Meeting Report Twenty-First Meeting of the Technical Advisory Group (TAG) on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region
21–23 August 2012 Manila, Philippines
Participants of the Twenty-First Meeting of the Technical Advisory Group (TAG) on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region 21–23 August 2012, Manila, Philippines
RS/2012/GE/47(PHL)
English only
REPORT
TWENTY-FIRST MEETING OF THE TECHNICAL ADVISORY GROUP (TAG) ON IMMUNIZATION AND VACCINE-PREVENTABLE DISEASES IN THE WESTERN PACIFIC REGION
Manila, Philippines 21–23 August 2012
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
Not for Sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines April 2013
NOTE
The views expressed in this report are those of the participants of the 21st Meeting of the Technical Advisory Group (TAG) on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region and do not necessarily reflect the policies of the Organization. The Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, would like to thank the Ministry of Health, Labour and Welfare of Japan for providing financial support for the meeting, including the production of this document.
Keywords:
Immunization programs / Vaccine – standards / Measles / Rubella / Hepatitis B / Poliomyelitis / Tetanus / Infection control
This report has been printed by the Regional Office for the Western Pacific of the World Health Organization for the participants of the 21st Meeting of the Technical Advisory Group on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region, which was held in Manila, Philippines, 21–23 August 2012.
LIST OF ABBREVIATIONS
AEFI AFP ANC BD cMYP CRS cVDPVs DALY DoV DPT3 DTP EPI ERP GAVI GIVS GPEI GVAP HB3 HBIG HBsAg HepB Hib HPV IB-VPD ICC IMB IEC INC ITD IPV JE MCH
adverse events following immunization acute flaccid paralysis antenatal care birth dose comprehensive multi-year plan congenital rubella syndrome circulation of vaccine-derived polioviruses disability-adjusted life year Decade of Vaccines three doses of diphtheria pertussis tetanus vaccine diphtheria–tetanus–pertussis vaccine Expanded Programme on Immunization Expert Resource Panel Global Alliance for Vaccines and Immunization Global Immunization Vision and Strategy Global Polio Eradication Initiative Global Vaccine Action Plan three-dose coverage of hepatitis B vaccine hepatitis B immune globulin hepatitis B surface antigen hepatitis B Haemophilus influenzae type b human papillomavirus invasive bacterial vaccine-preventable diseases Interagency Coordinating Committee Independent Monitoring Board information, education, communications Intergovernmental Negotiating Committee intratypic differentiation inactivated polio vaccine Japanese Encephalitis mother and child health
MCV MDG MMR MNCHN MNT MR NCC NEPI NIID NIP NITAG NRA NT NVC OPV OPV3 PCR PCV RCC RED RVC SAGE SBA SIA STOP TAG TT UNEP VDPV VPD WHA WHO WPV WPV1
measles-containing vaccine Millennium Development Goal measles–mumps–rubella vaccine Maternal, Newborn, Child Health and Nutrition maternal and neonatal tetanus measles and rubella National Certification Committee National Expanded Programme on Immunization National Institute of Infectious Diseases National Immunization Programme National Immunization Technical Advisory Group National Regulatory Authority neonatal tetanus National Verification Committee oral poliovirus vaccine three doses of oral poliovirus vaccine polymerase chain reaction pneumococcal conjugate vaccine Regional Certification Commission reaching every district Regional Verification Commission Strategic Advisory Group of Experts skilled birth attendance supplementary immunization activity Stop Transmission of Polio programme Technical Advisory Group tetanus toxoid United Nations Environmental Programme vaccine-derived poliovirus vaccine-preventable diseases World Health Assembly World Health Organization wild poliovirus wild poliovirus type 1
SUMMARY
This 21st meeting of the Technical Advisory Group (TAG) on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region was attended by seven TAG members, participants from 15 countries and areas, 44 representatives from partner agencies, and WHO staff from Headquarters, the Regional Office and country offices. Dr Shin Young-soo, WHO Regional Director for the Western Pacific, welcomed all participants, underlining the role the TAG has played over the last two decades. He asked the TAG to provide guidance on relevant issues, such as developing national vaccine regulatory authorities and surveillance systems for adverse events following immunization. He also asked the TAG to discuss the new Global Vaccine Action Plan approved by the 2012 World Health Assembly. Measles elimination and rubella control were the first topics addressed. The remarkable decline in measles incidence from 81.6 per million population in 2008 to 5.7 per million in 2012 was highlighted, as was the fact 32 countries and areas may have interrupted endemic measles transmission as of 31 July 2012. A staff member from WHO Headquarters reported that measles mortality fell by 74% globally and by 76% in the Western Pacific Region from 2000 to 2010. The draft Measles Elimination Field Guide was introduced by staff members from the WHO Regional Office for the Western Pacific. The chairperson of the Regional Verification Commission (RVC) for Measles Elimination in the Western Pacific Region introduced the Guidelines on Verification of Measles Elimination in the Western Pacific Region, an outcome of the first RVC meeting in April 2012. The TAG acknowledged the good progress made in the Western Pacific Region towards establishing regional verification mechanisms for measles elimination and listed nine general and five country-specific recommendations. Hepatitis B control activities that have taken place since the TAG met last year were reported. Discussions focused on the 2011 TAG recommendation to set a target year for the goal of less than 1% infection rate. The Chairperson of the Expert Resource Panel (ERP) said the ERP recommends 2017 as the target date and suggested, if the TAG agreed, to recommend its inclusion as an agenda item at the 2013 session of the WHO Regional Committee for the Western Pacific. TAG members endorsed the ERP proposal to set 2017 as the target year and provided five sets of recommendations. They also noted their pleasure with news of progress on the milestone of a less than 2% infection rate. Deliberations on maintaining poliomyelitis-free status focused on the World Health Assembly resolution declaring the completion of the polio eradication initiative a programmatic emergency for global public health, with a request to WHO Director-General to rapidly finalize a comprehensive poliomyelitis eradication strategy for 2014–2018. The TAG urged all countries and partners in the Western Pacific Region to strongly support full implementation of the World Health Assembly resolution. Other regional topics discussed during the meeting related to maternal and neonatal tetanus elimination; the Global Vaccine Action Plan (GVAP) that was endorsed by the World Health Assembly on 25 May 2012; strengthening national immunization programmes in the Western Pacific Region as preparation for GVAP implementation; national regulatory authorities; vaccine safety, management and security; and new vaccines.
CONTENTS Page 1. INTRODUCTION ................................................................................................................. 1 1.1 Objectives ..................................................................................................................... 1 1.2 Organization ................................................................................................................. 1 1.3 Opening remarks........................................................................................................... 1 2. PROCEEDINGS ................................................................................................................... 3 2.1 2.2 2.3 2.4 2.5 2.6 Measles elimination and rubella control ....................................................................... 3 Hepatitis B control ........................................................................................................ 9 Maintaining poliomyelitis-free status ......................................................................... 13 Maternal and neonatal tetanus (MNT) elimination update: main regional and global aspects ....................................................................................................... 16 Introduction to Global Vaccine Action Plan (GVAP) ................................................ 17 Strengthening national immunization programmes in the Western Pacific Region as preparation for Global Vaccine Action Plan implementation ........................................................................................................... 18 National regulatory authorities (NRAs) and vaccine safety, management and security........................................................................................................................ 18 New vaccines .............................................................................................................. 20 Partnership — Interagency Coordinating Committee (ICC) Meeting ........................ 22
2.7 2.8 2.9 3.
CONCLUSIONS AND RECOMMENDATIONS .............................................................. 23 Measles elimination and rubella control ..................................................................... 23 Hepatitis B control ...................................................................................................... 25 Maintaining poliomyelitis-free status ......................................................................... 27 Maternal and neonatal tetanus elimination ................................................................. 29 Strengthening national immunization programmes .................................................... 29 National regulatory authorities (NRAs) and vaccine safety, management and security........................................................................................................................ 30 3.7 New vaccines .............................................................................................................. 31 ANNEXES: ANNEX 1 — TIMETABLE ANNEX 2 — LIST OF PARTICIPANTS 3.1 3.2 3.3 3.4 3.5 3.6
1. INTRODUCTION
The 21st Meeting of the Technical Advisory Group (TAG) on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region was held in Manila, Philippines, from 21 to 23 August 2012. 1.1 Objectives (1) To review progress, identify obstacles and recommend key actions required to achieve the regional goals of measles elimination, rubella and hepatitis B control, and the maintenance of poliomyelitis-free status. (2) To identify priority areas for strengthening immunization systems, including ensuring vaccine safety and security through building the national regulatory capacity in the Region. (3) To review progress, discuss plans, specify critical issues and propose ways forward to accelerate the introduction of new vaccines and technologies in the Region. (4) To provide partners an opportunity to be updated on progress, challenges, priority activities, and funding requirements and gaps. 1.2 Organization
The meeting was attended by seven TAG members, three temporary advisers, 26 participants from 15 countries and areas, 44 representatives from partner agencies, and 34 WHO staff from Headquarters, the Regional Office and country offices. The timetable of the meeting is provided in Annex 1. The list of participants is included in Annex 2. 1.3 Opening remarks
Dr Shin Young-soo, WHO Regional Director for the Western Pacific, welcomed TAG members, participants and partners by highlighting the role the TAG has played over the last two decades in guiding the Region in setting goals and pressing for effective coordination to increase the impact of immunization efforts. In this context, 2012 had been set as the target year for eliminating measles, reducing hepatitis B infection in children to less than 2% and maintaining poliomyelitis-free status. Dr Shin congratulated Member States on their hard work towards achieving these targets and noted that the Region is on the verge of eliminating measles. China vaccinated more than 100 million children across the country in 2010. The result has been a substantial reduction in measles cases. Cases also declined steeply in Viet Nam after 97% of children were vaccinated in 2010, just as they did in Japan after implementation of a five-year immunization and surveillance plan. Vaccination campaigns during 2011 reduced significantly the number of measles cases in Cambodia, the Lao People's Democratic Republic, Papua New Guinea and the Philippines. Mongolia has had no confirmed measles cases reported in the past two years. Meanwhile, Brunei Darussalam, Hong Kong (China), Macao (China) and the Republic of Korea, as well as Fiji and other Pacific island countries and areas, report few
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confirmed measles cases, which are likely imported or importation related. At the time of the TAG meeting, 32 countries and areas may have interrupted endemic transmission, which Dr Shin considered a significant achievement. But Dr Shin also warned that despite the successes, measles still circulates in a few countries. Urgent and effective actions are required in these countries to interrupt sustained transmission as soon as possible, and the TAG was expected to provide during its meeting guidance on strategic approaches to achieving and sustaining measles elimination and preparing for the verification process. Dr Shin said the achievement of the hepatitis B milestone—reducing infection prevalence in children to less than 2%—also should be viewed as an unprecedented success. The milestone has been met by the Region as a whole and by at least 30 countries and areas individually, according to recent estimates. With this progress, TAG recommended setting a target year for the 1% control goal. In March 2012, the Region’s Hepatitis B Expert Resource Panel proposed 2017 as the target year. The TAG meeting was expected to provide further impetus towards a consensus for a target year to be announced at the 2013 session of the WHO Regional Committee for the Western Pacific. Dr Shin noted that after having been certified free of poliomyelitis for 10 years, China experienced an outbreak in 2011 from a wild poliovirus imported from Pakistan. He commended China on its swift and comprehensive response to contain the threat. Dr Shin said countries in the Western Pacific Region remain at risk from remaining pockets of poliomyelitis in the world. As ongoing immunization gaps and decreasing awareness of surveillance requirements are leaving several countries vulnerable to poliomyelitis importation, essential guidance from the TAG was expected to assess risks and plan appropriate interventions to keep the Region free of poliomyelitis. Dr Shin reiterated how strengthening immunization systems is at the core of disease control and elimination efforts by the Expanded Programme on Immunization (EPI) and recommended that the TAG discuss the new Global Vaccine Action Plan for the Decade of Vaccines that was approved by all WHO Member States during the 2012 World Health Assembly. He also urged the Western Pacific Region to take the lead and prioritize immunization efforts that are most needed. Dr Shin also requested the TAG to provide guidance on developing national vaccine regulatory authorities (NRA) and surveillance systems for adverse events following immunization (AEFI). In the Region, only seven countries have functional regulatory systems to make sure vaccines are safe and effective, according to WHO criteria. He also encouraged the TAG to consider how to accelerate the introduction of new and underutilized vaccines, especially in low- and middle-income countries. He said there is no reason for people to suffer from diseases that can be prevented with vaccines, such as pneumococcal disease, rotavirus gastroenteritis, human papillomavirus (HPV) and Japanese encephalitis (JE). Dr Shin concluded by thanking participants for making EPI a vibrant and productive force in the Western Pacific Region. He expressed his gratitude to all partners, donors and friends for their support in protecting so many children in the Region from vaccine-preventable and other diseases.
