepatitis B project supported by the Governments of Australia and New Zealand, UNICEF and WHO has been approved, commencing in 1996. It will provide full vaccine requirements for a period of three years (1996-1998) and partial supply of vaccine for a further two years (1999-2000). Additionally, there will be support for training, surveillance and evaluation of hepatitis B immunization activities. 4.2 Operational issues for hepatitis B immunization.
4.2.1 Integration with EPI schedules: Hepatitis B immunization has been successfully integrated into EPI in Pacific island countries, without major problems. There are several different schedules in use, which aim to give three doses of hepatitis B vaccine at existing EPI contacts, for example with BCG, DPTI and DPT3 (birth, six to eight weeks, 14-16 weeks). Experience has shown that if supply of vaccine can be maintained, high coverage can be achieved through this integrated approach. 4.2.2 Timing of first dose: WHO currently recommends that health care workers give the first dose of hepatitis B vaccine at the tirst contact with an infant. In some areas, this happens around six to eight weeks of age, at the first immunization contact. During the hepatitis B project, the possibility of field trials of innovative approaches to delivering the first dose of hepatitis B vaccine as close to birth as possible can be explored.
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4.2.3 Logistics: The sustained integration of hepatitis B vaccination into EPI requires good logistics planning. 4.3 Open vial policy
Hepatitis B vaccine is expensive and there is signiticant concern about vaccine wastage. Obtaining vaccine in single dose vials would greatly reduce wastage, but this is the most expensive formulation, and there would also be a major increase in freight and storage costs. Because of the good heat stability of hepatitis B vaccine, and recent recommendations from WHO on using open vaccine vials, the possibility of a new policy operating for hepatitis B vaccine was discussed. The proposed policy for hepatitis B vaccine in Pacific island countries is: "Provided that the vaccine is within the expiry date and kept within the cold chain, opened vials of hepatitis B vaccine can be kept and used in subsequent immunization sessions. It should be noted that the proposed open vial policy applies only to hepatitis B vaccine. All other opened vials of vaccine must continue to be discarded at the end of the working day."
4.4
Evaluation The following indicators for evaluation of hepatitis B control activities were discussed: (a) immunization coverage of infants with three doses of hepatitis B vaccine is the best process indicator, that is it demonstrates how well we are delivering hepatitis B prevention services. (b) the chronic hepatitis B carrier rate in children is the best outcome indicator of hepatitis B control activities. The objective of immunizing infants is to stop them from being infected by hepatitis B and becoming chronic carriers, so activities can be evaluated periodically by testing appropriate groups of children in selected countries to determine the carrier rates.
5. SAFE STERILIZATION AND INJECTION ISSUES
5.1
Introduction
Injection safety is important because unsafe injections can cause local reactions that are painful and unpleasant, and lead to people losing faith in the immunization programme and other health services. Unsafe injections can also infect people with hepatitis B virus or HIV, which may not be immediately obvious, but which can kill infected people in the longer term. In the Pacific island countries, up to 30% of the general population are infectious carriers of hepatitis B, which means that the risk of infecting people through unsafe injections is much higher than in other parts of the world. Although the rate of HIV infection in most Pacific island countries is still low, it is increasing and this adds further risk to unsafe injection practices.
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5.2
Current status of injection practices in the EPI
Most Pacific island countries use disposable injection equipment. Although in theory this equipment is supposed to be completely safe, there are widespread reports of unsafe injection practices, especially disposal of used syringes and needles, in Pacific island countries and areas. Common problems encountered in practice are: • • insufficient quantities of syringes and needles at health centre level, irregular delivery of new supplies, and no system for monitoring supplies; inadequate supervision of sterilization and injection procedures;
• difficulty in ensuring the destruction of old syringes and needles; and • where reusable equipment is available, steam sterilizers not correctly used. 5.3 Developing plans to ensure safe injection practices
Within the Region WHO/UNICEF recommend that each country should develop a plan of action to ensure sate injection practices. Plans of action need to include the following: • • • • • objectives and strategies; national policy on the type of injection equipment to be used; estimates of the annual equipment requirement for the whole country, by local government area, and the cost of this equipment; a distribution schedule for the equipment; national policy on disposal of used equipment, and where applicable a plan for the recovery of used syringes and needles from health centre level for destruction at higher levels; training requirements; and budget.
• • 5.4
PrQPosed indicators to mQnitor injection practices and supplies (I) Adequacy of syringe and needle supplies at health facility level frequency of deliveries of supplies to each facility (at least one time each year) minimum quantities required/quantities delivered (2) (3) Correct use of steam sterilizers Disposal of old equipment availability of accessible safe incinerators availability of incinerator boxes at health centre level
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presence of used syringes and needles in garbage, or close to health centres (4)
Sterile injections number of abscesses reported following injection.
5.5 Group discussions were held on safe injection issues, the conclusion of which was that most countries needed to develop a written plan to ensure safe practices, in particular the safe destruction of used syringes and needles.
6. GOVERNMENT OF JAPAN COLD CHAIN PROJECT
The Government of Japan project to provide cold chain equipment to 11 Pacitic island countries from 1996 to 2000 was discussed with the countries concerned, and arrangements made for the submission of appropriate requests to the Government of Japan. Countries concerned should prepare requests ti)r each of the live years of the project according to the lists of requirements developed in conjunction with WHO and UNICEF. Dr M. Furuhato, Ministry of Health and Welfare, Japan stated that the Japanese Government had decided to provide cold chain equipment for 11 Pacilic island countries in collaboration with WHO and UNICEF. The countries concerned are: Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Marshall Islands, Palau, Samoa, Solomon Islands, Tonga, Tuvalu and Vanuatu. A summary of the proceedings of the discussion on the project is included as Annex 2.