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2. PROCEEDINGS
2.1 2.1.1
Measles elimination and rubella control Measles elimination status
Dr Sergey Diorditsa, EPI Team Leader, WHO Regional Office for the Western Pacific, made a presentation on regional progress towards measles elimination which includes a case reduction of 86% between 2008 and 2011, and a decline in measles incidence from 81.6 per million population in 2008 to 5.7 per million population in 2012 at an annualized rate. In most countries, the number of measles cases was at an historic low in 2012, and 32 countries and areas may have interrupted endemic measles transmission as of 31 July 2012. Measles surveillance performance has been improving, however it has not been universally high across the countries or within some countries. There are several key challenges, including securing adequate resources, urgently interrupting sustained transmission in five countries (China, Malaysia, New Zealand, the Philippines and Singapore), closing immunity and surveillance gaps and improving outbreak preparedness and response. Vigilance is required to sustain existing achievements, which require sustained resources and efforts. 2.1.2 China Dr Xu Wenbo, Chief, Chinese National Laboratory for Measles of the Chinese Center for Disease Control and Prevention, presented the progress towards measles elimination in China. Following separate province-wide supplementary immunization activities (SIAs) conducted from 2003 to 2009, nationwide SIAs in 2010, and SIAs focused on high-risk counties and undervaccinated children in 2011 and 2012, the measles incidence in China has decreased dramatically, beginning in 2009 with the number and size of outbreaks becoming smaller. The incidence reached an historic low of 0.7 cases per 100 000 people in 2011 and further decreased from January to June 2012. The proportion of cases among children was higher in western provinces, where the routine coverage is relatively lower. There were more infant and adult cases in eastern provinces, where routine coverage is higher. China’s measles surveillance performance has improved since 2009, with very strong support from China’s laboratory network. The indicators of discarded rate, suspected cases with adequate investigation and blood specimens have reached WHO standards. Besides more than 400 endemic H1 measles viruses, a few importation strains of D11 and D9 were also detected by the surveillance system in 2011 and 2012. However, major challenges remain for adequate population immunity. Measles virus circulated among adults and infants, with few cases in children; apparently nosocomial infection plays an important role in transmission. Surveillance indicators were not uniformly high in all provinces. As China’s health authorities pay more attention to measles elimination, a new regulation to ensure financial support for vaccination providers aims at strengthening the routine immunization programme. China’s action plan for measles elimination will be updated, and the verification process is planned to start at provincial level with the support from WHO. Interrupting measles virus transmission
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Philippines Dr Joyce Ducusin, EPI Manager and Medical Specialist IV of the National Center for Disease Prevention and Control, Department of Health, reported on strategies for reaching every high-risk community in the Philippines and interrupting measles virus transmission. The country experienced major measles outbreaks from 2009–2012. A nationwide measles–rubella SIA was conducted, vaccinating 84% of targeted children nine to 95 months of age. The campaign significantly reduced measles incidence but did not completely stop transmission, particularly in six provinces and some cities of the National Capital Region. Fifty percent of confirmed cases were found in children younger than nine months and people older than 20 years old; many did not receive at least two doses of measles-containing vaccine (MCV). To stop measles virus transmission in these areas, a high-risk community approach was initially undertaken in Dasmariñas, Cavite province, to implement a catch-up immunization activity. Local data on MCV coverage, surveillance and the socio-political situation were triangulated, and guided by maps, high-risk communities were identified. Master listing, tracking and vaccination of all under-immunized children in every community were conducted to rapidly close the immunization gap among children below five years old in each high-risk community. Of the 166 under-vaccinated children younger than five years, 98% had received two doses of MCV after the catch-up activity. The catch-up activity in Cavite is still being completed. The high-risk community approach in closing large immunity gaps proved to be successful but will require national and local political commitment, good risk analysis using available data, microplanning with contingency plans, clear field guidelines to eliminate variations in implementation, timely quality monitoring and supervision, and sensitive measles surveillance. Malaysia Dr Rohani Binti Jahis, Manager of the National Immunization Programme, Ministry of Health, reported on the achievements and challenges for measles elimination in Malaysia. From May 2011 through July 2012, Malaysia experienced prolonged and widespread measles virus transmission with 100–200 measles cases confirmed monthly. The national measles elimination plan of the Ministry of Health focused on three areas: increasing population immunity; sensitive and timely surveillance; and verification of suspected cases. Efforts have been made to increase population immunity by improving coverage with one dose of MCV (MCV1) through home visits, increased supervision and raising population awareness through information, education and communications materials. In addition, risk assessment evaluations have been conducted at the district level through the use of a scoring tool to determine the need for measles SIAs. Case-based surveillance is functioning well at the national level with eight reported non-measles suspected cases per 100 000 total population and more than 93% of districts reporting more than one non-measles suspected case per 100 000 people. Few specimens have been collected for virus isolation and genotyping. Strains isolated in 2011 and 2012 were limited to D8 and D9. A national measles verification committee was established in 2011 and meets twice a year to review cases. New Zealand Mrs Kim Albrecht, National Immunization Programme Manager, Sector Capability and Implementation, Ministry of Health, reported on the progress of the country's National Immunization Programme. The country experienced an imported measles (D4 genotype) outbreak from May 2011 through June 2012, with 517 laboratory-confirmed measles cases in 2011–2012. The highest incidence rates were in the greater Auckland area (more than 10 people per 100 000 population) and among children in age groups of less than one year of age, one to
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four years of age and 10 to 14 years of age. Approximately half of all reported cases were among adults. New Zealand has had a National Immunization Registry since 2005 that provides real-time information accessible to vaccination providers as well as to District Health Boards and the Ministry of Health. Since 2007, estimates have shown steady improvement in overall immunization coverage, including among ethnic minority and underserved communities. Vaccine refusal is rare and occurs with caregivers of less than 4% of eligible children. A number of educational and promotional strategies have been employed to minimize vaccine refusal. Current strategies to achieve measles elimination include implementation of a two-dose routine measles immunization schedule at 15 months and 4 years of age and communications campaigns targeting children 12–13 years of age, young parents and travellers. Detailed modelling studies are planned for 2013 to identify pockets with low immunity. Singapore Mr Yuske Kita, Senior Public Health Officer (Policy and Control), Ministry of Health , reported on recent measles trends in Singapore, as well as strategies and control measures. From 2007–2009, less than 20 cases of measles were reported annually. However, from 2010 an increase in the incidence of measles was noted. More than 140 measles cases were reported in 2011. The majority (83%) were sporadic cases and occurred primarily among children younger than one year of age (incidence rate of 80/100 000) and among children one to four years of age (33/100 000). Most were unvaccinated. Therefore, the Expert Committee on Immunization recommended that the age of the first dose of measles mumps rubella vaccine (MMR) be set at 12 months rather than 12–24 months and to decrease the age of second dose of MMR from six to seven years of age (before the first year of primary school) to 15–18 months of age. Since these changes were implemented in December 2011, 26 measles cases were reported between January and August 2012, as compared to 85 cases during the same period in 2011. In addition, laboratory confirmation (with polymerase chain reaction [PCR] for young children and PCR and serology for adolescents and adults) of reported clinical cases has been implemented since June 2012. 2.1.3 Key steps towards achieving, sustaining and verifying measles elimination
Global development on measles elimination Dr Peter Strebel, EPI Medical Officer, WHO Headquarters, presented global developments on measles elimination and rubella control. Globally, the number of reported measles cases was stable in 2010–2011, and MCV1 coverage reached 84% in 2011. Measles mortality fell by 74% globally and by 76% in the Western Pacific Region from 2000–2010. In 2012, a new Global Measles and Rubella Strategic Plan was endorsed by the key partners of the Measles and Rubella Initiative. The new plan is aligned with the Decade of Vaccine and Global Vaccine Action Plan. In the recent years, global attention and action on accelerating rubella control through vaccination have been increasing. New support from the Global Alliance for Vaccines and Immunization (GAVI) on measles rubella SIAs has been available to all eligible countries beginning in 2012. To guide regional and country work, early in 2012, WHO formed three subgroups under the WHO EPI Strategic Advisory Group of Experts (SAGE) working group on measles and rubella to work on an age range for respective campaigns, outbreak response immunization, standardization of definitions and approaches to verification, and the research agenda. It was concluded that the Western Pacific Region will be the next region to achieve measles elimination and this will provide impetus for establishing a global eradication goal.
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Cambodia Professor Sann Chan Soeung, Deputy Director-General for Health and Manager of the National Immunization Programme, Ministry of Health, reported on Cambodia’s measles elimination programme that aims to reach every community. In 2009, measles virus circulation increased in Cambodia, with cases occurring in children under five years of age who were not included in the last measles SIA in 2007, as well as older children who had missed both routine and SIA vaccination opportunities. A 2010 EPI review found that most infants missing routine immunization services lived in socioeconomically disadvantaged populations or in high-risk communities; they will need be to a particular focus for future measles elimination efforts. These communities could not be identified by coverage data alone, and require community visits and assessments of infant immunization status for accurate identification. To address the measles immunity gaps in the lead-up to measles elimination, the National Immunization Programme in 2011 developed a three-component strategy that linked measles SIA, identification of high-risk communities and strengthening routine EPI delivery. Firstly, an initial measles SIA took place in February 2011 that targeted infants aged nine to 59 months with measles vaccine, and required health centres to identify high-risk communities for additional oral poliovirus vaccine (OPV) administration and intensive monitoring and supervision. Secondly, a second-round SIA in November 2011 focused on high-risk communities only, targeted children five to nine years of age with measles vaccine and children under five years with OPV, and conducted rapid assessments of routine immunization coverage for children younger than two years. Thirdly, from 2012 onwards the focus on high-risk communities was shifted to routine EPI, specifically ensuring high coverage with the new measles vaccine second dose at 18 months of age. During the 2011 SIAs, the routine immunization status of 32 500 infants in 2200 socioeconomically disadvantaged villages was assessed, and detailed mapping by district of high-risk villages across the whole country was performed to identify socioeconomic and service delivery risk factors. Efforts to strengthen routine immunization coverage in these communities are being implemented in 2012 in conjunction with the introduction of a second measles vaccine dose at 18 months of age, new guidelines for micro-planning, targeted coverage assessments in high- risk communities, and better links between health centres and village health volunteers. Cambodia considers itself in a strong position to achieve its measles elimination goal given its efforts to reach all communities with the measles SIAs and assess merits of immunization coverage in high-risk communities for targeted support to strengthen routine immunization service delivery. The targeted approach of the 2011 SIAs on high-risk communities appears successful, with the last laboratory-confirmed measles cases identified in November 2011. Gap analysis: surveillance performance Dr Jorge Mendoza-Aldana, EPI Technical Officer, WHO Regional Office for the Western Pacific, started with a general review of measles surveillance outlining core surveillance indicators. After an overview of the completeness and timelines of measles surveillance reporting since 2007, he offered a comparison over time of surveillance indicators for the Region, emphasizing the importance of surveillance sensitivity and its measurement, the discarded measles rate at the subnational level. He then presented the progress in discarded measles rate since 2011 for Cambodia, the Lao People’s Democratic Republic, Papua New Guinea, the Philippines and Viet Nam. Using maps of subnational levels, he combined this indicator with the distribution of confirmed measles cases and population density.
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He also reported the good progress made in the Region for the indicator “adequate specimen collection”, which was close to the target, in 2012. He concluded that in 2012, the subnational discarded rate for the countries that reported had worsened and it was noticeable that subnational levels with poor discarded rates also show fewer or no measles cases. Performance of the WHO Measles and Rubella Laboratory Network Dr Youngmee Jee, EPI Scientist, WHO Regional Office for the Western Pacific, presented updates on the network, which expanded to 385 laboratories with addition of two subnational laboratories in Viet Nam and one subnational laboratory in Sabah, Malaysia. All but one of the network laboratories are accredited by WHO. While laboratory-confirmed measles cases decreased in 2012, laboratory-confirmed rubella cases from outbreaks or sporadic cases were increasingly detected in 2011. Some discrepancies in the surveillance and laboratory reports from countries on laboratory-confirmed cases were noted especially when non-WHO network laboratories were involved in measles rubella testing in countries, e.g. Australia, New Zealand and Singapore. To ensure the quality of performance, network laboratories, including those in China, participated in WHO annual proficiency and confirmatory testing programmes and obtained excellent scores. Extensive genotyping was conducted for measles and rubella viruses circulating in the Region. This information will provide critical evidence to demonstrate measles elimination in the Region. Highlights of the ‘Measles Elimination Field Guide’ (draft) Dr Wang Xiaojun, EPI Medical Officer, WHO Regional Office for the Western Pacific, briefly introduced a draft Measles Elimination Field Guide. The guide is built on the good practices and evolving progress at the country level, aiming to provide operational guidance for all national immunization programmes. The contents of the guide are structured around key actions and steps proposed to address four key challenges: interrupting endemic measles transmission through closing immunity gaps; ensuring adequate outbreak preparedness and response; ensuring high-quality surveillance is in place; and preparing for verification of measles elimination. In particular, the guide explains how to identify and close immunity gaps at the community level through a high-risk approach focusing underserved populations and communities, provides innovative and practical guidance on outbreak response immunization, proposes a simplified flowchart for measles case classification, advises steps on managing measles and rubella integrated surveillance, and provides steps for documenting verification for measles elimination. All participants were invited to comment on the draft guide during and after the meeting. Verification of measles elimination in the Western Pacific Region Professor David Durrheim, Director of Health Protection and Health Medicine Hunter New England Population Health, Australia, on behalf of the Regional Verification Commission (RVC) for Measles Elimination, reported the outcomes of the first RVC meeting in April 2012. The RVC was established in January 2012 and held its first meeting in April 2012 to develop the regional verification guidelines for measles elimination, including two criteria, four verification components and standards, and additional indicators under each component, verification process and structures, and proposed functions of RVC and national verification committees (NVCs). It was agreed that verification of elimination will first proceed independently for countries and areas. Verification of elimination in the Region can only be achieved at least three years after the last endemic case. The documentation process should be standardized to guide preparation work at both country and regional levels. Next steps include
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convening the second RVC meeting in early 2013 to finalize the regional verification guidelines and to provide orientation on NVCs; and submission of first progress reports in 2013 by all countries and areas. 2.1.4 Beyond measles elimination
Lao People’s Democratic Republic Dr Anonh Xeuatvongsa, Manager of the National Immunization Program, Ministry of Health, reported that the country has made great achievements towards measles elimination and accelerated rubella control in recent years. Measles vaccination in the Lao People’s Democratic Republic was introduced with the launch of the EPI in 1984. By 1998, the Lao People’s Democratic Republic adopted the regional measles control programme and in 2003 the Government adopted the measles elimination goal. As part of these control and elimination activities, the Lao People's Democratic Republic piloted its first measles SIA in 2001; nationwide SIAs were conducted in 2002 (targeting children nine to 59 months of age), in 2007 (targeting children nine months to 15 years of age) and in 2011 (targeting people nine months to 19 years of age). Recent data indicated that up to 36% of women 15–19 years of age were susceptible to rubella infection. Also, the country experienced several rubella outbreaks in different areas. In this context, measles and rubella vaccine was used for the first time in the last 2011 SIA, and this vaccine will be introduced in the routine schedule during the second half of 2012. The successful implementation of the measles and rubella SIA reported coverage of 97% as well as high coverage for the other combined interventions. Furthermore, the introduction of the new vaccine in the routine schedule represents the culmination of an integrated disease control approach that started in previous years with an integrated surveillance model for both diseases and development of combined information, education and communication (IEC) materials. Together with the introduction of the new vaccine in the routine schedule, some of the activities that will be conducted in the context of measles elimination and rubella control include the establishment of a national verification committee for measles elimination, development of a comprehensive outbreak response plan and enhancement of integrated surveillance activities, including congenital rubella syndrome burden studies. 2.1.5 Regional actions on measles elimination
Measles and equity in immunization Dr Wang Xiaojun, EPI Medical Officer, WHO Regional Office for the Western Pacific, emphasized that promoting equity in immunization should be an essential part of measles elimination in the Region, as the measles elimination goal is intended to create momentum for improving immunization service delivery, particularly for the most marginalized populations. Thus measles elimination should not be seen as a measles-specific initiative. Instead, measles can serve as a sensitive indicator of inequities for immunization and health. The new concept of putting a “face” on measles is proposed, wherein field case investigators obtain detailed information about the socioeconomic characteristics of measles cases and the community, as well as the status of immunization services in order to guide further actions to the delivery of equitable immunization services. A high-risk community approach is required, involving steps to identify underserved communities and populations, prioritize them for action
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(e.g. microplanning, monitoring and supervision) and reach them through improved service delivery. Summary of the day Dr Sergey Diorditsa, EPI Team Leader, WHO Regional Office for the Western Pacific, proposed actions at both country and regional levels to effectively address the key challenges he had emphasized in his earlier progress report. The proposed actions to accelerate efforts towards measles elimination include: • • • • • • • • • • • • 2.2 2.2.1 advocating for measles elimination through active communications strategies; identifying and implementing intensified and focused operational strategies; adapting the Measles Elimination Field Guide once it is published; conducting regular programmatic risk assessments; ensuring budgeted national action plans are in place; reaching every community through an approach focusing to serve high-risk communities and underserved populations; ensuring outbreak preparedness and response is in place, with a rapid funding allocation mechanism identified; planning activities to address existing surveillance gaps; improving sensitivity and specificity of measles surveillance; synergizing measles elimination and rubella control activities through use of measles rubella containing vaccines and integration of surveillance; finalizing regional verification guidelines; and establishing national verification committees and submitting first progress reports by 2013.
Hepatitis B control Regional update
The presentation by Dr Karen Hennessey, EPI Technical Officer, WHO Regional Office for the Western Pacific, covered hepatitis B control activities that have taken place since the TAG meeting in 2011 by strategic areas including vaccination, hepatitis B prevalence surveys, verification of achievement of infection reduction targets and the vaccination of high-risk groups. Regional three-dose coverage of hepatitis B vaccine (HB3) has increased from 68% in 2000 to approximately 95% over the last three years. Birth dose vaccination within 24 hours of birth increased from 47% in 2000 to 85% in 2011. By 2010, all countries had reached coverage targets of at least 85% HB3 and 65% birth dose coverage were reached, except in nine priority countries: Cambodia, Kiribati, the Lao People’s Democratic Republic, Papua New Guinea, the Philippines, Samoa, Solomon Islands, Vanuatu and Viet Nam. As a means to increase birth dose coverage, three priority countries conducted formal assessments of birth dose immunization practices in health facilities (Cambodia, the Lao People’s Democratic Republic and the Philippines). The birth dose assessments provided valuable data to guide programmes. A consultation on improving and monitoring birth dose vaccination was convened in Manila, Philippines in 2012. The consultation provided an opportunity for collaboration and joint planning between immunization and mother-and-child health (MCH) programmes, especially on activities to facilitate administration of birth dose vaccinations during home deliveries or during the first post-natal care visit.
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In 2012, China and Mongolia were verified to have reached the goal of less than 1% hepatitis B prevalence, marking a tremendous public health achievement. The final status of the 2012 milestone of reducing hepatitis B prevalence in children to less than 2% is not yet confirmed, but it is estimated that at least 30 countries and areas (more than 95% of Region’s population) have met the goal. This is based on seroprevalence estimates of chronic hepatitis infection and immunization coverage available to date. In 2011, TAG recommended to set a target year for the less than 1% hepatitis B prevalence goal. In January 2012, the Region’s Hepatitis B Expert Resource Panel recommended 2017 as the target year. A consensus on the target year should be reached during the 2013 session of the WHO Regional Committee for the Western Pacific. 2.2.2 Cambodia
Dr Chheng Morn, Deputy Manager of the National Immunization Program, National Maternal and Child Health Center, Ministry of Health, reported on the country's successful strategies and targeted activities in hepatitis B control. Hepatitis B (HepB) vaccine was fully introduced into the routine EPI schedule in 2010 in Cambodia, at birth and in combination with diphtheria tetanus pertussis vaccine (DTP-HepB) and Haemophilus influenza type B (Hib) vaccine. High coverage was achieved for HepB3 (more than 90% since 2008) and 68% coverage for HepB birth dose (within 24 hours) in 2011. A rapid increase in HepB birth dose coverage since 2007 was primarily driven by Government efforts to increase facility-based deliveries through incentives to midwives. A 2006 national study of five-year-old children showed pre-vaccine levels of hepatitis B surface antigen (HBsAg) to be 3.4%. Specific efforts by the National Immunization Program (NIP) in 2011 to assess the impact of the HepB vaccination programme and ensure that opportunities to deliver a timely birth dose were maximized. Firstly, a HepB serosurvey was conducted in over 2400 five-year-old children in three representative provinces with HepB seroprevalence rates of 0.33 % (urban), 1.41% (rural) and 3.45% (remote). Based on these results, it is likely that Cambodia achieved the WHO 2% seroprevalence goal in 2012. Secondly, a HepB birth dose assessment was conducted at a variety of provincial and district hospitals and health centres to ensure that all facility-born infants were receiving a timely HepB birth dose. A key finding of this assessment was that hospitals that gave the HepB birth dose onsite had higher coverage rates than facilities that directed women to take their newborn children to health centres, usually on the hospital grounds, for vaccination. For hospitals that vaccinated onsite, HepB birth dose coverage rates were higher when administrated in the delivery ward. The main barriers to onsite vaccination were lack of cold chain equipment, a lack of training and formal written instructions, and extended HepB vaccine stock outages at the national store. Actions from the NIP to further improve the impact of HepB vaccine focus on ensuring that all facility-born infants receive a timely birth dose and addressing factors that lead to HepB vaccine stock outages; developing Birth Dose Vaccine Guidelines for midwives for training and reference; and obtaining cold chain equipment for all 24 provincial hospital delivery units to allow the storage and administration of HepB vaccine onsite. Challenges still remain in immunizing infants born outside of health centres, mostly in high-risk communities, and in coordinating with private birthing facilities in urban areas. 2.2.3 The Philippines
Dr Joyce Ducusin, EPI Manager and Medical Specialist IV of the National Center for Disease Prevention and Control, Department of Health, presented opportunities to increase the facility-based birth dose coverage. The Philippines is considered to be highly endemic for
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hepatitis B, with a population seroprevalence of 9%. Birth dose administration was introduced nationally in 2007. In 2011, the birth dose coverage was only 44%, which is fairly consistent with the rate of health facility deliveries (42%). Skilled birth attendants are involved in 18% of deliveries. The majority of births (58%) still occur at home in many parts of the country. It is a known fact that the location of birth can impact administration of a timely birth dose. To determine barriers to achievement of higher birth dose coverage, a rapid assessment of the administration of hepatitis B vaccine at birth was conducted across 142 government and private health facilities in 24 selected provinces and cities from April to May 2012. Ninety percent of the health facilities visited provided birth doses. The assessment revealed several opportunities to improve birth dose vaccination. Training staff on duty at the delivery unit to provide the birth dose, rather than waiting for EPI officer, will increase coverage in three-fold. Many health facilities are providing the birth dose, but are not submitting data because no one is collecting it. Regular monitoring and supervision will provide an opportunity to collect data on birth dose administration and improve health worker practices. It is also critical to strengthen coordination with the private hospitals and to develop a mechanism which will enable health workers to administer the HepB vaccine when assisting home deliveries. Lastly, the Government needs to develop a sustainable mechanism for vaccine procurement to ensure continuous and adequate supply of all vaccines used in the routine immunization programme. The new law on mandatory immunization of children, which highlights the importance of the HepB birth dose administration, provides strong policy support. Current efforts to strengthen the maternal, newborn, child health and nutrition (MNCHN) package, with the administration of both the HepB birth dose and succeeding doses, will serve as the vehicle for improving coverage. 2.2.4 Lao People’s Democratic Republic
Dr Anonh Xeuatvongsa, Manager of the National Immunization Program, Ministry of Health, reported that HepB vaccines have been in use in the Lao People’s Democratic Republic since 2002, when the first pilot interventions started. Full nationwide introduction was achieved in 2003 in a combination vaccine and in 2008 for birth doses. Coverage of HepB3 has steadily increased in recent years, reaching 79% national coverage in 2011. On the other hand, HepB birth dose coverage has been more challenging and only modest increases have been achieved, recently reaching national coverage of 34% in 2011. Recent seroprevalence studies conducted in the country showed a relatively low prevalence of HBsAg of 1.5% in children five to nine years of age. The Government of the Lao People’s Democratic Republic and development partners have intensified efforts to address the main challenges to expanding birth dose delivery across the country. Some of these challenges are due to most births taking place outside of health facilities and the lack of skilled health staff to attend births that occur outside health facilities. A recent assessment of the birth dose delivery at health facilities and home birth visits and a national EPI review were conducted. It was found that these challenges still prevent adequate delivery of a timely birth dose. There are also health system issues that, for instance, do not allow for all facility births to receive a timely birth dose. The Government of the Lao People’s Democratic Republic has initiated the following activities to overcome these challenges: training new midwifes and skilled birth attendants; developing national policy guidelines for timely birth dose administration; and conducting free birth deliveries in selected poor districts, with plans to expand to all districts, as well as antenatal and postnatal care and the extension of the home birth visits, including birth dose.
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Future plans include piloting a system to report community home births using mobile phones, linking birth doses with the Government’s free delivery policy, the use of birth doses outside the cold chain, and strengthening the coordination between EPI and MCH department at all levels. 2.2.5 Hepatitis B Expert Resource Panel (ERP)
Dr Takaji Wakita, Hepatitis B Expert Resource Panel Chairperson, Deputy Director, Tuberculosis and Infectious Diseases Control Division, Ministry of Health, Labour and Welfare, Japan, said that the Hepatitis B ERP recognized the significant public achievement by China and Mongolia as they were officially verified this year to reach the control goal of less than 1% prevalence of chronic hepatitis B infection in children and by Tonga for reaching the milestone of less than 2% prevalence. With important progress made towards the less than 2% milestone, in 2011, the TAG recommended that the ERP propose a target year for the less than 1% prevalence control goal. The ERP deliberated in an effort to set a target year, with two guiding principles: the target year be in the near future to maintain awareness and momentum; and the target year be feasible for the Region as a whole and for most countries, representing most of the population but not necessarily every country. In February 2012, the ERP put forth the following recommendation: With consideration to the important and sustainable gains made in hepatitis B control in the Region thus far and the progress being made in countries with substantial challenges, the ERP recommends setting 2017 as the target year for reaching the goal of reducing chronic hepatitis B infection rates to less than 1% among children at least five years of age. This decision was based on the following factors: • • • 2017 is a feasible Region-wide target and for all, or almost all, countries; many countries have already met the less than 1% goal; and priority countries have increased coverage over the last five years.
If Member States agree and the TAG endorses the ERP recommendation, next steps would include the WHO Regional Office for the Western Pacific corresponding with each Member State regarding its position on 2017 as the target year, and if there is a consensus, proposing a target year as an agenda item at the 2013 session of the WHO Regional Committee for the Western Pacific. Other special topics the ERP plans to provide guidance on over the next year include: • • • • spacing between the birth dose and the first dose of combination vaccine; appropriate use of the hepatitis B surface antigen rapid test for conducting serologic surveys; coverage estimates needed for reaching the 1% goal that provide flexibility to allow for varying country-specific parameters; and options for ensuring gains are maintained, including a possible recommendation that countries adopt subnational prevalence targets or that smaller-scale prevalence surveys take place after verification.
After the presentation, the TAG chairperson opened the floor for discussion and encouraged Member States to comment on the proposed 2017 target year. There were no
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interventions from Member States on the target year; the TAG chairperson announced that he received this as agreement with the proposal. Afterwards, suggestions were made to have the ERP also consider providing guidance and advocacy on using hepatitis B vaccine in a controlled temperature chain and on increasing the understanding and awareness of contraindications to hepatitis B birth dose vaccination, as they are presented in the 2009 WHO position paper on hepatitis B vaccines. 2.3 2.3.1 Maintaining poliomyelitis-free status Status of global poliomyelitis eradication — key aspects
Dr Sigrun Roesel, EPI Medical Officer, WHO Regional Office for the Western Pacific, noted that levels of poliomyelitis cases were at an all-time low, but poliomyelitis can still spread quickly from the remaining reservoirs as the outbreak in China last year once more confirmed. Poliomyelitis has been stopped in all but three endemic countries—Afghanistan, Nigeria and Pakistan—and can technically be eradicated entirely. At the end of July 2012, there had been about 100 cases, compared to about 300 cases at the same time in 2011. Before the programme began in 1988, there were 350 000 cases that year. India, long-regarded as the most difficult place to achieve the eradication target, was declared poliomyelitis-free in February 2012, raising the urgency to stop transmission in other countries as soon as possible. However, there has been a rise in new poliomyelitis cases in the three remaining endemic countries over the past three years. International spread of poliomyelitis has been linked to continued virus transmission in Nigeria and Pakistan, underscoring the risk endemic poliovirus poses to all children, no matter where they live. Over the past three years, approximately half of all global cases occurred as a result of outbreaks in previously poliomyelitis-free countries, including China and Russia. Some of these outbreaks, affecting adults, killed half of those infected. Poliomyelitis eradication is at the tipping point. If immunity is not raised in the three remaining endemic countries to levels necessary to stop poliovirus transmission, poliomyelitis eradication will fail. Subsequently, the World Health Assembly in May 2012 adopted a resolution to declare the completion of poliomyelitis eradication a programmatic emergency for global public health, with overwhelming support from Member States in the Western Pacific Region. The Global Polio Eradication Initiative (GPEI) has launched a global Emergency Action Plan representing urgent escalation of national and international efforts to eradicate poliomyelitis. The plan aims to boost vaccination coverage in Afghanistan, Nigeria and Pakistan, the three remaining poliomyelitis endemic countries, to levels needed to stop poliomyelitis transmission. Developed in coordination with country national emergency plans, the global plan builds on India’s success in stopping poliomyelitis transmission and outlines a range of new strategies and initiatives to better support eradication efforts. Following the interruption of wild poliovirus transmission globally, additional activities will be needed to certify eradication and minimize the risks of poliovirus reintroduction (due to a containment failure) or re-emergence (due to the circulation of vaccine-derived polioviruses, or cVDPVs). The GPEI is intensifying its focus on managing the long-term risks of poliomyelitis, including preparing for the eventual cessation of the use of all oral poliovirus vaccines in routine immunization programmes. The 2012 World Health Assembly requested WHO DirectorGeneral Dr Margaret Chan to rapidly finalize a comprehensive poliomyelitis eradication and endgame strategy 2014–2018 and inform Member States about a potential switch from trivalent to bivalent OPV for all routine immunization programmes.
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The poliomyelitis endgame strategy is based on new diagnostic tests for cVDPVs, the availability of bivalent OPV, new low cost approaches for the introduction and use as appropriate of inactivated polio vaccine (IPV), and supplementary surveillance and mass immunization activities. The Polio Eradication and Endgame Strategic Plan 2014–2018 will be finalized for the Sixty-sixth World Health Assembly in May 2013. 2.3.2 China: 2011 poliomyelitis outbreak
Dr Li Quanle, Director, Bureau of Disease Prevention and Control, Ministry of Health, presented on the emergency response to the outbreak of imported wild poliovirus in the Xinjiang Uyghur Autonomous Region, China. From July to October 2011, an outbreak of wild poliovirus type 1 (WPV1) was detected in 21 case-patients in four prefectures. Genetic sequencing of this virus suggested that its closest relative (99% homology) was a virus circulating in Pakistan in 2010. Ten of the WPV1 affected persons were below five years of age and 11 were adults 19 to 31 years old. Seventy-five percent of affected children one to five years old had received three or more doses of OPV. The Ministry of Health acknowledged the outbreak as a national public health emergency, invested 340.7 million renminbi (RMB) for outbreak control, carried out five province-wide immunization campaigns with 43.6 million doses vaccine given to children and adults, and achieved more than 95% coverage. To increase the sensitivity of acute flaccid paralysis (AFP) surveillance, the programme increased the number of hospitals for vigilance and required reporting AFP cases in any age. The last person with the WPV1 strain isolated had paralysis onset on 9 October 2012. A WHO surveillance assessment conducted in June 2012 concluded the system was sensitive to rapidly detect AFP cases and considered it highly unlikely that undetected wild poliovirus was continuing to circulate in the Xinjiang Uyghur Autonomous Region. This was the first poliomyelitis outbreak due to imported WPVs in China in over a decade. The response activities demonstrated that political commitment, intersectoral coordination, support mechanisms and social mobilization are critical for successful campaigns to interrupt virus transmission. However, it also urged the acceleration of global poliomyelitis eradication given the fact that adolescents and adults will also be affected and that resources for outbreak control are expensive and unaffordable. 2.3.3 Viet Nam: Vaccine-derived poliovirus (VDPV) emergence
The presentation of Associate Professor Nguyen Tran Hien, Director, National Institute of Hygiene and Epidemiology, focused on type 2 VDPV case detection and response. Two cases were detected in April and June in Soc Trang and Dong Nai provinces in southern Viet Nam as unrelated cases—epidemiologically and virologically confirmed by the global polio reference laboratory at the National Institute of Infectious Diseases in Japan. Responding to these cases, joint field investigations, including stool sample collection from contact persons, rapid coverage assessments around cases, and retrospective hospital record reviews of the districts and provinces concerned, was conducted by the National EPI, the National Certification Committee (NCC) and WHO. After the assessments, an immediate OPV immunization campaign was conducted in June and July 2012 in Vin Chau and Tan Phu districts, where the cases were reported. In addition, large-scale OPV campaigns will be conducted in October and November 2012 in 79 high-risk districts in 19 provinces where the OPV3 coverage is under 80% and surrounding districts of Tan Phu and Vin Chau. The importance of maintaining high-quality AFP surveillance and high population immunity were emphasized.