7. IMPROVING ESTIMATION OF VACCINE REQUIREMENTS
7.1
Current situation
The current situation of vaccine requirements estimates in Pacific island countries is that most Pacific island countries do not systematically calculate vaccine requirements. This was previously less of a problem because all vaccine was supplied by UNICEF. However, with the introduction of the Vaccine Independence Initiative and a shift towards countries assuming responsibility for their own vaccine purchase, it is more important for countries to know how much vaccine is needed. 7.2 Methods of calculating requirements There are various methods of estimating vaccine requirements, based on: • historical use: currently the most commonly used method, inaccurate, not
recommended • number and size of immunization sessions: more accurate, but complicated and difficult to change, not recommended
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• target pop~lation, number of doses, and wastage factor: accurate, easy to calculate, easy to adjust, recommended method The formula which can be used for calculat,on of requirements based on the recommended method is: target population x number of doses x wastage factor • target population relates to the vaccine - BCG, OPT, OPV, HBV, MV target is children under one year of age - IT target is pregnant women or child-bearing age women (CBA W) • the wastage factor varies depending on the circumstances of the country and the immunization strategy 7.3 Possible actions to improve vaccine requirements estimations in Pacific island countries
The results of discussions in the workshop indicate<l that EPI managers in Pacific island countries should: • identify who is responsible for ordering vaccines nationally;
• check on the current method of vaccine requirements estimations used; • try to apply the recommended method of estimation and identify any major differences between the quantities currently being ordered and the formula estimation; and • standardize the method of estimation based on the formula, adjusting for local variations in wastage, and develop annual estimates of requirements for trial use.
8. PROGRESS TOWARDS CERTIFICATION OF POLIOMYELITIS ERADICATION
8.1
Background
In February 1995, WHO convene<l the tirst meeting of the Global Commission tor the certification of the eradication of poliomyelitis. The Global Commission established the basis, principles, and essential criteria for global certitication of poliomyelitis. The Global Commission decided that certification should proceed on a regional basis, with the establishment of Regional Commissions which should review the documentation provided by national committees and, if appropriate, eventually certify the respective Region as poliomyelitis-free. The WHO recommends four strategies for achieving, contirming and maintaining the eradication of poliomyelitis in countries where the disease is endemic: high OPV3 routine immunization coverage, supplementary immunization campaigns, surveillance for acute flaccid paralysis, and accredited laboratory services for enterovirus isolation and identitication.
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A number of indicators have been established to monitor the performance of AFP surveillance systems. For example, even in the absence of wild poliovirus circulation, surveillance systems should be capable of detecting at least one case of AFP per 100 ()()() population aged less than 15 years, due to the incidence of other conditions such as GuillainBarre syndrome and transverse myelitis. Most importantly, at least 80% of AFP cases should have two adequate stool specimens collected, 24 hours-48 hours apart, within 14 days of the onset of paralysis. Confirmation nf paralysis due to wild poliovirus requires that the stool specimens from each AFP case are analysed in a WHO-accredited laboratory. 8.2 Criteria for the certification of regional poliovirus eradication
In keeping with the recommendation of the Global Commission for the Certification of the Eradication of Poliomyelitis, the Western Pacific Region of WHO will only be certified as poliomyelitis-free after all countries of the Region have met the following criteria: (I) No evidence of indigenous wild poliovirus transmission has been detected for a period of at least three years during which surveillance has been maintained at the level of performance needed for certitication. (2) A National Cenitication Committee in each country has validated and submitted the certitication documentation required by the Regional Commission. (3) Appropriate measures are in place to detect and respond to importations of wild poliovirus. 8.3 The strategy for the certitication of poliomyelitis eradication in the Western Pacific Region
The certitication of wild poliovirus eradication in the Western Pacitic Region will be the decision of an eight-member Regillnal Commission. The Regional Commission will base its decision upon the review of poliomyelitis eradication documentation provided by the National Certification Committee of each Member State and a Subregional Certitication Committee for the Pacific islands. The National and Subregional Certitication Committees will be responsible for working with the national immunization and surveillance personnel to assemble, review and verify the documentation proving that poliomyelitis has been eradicated. When the Committee members have completed the documentation needed to assert that there is no circulation of wild polioviruses in the country, the documentation will be forwarded to the Regional Commission for consideration. As noted above. the Regional Commission will only consider certitication of the Western Pacific Region when all Member States have been free of indigenous wild poliovirus for at least three years. in the presence of surveillance that meets the level of performance needed for certitication. The organogram in Figure I illustrates the organization of the certitication process in the Western Pacific Region.
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Figure L Certification process in the Western Pacific Region
.---~~~~~~ National Committees National [PI & Sun·cillancc
National [PI & Sun"eillance
The membership, terms of reference and timetahle of activities for each level are outl ined below. 8.4 Regional Certitication Commission for the Western Pacific
The Regional Certification Commission has heen appointed by the Regional Director and is composed of eight persons with the appropriate training and experience to contribute to deliberations on the regional eradication of poliomyelitis (public health ofiicials, virologists, epidemiologists, and neurologists). The first meeting of the Regional Commission for poliomyelitis eradication was held on 16 April 1996 in Canberra, Australia. 8.5 National Certification Committees
National Committees for the certitication of poliomyelitis eradication will be required in each of the recently endemic and non-endemic countries listed helow. A Suhregional Committee will he established for the Pacitic island countries and areas due to their unique epidemiological situation. Recently Endemic Countries Cambodia China Lao People's Democratic Repuhlic Malaysia Mongolia Papua New Guinea Philippines Viet Nam Countries Non-endemic for > 5 yrs Australia Brunei Darusssalam Hong Kong Japan Macao Republic of Korea New Zealand Singapore
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8.6
Subregional Certification Committee for the Pacific islands
The standard surveillance and laboratory indicators that are used to assess the performance of national poliomyelitis eradication initiatives are not adequate for the Pacific island countries and areas due to the limited size of their populations. Similarly, indigenous circulation of wild poliovirus could probably not persist on any of the islands if high OPV3 immunization coverage is maintained. Therefore, the Pacific island countries and areas listed below will be considered as a single epidemiological block for the purpose of certifying the eradication of wild poliovirus. To facilitate the certification of this epidemiological block, a Subregional Certification Committee will be responsible for coordinating the activities which would normally be conducted by National Committees. The Subregional Certilication Committee will be responsible for the following countries: Pacific island countries and areas American Samoa Cook Islands Fiji French Polynesia Guam 8.7 Kirihati Mariana Islands Marshall Islands Federated States of Micronesia Nauru New Caledonia Niue Palau Samoa Solomon Islands Tokelau Tonga Tuvalu Vanuatu Wallis and Futuna
Surveillance activities and standards required for certification
The eradication of wild poliovirus in a country can only be confirmed when there is sufficient evidence to verify that the performance of the surveillance system has met specific standards. 8.7.1 Performance of AFP surveillance and virologic investigations
The Global Commission for poliomyelitis eradication has stated that five indicators should have precedence in demonstrating that an AFP system meets the level of performance required for certification. The indicators and performance levels that are required are as follows: (i) (ii) (iii) (iv) At least 80% of expected routine AFP surveillance reports should be received on time. The AFP surveillance system should detect a non-poliomyelitis AFP rate of;:, one case per 100 000 population aged less than 15 years. 100% of reported AFP cases should be investigated. At least 80% of AFP cases should have two adequate stool specimens examined in an accredited laboratory and a follow-up exam for residual paralysis at 60 days after the onset of the paralysis. All virus isolation tests, including negative results, must be performed by accredited laboratories.