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2.3.4 The Regional Commission for the Certification of Poliomyelitis Eradication (RCC): main conclusions and recommendations (November 2011) Professor Anthony Adams, RCC Chairman, said the commission has remained greatly concerned about the global poliomyelitis eradication situation, the mixed progress and generally concurred with recent conclusions of the GPEI Independent Monitoring Board (IMB). The RCC emphasized how further delays in reaching global goals have significant implications for the Western Pacific Region in terms of resource mobilization (money, staff and commitment), advocacy and communication, and development and implementation of midterm plans. The RCC therefore requested the WHO Secretariat to update the Poliomyelitis Regional Strategic Plan 2008-2012; in close consultation with Member States and ideally for review at the next RCC meeting. Based on country reports received in November 2011, the RCC concluded that the Western Pacific Region, with the exception of China, had remained free of circulating poliovirus. However, maintenance of the status cannot been taken for granted, mainly due to the situation in Pakistan, further delays to global eradication, continued immunization coverage gaps in several countries and areas in the Region, decreasing awareness of objectives and requirements of AFP surveillance, low AFP surveillance performance in some countries, and vulnerability also in older age groups. The RCC commended the very comprehensive investigation and vigorous and extensive response activities, as well as the strong leadership and responsibility taken by China to control the 2011 poliomyelitis outbreak. The RCC has followed the developments in China very closely, commended China for controlling the outbreak within six months and welcomed the outcomes of the recent AFP surveillance review. The RCC will review all evidence at its 18th meeting scheduled 26–30 November 2012 in Beijing and decide upon maintaining the Region’s poliomyelitis-free certification. The RCC commended risk assessments conducted by EPI, WHO Regional Office for the Western Pacific, and Member States, as well as the activities conducted and planned to reduce immunity gaps. But it urged comprehensive action that needs to be taken to improve surveillance quality. Plans for supplementary immunizations appear comprehensive, but integrating OPV in other SIAs and health interventions should continue. Successful approaches for reliable identification of high-risk communities, as well as failures and achievements, should be widely shared. Plans to address surveillance challenges are urgently required; this should include performance desk reviews and in-country field reviews as appropriate. 2.3.5 Regional poliomyelitis laboratory network
Dr Youngmee Jee, EPI Scientist, WHO Regional Office for the Western Pacific, presented the key developments of the Western Pacific Region poliomyelitis laboratory network to improve the quality and timeliness of poliovirus detection. She said the poliomyelitis laboratory network in China experienced a surge of samples during the wild poliomyelitis outbreak in Xinjiang Uyghur Autonomous Region but efficiently provided timely virus identification results by introducing the rapid molecular detection method in parallel with the standard virus isolation method. The Chinese Center for Disease Control and Prevention also decided to introduce the new algorithm for virus isolation and intratypic differentiation (ITD) and VDPV screening using real time PCR, developed by the United States Centers for Disease Control and Prevention, among provincial laboratories in China. National workshops to introduce the new algorithm for virus isolation and a real-time PCR workshop for ITD and VDPV screening were organized in February and March 2012, respectively. In addition, three national poliomyelitis laboratories in the Philippines and Viet Nam will be also trained for real-time PCR in December 2012. With the
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addition of poliomyelitis ITD laboratories in China, the Philippines and Viet Nam and the introduction of the new algorithm in China starting from 2013, the timeliness of poliovirus isolation and ITD will be further improved in this Region. 2.3.6 Maintaining poliomyelitis-free status
Dr Sigrun Roesel, EPI Medical Officer, WHO Regional Office for the Western Pacific, presented on how risk assessments conducted in 2011 on imported wild poliovirus led to a highrisk classification for potential poliomyelitis outbreaks and subsequent implementation of risk mitigation activities in Cambodia, the Lao People’s Democratic, Papua New Guinea and the Philippines. In addition, several countries conducted subnational risk assessments to guide response activities in a targeted fashion. Risk assessment remains qualitative in nature and considers components of population susceptibility, the ability to rapidly detect and monitor poliomyelitis cases, and other factors that influence poliovirus exposure and transmission in the population. These components are estimated and monitored by using indicators from a variety of sources and risk points are assigned. Subnational risk assessments will be updated annually and work is in progress for assessments across other WHO regions. While importations of wild poliovirus cannot be prevented, the spread of the virus can be prevented with high population immunity. The minimum requirement is at least 80%, as agreed at the World Health Assembly in 2006, and should be universally reached throughout a country. The Global Immunization Vision and Strategy (GIVS) calls for at least 90% routine immunization coverage for all EPI antigens. In 2011, three countries reported coverage at or below 80% (the Lao People’s Democratic Republic, Papua New Guinea and the Philippines). Further data analysis suggested a large range of subnational performance levels, and immunization status analysis of AFP cases suggested coverage problems in some countries. Complete and timely investigation of AFP cases remains essential to reliably detect polioviruses. In terms of key aspects of AFP surveillance quality, four countries with nationwide AFP surveillance did not reach the minimum non-polio AFP rate of one per 100 000 children under 15 in 2011, while adequate stool specimen collection rates of at least 80% were not reached by several countries. Reporting of AFP cases in 2012, as of week 31, is below the minimum rate in at least four countries. 2.4 Maternal and neonatal tetanus (MNT) elimination update: main regional and global aspects
Dr Sigrun Roesel summarized the main achievements of the global alliance for MNT elimination, demonstrated by a 90% decline in MNT deaths from an estimated 787 000 in 1988 to an estimated 59 000 in 2008. More than 20 countries have eliminated MNT, and there are continued improvements in reported coverage with DPT3 coverage exceeding 80% and the coverage of two or more doses of tetanus toxoid (TT2+) exceeding 75%. The number of nonneonatal tetanus deaths has also been reduced. Still, MNT elimination activities remain very important. Of 358 000 maternal deaths in 2008, 15% were infection-related, including maternal tetanus, and among 3.6 million neonatal deaths in 2008, neonatal infections (sepsis, tetanus and pneumonia) were attributed at 11%. Benefits of tetanus elimination strategies directly benefit mothers and newborns through immunizations, antenatal care, skilled birth attendance (SBA) and clean birth and cord care practices, particularly in the most vulnerable populations. On a larger scale they support progress towards Millennium Development Goals (MDGs) 4 and 5, collaboration between different health programmes, advocacy opportunities for the integrated package for maternal and newborn health, and community involvement.
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Data comparisons demonstrate the adverse relationship between antenatal care (ANC) and tetanus and SBA and tetanus. Estimates based on more than 70 countries with available data (2003–2009) on skilled attendance at delivery by household wealth quintile representing 69% of births in developing countries highlight that the poorest women are less likely to deliver with skilled birth attendance. In the Western Pacific Region, momentum towards MNT elimination has been maintained in all countries concerned (Cambodia, China, the Lao People’s Democratic Republic, Papua New Guinea and the Philippines), with country-specific approaches like the promotion of and subsidies for facility-based deliveries (China), integrated immunization campaigns combining tetanus toxoid (TT) with other EPI antigens (Papua New Guinea) or very targeted outreach (the Philippines). However, challenges remain, particularly in terms of the resurfacing TT controversy (in Papua New Guinea and the Philippines), incomplete neonatal tetanus (NT) surveillance (in all countries) and a high percentage of home births and unclean deliveries (Cambodia, the Lao People’s Democratic Republic, Papua New Guinea and some parts of the Philippines). 2.5 Introduction to Global Vaccine Action Plan (GVAP)
Dr Okwo-Bele, Director, Family and Community Health Immunization, Vaccines and Biologicals, WHO Headquarters, presented the GVAP which was endorsed by the World Health Assembly on 25 May 2012. The overall mission of the GVAP is attainment of a world in which all people at risk are protected against vaccine-preventable diseases and to achieve the following goals by 2020: • • • • Certification of a poliomyelitis-free world. Measles and rubella elimination in at least five WHO regions. Reach 90 % national coverage and 80% district coverage with all vaccines. License and launch vaccines against at least one disease for which vaccines do not exist now.
Thus, the GVAP is overarching with the GIVS, but it builds more on immunization services to reach all communities, monitoring the morbidity reduction and economic impact of immunization services, focusing not only on poor countries but also on middle-income countries. Immunization means more than achieving high coverage; it also serves as a tool for comprehensive diseases control, elimination and prevention. During the Decade of Vaccines, the situation should evolve so that immunizations and additional new vaccines will be demanded by individuals and communities. Countries should have ownership to sustain immunization, and giving equitable access of immunization services to all segments of its populations should be confirmed in national health plans. The TAG and representatives of National Immunization Programmes were informed that a new World Health Assembly resolution urges Member States to apply the new vision and strategies according to their epidemiological situation, paying particular attention to improving EPI performance. They should commit resources to achieve the goals and key milestones, designate the last week of April, when appropriate, as World Immunization Week, and report every year on the progress during annual sessions of the WHO Regional Committee for the Western Pacific.
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2.6
Strengthening national immunization programmes in the Western Pacific Region as preparation for GVAP implementation
Strengthening national immunization programmes, by implementing strategies and activities recommended by the GIVS endorsed by the World Health Assembly in 2005, continues to be the critical foundation for vaccine-preventable disease (VPD) control in the Western Pacific Region; for achieving the regional goals of maintaining poliomyelitis-free status, eliminating measles and controlling hepatitis B; and contributing to reaching the MDGs 4 and 5. In May 2012, the Sixty-fifth World Health Assembly endorsed the GVAP for the Decade of Vaccines building on the GIVS 2006–2015 and urged Member States to apply the GVAP vision and strategies in developing the vaccines and immunization components of their national health strategy and plans with particular attention to improvement of the EPI performance (resolution WHA 65.17). Dr Yoshihiro Takashima, EPI Technical Officer, WHO Regional Office for the Western Pacific, summarized selected activities carried out for the implementation of GIVS in the Western Pacific Region in 2006–2011; reviewed them in the framework of GVAP, with reference to GVAP strategic objectives; summarized the status of preparation for and identified issues against implementation of GVAP in Western Pacific Region; and suggested actions for countries and proposed actions for WHO for implementation of GVAP in the Region. In the Western Pacific Region, many countries have been developing and implementing core actions for GVAP strategic objectives through implementation of GIVS strategies in 2006–2011, which include: conducting international EPI reviews; developing national immunization plans (e.g. comprehensive multi-year plans); establishing and strengthening national immunization technical advisory groups (NITAGs); conducting regional and national immunization weeks; assessing EPI performance and VPD risks at subnational levels; introducing the reaching-every-district (RED) approach; and conducting national training for mid-level EPI managers, among other activities. It was mentioned that all countries in the Western Pacific Region were on track towards achieving Decade of Vaccine goals, while the level of progress towards achievement of GVAP strategic objectives measured by GVAP indicators varied country by country. To accelerate progress made towards achievement of GVAP strategic objectives in the Region, Dr Takashima suggested countries immediately review existing national immunization plans (e.g. comprehensive multi-year plans), strategies and activities (e.g. RED approach) from the perspective of the GVAP's vision and strategies, and prepare national action plans for implementation of GVAP according to country-specific situations so as to further strengthen National Immunization Programmes. He also proposed that WHO continues to work with countries in the Region in reviewing the status of preparation, and in identifying needs, for implementation of the GVAP at country level and to prepare a Western Pacific Regional Vaccine Action Plan to support countries in the preparation and operation of national action plans for the GVAP implementation at the country level. 2.7 2.7.1 National regulatory authorities (NRAs) and vaccine safety, management and security Regional priorities in NRA systems and vaccine safety
Dr Md. Shafiqul Hossain, EPI, Technical Officer, WHO Regional Office for the Western Pacific, summarized and updated on formulating a regional alliance for national regulatory authority for vaccines in Western Pacific and a subregional causality assessment committee on AEFI for Pacific island countries and areas.
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As of July 2012, seven countries in the Western Pacific Region have been documented as having functional regulatory systems meeting WHO criteria. However, many countries in the Region have the potential to develop and strengthen their NRA systems and their relevant regulatory functions. For building national regulatory capacities, many countries in the Region have expressed a need to increase the exchange of regulatory information and expertise through collaborative exchange programmes. During the first NRA workshop for vaccines 2011 in Seoul, Republic of Korea, participants from Member States proposed the creation of a regional alliance for NRA for effective and efficient coordination and to support the establishment and/or strengthening of NRA systems and required functions in all countries with non-functional NRAs. As per conclusions from that meeting, the WHO Regional Office for the Western Pacific organized an informal task force meeting in May 2012 in Canberra, Australia, to finalize a draft concept paper including a road map and workplan for the proposed regional alliance. Draft concept paper, road map and workplan will be shared with the Member States at the second NRA workshop for finalization, which is planned for the first quarter of 2013. Strong AEFI surveillance systems are needed to monitor existing and new vaccines in order to be able to sustain confidence in national immunization programmes. The quality of AEFI surveillance systems and their functionality in Pacific island countries and areas vary widely. There have been discussions in different meetings, including Pacific Immunization Programme Strengthening (PIPS) workshops, to strengthen AEFI surveillance systems in Pacific island countries and areas. These systems also rely on an expert committee for determination of causal association. Subsequently, WHO organized a training workshop on basic AEFI surveillance in the Pacific island countries and areas in January 2012. One of the conclusions from the workshop was to establish a subregional AEFI causality assessment committee to support individual countries in determining the causal relationship of reported serious AEFI cases and to solve any vaccine-related concerns. But the majority of Pacific island countries and areas do not have adequate experts to form such causality committees. As such, WHO has started the process to form a subregional AEFI causality committee in Pacific as per demand from countries and areas. 2.7.2 Vaccine stock management and importance of monitoring vaccine stock-outs in countries It is important that the correct quantity of vaccine stocks are kept at each level of the cold chain as health-care workers can only be effective and immunize target populations when vaccines and other ancillaries are available to them. Dr Md. Shafiqul Hossain described the stock management system in the Region, including monitoring, the status of stock outages and available tools for stock management. According to available information, there are different types of vaccine stock management and monitoring systems in place in many countries and areas. He also shared data showing stock outages in some countries and areas at the district, provincial or national level due to mainly faulty forecasting and improper stock management. Stock management and monitoring systems should be strengthened, and they should be established where not yet in place. If the practice of inadequate stock monitoring continues, disease control goals set by Member States may be delayed and there might be additional programmatic and financial implications. He further shared the available existing tools for stock management and monitoring and encouraged countries to adapt and use those tools. 2.7.3 Update on thiomersal controls and impact on vaccines
Dr Md. Shafiqul Hossain updated participants on thiomersal controls and their impact on vaccines.
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In 2009, at its twenty-fifth session, the United Nations Environmental Programme (UNEP) Governing Council requested an Intergovernmental Negotiating Committee (INC) to prepare a global legally binding instrument on mercury. Negotiations will be taking place over five INC meetings. The proposed treaty includes provisions to reduce the use of mercury in products and processes as to reduce risk to human health and the environment. Many health-related products currently include mercury and there are many mercury-containing products, such as thiomersal, an organic form of mercury used as preservative in vaccines with multi-dose vial presentations. Dr Hossain discussed mercury, thiomersal and its importance, alternative preservatives and their implications, and the impact of removal of thiomersal from vaccines. The issue of thiomersal in vaccines was raised in the second INC meeting and again in the third INC meeting held from 31 October to 4 November 2011, and WHO advised countries that the quantities of mercury included in thiomersal-containing vaccines is exceedingly small compared to the other sources of mercury. Furthermore, there is no evidence suggesting a possible health hazard with the amounts of thiomersal currently used in vaccines. The advice from WHO emphasized that the use of thiomersal in vaccines is already governed by a health regulatory process to ensure that all additives in vaccines are necessary and safe. He further described WHO input and recommendations from different advisory groups in terms of thiomersal to be used in vaccines. 2.8 New vaccines
2.8.1 Regional update: progress in new vaccine introduction, key challenges, tools and resources for support Dr Kimberley Fox, EPI Technical Officer, WHO Regional Office for the Western Pacific, presented an update of progress and challenges in new vaccines introduction. Available new and underutilized vaccines include those for Hib, pneumococcal conjugate vaccine (PCV), rotavirus, JE, HPV, rubella, influenza, typhoid and cholera. In addition, vaccines against dengue, malaria and other important diseases are in development. Vaccine-preventable diseases (VPD) still account for more than 12% of children under five years in deaths in the Western Pacific Region, and the vast majority of these VPD deaths are due to pneumococcus, Hib and rotavirus. WHO recommends the inclusion of Hib, pneumococcal conjugate and rotavirus vaccines in all national immunization schedules. To date, 32 countries and areas in the Region have introduced Hib vaccine, 15 have introduced PCV, and eight have introduced rotavirus vaccine. WHO recommends introduction of HPV vaccine where cervical cancer is a public health priority, and vaccination is feasible and sustainable. To date, 18 countries and areas in the Region have introduced HPV vaccine. WHO recommends JE vaccination where JE constitutes a public health problem; seven of the 12 Western Pacific Region countries with JE risk areas have introduced JE vaccine. Introduction of new and underutilized vaccines requires consideration of disease burden, vaccine efficacy and safety, alternative interventions, economic and financial issues, and programmatic issues. Obtaining disease burden evidence is often a challenge; WHO produces disease burden estimates and coordinates surveillance networks to help address this challenge. The rotavirus surveillance network is now producing data useful to policy-makers, while substantial difficulties remain in diagnostic testing in invasive bacterial VPD (IB-VPD) surveillance. Economic evaluation is useful to provide data on cost, cost-effectiveness and other measures. Programmatic challenges include delivering vaccination to new age groups and in new settings such as schools. Finally, the process and impact of vaccine introduction should be evaluated to identify lessons learnt for programme improvement and to provide policy-makers with evidence of the value of the investment in vaccination.