(v)
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8.7.2
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 islands 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 reporting in the Pacific island countries). Therefore, the following data and activities will contribute substantially to the evidence that there is no wild poliovirus circulation: • a 'key-physician' based AFP active surveillance system in all Pacific islands that ensures all AFP cases are reported and fully investigated by regularly (i.e., biweekly or monthly) interviewing those physicians who see paralysed children;
• full investigation of the limited number of AFP cases which do occur, including, most importantly, the analysis of two adequate stool specimens from each case in a WHO-accredited laboratory; • supplementary OPV immunization in those geographical areas or among those populations where OPV3 coverage is less than 80%; • background information on the organization of health services in each Pacific island country demonstrating that paralysed children would have access to, and be brought to health facilities; • record reviews for paralysed children: periodic retrospective record reviews for childhood paralysis should be conducted in all of the paediatric hospitals, rehabilitation centers, infectious disease hospitals, referral hospitals and general hospitals with paediatric and neurology wards. 8.8 Documentation required from each country for certification
The Subregional Committee for the Pacific islands 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 purpose of the documentation is to provide the Regional Commission with a set of standard data upon which it can base its decision whether or not to certify the country as poliomyelitis-free. When the Regional Commission certities the Western Pacific as poliomyelitis-free, the country documentation may be used by the Global Commission as a basis for endorsing the decision of the Regional Commission. The documentation must cover five general subject areas: • country background information: demography, geography and organization of health services; • structure of the poliomyelitis eradication initiative; • poliomyelitis immunization activities; • surveillance for paralytic poliomyelitis and polioviruses; • laboratory services for poliomyelitis eradication.
- 14 -
8.9
Role of the WHO Secretariat in the certification of poliomyelitis eradication
The WHO EPI Secretariat will be responsible for supporting the work of the Regional Commission, National Committees and Subregional Committee for the Pacific island countries. The WHO EPI Secretariat will support the implementation of the certification strategy at the national and subregional level and, when appropriate, act as a liaison between the Committees and Regional Commission. The WHO EPI secretariat will be responsible for identifying the unmet resource requirements for the certification process. 8.10 8.10.1 Progress in poliomyelitis eradication in Pacific island countries Disease surveillance
Wild poliovirus has not been identitied in any of the 20 Pacitic island countries and areas since 1982. It seems likely that poliomyelitis has been eradicated through a combination of high immunization coverage and geographic isolation. This apparent public health success still requires certification, which is not yet possible because surveillance for acute flaccid paralysis is currently inadequate in the Pacific. Definite progress has been achieved in the last few years, particularly in a few countries. This may be attributed to individual commitment, rather than to existing notifiable disease surveillance and investigation procedures. Although all countries have both a routine and an urgent reporting mechanism in place for selected communicable diseases, these represent, with a few exceptions, very incomplete and delayed sources of information. This is especially true for urgent reporting systems. Even when reports are made, public health action may be inadequate, delayed, or absent. 8.10.2 AFP surveillance
Most countries include poliomyelitis in their routine (although not in their urgent) reporting systems. However it is AFP reporting, rather than poliomyelitis, that is mandatory for the certification etl'ort. Only one country (Vanuatu) has adopted AFP into its reporting system, although several others are considering such a move. Despite inadequate formal disease surveillance mechanisms, ten AFP cases have been reported and investigated since early 1993: 1993 1994 1995 1996 (through July)
2
Fiji Tonga
3 4
Fiji Fiji
The total population of the 20 Pacitic island countries and areas is about 2.5 million, of whom about one million are children under the age of 15 years. The established global background rate of non-poliomyelitis AFP is one case per 100 000 children under age 15 years. This means that the Pacitic island countries should identify, on average, ten AFP cases a year. Although the ten reported cases since 1993 represent almost a third of those expected in the Pacific, nine of the ten were reported from the paediatrics ward at a single hospital, the Colonial War Memorial (CWM) Hospital in Suva, one of Fiji's three tertiary care hospitals.
- 15 -
All ten AFP cases were fully inves.tigated, including the virological testing of stool specimens. Howev~r, onl.y ~ree of the ten patients had stool samples collected within 14 days of onset of paralysIs, which IS the global standard indicating adequacy of stool specimen collection and testing. Five others were obtained 15 days-30 days after onset. In addition to AFP reporting and investigation, seven of the 18 Pacific island countries and areas have conducted three-year retrospective active searches of medical records to identify and review suspect cases of AFP. Although at least one new case was identified which met clinical case criteria (residual paralysis, no stool testing), there were no cases suspicious for poliomyelitis and, in five of the seven countries, no AFP at all. 8.10.3 Progress towards certitication in the Pacific islands
The situation noted above, while encouraging, is inadequate to meet global surveillance criteria for certification. Two of live criteria have been met since 1993: (I) all reported cases were investigated; and (2) all slOol examinations were performed in an accredited laboratory. However, (3) the background AFP rate of one per 100 000 children has not been reached (with the exception of CWM Hospital in the Central Division of Fiji); (4) only 30% rather than the required 80% of cases had stools collected within 14 days of onset of paralysis; and (5) no routine AFP reports (of the required 80%) were received on time. With adequate attention and commitment, the tirst two of these unmet criteria are achievable, but because of existing surveillance systems in the Pacific, the last is not possible in time to achieve certification by 2000. Because these criteria may be moditied if acceptable to the Regional Commission, innovative strategies to document adequate surveillance should be considered. These can include active search and active surveillance.
9. IMPROVING EPI SURVEILLANCE IN PACIFIC ISLAND COUNTRIES
9.1
Pu!]2ose of improving surveillance
When EPI coverage reaches high levels (> 90%) the effect of the immunization programme cannot be measured by coverage alone. As the aim of the EPt is to reduce morbidity and mortality from tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles, surveillance for these diseases is the best way to monitor the true effect of the EPI. Routine disease surveillance systems are usually incomplete and subject to delay, even in countries where communications are highly efticient. Poliomyelitis eradication, neonatal tetanus elimination and measles control are all disease control initiatives within the EPI that require high standards of surveillance including the reporting and investigation of every case of these diseases. 9.2 Surveillance for poliomyelitis eradication in the Western Pacitic Region
In countries where poliomyelitis has been a problem in the Western Pacific Region, the eradication of the disease has required separate surveillance for the rapid reporting and investigation of all cases of acute tlaccid paralysis. These national AFP surveillance systems are now working well enough to report and investigate over 90% of the expected background rate of AFP in 1995 including virological analysis of stool samples on 80% of these cases. Figure 2 shows that as surveillance for AFP has improved from 1992 to 1995, confirmed poliomyelitis cases, and wild poliovirus circulation have decreased.
- 16 -
Figure 2. Reported AFP, confirmed poliomyelitis and wild poliovirus Western Pacific Region 1992-1995 Thousands
-Wild Virus
7 6
!DConfirmed Poli
DAFP r
rted
5 4 3
:~~~~ 1992 1993 1994 1995
9.3 9.3.1
Why do Pacific island countries need AFP surveillance? For the certitication of poliomyelitis eradication
While poliomyelitis is no longer a public health problem in Pacitic island countries and areas, all countries are all still required to have sufficiently reliable surveillance systems to document the eradication of poliomyelitis for the Regional Certitication Commission. Even though most Pacific island countries have not reported poliomyelitis cases for several years and will rarely see cases of AFP (which occurs at an estimated rate of one per 100 000 children under 15 years of age), all countries must be able to provide documented evidence that their surveillance systems are sufficient to meet the criteria for certification mentioned in paragraph 8.2.
9.3.2
To establish surveillance systems that can be used for other EPI diseases
Experience in countries of the Western Pacitic Region has shown that once an AFP surveillance system has been establiShed, other EPI diseases including measles, neonatal tetanus (and diphtheria in some countries) can be successfully added.
9.4
Improving surveillance for EPI diseases
The first step in improving surveillance is to improve the management of the system as follows: • • Establish management structure: national and provincial surveillance managers responsible for surveillance of EPI diseases. Establish duties and responsibilities: who reports cases, who investigates, who follows up.
- 17 -
•
Establish reporting sites: select health facilities for rapid reporting and zero reporting (all hospitals).
There are four methods by which surveillance for EPI diseases in Pacitic island countries can be improved: (1) Active surveillance (2) Rapid reporting (3) Zero reporting (4) Record search 9.4.1 Active surveillance for AFP, measles, and neonatal tetanus
Active surveillance is a method of surveillance in which surveillance staff visit major health facilities regularly to identify, report and investigate cases of EPI diseases that are seen or admitted. For disease control, and especially for eradication of poliomyelitis, an active, rapid, reliable surveillance system is needed to enable timely detection, reporting, investigation (including stool collection), and follow up of cases. When surveillance staff visit hospitals every week, they can rapidly report and investigate cases that may still be in the hospital when they visit. Active surveillance visits should be monitored on a visit summary form and weekly or monthly monitoring form (see Annex 3). NB: The difference between active and passive surveillance: With active surveillance, surwillance staff take an active part by visiting health facilities to look for cases and reports. With passive, or routine surveillance. health facility staff send routine reports of EPI diseases to the surveillance unit. 9.4.2 Rapid reporting of AFP, measles, and neonatal tetanus (NT)
For all health units especially those nnt covered by active surveillance, a system of rapid reporting to the surveillance unit must be put into place. The central surveillance centre should establish a means of immediately reporting by telephone, radio or other rapid, reliable means any case of AFP, measles or NT. The minimum requirements for rapid reporting are: (1) (2) Every health facility should have standard case detinitions of AFP, measles and NT (see Annex 4). Every health facility should have information on to whom and by what method an immediate report of AFP, measles and NT should be made. Ideally, a poster should be displayed with standard case definitions, pictures of cases, and a space for inserting the name, address and telephone number of the person to report to.