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2.8.2
Country experiences
Papua New Guinea Dr William Lagani, Principal Manager, Family Health Services, National Department of Health, summarized the findings from the BinaxNOW® testing for Streptococcus pnuemoniae in Papua New Guinea. While highlighting the need for continuing with latex agglutination testing for IB-VPD surveillance, he provided the rationale to introduce Binax testing in Papua New Guinea. The introduction of Hib vaccine in Papua New Guinea as DTP-HepB-Hib vaccine will lead to a decrease in the number of Hib cases, while the number of pneumococcal cases detected by latex in the existing IB-VPD surveillance appears to be increasing. With limited detection of cases by culture and poor sensitivity of latex, the possible introduction of PCV-13 in 2014 warrants a system to monitor vaccine impact. Dr Lagani shared the results of a 14-month period of Binax testing in Port Moresby General Hospital that found that 10% of latexnegative cases tested positive for S. pneumoniae by Binax. The Binax results supported the clinical management by the treating paediatricians. The additional yield due to Binax may be related to the high prevalence of pre-hospital antibiotic use found among patients admitted to Port Moresby General Hospital. With the encouraging findings of Binax in Port Moresby General Hospital, the Government of Papua New Guinea plans to expand Binax testing to another provincial hospital to determine if the findings can be replicated in a more resourceconstrained setting. The Government of Papua New Guinea also plans to test the S. pnuemoniaepositive cases to determine the serotypes as part of the preparation to assess vaccine impact. Viet Nam Associate Professor Nguyen Tran Hien, Director, National Institute of Hygiene and Epidemiology, presented the preliminary results of cost and impact analyses conducted to demonstrate the value of EPI and to provide economic data for consideration in the decisionmaking process for introduction of new vaccines. The overall impact and cost-effectiveness of the national EPI from 1980 through 2010 was estimated. Compiling officially-reported cases and deaths from poliomyelitis, measles, neonatal tetanus, diphtheria and pertussis during this period and using a conservative adjustment for under-reporting, it was estimated that the immunization programme prevented 51 480 deaths and cost a total of US$ 154.5 million. The cost per life-year saved was US$ 190, indicating that EPI is very cost-effective. A rotavirus cost-effectiveness analysis considered direct and indirect effects, and medical and non-medical costs, using the Consensus on Rotavirus Vaccination (CoRoVa) model. Assuming a market price of US$ 5/dose for the rotavirus vaccine produced in Viet Nam, the cost per disability-adjusted life year (DALY) averted was US$ 1404. Given the GAVI-subsidized price of US$ 0.2/dose, the vaccine was cost-effective. A similar analysis was conducted for rubella using data from a facility-based survey, estimated congenital rubella syndrome (CRS) incidence, a serological study, and cost data from healthcare providers and patients. It was estimated that a measles-rubella vaccination campaign targeting nine month to 14 year olds followed by introduction of measles and rubella containing vaccine into routine EPI would prevent 82 231 cases of CRS in the next 10 years. The cost analysis for rubella will be completed so that cost-effectiveness can be calculated. These analyses used country data resulting in estimates for impact and cost-effectiveness which are applicable to the Viet Nam programme. These data can therefore be used for further resource mobilization and advocacy in the Government, and as evidence for prioritization of new vaccines for introduction into routine EPI.
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Malaysia Dr Rohani Binti Jahis, Manager of the National Immunization Programme, Ministry of Health, summarized the achievements and challenges of Malaysia in implementing an HPV vaccination programme. The Malaysian policy states that free HPV vaccination should be provided to Malaysian girls at age 13 years, starting in 2010. To implement this policy, HPV vaccination is provided with parental consent to girls in year 7 in all registered schools. HPV vaccination for out-of-school 13-year-old girls is available through 480 vaccination centres. Key factors leading to success of the programme have been: close coordination with the Ministry of Education, delivery of cold chain equipment along with vaccine, communication with parents and children, print and social media campaigns, onsite immunization and AEFI management guidelines, and programme monitoring at all levels. Acceptance was high, with more than 95% coverage for the first dose, but coverage dropped substantially by the third dose in most states, due to refusal by many of the girls. With over 670 000 doses administered, there were no serious AEFI. As of July 2012, the National Population and Family Development Board is providing HPV vaccination to 18-year-old girls in universities and will expand to include older women. Philippines Dr Joyce Ducusin, EPI Manager and Medical Specialist IV of the National Center for Disease Prevention and Control, Department of Health, presented on the Philippines' experience with sustainable financing for immunizations. The Philippines, a lower middle-income country, maintains a high commitment to child health and immunization as evidenced by the signing of the Mandatory Childhood Immunization Law (RA 101521) and an 80% increase in the budget allocation for the routine immunization service in 2012 from 2002. In 2012, the country successfully introduced rotavirus vaccine with priority given to poor families, expanded the pentavalent vaccination for nationwide implementation and introduced influenza and pneumococcal polysaccharide vaccine for the elderly. Future plans include the introduction of PCV, JE vaccine and diphtheria and tetanus toxoid vaccine as part of routine childhood immunization. The country has achieved several milestones in securing safe and effective vaccines for the national immunization programme. It has moved from donor-dependence to self-procurement of vaccines and logistics using government funds for 100% of the vaccine procurement requirements. However, there are still challenges to ensuring high-quality and effective immunization services. The three major challenges include (1) securing the nearly US$ 3.5 million needed to expand cold chain capacity to accommodate all the planned vaccines for national implementation; (2) the non-functionality of the vaccine national regulatory authority; (3) strengthening of post-marketing pharmaco-vigilance; and (4) developing a mechanism to obtain lower vaccine prices and sustain the Government’s vaccine self-procurement scheme. The Philippines requested WHO to develop a mechanism to allow lower middle-income countries to access vaccine prices offered to low-income countries and/or explore the possibility of pooled procurement for countries with annual budget releases. 2.9 Partnership — Interagency Coordinating Committee (ICC) Meeting
The WHO Regional Office for the Western Pacific and country offices have been supported in 2012 with adequate funding to conduct basic priority activities. Operational workplans by area of work were developed in 2011 to address the basic regional needs to fulfil our mandates and continue progress on the established goals. However, despite the remarkable progress made on the elimination of measles and maternal and neonatal tetanus elimination, the control of hepatitis B and maintenance of the Region is poliomyelitis-free status, there are many areas of work that continue to be unfunded or underfunded.
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ICC members are fully aware of the current situation and demonstrated their commitment to continue supporting technical and financial areas of work in the Region. The Region continues to depend on the generous support of a few traditional donors. Discussions took place about bringing new partners to the table and developing innovative approaches and enhanced collaboration with existing partners, as well as the inclusion of the private sector as new partners in the Region. Only with these new approaches in place, operational workplans can be designed with more ambitious goals. 3. CONCLUSIONS AND RECOMMENDATIONS
3.1
Measles elimination and rubella control
Conclusions The WHO Regional Committee for the Western Pacific at its 2005 session endorsed a recommendation setting 2012 as the target year for measles elimination in the Region. All countries and areas in the Region have made tremendous efforts to achieve and sustain measles elimination. As a result, the Region is making rapid and remarkable progress and now is on the verge of eliminating measles. Thirty-two countries and areas may have already interrupted endemic measles transmission. The number of measles cases declined by 86% from 145 935 in 2008 to 21 054 in 2011, and annual measles incidence fell from 81.6 per million in 2008 to 11.6 per million population in 2011. In 2012, the number of measles cases has continued to decrease in the Region, with a reduction of 69% to 5150 measles cases in January–June 2012 from 16 431 cases during the same period in 2011, and the number of measles cases is at historic low in most countries. However, some critical challenges remain before endemic transmission eventually can be interrupted in all countries and areas, including greater political commitment, additional resources and intensified efforts. In the remaining months of 2012 and in 2013, commitment from and further progress made by the countries with sustained measles virus transmission will largely determine the status of measles elimination in the Region. Again, urgent action will be required to interrupt measles virus transmission as soon as possible. Experiences in Australia, Japan and other countries have highlighted the fact that the importation of the measles virus poses a continuing threat to all countries and areas. Sustaining the achievement of measles elimination is also challenging but provides a great opportunity for countries to reach every community with adequate vaccination services and promote equity in immunization. It is imperative for every country and area to implement proper strategies and activities to close immunity and surveillance gaps using practical means. They must also rapidly identify risks (areas and population groups) and adequately prevent, prepare for and respond to outbreaks caused by either endemic or imported measles virus. The Region and its Member States should continue prioritizing measles elimination and use measles elimination as a means to advocate for synergy with rubella control activities and equity of immunization and other health-care services. The TAG acknowledged the good progress made in the Region towards establishing the regional verification mechanisms for measles elimination, including criteria, indicators, structure and processes.
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Recommendations (1) The TAG reaffirmed the critical importance, based on the 2009 Measles Vaccines: WHO position paper, for all children to receive at least two doses of measles vaccine, either through the routine programme or SIAs. Ideally, the second dose of measles containing vaccine (MCV2) should be provided in the second year of life, to minimize the accumulation of susceptible children. (2) The TAG urged that countries with sustained measles virus transmission identify and implement intensified and focused efforts to interrupt measles virus as a matter of urgency. This includes China, Malaysia, New Zealand, the Philippines and Singapore. (3) The TAG recommended that countries systematically and precisely identify high- risk communities with underserved populations, and make effective and sustained efforts to reach these communities with measles-containing vaccines and other EPI vaccines, and regularly monitor progress. (4) The TAG urged all countries and areas to assess their measles surveillance performance by province and district, to plan activities to address existing surveillance gaps, and to improve the sensitivity and specificity of surveillance, emphasizing case detection and notification, in-depth case investigation, sample collection for serology and virus identification (blood and swab), and proper case classification. a. The TAG advised that every country and area should comprehensively describe every measles case and the affected community, including socioeconomic and service delivery details, to help guide a decision on rational outbreak control interventions. b. The TAG recommended all countries to implement the 2010 TAG recommendation calling for the establishment of an expert review committee (ERC) whenever possible, while clear instructions should be developed to ensure that ERC function properly. (5) The TAG emphasized that regular risk assessments and adequate preparedness and response to measles outbreaks, caused by either endemic or imported measles viruses, are critical for all countries and areas to achieve and sustain measles elimination. Preparedness plans should address the risk of cross-border and remote importations. Where appropriate, countries should organize cross-border coordination activities. Given the growing concern about importation from extra-regional locations, the TAG recommends that the Regional Director, the WHO Regional Office for the Western Pacific and Member States advocate with other regions for achieving their regional elimination or control goals, which will reduce the risk of importation into the Western Pacific Region. (6) The TAG suggested countries and areas synergize measles elimination and rubella control activities by using measles and rubella combination vaccines and integrating measles and rubella surveillance, whenever possible. (7) The TAG encouraged WHO and the United Nations Children's Fund (UNICEF), as a priority, to provide technical assistance to GAVI-eligible countries in the Western Pacific Region to prepare their applications to GAVI for conducting catch-up supplementary immunization activities (for those younger than 15 years old) with measlesrubella containing vaccine and the introduction of rubella-containing vaccine and a routine measles second dose into their routine immunization programmes.
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(8) TAG encouraged the Region and countries and areas to adopt good communications strategies and messages to advocate for measles elimination, including the promotion of both equity in immunizations and immunization day or week activities. (9) The TAG acknowledged the efforts of the WHO measles and rubella laboratory network to support the regional goal. It encourages network laboratories with pending accreditation status to be accredited as soon as possible and the high performance level of all network laboratories to be maintained. Country-specific recommendations (1) The TAG acknowledged the strong political commitment from the Government of China and the tremendous effort made at each level, and congratulates China on the remarkable progress made to dramatically reduce the number of cases in recent years. Given the diversity in epidemiology, demography, geography and health systems by province, the TAG recommends that China implement tailored strategies for each province based on an in-depth review. Joint national and international consultation may be helpful. (2) The TAG found the increased and continued measles transmission in Malaysia worrying and recommends that the country implement intensified vaccination strategies to rapidly interrupt the current transmission, take further actions to reach 95% routine coverage at community level, strengthen cross-border coordination of measles control activities, and more effectively reach migrant and transient populations. (3) In support of efforts to improve routine immunization, the TAG recommended that Papua New Guinea consider a second dose of measles vaccine in the second year of life and reconsider the need and relevance of a six-month dose of measles in the present context. Papua New Guinea should make use of GAVI assistance and consider introducing measles-rubella vaccine in the routine immunization schedule following a wide age range catch-up measles-rubella SIAs. (4) The TAG acknowledged the great efforts made by the Philippines to control large measles outbreaks in 2010–2011 by conducting a national measles-rubella SIA in 2011. Measles transmission is now concentrated in only a few provinces. Further focused efforts will be needed to interrupt residual transmission in these provinces, as well as to prevent re-emergence of measles in other provinces. Given the challenges in reaching 95% coverage universally throughout the country, the TAG urged the country to develop or intensify the current strategies to regularly conduct risk assessment, identify high-risk areas, take effective actions and monitor the progress. (5) The TAG recommended that Singapore closely measures immunity gaps and ensure that proactive strategies are in place to close the immunity gaps that are identified. 3.2 Hepatitis B control
Conclusions In 2012, China and Mongolia were verified to reach the less than 1% prevalence goal marking a tremendous public health achievement. While the final status of the 2012 milestone of reducing hepatitis B prevalence in children to less than 2% is not yet confirmed, it is estimated to be met by the Region as a whole and by least 30 countries and areas (more than 95% of Region’s population). This is based on seroprevalence estimates of hepatitis B surface antigen and immunization coverage available to date. The six remaining countries (Kiribati,
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Papua New Guinea, the Philippines, Samoa, Solomon Islands and Vanuatu) have not conducted recent prevalence surveys or reached target coverage levels. These countries have substantial challenges in reaching home births and/or not fully integrating hepatitis B vaccination in facility settings. In addition, although seroprevalence surveys indicate that Cambodia, the Lao People’s Democratic Republic and Viet Nam may have met the less than 2% prevalence milestone, they are also priority countries for strengthening birth dose vaccinations. The TAG was pleased with the progress on the less than 2% prevalence milestone. Hepatitis B birth dose assessments have provided valuable data to guide programmes, have raised awareness, and have been an efficient and worthwhile use of public health resources. The hepatitis B birth dose consultation provided an opportunity for collaboration and joint planning between immunization and mother and child health programmes, especially regarding activities to facilitate the administration of birth dose vaccinations during home deliveries or during the first postnatal care visit. Serosurveys conducted in priority countries have been valuable for gauging the progress and next steps for strengthening immunization programmes. The value and efficiency of the verification process is noted, and the TAG is encouraged by the number of countries that have embarked on or completed the process since its last meeting. In 2011, the TAG recommended to set a target year for the less than 1% prevalence goal. In January 2012, the Region’s ERP recommended 2017 as the target year for that goal. Member States endorsed the 2017 proposal. Recommendations (1) The TAG endorsed the Region’s Hepatitis B ERP proposal to set 2017 as the target year to achieve the goal of reducing childhood hepatitis B prevalence to less than 1%. The TAG encouraged Member States to communicate their position on the target year in preparation for the 2013 session of the WHO Regional Committee for the Western Pacific. (2) Increased birth dose coverage will be needed in some countries to reach the less than 1% prevalence goal. The TAG agreed with the conclusions of the 2012 birth dose consultation and encourages priority countries to implement actions identified, especially in: a. ensuring at least 90% birth dose coverage among facility-delivered births;
b. coordinating EPI and MCH activities to train and equip staff to give birth dose vaccinations during home deliveries and during first postnatal care visits, especially when EPI and MCH are different organizational units; and c. exploring special efforts to reach home births, including outreach vaccinations and using vaccines in a controlled temperature chain. (3) The TAG encouraged specific activities to take place in the next 12 months, including seroprevalence surveys to document the impact of vaccination programmes and the verification of achievement of prevalence targets: a. The following 10 Pacific island countries and areas to conduct seroprevalence surveys to document impact of their vaccination programmes: French Polynesia, Guam, Marshall Islands, Federated States of Micronesia, Nauru, New Caledonia, Niue, Tokelau, Tuvalu, and Wallis and Futuna.