- 18 -
9.4.3
Zero reporting
For management purposes, in addition to rapid reporting of all cases of AFP, measles and NT, all reporting sites could be required to send a report of the number of AFP, measles and NT cases seen every week or every month even if the number is zero. A zero report not only indicates no cases during the reporting period, it also indicates that the reporting site is functioning. This will enable managers to monitor the quality of surveillance. Zero reports should be monitored for completeness and timeliness (see Annex 5). 9.4.4 Record search
A record search is a method of surveillance in which health facility records and reports are reviewed regularly to search for cases of AFP, measles and NT. The period under review will depend upon the frequency of active searches, but should be at least six monthly. During record search, all possible sources of data are reviewed and minimum data is entered on a Record Search Data Collection Form (see Annex 6). Later the case notes are found and a case investigation form is completed as far as possible from these hospital data. Record search is a r~trospective method and does not enable full case investigation to be carried out. The results of record searches should be documented on a Report of Record Search form (see Annex 6). The results of record searches will be used as part of the documentation required for the certification of poliomyelitis eradication. In addition, record searches will help to monitor the effectiveness of surveillance systems by identifying previously unreported cases. 9.5 Proposed approaches for surveillance in Pacific island countries
A combined strategy is proposed to accomplish comprehensive AFP reporting in the Pacific islands. This builds on current passive systems of notifiable disease reporting, supplementing these with active surveillance among key providers, and active search of medical records. 9.5.1 Rapid reporting of AFP, measles, and neonatal tetanus
Although the passive system of immediately reporting AFP to national authorities has had only limited success in the Pacific, some clinicians have made significant contributions. The urgent reporting of any case of AFP in a child under age 15 years, with immediate case investigation, remains a key strategy. The concept of and reasons for AFP reporting need regular reinforcement among clinicians, and protocols for case investigation and follow-up need to be adopted in all countries. This is equally true for measles and neonatal tetanus. 9.5.2 Active search and surveillance in major hospitals
It is assumed that all cases of AFP in the Pacific island countries and areas would be referred to one of approximately 70 larger hospitals. A strategy of regular hospital visits by EPI or other staff would enable the detection of such cases, if not already reported through the urgent reporting system. These visits should include a review of relevant hospital records (admission or discharge registers, emergency room log books, etc.), and meetings or communication with key clinicians (such as paediatrics ward staff) to identify any children with diagnoses consistent with AFP seen since the last visit. Suspect cases should be fully investigated. The visit provides an opportunity to remind clinicians that AFP should be reported immediately.
- 19 -
Implementation of this approach requires determining staff responsibilities and schedules for hospital visits, identifying the hospital data sources for review and the key clinicians for contact, and introducing a system of recording details about each hospital visit. Surveillance for measles and neonatal tetanus may be incorporated with little additional effort. Ideally these visits would take place weekly, but monthly visits would be adequate as long as the need for urgent reporting in the interim is reinforced, and AFP cases are being identified and investigated in a timely manner. 9.5.3 Regular communication with key clinicians
Just as most AFP cases will be seen at a major hospital, nearly all will be seen by one of a small number of key clinicians. In most countries of the Pacific, there are about two to ten physicians or other key clinicians who would be the referral destination for such cases (in the larger countries or those with an extensive private sector, e.g., Fiji, French Polynesia, Guam, and New Caledonia, the number of key clinicians may be much larger). Regular contact (probably every month) with this group can further help reinforce the need for urgent reporting and, if a written record is obtained, serve as a source of zero reporting. This surveillance should be as simple and convenient as possible. In many cases it may be incorporated into monthly hospital visits since most of these clinicians are affiliated with the hospitals. To supplement this, contact could be made by mailing a one-question form periodically to each key clinician, with a return envelope, asking whether any AFP cases had been seen, and reinforcing the need and rationale for urgent reporting. Delinquent reports would need follow-up by the national coordinator. The completed and signed forms would eventually accumulate into a documented national profile of zero reporting. Because national situations vary widely in the Pacitic, a country may tind it more appropriate to emphasize one or the other of these approaches, either hospital-based or clinician-based active surveillance. Both may be accomplished, but at least one must be done very well. 9.5.4 Record search
An additional required strategy, less frequent than active surveillance, is the periodic retrospective search of registers and databases to identify AFP cases which may have been missed in routine surveillance (see 9.4.4). Many countries have already completed one such search. The remainder should conduct a five-year retrospective search for diagnoses or ICD codes consistent with AFP. Those identified should have a chart review undertaken, and individual follow-up if necessary. Retrospective active searches will likely need to be repeated during or at the end of the certitication process. 9.6 Case investigation of acute tlaccid naralysis cases
Regardless of how cases are identified, a full case investigation is required. The highest priority is to obtain two stool specimens (at least 24 hours apart) as soon as possible after onset of paralysis. These should be frozen and forwarded in approved containers, with ice packs and all relevant paperwork, to an accredited laboratory for poliovirus testing. For most Pacific island countries and areas, this is the Victoria Reference Laboratory in Melbourne, Australia; for some of the American-associated countries and areas this is the laboratory at the Centers for Disease Control and Prevention in Atlanta, United States of America; and for French Polynesia, it is through the Pasteur Institute to a reference laboratory in Paris, France. In addition, a case investigation form must be completed either by the child's physician or by a person designated by the national health office, providing all details of the case. Each case requires follow-up after 60 days to determine if there is residual paralysis.
- 20-
Table 2. Dispatch or stool specimens to Rererence Laboratory CountrY American Samoa Cook Islands Fiji French Polynesia Guam Kiribati Marianas Islands, Nonhern Marshall Islands Micronesia, Fed. States of New Caledonia Niue Palau Samoa Solomon Islands Tonga Tokelau Tuvalu Vanuatu
Reference Laboratorv Victoria Referen"" Laboratory V ictori. Reference Laboratory Victoria Reference Laboratory Pasteur Institute, Paris CDC, Atlanta Victoria Reference Laboratory CDC, Atlanta CDC, Atlanta V ictori. Reference Laboratory Victori. Reference Laboratory V ictori. Reference Lahoratory CDC, Atlanta Victoria Reforenee Lahoratory Victoria Reference Lahoratory V ictoria Reference Laboratory
Means/route Courier Courier Courier
Courier (Pasteur lnst. Noumea) Courier Courier Courier Courier Courier Courier
Courier or Tonga Courier Courier Courier
Victoria Rd~rence laboratory Victoria Rddrence Laboratory Victoria Reference Laboratorv
Nadi: courier Samoa: Courier Nadi: courier Courier
9.7
Group discussions: nrenaration of country plans of action
During group discussions draft plans of action to improve surveillance were prepared by all countries. These plans will be discussed within the appropriate government departments on the return of the participants to their respective countries.
10. ACCELERATED SURVEILLANCE AND CONTROL OF MEASLES
10.1
Measles control and elimination in the Western Pacitic Region
The establishment of a framework for the elimination of measles in Pacific island countries and areas of the Western Pacific Region was discussed, with the following objectives : • to predict and prevent outbreaks or epidemics of measles in Pacitic island countries of the Region; to eliminate indigenous transmission of measles virus; to improve the timeliness and completeness of measles surveillance.
• •
10.2 Epidemiology of measles in Pacitic island countries Analysis of reported measles cases in the Pacific islands shows that outbreaks in different island groups are related in time (see Figure 3 and Table 3). All Pacific island countries and areas experien~e periodic epidemics of measles. The epidemics usually occur simultaneously in related groups of islands.
- 21 -
FIgure 3.
Reported Maasles Qlses
Pacific Island ~ -1973-1995 ~ '-'eIaleSia Tda! o ... o.
Macnesia TdE F\JIyre!ia Teta!
o
•
t
. [7~ }::J o 1973 1915
; .
, , , , , , ,
,,'. . . 7" . ,
,,
" "
T\ 1fJTl
l
, 0
,.' -.' .\
1\..l/ :
/\ \ A' ,-/\ 1983 1se5 _
,,
,
,
"
1919
1981
• . • ~/''Y( , --I • . 'f
,, {o· .•..... o.-f..~ , __ " 19O19 1931 1993 _
..
Table 3. Distribution or measles outbreaks by country and year, Pacific islands 1980-1995
- 22 -
It is clear that outbreaks are not restricted to single countries; they spread from island to island throughout the Pacific. Because of this, measles control activities in Pacific island countries and areas should be coordinated and synchronized. No single island or group of islands can expect to eliminate measles separately. 10.3 Strategies for measles elimination There has been much progress towards measles elimination in the Americas (see 10.5). It is anticipated that measles elimination in the Western Pacific will be built on strategies similar to poliomyelitis eradication. • • • I. 2. 3. 4. 5. sustained high routine immunization coverage reliable and complete disease surveillance supplementary mass immunization activities Achieve and maintain routine immunization at 90% fllr infants. with one dose of measles vaccine given as soon as possible after nine months of age. Identify low coverage, 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. Conduct mass measles immunization campaigns fl)r all children aged nine months to 14 years (or according to epidemiological situation) regardless of immunization status. Follow up mass campaigns subsequent to initial campaign according to epidemiological situation.
The systems and expertise developed in poliomyelitis eradication will be used for measles elimination, for example. measles will be added to the active surveillance system for AFP, and supplementary immunization for measles will make use of planning and logistics expertise developed for poliomyelitis NlDs. 10.4 Phasing in of measles elimination strategies Measles elimination activities in Pacific island countries and areas should be phased in over a period of three years (see Table 4). The initial stage is to ensure that reliable surveillance systems are in place. and that every district has a high level of coverage for routine measles immunization. Without achieving this. there is a risk that elimination will be compromised as undetected measles transmission may continue. Pacific island countries and areas should concentrate on strengthening surveillance, and ensuring that there are no pockets of unimmunized infants, as a lead-up to commencing largescale measles immunization campaigns in 1997-1998.
- 23-
Table 4. Surveillance and immunization activities 1996 to 1998
Pacific Islands and industrialized Countries
Surveillance activities
1996 -1991
- Establish measles laboratory confirmation for index Case of outbreak - Improve hospital recording and reporting of measles cases and deaths
. Investigation of every case 1998 - Introduce measles surveillance monitoring indicators - All measles cases to be lab-<:onfinned - Improve routine measles coverage for infants - Identify high-risk areas with low immunization coverage - Conduct large scale measles campaigns for measles to reduce susceptibles
Immunization activities
1996 -1991 1997-1998
10.5 Measles elimination in the Americas The experience in the Americas, United Kingdom and the Scandinavian countries confirm that the current vaccines and strategies can eliminate measles. It is also clear that more than one dose of measles vaccine is necessary for the eradication of measles. The most effective method to quickly interrupt measles transmission is to carry out a one-time measles, "catch-up campaign" targeted at vaccinating all children under 15 years of age. The primary purpose of the catch-up campaign or measles NID is to reduce the build-up of susceptibles, not immediate cessation of transmission of the measles virus. Experience in the Americas has shown that a month-long campaign which all countries commence at the same time has been extremely effective in vaccinating the target population. Rolling or staggered campaigns, where time-frames have been established for different provinces/districts to start vaccination activities have also worked well. Because measles NID permit a long time-frame for completion of activities, the demand for additional resources are minimal. The eradication of poliomyelitis has helped build a cold chain infrastructure which has not only become the basis for routine service delivery of vaccination services but has also provided the support for undertaking measles elimination NIDs. To prepare for the measles catch-up campaigns the countries of the English-speaking Caribbean bad to prepare a plan of action that detailed activities for the following technical components: • • • • Vaccine/Syringes Cold Chain Training Social Mobilization • • • • Supervision Operational Surveillance Evaluation
Most crucial to launching a measles NID are the efforts made to ensure timely delivery of supplies of vaccines and syringes, and mobilizing all sectors of society to support the NID. Good planning is required to assure that social mobilization materials are prepared and distributed in time for supporting the NID. Experience in the Americas has shown that measles campaigns can be effectively carried out over a period of four to six weeks. The campaign can be planned in a "rolling or staggered" fashion where a selected geo-political unit or a few selected ones begin first with the remaining ones carrying out their vaccination activities on an agreed schedule. This approach has the advantage of reducing requirements for additional resources.