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b. The following four countries to proceed with verification: American Samoa, Brunei Darussalam, Cook Islands and Fiji. c. The ERP to confirm if the following four countries should proceed with verification: Japan, the Commonwealth of Northern Mariana Islands, Palau and Singapore. (4) All countries should ensure vaccination of health-care workers with occupational exposure to hepatitis B virus; the WHO Regional Office for the Western Pacific should monitor and support implementation as per the 2009 TAG recommendation and report status back to the 2013 TAG. (5) The TAG requested that ERP, in collaboration with the Strategic Advisory Group of Experts (SAGE), review issues related to implementation of hepatitis B control in the Western Pacific Region such as using hepatitis B immune globulin (HBIG) for infants born of mothers with known chronic hepatitis B virus infection, using vaccine in a controlled temperature chain, spacing the birth dose and the first dose of hepatitis Bcontaining combination vaccine, developing methods for estimating coverage needed to achieve the less than 1% prevalence goal, providing guidance on improving the understanding of contraindications to birth dose vaccination in line with the 2009 WHO position paper on hepatitis B vaccine, and providing guidance on the types of rapid tests that are acceptable. 3.3 Maintaining poliomyelitis-free status
Conclusions The TAG and the Regional Certification Commission (RCC) have continuously highlighted the risk of the return of poliomyelitis to the Region as long as global eradication has not been achieved, no matter how long a country has been free of poliomyelitis. While the morbidity and mortality caused by the poliomyelitis outbreak in China following wild poliovirus importation are unfortunate, the TAG was highly impressed by the rigorous response the Government of China has mounted and considers it a model for other countries facing an importation. With all key milestones met in a timely fashion, the TAG is optimistic that the RCC will be able to reaffirm China’s and the Region’s poliomyelitis-free certified status later in the year. The WHO poliomyelitis regional reference laboratory at the Chinese Center for Disease Control and Prevention provided timely and reliable laboratory confirmation, including sequencing results during the wild poliovirus outbreak in 2011. Excellent collaboration among provincial laboratories in China, WHO, the United States Centers for Disease Control and Prevention, and the National Institute of Health, Pakistan, allowed the immediate detection of wild poliomyelitis cases and the identification of the source of importation. The TAG noted that sharing of China’s experience in achieving and sustaining poliomyelitis eradication is of benefit to the rest of the world and applauds the Government’s efforts to participate in the Stop Transmission of Polio (STOP) programme, including the current assignment of 10 staff members to Pakistan. Considering global eradication as the ultimate protection for the Region to stay poliomyelitis-free, the TAG welcomed the World Health Assembly resolution declaring the completion of poliomyelitis eradication a programmatic emergency for global public health. Every Member State has to fully recognize the responsibilities that come with it and act
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accordingly. Failure to eradicate poliomyelitis would present a major failure for global public health. The TAG acknowledged the poliomyelitis risk assessment work conducted at various levels and in coordination with neighbouring regions. While the results help guide targeted risk mitigation activities, too many gaps in immunization coverage and surveillance remain in several countries and need to be addressed as a matter of priority so that certification quality standards will be achieved and maintained. The TAG commended the identification of VDPVs indicating good levels of AFP surveillance and laboratory performance but is concerned about the gaps in immunization coverage that their emergence signals. These community situations could also easily support spread of imported wild poliovirus and major poliomyelitis outbreaks. Recommendations (1) The TAG strongly encouraged the Ministry of Health, China, to summarize for publication the epidemiology of the 2011 poliomyelitis outbreak and disseminate in detail the implementation response activities in line with the national preparedness plan, with particular focus on lessons learnt on political commitment, accountability, intersectoral coordination, support mechanisms and social mobilization. (2) The TAG urged all countries and poliomyelitis partners in the Western Pacific Region to strongly support full implementation of the 2012 World Health Assembly resolution. Future control of poliomyelitis outbreaks following importation will become increasingly complex due to the changing epidemiology over time; adolescents and adults are also likely to be affected and there will be increased disease severity in adults with higher fatality rates. Outbreaks due to gaps in population immunity affecting a wider range of age groups will be more difficult to control and have higher resource requirements. In this context the polio surveillance system should have heightened awareness of the potential for poliomyelitis to occur in people older than 15 years of age. (3) The TAG strongly encouraged Member States to conduct regular subnational risk assessments and take additional measures to reduce the risk of new outbreaks caused by the international spread of wild polioviruses or the emergence of cVDPV, as required. These measures include supplementary and routine immunization activities to close gaps in population immunity, very high-quality surveillance, and the consideration of the vaccination of travellers to and from poliomyelitis-affected areas. (4) The TAG highlighted the need for the following elements to be included in their regular risk assessments, including at subnational levels where appropriate: a. plan for supplementary immunization that integrates OPV in other SIAs (e.g. for measles) and health interventions in countries concerned; b. catch-up immunizations for populations for which insufficient poliomyelitis vaccine coverage has been identified; c. successful approaches for reliable identification of high-risk communities, as well as failures and achievements, should be widely shared; d. plans to address surveillance challenges are urgently required, which may include performance desk reviews and in-country field reviews as appropriate; and
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e.
ensure that updated importation preparedness plans remain in place.
(5) The WHO Regional Office for the Western Pacific should closely monitor the introduction of the new algorithm among provincial laboratories in China and the implementation of real-time PCR for ITD and VDPV screening for China and countries that participated in the second hands-on training for the real time PCR and VDPV screening planned in December 2012 to ensure sensitivity and timeliness of poliovirus identification in 2013. a. The Chinese Center for Disease Control and Prevention should closely follow up with the implementation of the new virus isolation algorithm and realtime PCR for intratypic differentiation of polioviruses and VDPV screening among provincial laboratories in China. (6) The TAG welcomed the continued cross-regional collaboration the WHO Regional Office for the Western Pacific is coordinating and encouraged WHO and relevant poliomyelitis partners to prioritize plans for conducting cross-border meetings for countries concerned, including organizing an event to follow up on the 2011 international poliomyelitis workshop among poliomyelitis-free countries and regions that occurred in Urumqi, China, and providing support for synchronized SIAs among bordering countries, where appropriate. 3.4 Maternal and neonatal tetanus elimination
Conclusions The TAG commended the continued progress towards and commitment for maternal and neonatal tetanus (MNT) elimination in the countries concerned (Cambodia, China, the Lao People’s Democratic Republic, Papua New Guinea and the Philippines) but also notes the remaining challenges of incomplete surveillance, improving routine immunization in hard-to-reach communities, and counteracting controversies about tetanus toxoid. As an indication for its continued importance and priority, the TAG noted that the GVAP has established global MNT elimination by 2015 as one of its overarching goals. Having made significant progress in reaching MNT elimination, the Western Pacific Region and its countries are leading these efforts. Recommendations The TAG reminded national programmes and partners that MNT elimination strategies are a means of reaching women that are usually unreached and thus offers opportunities for comprehensive health service delivery (EPI, MCH and basic newborn care) to contribute to reducing maternal and neonatal mortality. Special efforts should be made to promote the benefits of immunization to counteract the tetanus toxoid controversy, which is a strong example of the potential damage anti-vaccination groups can cause. 3.5 Strengthening national immunization programmes
Conclusions The WHO Regional Office for the Western Pacific and Member States in the Western Pacific Region have been actively implementing key elements of the GIVS since 2006 for
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strengthening national immunization programmes (NIPs) and many of these elements are consistent with the vision and the strategies of the new GVAP. The impact of GIVS, however, still varies in the Region, between and within countries, leaving disparities between different geographic areas and population groups. Several priority countries in the Western Pacific Region are still facing substantial challenges in achieving GIVS coverage targets, which in turn have been adapted as GVAP coverage targets, i.e. more than 90% at national level and more than 80% in every district. Recommendations In order to further strengthen NIPs as a critical foundation for VPD control in the Western Pacific Region, achieve the regional disease control goals and contribute to reaching the MDGs, Member States, WHO and immunization partners in the Region, including civil society organizations, should continue to closely collaborate in implementing strategies and activities as outlined in the GIVS and now in the GVAP and in adding new strategies and activities as needed. This should also include logistics and cold chain and vaccine management. Member States should: (1) Review their national immunization programmes from the perspective of the GVAP’s vision and strategies with a view towards the NIP’s organizational position within the Ministry of Health and coordination between central and the local governments, including current relevant national policies and future plans related to strategies and activities. (2) Ensure that a national action plan for further strengthening of the national immunization programme is in place according to the country’s specific situation, drawing from GVAP principles. WHO Regional Office for the Western Pacific should: (1) Develop a draft Western Pacific Regional Vaccine Action Plan 2013–2015 to support Member States and ensure that national action plans are in place for implementation of the GVAP at the country level. The Regional Office should also ensure that key GIVS strategies and activities being carried out by WHO and Member States in the Western Pacific Region are incorporated into these regional and national plans, as well as any additional relevant strategies and activities as outlined in the GVAP. (2) 3.6 Submit the draft plan to the next TAG meeting for its review and endorsement.
National regulatory authorities (NRAs), vaccine safety, management and security
Conclusions The TAG noted that NRA systems and functions in many of the Region's countries and areas can be strengthened. The TAG appreciated the efforts of the WHO Regional Office and Member States in the new initiative to formulate a Regional Alliance to coordinate and support countries with non-functional NRAs. Due to lack of required expertise needed for AEFI causality assessments in most Pacific island countries and areas, there is a need to establish a subregional AEFI expert committee to support decisions and conclusions of reported AEFI cases.
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The TAG noted the frequent vaccine shortages that have taken place in the Region and takes seriously this missed opportunity to protect children from vaccine-preventable diseases. The contributing factors are many but most importantly countries need to improve their ability to conduct vaccine forecasting, better manage stocks and prevent shortages of vaccines that disrupt routine immunization programmes. The TAG considered thiomersal to be a safe and necessary component of vaccines. Recommendations (1) The TAG supported the proposal for formulating a Regional Alliance for NRAs in the Western Pacific Region as a platform to strengthen NRA systems and functions, including national control laboratory functions, in countries that lack functioning NRAs. The TAG asked the WHO Secretariat to support and conduct necessary activities to implement this Regional Alliance in coordination with countries and other partners. The Secretariat should consider this proposal as an agenda item in the 2013 session of the WHO Regional Committee for the Western Pacific. (2) The TAG endorsed the proposal for establishing a subregional AEFI causality assessment committee for Pacific island countries and areas. The WHO Secretariat should support and conduct necessary activities to facilitate this establishment. The Secretariat should consider this proposal as an agenda item at the 2013 session of the WHO Regional Committee for the Western Pacific and at the Pacific Island Countries Health Ministers' meeting in 2013. (3) Countries experiencing problems with their vaccine stock management and monitoring systems should devote attention to strengthening their capacities in order to prevent disruptions in their vaccine supply. (4) The TAG urged countries to develop their positions in preparation for the upcoming INC meeting in January 2013 in recognition of the ongoing need for thiomersal use in vaccines to continue to saving lives and ensuring the viability of immunization programmes and cost-effectiveness of vaccines. 3.7 New vaccines
Conclusions As the mortality due to traditional vaccine-preventable diseases has been substantially reduced, the TAG noted that over 90% of vaccine-preventable deaths among children under five years old in the Western Pacific Region are now due to pneumococcus, Hib and rotavirus. Japanese encephalitis continues to cause substantial morbidity and mortality among children, and many countries in the Region have a high burden of cervical cancer. Despite significant progress, most low- and middle-income countries in the Western Pacific Region have not yet been able to introduce new or underutilized vaccines other than Hib. Key challenges include obtaining the disease burden evidence needed to determine the public health priority of the vaccine, conducting the economic analyses required to assess the cost-effectiveness and longterm sustainability of vaccine introduction, and developing systems to reach age groups beyond the traditional EPI target groups (e.g., adolescents for HPV vaccine). Several Member States are gaining experience successfully addressing these challenges, and these experiences can be useful for other Member States in working towards introduction of priority new vaccines.
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Surveillance provides important inputs to disease burden evidence and is critical to measuring the impact of vaccine introduction. The WHO-coordinated rotavirus surveillance network is now relatively stable and producing useful data on disease burden and strain variation. The WHO-coordinated IB-VPD surveillance network continues to face challenges, and substantial improvements in enrolment and testing are needed to ensure that data are useful to programme decision-making. The TAG noted the significant progress made in transitioning rotavirus and IB-VPD surveillance to a Ministry of Health ownership during the past year. Recommendations (1) The TAG recommended countries to continue obtaining the evidence necessary for policy decisions on key new vaccines, and to raise the priority of introducing new vaccines as cost-effective strategies to decrease morbidity and mortality caused by vaccinepreventable diseases. (2) The TAG requested WHO to provide technical support to selected countries as needed to develop burden of disease evidence including high-quality surveillance data; to conduct economic analyses, post-introduction evaluations and impact assessments; and to collect and use other data to support policy decisions on new vaccine introductions and scale ups. (3) The TAG reaffirmed the importance of Ministry of Health ownership in enhancing the value and relevance of rotavirus and IB-VPD surveillance data to programme decisionmaking, and urges countries to take steps to improve the quality of IB-VPD surveillance and to continue to strengthen Ministry of Health leadership in this area.