- 24-
Social mobilization efforts must be targeted to all levels of society but in particular to health workers, political leaders, parents, and school educators. It is crucial to monitor the progress of the measles NID in order that areas of low coverage be targeted for· mop-up· activities. Planning for an enhanced surveillance system capable of detecting all cases of measles should begin as soon as possible in order that the impact of the measles NID can be documented. More importantly, the prompt detection of measles cases will allow health authorities to determine the reasons for continued measles transmission and to design control activities or mop-up activities for elimination of pockets of susceptible. The experience of the Americas has shown that a pool of susceptibles will grow even after carrying out a catch-up campaign. The rate of build-up of susceptibles is dependent upon the routine coverage attained every year and the estimated number of vaccine failures. In order to prevent the build up of susceptibles and thus prevent an explosive outbreak from occurring follow-up campaigns to vaccinate this group must be carried out. Generally, the follow-up campaign is undertaken when the pool of susceptibles is equal to one new birth cohort. As countries begin planning for measles elimination activities they should also review their disease surveillance systems in order to measure the impact of the measles NlDs, and detect any chains of ongoing measles transmission. Enhancement of the measles surveillance should build on the AFP surveillance system used for poliomyelitis eradication.
II. CONCLUSIONS
(I)
Overview of EPI progress in Pacific island countries and areas
Pacific island countries and areas have generally maintained high coverage since 1990, and the EPI is now a well established programme in every country. However, areas of low coverage remain, and outbreaks of measles are still occurring in most countries. In addition disease surveillance is not yet adequate for the certitication of poliomyelitis eradication and accelerated measles control. (2) Progress with hepatitis B immunization
Hepatitis B immunization is well integrated into the EPI, and II countries now have coverage of over 80% of infants with three doses of vaccine. The major operational issues to focus on in order to consolidate the integration of hepatitis B vaccine in the EPI are: (i) (ii)
All countries should focus on giving the first dose as close to birth as possible, and achieving high coverage with three doses of the vaccine. The open vial policy can be adopted for hepatitis B vaccine under circumstances where it will reduce wastage. Evaluation of hepatitis B immunization should be by monitoring coverage in all countries and assessment of protection in selected countries.
(iii)
- 25 -
(3)
Safe sterilization and injection practices
Disposable equipment is now used in all countries except one. All countries have some degree of problems with supply, distribution and disposal of injection equipment. Management and supervision of injection practi·;es requires strengthening, and all countries should develop national plans for safe injection practices, with special emphasis on safe disposal, preferably by incineration of used injection equipment. The possibility of bulk purchase of disposable equipment will be explored. (4) Estimation of vaccine requirements
Most Pacific island countries currently do not have a systematic way of estimating vaccine requirements. Reliable estimates will become more critical as the Vaccine Independence Initiative takes effect and countries are increasingly responsible for funding their own vaccines. All countries should review their method of estimating vaccine requirements and where possible apply the method recommended by WHO WPRO. (5) Cold chain project through support of the Government of Japan
The Government oi Japan project to provide cold chain equipment to 11 Pacific island countries from 1996 to 2000 was discussed with the countries concerned, and arrangements made for the submission of appropriate requests to the Government of Japan. Countries concerned should prepare requests for each of the five years of the project according to the lists of requirements developed in conjunction with WHO and UNICEF. A summary of the proceedings of the discussion on the project is included as Annex 2. (6) Certification of poliomyelitis eradication in Pacific island countries and areas
Pacific island countries and areas should prepare a draft plan of action for certification of poliomyelitis eradication which will establish and maintain AFP surveillance of the standards of quality required by the Regional Commission for the certification of poliomyelitis eradication in the Western Pacific. The draft plan of action for certification of poliomyelitis eradication should be finalized by each country for submission to the respective Ministers of Health. Pacific island countries should prepare documentary evidence of the eradication of poliomyelitis for submission to the Subregional Committee in 1997. Measles and neonatal tetanus surveillance should be integrated with AFP surveillance wherever possible. (7) Measles elimination
Pacific island countries and areas have made great progress in controlling measles through high routine immunization coverage. However, serious outbreaks of measles still occur and outbreaks tend to spread from country to country. In order to achieve a higher degree of measles control the following actions can be taken: (i) (ii) Measles elimination activities should be phased in over the period 1996 to 1998. All countries should begin by improving reporting and investigation of measles cases and outbreaks, and integrating measles with AFP surveillance wherever possible.
- 26-
(iii) (iv)
Arrangements should be made for laboratory confirmation of suspected measles cases.
All Pacific island countries and area~ should begin to prepare plans of action for national measles immunization campaigns.
TABLE OF EPIINDICATORS BY COUNTRY FOR 1995
OPV3
COVERAGE MEASLES HB3
TT2+
AFP
MEASLES
CASES NT
REPORT COMPLETE NESS NA 85 100 NA NA 80 12 NA NA NA NA NA NA 80 100 100 NA 70
AFP RECORD SEARCH YES YES YES NA NA NA YES NA NA NA NA NA NA YES NA NA NA YES
American Samoa Cook Islands Fiji French Polynesia Guam Kiribati Marshall Islands Federated States of Micronesia New Caledonia Niue Northern Marianas Islands Palau Samoa Solomon Islands Tokelau Tonga Tuvalu Vanuatu
72
92 97 93 (IPV3) 90 60 70 81 88 (IPV3 100 93 100 94 68 80 93 91 74 -~-
59 96 94 96 94 47 57 90 91 100 84 100 96 68 100 94 94
47 86 82 77 91 36 47 82 93 100 94 100 96 68 NA 91 49
NA 80 72 NA NA 38 58 NA NA NA NA NA 98 71 NA 83 53 18
0 0 9* 0 0 0 0 0 0 0 0 0 0 1** 0
0 7 414 7 0 4 0 0 2 0 0 0 87(996) 0 13i(1996) 0 0 NA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NA
l
I
..., ....
1*** 0 NA
60 --
-
66
-
NOTES: Data from Nauru and Wallis and Futuna not available as these countries did not attend workshop * Fiji AFP cases: 1993 - I, 1994 - I, 1995 - 3, 1996 - 4 (TOTAL 9)
**Solomon Is AFP case: 1996 - 1. **. Tonga AFP case: I, 1993
~ -
- 29ANNEX 2
SUMMARY OF PROCEEDINGS OF DISCUSSIONS ON THE GOVERNMENT OF JAPAN PROJECT FOR SUPPORT FOR THE EPI IN PACIFIC ISLAND COUNTRIES 1996-2000
Dr M. Furuhato, (Ministry of Health and Welfare, Japan) stated that the Japanese Government has decided to provide cold chain equipment for II Pacific island countries (PICs) and also the Japanese Government expects a close relationship with WHO and UNICEF for their support. The countries concerned are: Cook Islands; Federated States of Micronesia; Fiji; Kiribati; Republic of Marshall Islands, Palau, Samoa, Solomon Islands, Tonga, Tuvalu and Vanuatu. Mr N. Mikuni (HCA) explained the mechanisms of the Japanese Government support. Plans of cold chain equipment requirement had already been prepared in collaboration with UNICEF, WHO and national EPI managers, the next step was for the appropriate request to be made to the Japanese Government for IIi~ir support. All participants were instructed in how to complete A4 forms. Those participants who came from Cook Islands; Federated States of Micronesia; Fiji; Kiribati; Solomon Islands and Vanuatu, were required to make submissions for funding in 1996. As the requests must be received in Tokyo by the end of September 1996, these participants were asked to handcarry the A4 forms back to their respective countries, so their Ministers of Health could clear them and forward them through their Ministries of Foreign Affairs. They also agreed to the following:
1. 2.
The A4 form should be completed by 9 of September 1996; The A4 form with a covering letter written by the Foreign Affairs Department should be sent to: (a) (b)
Japanese Embassy in Fiji through WR, South Pacitic Fiji, Vanuatu, Kiribati Japanese Embassy in New Zealand through WR, South Pacific, Cook Islands Japanese Embassy in Solomon Islands, Solomon Islands
(c)
(d) Japanese Embassy in FSM Federated States of Micronesia 3. Requirements and plans for 1997-2000 should be again discussed prior to submission of A4 forms at a laler date, which will be advised by WR, South Pacific.
- 31 ANNEX :\
Active Surveillance Visit Summary Form NAME OF HOSPITAL: _ _ _ _ _ __ DATE OF VlSIT: _ _ __ Source chod,~d
Sources
AFP, measles and NT cases
AFP cases CaSH
u'oslno)
register register register
inten'ic,,'s
room
in hospital centre
NOTES 1. Enter yes or no according to whether source of data was checked during this visit 2. Enter the nwnber of AFP. measles or NT cases found. or '0' if no cases, for each source of date 3. If AFP case found, complete a case investigation form, and take 2 stool samples 24 hours apart, to send to laboratory, If measles case found complete details on reverse of this ronn.
WEEKLY MONITORING AFP, NEONATAL TETANUS, AND MEASLES ACTIVE SURVEILLANCE JAN ~
FEB
MAR
APR
MAY
JUN
JUL
A~
Sf
oc
NC
DE
~
~11J ~I~I"I~I ~I~IEI~I ~I~I"I~I ~I~I"I~I ~1~lcl~1 ~1~lcl~1 ~1~cl~1 ~1~lcl~1 ~I~I~I~I il~lcl~1 il~I~I~1 il~I~I~ 4
!
~ 1
2
3 ·4
5 1
. 2 3
4
..... N
15 1 2 , 4
5 2
3 4
hOTAL. Noles: Siles (hospilalslhealth facilities) should be visiled each week Under 'date' enter the date of the visil for each week of the month Under 'afp' , 'nl', and 'ms' enler Ihe number of AFP, NEONATAL TETANUS and MEASLES cases found on Ihal visit,or zero If no cases Under 'sile' enler Ihe name of Ihe health facilily being visited
5
- 33 ANNEX 4
STANDARD CASE DEFINITIONS
ACUTE FLACCID PARALYSIS Any case of acute or sudden onset of flaccid (floppy) paralysis in children under the age of
fifteen years. All cases of AFP should have two stool samples taken 24 to 48 hours apart, within 14 days of onset of paralysis, and sent under refrigerated conditions to the Regional reference laboratory at Fairfield, Victoria, Australia. MEASLES Any rash and Fever (i.e 38° C or more, or hot to touch) and at/east one of the following Cough, runny nose, conjunctivitis
NEONATAL TETANUS Normal suck and cry at birth, trouble with sucking between 3rd and 28th day, death usually within 28 days of birth
FORM FOR MONITORING COMPLETENESS AND TIMELINESS OF REPORTS (INCLUDING ZERO REPORTS) FROM REPORTING SITES REPORTING SITE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
.... VI
Completeness Timeliness ~----
Notes: 1. Enter the name of each reporting site in the first column. 2. Write the date that the sUf'\leiliance report was received according to the month of the reporting period (e.g if January's report received on 15 February, write 15/2 under the JAN column). 3. Compleleness = reports received per month I total reporting sites 4. Timeliness = reports received on time I total reporting sites
> Z Z
~
VI
- 37 ANNEX 6
RECORD SEARCH DATA COLLECTION FORM NAME OF REPORTING SITE:_ _ _ _ __ PERIOD COVERED BY SEARCH OF RECORDS: FROM: TO: _ __ AFP ....CASE MEASLES CASE ADATE OF NUMBER AL~.<:
DATEI~~N
eASE Nl
."NUS A~ATE OF
~':;:~
Notes: For each case of AFP, measles or neonatal tetanus found:Enter the case number and date of admission For further details, find hospital case notes and complete a case investigation form.
REPORT OF RECORD SEARCH NAME OF REPORTING SITE PERIOD COVERED BY RECORD SEARCH FROM TO PEKSON(SI CONDUCTING SEARCH AFP
( MEASLES NEONATAL TETANUS
,
'"
00
TOTAL
~
Notes: For each reporting site (usually hospital) 1. The period which the record search covers (from .. to) 2. The number of cases found by each search. 3. The total number of cases found.