ANNEX 1 TWENTY-FIRST MEETING OF THE TECHNICAL ADVISORY GROUP ON IMMUNIZATION AND VACCINE-PREVENTABLE DISEASES IN THE WESTERN PACIFIC REGION Manila, 21–23 August 2012 TIMETABLE Time 08:00–08:30 08:30–09:00 Tuesday, 21 August 2012 REGISTRATION 1. Opening • Opening speech • Self–introduction • Election of officers: Chairperson, Vice–Chairperson and Rapporteur • Administrative announcements • Group photo 09:00–09:20 2. Introduction and objectives of the 2012 Technical Advisory Group (TAG) Meeting 3. Measles elimination and rubella control 09:20–09:50 3.1 Measles elimination status • Progress report: Achievements and Challenges • Discussion 09:30–10:00 08:00–08:30 Time Wednesday, 22 August 2012 4. Hepatitis B control 4.1 Regional update • Presentation on status of 2012 control milestone • Discussion 4.2 Cambodia • Presentation on successful strategies and targeted activities • Discussion 4.3 The Philippines • Presentation on opportunities to increase facility–based birth dose coverage • Discussion 4.4 Lao People's Democratic Republic • Presentation on responding to significant challenges • Discussion Time
English only
Thursday, 23 August 2012 9. National Regulatory Authorities (NRA), vaccine safety, management and security
08:30–08:50
9.1 Regional priorities in NRA systems and vaccine safety 9.2 Vaccine stock management and importance of monitoring vaccine stock–outs in countries 9.3 Update on thiomersal controls and impact on vaccines Discussion 10. New vaccines
08:30–09:00
08:50–09:05
09:05–09:20
09:00–09:30
09:20–09:40
09:40–10:05
10.1 Regional update: progress in new vaccine introduction, key challenges, tools and resources for support Discussion COFFEE BREAK 10.2 Country experiences • Papua New Guinea – Strengthening surveillance: Use of Binax to increase detection of pneumococcal meningitis • Viet Nam – Evidence for vaccine introduction: Cost– effectiveness analysis for rubella and rotavirus vaccines • Discussion • Malaysia – Vaccination for all ages: Solving the challenges of human papillomavirus (HPV) vaccine introduction • Philippines – Planning for financing and sustainability of new vaccines: Perspective from a middle–income country • Discussion
10:05–10:15 09:50–10:10 10:10–12:00 COFFEE BREAK 3.2 Interrupting measles virus transmission • Country presentations and highlights o China o Philippines o Malaysia o New Zealand o Singapore • Discussion 10:00–10:30 10:30–11:00 COFFEE BREAK 4.5 Hepatitis B Expert Resource Panel • Presentation on setting target year for 1% goal • Discussion 5. Maintaining poliomyelitis–free status 11:00–11:30 5.1 Status of global of poliomyelitis eradication — key aspects • Presentation • Discussion 5.2 China: 2011 poliomyelitis outbreak • Presentation • Discussion 10:15–10:45
10:45–11:00
11:00–11:15
11:15–11:30 11:30–11:45
11:30–12:00
11:45–12:00
12:00–12:30
12:00–13:00 13:00–15:00
LUNCH BREAK 3.3 Key steps towards achieving, sustaining and verifying measles elimination • Global development on measles elimination • Close immunity gap: Reaching Every Community • Gap analysis: surveillance performance • Performance of the WHO Measles and Rubella Laboratory Network • Highlights of Measles Elimination Field Guide • Discussion
12:00–13:00 13:00–13:30
LUNCH BREAK 5.3 Viet Nam: Vaccine derived poliovirus (VDPV) emergence • Presentation • Discussion 5.4 Regional Certification Commission: main conclusions and recommendations (November 2011) • Regional aspects of surveillance, immunization and outbreak preparedness • China poliomyelitis outbreak response • Discussion 5.5 Regional poliomyelitis laboratory network • Key developments to improve quality and timeliness of poliovirus detection • Discussion 5.6 Maintaining poliomyelitis-free status • Understanding the threat, assessing the vulnerability and mitigating the risks • Discussion 6. Maternal and neonatal tetanus elimination (MNTE) update: main regional and global aspects COFFEE BREAK 7. Introduction to Global Vaccine Action Plan 8. Strengthening national immunization programmes regional update and current priorities • Discussion on both agenda items
12:30–13:30 13:30–15:00
LUNCH BREAK 11. Partnership – Interagency Coordinating Committee (ICC) Meeting 12. Drafting conclusions and recommendations
13:30–13:45
13:45–14:00
14:00–14:30
14:30–15:00
15:00–15:20 15:20–16:00 • • 16:00–16:45
COFFEE BREAK Verification of measles elimination in the Western Pacific Region Discussion
15:00–15:30 15:30–16:00 16:00–16:30
15:00–15:30 15:30–16:30 16:30–17:00
COFFEE BREAK 13. Review draft conclusions and recommendations 14. Closing
3.4 Beyond measles elimination • Synergy of measles elimination and rubella control • Measles and equity in immunization • Discussion 3.5 Regional actions on measles elimination
16:30–17:00
16:45–17:00 18:00
REGIONAL DIRECTOR'S RECEPTION
ANNEX 2 WORLD HEALTH ORGANISATION MONDIALE DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL TWENTY-FIRST MEETING OF THE TECHNICAL ADVISORY GROUP (TAG) ON IMMUNIZATION AND VACCINE-PREVENTABLE DISEASES IN THE WESTERN PACIFIC REGION Manila, Philippines 21–23 August 2012 ENGLISH ONLY
TECHNICAL ADVISORY GROUP MEMBERS, EPI NATIONAL MANAGERS/SURVEILLANCE OFFICERS, MINISTRY/DEPARTMENT OF HEALTH STAFF, TEMPORARY ADVISERS, OBSERVERS/REPRESENTATIVES AND SECRETARIAT 1. TECHNICAL ADVISORY GROUP MEMBERS Dr Robert Hall, Senior Lecturer, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Commercial Road, Melbourne, Victoria 3004, Australia. Telephone: 61 3 9093 0452 • Facsimile: 61 3 9903 0556 • E-mail: robert.hall@monash.edu Dr Hiroshi Yoshikura, Director General Emeritus, National Institute of Infectious Diseases, Department of Food Safety, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Japan. Telephone: 81 3 3595 2142 • Facsimile: 81 3 3503 7965 • E-mail: yoshikura-hiroshi@mhlw.go.jp Dr Stephen L. Cochi, Senior Advisor, Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, NE – Mailstop A-04 Atlanta, Georgia 30333, United States of America. Telephone: 1 404 639 8723 • Facsimile: 1 404 639 8573 • E-mail: scochi@cdc.gov ; slc1@cdc.gov Dr Ichiro Kurane1, Deputy Director-General, National Institute of Infectious Diseases 1-23-1 Toyama Shinjuku-ku, Tokyo 162-8640, Japan. Telephone: 81 3 5285 1111 (ext. 2003) • Facsimile: 81 3 5285 1356 • E-mail: kurane@nih.go.jp Dr Jong-Koo Lee, Vice President, Policy and Development, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea. Telephone: 822 2072 2215 • Facsimile: 822 2072 0318 • E-mail: docmohw@snu.ac.kr
1
Dr Ichiro Kurane will represent Dr Tokuaki Shobayashi who is unable to attend the meeting.
Dr Cui Fuqiang2, Professor and Deputy Director, National Immunization Program Chinese Center for Disease Control and Prevention, Manager, GAVI/MOH Project Office Nanwei Road 27, Xuanwu District, Beijing, China. Telephone: (8610) 6302 2040 • Facsimile: (8610) 6302 2040 • E-mail: Cuifuq@126.com Professor Helen Oh May Lin, Senior Consultant, Department of Medicine, Changi General Hospital, 2, Simei Street 3, Singapore 529889, Republic of Singapore. Telephone: 65 6850 3736 • Facsimile: 65 6781 6202 • E-mail: helen_oh@cgh.com.sg 2. TEMPORARY ADVISERS Dr Anthony Adams, Chairman, Regional Commission for the Certification of Poliomyelitis Eradication, No. 6/2 Chapman Crescent, Avoca Beach, New South Wales 2251, Australia. Telephone: 61 2 4382 6516 • E-mail: aarr@netspeed.com.au Professor David Durrheim, Director of Health Protection and Health Medicine Hunter New England Population Health, New Lambton, New South Wales 2305 Australia. Telephone: 61 2 6926 6395 • Facsimile: 61 2 4924 6215 • E-mail: david.durrheim@newcastle.edu.au Dr Takaji Wakita, Director, Department of Virology II, National Institute of Infectious Diseases, 1-23-1, Toyama, Shinjuku, Tokyo 162-8640, Japan. Telephone: 81 3 5285 1111 ext. 2500 • Facsimile: 81 3 5285 1161 • E-mail: wakita@nih.go.jp 3. PARTICIPANTS
AUSTRALIA
Ms Julianne Quaine, Assistant Secretary, Health Protection and Programs Branch, Department of Health and Ageing, G.P.O. Box 9848, Canberra, A.C.T. 2600. Telephone: 61 2 6289 7705 • Facsimile: 61 2 6289 3677 • E-mail: julianne.quaine@health.gov.au Dr Yung Chee Tee, Senior Medical Officer, Department of Health Services, Ministry of Health, Brunei Darussalam, Jalan Menteri Besar, Bandar Seri Begawan. Telephone: 673 8786111 • Facsimile: 673 2381165 • E-mail: cheetee@yahoo.com Professor Sann Chan Soeung, Deputy Director-General for Health and Manager of the National Immunization Program, Ministry of Health, Kingdom of Cambodia, 151-153 Kampuchea Krom Avenue, Phnom Penh. Telephone: 855 12 933344 • Facsimile: 855 23 426167 • E-mail: workmoh@gmail.com
BRUNEI DARUSSALAM
CAMBODIA
2
Dr Cui Fuqiang will represent Dr Lei Zhenglong who is unable to attend the meeting.
CAMBODIA
Dr Chheng Morn, Deputy Manager, National Immunization Program National Maternal and Child Health Center, Ministry of Health, Kingdom of Cambodia, 151-153 Kampuchea Krom Street, Phnom Penh. Telephone: 855 12 913 794 • Facsimile: 855 23 426 257 • E-mail: chheng_morn@yahoo.com Mr Lor Pharith, National Immunization Program Staff, Immunization Officer, Ministry of Health, Kingdom of Cambodia No. 6A, Prek leap, Khan Reussey keo, Phnom Penh. Telephone: 855 17 978080 • Facsimile: 855 23 426257 • E-mail: pharith.lor@gmail.com
CHINA
Dr Li Quanle, Director, Bureau of Disease Prevention and Control, Ministry of Health, No. 1 Xizhimenwai Nanlu, Xicheng District, Beijing 100044 Telephone: 8610 6879 2958 • Facsimile: 8610 6879 2357 • E-mail: li_quanle@163.com Dr Li Li, Professor and Director of National Immunization Programme Chinese Center for Disease Control and Prevention, Nanwei Road 27, Xicheng District, Beijing, Telephone: 8610 6303 8203 • Facsimile: 8610 6303 8203 • E-mail: llsdin@163.com Dr Xu Aiqiang, Deputy Director, Shandong Center for Disease Prevention and Control, 16992 Jingshi Road, Jinan, Shandong 250014. Telephone: 86 531 82679606 • Facsimile: 86 531 82679620 • E-mail: aqxuepi@163.com Dr Xu Wenbo, Chief, National Laboratory for Measles Acting Chief, National Laboratory for Poliomyelitis Institute of Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention 155 Changbai Road, Changping District, Beijing 102206. Telephone: 8610 5890 0187 • Facsimile: 8610 5890 0187 • E-mail: wenbo_xu1@yahoo.com.cn
HONG KONG (CHINA)
Dr Vivian Chan, Senior Medical Officer (Surveillance Section) Vaccine Preventable Diseases Office, Centre for Health Protection Department of Health, Room 452, 147C Argyle Street, Kowloon. Telephone: 852 21252230 • Facsimile: 852 27110927 • E-mail: smo_ss3@dh.gov.hk Dr Koji Nabae, Deputy Director, Tuberculosis and Infectious Diseases Control Division, Health Service Bureau, Ministry of Health, Labour and Welfare, 1-2-2, Kasumigaseki, Chiyoda-ku, Tokyo 100-8916. Telephone: 81 3 3595 2257 • Facsimile: 81 3 3581 6251 • E-mail: nabae-koji@mhlw.go.jp Dr Young-Joon Park, Medical Officer, Division of VPD control and NIP Korea Centers for Disease Control and Prevention, 643, Yeonje-ri, Gangoe-myon, Cheongwon-gun, Chungcheongbuk-do, 363-951. Telephone: 82 43 719 7354 • Facsimile: 82 43 719 7379 • E-mail: pahmun@hanmail.net
JAPAN
KOREA, REPUBLIC OF
LAO PEOPLE'S DEMOCRATIC REPUBLIC
Dr Inlavanh Keobounphanh, Vice Minister, Ministry of Public Health Simuang Road, Vientiane. Telephone: 856 21 253 017 • Facsimile: 856 21 214003 • E-mail: inlavan.k@moh.gov.la ; vmsecretary@hotmail.com Dr Anonh Xeuatvongsa, Manager of the National Immunization Program Ministry of Health, Simeuang Road, Vientiane. Telephone: 856 21 312352 • Facsimile: 856 21 312120 • E-mail: anonhxeuat@yahoo.com Dr Khampiou Syhakhang, Manager of the National Immunization Program Ministry of Health, Simeuang Road, Vientiane. Telephone: 856 21 312352 • Facsimile: 856 21 312120 • E-mail: s_khamp@yahoo.com
MALAYSIA
Dr Rohani Binti Jahis, Senior Principal Assistant Director, Disease Control Division, Ministry of Health Malaysia, Level 4, Block E10, Complex E Federal Government Administrative Centre, 62590, Putrajaya Telephone: 603 8883 4411 • Facsimile: 603 8889 1018 • E-mail: rohbj@moh.gov.my Dr Tugsdelger Sovd, Director, Public Health Policy Coordination Department Ministry of Health, Olympis St 2, Government Building 8, Ulaanbaatar 210648. Telephone: 946 51 262990 • E-mail: tugsdelgersovd@moh.mn Dr Tsend Navaansodov, Adviser, Department of Infectious Diseases Surveillance, National Center for Communicable Diseases Str. Nam Yan Ju, Bayan zur District, Ulaanbaatar. Telephone: 976 8885 8929 • Facsimile: 976 11 454921 • E-mail: tsend@magicnet.mn
MONGOLIA
NEW ZEALAND
Mrs Kim Meredith Albrecht, Acting National Programme Manager, Immunization, Sector Capability and Implementation, Ministry of Health P.O. Box 5013, Wellington 6145. Telephone: 64 4 816 2435 • Facsimile: 64 4 816 2091 • Mobile: 64 21 245 9404 • E-mail: kim_albrecht@moh.govt.nz Dr William Lagani, Principal Manager, Family Health Services National Department of Health, P.O. Box 807, National Capital District Waigani. Telephone: 675 301 3707 • Facsimile: 675 325 1175 • E-mail: william_lagani@health.gov.pg Dr Maria Joyce U. Ducusin, Medical Specialist IV, National Center for Disease Prevention and Control, Department of Health, San Lazaro Compound, Rizal, Avenue, Sta. Cruz, Manila. Telephone: 63 2 732 9956 • Facsimile: 63 2 711 7846 • E-mail: juducusin@yahoo.com Dr Honorata L. Catibog, Director III, National Center for Disease Prevention and Control, Department of Health, San Lazaro Compound, Rizal, Avenue, Sta. Cruz, Manila. Telephone: 632 732 9956 • Facsimile: 632 711 7846 • E-mail: honoratacatibog@yahoo.com
PAPUA NEW GUINEA
PHILIPPINES
PHILIPPINES
Ms Dulce C. Elfa, Nurse IV, National Epidemiology Center Building No. 19, San Lazaro Compound, Sta. Cruz, Manila Facsimile: 632 7329057 • Mobile: 63 9195703263 • E-mail: elfad721@yahoo.com Mr Yuske Kita, Senior Public Health Officer (Policy and Control) Ministry of Health Singapore, College of Medicine Building 16 College Road, Singapore 169854. Telephone: 65 6325 8600 • Facsimile: 65 6325 1168 • Mobile: 65 9765 1780 • E-mail: yuske_kita@moh.gov.sg Associate Professor Nguyen Tran Hien, Director, National Institute of Hygiene and Epidemiology, No. 1, Yersin Street, Hanoi. Telephone: 84 4 821 3241 • Facsimile: 84 4 821 0853 • E-mail: ngtrhien@yahoo.com Dr Nguyen Minh Hang, Chief, Division of Vaccines, Biologicals and Biosafety, General Department of Preventive Medicine, Ministry of Health 135 Nui Truc, Ba Dinh, Hanoi. Telephone: 84 4 3846 2364 • Facsimile: 84 4 3736 7379 • E-mail: haminhvn@yahoo.com
SINGAPORE
VIET NAM
4. OBSERVERS/REPRESENTATIVES
ASIAN LIVER CENTER (ALC)
Dr Samuel So, Director, Asian Liver Center, Stanford, California 94305, United States of America. Facsimile: 1 650 566 8863 • E-mail: samso@stanford.edu; samso1@gmail.com Ms Magdalena Robert, Director, Decade of Vaccines Collaboration, Barcelona Institute for Global Health, Hospital Clinic – Universitat de Barcelona, Carrer Rosselló 132, E-08036 Barcelona, Spain. Telephone: 34 93 227 1846 • Mobile: 34 648 896 320 • E-mail: magda.robert@isglobal.org Ms Priya Mannava, Centre for International Health Burnet Institute, GPO Box 2284, Melbourne, Australia 3001. Facsimile: 61 3 8506 2316 • E-mail: priyam@burnet.edu.au Elder Steven Hadlock, LDS Charities Welfare Services 13 Temple Drive, White Plains Avenue, Greenmeadows Quezon City 1110, Philippines. Telephone: 63 2 683 7214 • Facsimile: 63 2 683 7268 • E-mail: steven.hadlock@ldschurch.org Elder Roger Hardick, LDS Charities Welfare Services 13 Temple Drive, White Plains Avenue, Greenmeadows Quezon City 1110, Philippines. Telephone: 63 2 683 7214 • Facsimile: 63 2 683 7268 • Email: roger.hardick@ldschurch.org
BARCELONA INSTITUTE FOR GLOBAL HEALTH
BURNET INSTITUTE
CHURCH OF THE LATTER DAY SAINTS
CHURCH OF THE LATTER DAY SAINTS
Mr Benson Misalucha, LDS Charities Welfare Services 13 Temple Drive, White Plains Avenue, Greenmeadows Quezon City 1110, Philippines. Telephone: 63 2 683 7214 • Facsimile: 63 2 683 7268 • E-mail: benson.misalucha@ldschurch.org Ms Luzviminda C. Garcia, Supervising Health Program Officer, National Center for Disease Prevention and Control, Department of Health, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila, Philippines. Facsimile: 632 753 1937 • Mobile: 63 917 5856610 • E-mail: luzcgarcia@ymail.com Ms Erlyn Hampac, EPI Nurse Coordinator, Center for Health Development for ARMM. Mobile: 63 905 8442606 • E-mail: erlynhampac@yahoo.com Ms Asuncion Ilogon, EPI Nurse Coordinator, Center for Health Development for Northern Mindanao. Mobile: 63 906 8109405 • E-mail: asuncion_ilogon2000@yahoo.com Dr Vito G. Roque Jr., Medical Specialist IV, First Floor, Building 9, National Epidemiology Center, Department of Health, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila, Philippines. Telephone: 632 251 4203 • Facsimile: 632 743 6076 • E-mail: vitoroquejr@yahoo.com ; vitoroquejr@gmail.com
DEPARTMENT OF HEALTH, PHILIPPINES
GAVI ALLIANCE
Dr Raj Kumar, Senior Programme Officer, Programme Delivery Team, GAVI Alliance, GAVI Alliance Secretariat, 2 chemin des Mines CH-1202 Geneva, Switzerland. Telephone: 41 22 909 6500 • Facsimile: 41 22 909 6555 • E-mail: rajkumar@gavialliance.org Mr Roberto Taboada, President and Managing Director, Glaxo Smith Kline Philippines, 2266 Chino Roces Avenue, Makati, Philippines. Telephone: 632 8920 761 Dr Batmunkh Nyambat, Research Scientist, International Vaccine Institute SNU Research Park, San 4-8, Nakseongdae-dong, Seoul 151-919 Republic of Korea. Facsimile: 822 872 2803 • E-mail: bnyam@ivi.int Ms Saeda Makimoto, Director, Health Division 3, Japan International Cooperation Agency, Nibancho Center Building 5-25, Niban-cho, Chiyoda-ku, Tokyo 102-8012, Japan. Telephone: 81 3 5226 8356 • Facsimile: 81 3 5226 6341 • E-mail: makimoto.saeda@jica.go.jp Dr Nobuhiko Okabe, Director General, Kawasaki City Institute for Public Health , 5-13-10 Oshima Kawasaki-ku Kawasaki-city, Kanagawa 210-0834 Japan. Telephone: 81 44 244 4985 • Facsimile: 81 44 246 2602 • E-mail: okabe-n@city.kawasaki.jp ; okabe.nobu46@gmail.com
GLAXO SMITH KLINE PHILIPPINES
INTERNATIONAL VACCINE INSTITUTE (IVI) JAPAN INTERNATIONAL COOPERATION AGENCY (JICA) KAWASAKI CITY INSTITUTE FOR PUBLIC HEALTH
KOREA CENTERS FOR DISEASE CONTROL AND PREVENTION (KCDC) MINISTRY OF HEALTH, CAMBODIA
Mr Young June Choe, Medical Officer/Epidemic Intelligence Service Officer, Division of VPD Control and NIP, Korea Centers for Disease Control and Prevention, Osongsaengmyeong 2-ro, Osong-eup Cheongwon-gun, Chungcheongbuk-do, Republic of Korea. Telephone: 82 10 8999 0212 • Facsimile: 82 43 719 7379 • E-mail: choeyj@yahoo.com Mrs Ros Phala, MNTE Surveillance Officer, National Immunization Programme, Ministry of Health, No. 37 E2 Street, 126, Sangkat Psar Thmei I Khan Daunh Penh, Phnom Penh, Cambodia. Telephone: 855 12 868528 • Facsimile: 855 23 426257 • E-mail: rosphala@yahoo.com Mrs Ngeth Savary, Measles/Rubella Surveillance Officer National Immunization Programme, Ministry of Health No. 37 E2 Street, 126, Sangkat Psar Thmei I, Khan Daunh Penh Phnom Penh, Cambodia. Telephone: 855 12 679 896 • E-mail: ngethsavry@yahoo.com Dr Chansay Pathammavong, Deputy EPI Manager, National Immunization Programme (NIP), Ministry of Health, Simouang Road, Vientiane, Lao People’s Democratic Republic. Telephone: 86521 312 352 • Facsimile: 85621 312120 • E-mail: chansay_epi@yahoo.com
MINISTRY OF HEALTH, CAMBODIA
MINISTRY OF HEALTH, LAO PEOPLE'S DEMOCRATIC REPUBLIC
Dr Anoma Singhavong, Ministry of Health, Simouang Road, Vientiane, Lao People’s Democratic Republic. Telephone: 856 21 214001 • Facsimile: 856 21 214003 • E-mail: vmsecretary@hotmail.com MERCK SHARP & DOHME (MSD) NATIONAL CENTER FOR GLOBAL HEALTH AND MEDICINE (formerly IMCJ) Dr Ernest Smith, Regional Director Medical Affairs Vaccines – Adult and Paediatrics, MSD Asia Pacific, Shanghai, China Dr Masahiko Hachiya, Expert Pediatrician, Head, Infectious Disease Control Group, Bureau of International Medical Cooperation National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. Telephone: 813 3202 7181 • Facsimile: 813 32057860 • E-mail: m-hachiya@it.ncgm.go.jp Mr Naofumi Hashimoto, Medical Technologist, Bureau of International Medical Cooperation, National Center for Global Health and Medicine 1-21-1, Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. Telephone: 813 3202 7181 • Facsimile: 813 3205 7860 • E-mail: n-hashimoto@it.ncgm.go.jp NATIONAL DEPARTMENT OF HEALTH, PNG Mr Gerard Sui, National EPI Manager-Designate, National Department of Health, P.O. Box 807, National Capital District, Waigani, Papua New Guinea. Telephone: 675 3013 701 • Facsimile: 675 323 9710
NATIONAL INSTITUTE OF INFECTIOUS DISEASE (NIID), JAPAN
Dr Makoto Takeda, Director, Department of Virology III National Institute of Infectious Diseases, 4-7-1 Gakuen, Musashi-murayama Tokyo 208-0011, Japan. Telephone: 81 42 848 7060 • Facsimile: 81 42 562 8941 • E-mail: mtakeda@nih.go.jp
Dr Kazunori Oishi, Director, Infectious Disease Surveillance Centre National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku Tokyo 162-8640, Japan. Telephone: 81 3 6380 3056 • E-mail: oishik@nih.go.jp NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY, HANOI Dr Nguyen Manh Hung, National EPI Staff, National Institute of Hygiene and Epidemiology, No. 1 Yersin Street, Hanoi, Viet Nam. Telephone: 844 381 23764 • Facsimile: 844 381 23782 • E-mail: hungnihe@gmail.com
Dr Dang Thi Thanh Huyen, National EPI Staff, National Institute of Hygiene and Epidemiology, No. 1 Yersin Street, Hanoi, Viet Nam. Telephone: 844 397 21334 • Facsimile: 844 381 23782 • E-mail: epi.huyen@gmail.com PROGRAM FOR APPROPRIATE TECHNOLOGY IN HEALTH (PATH) RESEARCH INSTITUTE FOR TROPICAL MEDICINE (RITM) ROTARY INTERNATIONAL DISTRICT 2650, JAPAN Dr Chham Samnang, Program Team Leader, PATH/CVP PO Box No. 1684, Phnom Pehn, Cambodia. Telephone: 855 23 215 005 • Facsimile: 855 23 222 330 • E-mail: csamnan@path.org
Dr Rosario Z. Capeding, Medical Specialist III, Research Institute for Tropical Medicine, Filinvest Corporate City Compound, Alabang, Muntinlupa City 1781, Philippines. Telephone: 632 7724916 • Facsimile: 632 9522637 • E-mail: lerosecap@yahoo.com.ph Mr Kingo Iwamoto, Vice Chair WCS Committee, Rotary International District 2650, International Service Committee, Governor’s Office Shin Kyoto Center Bldg. 520, Kyoto 600-8216, Japan. Telephone: 0742 41 2200; 090 3563 7774 • E-mail: kikyo@sirius.ocn.ne.jp Mr Atsushi Urashima, Member of WCS Committee Rotary International District 2650, International Service Committee, Governor’s Office Shin Kyoto Center Bldg. 520, Kyoto 600-8216, Japan. Telephone: 06 6748 6226; 909 2591 6666 • E-mail: atsushi-u@itsuki-s.jp Ms Noemi Matsuura, Member of WCS Committee, Rotary International District 2650, International Service Committee, Governor’s Office Shin Kyoto Center Bldg. 520, Kyoto 600-8216, Japan. Telephone: 080 1443 2522 • E-mail: noemicosme@mail.goo.ne.jp
ROTARY INTERNATIONAL DISTRICT 2650, JAPAN
Mr Nobuhiro Imanishi, Past Governor, Rotary International District 2650 International Service Committee, Governor’s Office, Shin Kyoto Center Bldg. 520, Kyoto 600-8216, Japan. Telephone: 075 211 4154 • E-mail: nobimani@imayo.jp Mrs Tomoko Imanishi, Rotary International District 2650 International Service Committee, Governor’s Office, Shin Kyoto Center Bldg. 520, Kyoto 600-8216, Japan. Telephone: 075 211 4154
UNITED NATIONS CHILDREN’S FUND, EAST ASIA AND PACIFIC REGIONAL OFFICE (UNICEF EAPRO) UNITED NATIONS CHILDREN'S FUND, PHILIPPINES
Dr Paulo Froes, Immunization Specialist, Child Survival and Health Section UNICEF East Asia and Pacific Regional Office, 19 Phra Atit Road Chanasongkram, Phra Nakorn, Bangkok 10200, Thailand. Telephone: 662 356 9499 • Facsimile: 662 280 3563 • E-mail: pfroes@unicef.org
Dr Mariella Castillo, Health Specialist, Health and Nutrition UNICEF Manila, 31st Floor, Yuchengco Tower, Rizal Commercial Banking Corporation (RCBC) Plaza, Ayala Avenue, Makati City, Philippines. Telephone: 63 2 9010151 • Facsimile: 63 2 7294525 • E-mail: mscastillo@unicef.org Dr Ataur Rahman, Immunization Specialist, Health and Nutrition Section UNICEF Vientiane, Lao People's Democratic Republic Telephone: 856 21 3152 0004 (ext. 108) • Facsimile: 856 20 5428 2357 • E-mail: atrahman@unicef.org Dr Maya van den Ent, Health Specialist (Measles and Health Emergencies) United Nations Children's Fund, 3 UN Plaza, New York 10017, United States of America. Telephone: 1 212 326 7229 • Facsimile: 1 212 824 6460 • Mobile: 1 917 250 6468 • E-mail: mvandenent@unicef.org Dr Andrea Gay, Executive Director of Children's Health Children's Health Programme, United Nations Foundation, Washington, D.C. 20036, United States of America. Telephone: 1 202 887 9040 • Facsimile: 1 202 887 9021 • E-mail: agay@unfoundation.org Dr Rebecca Martin, Director, Global Immunization Division Centres for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, United States of America. Telephone: 1 404 639 6232 • Facsimile: 1 404 639 8573 • E-mail: rebecca.martinzilla@cdc.hhs.gov
UNITED NATIONS CHILDREN’S FUND, LAOS
UNITED NATIONS CHILDREN'S FUND, NEW YORK
UNITED NATIONS FOUNDATION
UNITED STATES CENTRES FOR DISEASE CONTROL AND PREVENTION (US CDC), ATLANTA
UNITED STATES CENTRES FOR DISEASE CONTROL AND PREVENTION (US CDC), ATLANTA
Dr Linda Quick, Team Leader for the Western Pacific Office Disease Eradication and Elimination Branch, Global Immunization Division National Center for Immunizations and Respiratory Diseases Centers for Disease Control and Prevention, 1600 Clifton Road, NE Atlanta, Georgia 30333, United States of America. Telephone: 1 404 639 8904 • Facsimile: 1 404 639 8676 • E-mail: maq2@cdc.gov Dr Terri Hyde, Medical Epidemiologist, Team Lead, Surveillance and Vaccine Introduction, CGH/GID/Strengthening Immunization Systems Branch, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, Mailstop A-04, Atlanta, GA 30333, United States of America. Telephone: 1 404 639 8764 • Facsimile: 1 404 235 3566 • Mobile: 1 404 3943171 • E-mail: thyde@cdc.gov
WHO FELLOW
Dr Miyuki Tsuruoka, WHO Fellow, Expanded Programme on Immunization, c/o WHO Representative Office, Hanoi, Viet Nam. Telephone: 844 00203 943 3734 • Facsimile: 844 3943 3740 • E-mail: tsuruokam@wpro.who.int
5. SECRETARIAT
WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC (WPRO)
Dr John Patrick Ehrenberg, Director, Combating Communicable Diseases World Health Organization, Regional Office for the Western Pacific United Nations Avenue, 1000 Manila. Telephone: 63 2 528 8001 • Facsimile: 63 2 521 1036 • E-mail: ehrenbergj@wpro.who.int Dr Sergey Diorditsa, Team Leader, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9045 • Facsimile: 63 2 521 1036 • E-mail: diorditsas@wpro.who.int Dr Yoshikuni Sato, Medical Officer, World Health Organization Regional Office for the Western Pacific, United Nations Avenue 1000 Manila. Telephone: 63 2 528 9742 • Facsimile: 63 2 521 1036 • E-mail: satoy@wpro.who.int Dr Sigrun Roesel, Medical Officer, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9741 • Facsimile: 63 2 521 1036 • E-mail: roesels@wpro.who.int Dr Youngmee Jee, Scientist (Laboratory Virologist) World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9744 • Facsimile: 63 2 521 1036 • E-mail: jeey@wpro.who.int
Mr Gabriel Anaya, Programme Management Officer, Expanded Programme on Immunization, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9740 • Facsimile: 63 2 521 1036 • E-mail: anayag@wpro.who.int Dr Jorge Mendoza-Aldana, Technical Officer, Expanded Programme on Immunization, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9751 • Facsimile: 63 2 521 1036 • E-mail: mendozaaldanaj@wpro.who.int Dr Yoshihiro Takashima, Technical Officer, Expanded Programme on Immunization, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9746 • Facsimile: 63 2 521 1036 • E-mail: takashimay@wpro.who.int Dr Md. Shafiqul Hossain, Technical Officer, Expanded Programme on Immunization, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9750 • Facsimile: 63 2 521 1036 • E-mail: hossains@wpro.who.int WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC (WPRO) Dr Kimberley Fox, Technical Officer, Expanded Programme on Immunization, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9033 • Facsimile: 63 2 521 1036 • E-mail: foxk@wpro.who.int Dr Fem Julia Paladin, Technical Officer, Expanded Programme on Immunization, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9737 • Facsimile: 63 2 521 1036 • E-mail: paladinf@wpro.who.int Dr Karen Hennessey, Technical Officer, Expanded Programme on Immunization, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9034 • Facsimile: 63 2 521 1036 • E-mail: hennesseyk@wpro.who.int Dr Wang Xiaojun, Medical Officer, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9747 • Facsimile: 63 2 521 1036 • E-mail: wangx@wpro.who.int Ms Momoe Takeuchi, Technical Officer (Quality & Health Systems Strengthening), World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9084 • Facsimile: 63 2 521 1036 • E-mail: takeuchim@wpro.who.int Mr Seong Joo Kim, Intern, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 9042 • Facsimile: 63 2 521 1036 • E-mail: kims@wpro.who.int
Mr Jeffrey Mark Erfe, Intern, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila. Telephone: 63 2 528 8001 • Facsimile: 63 2 521 1036 • E-mail: erfem@wpro.who.int Ms Naoko Fuji, Intern, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila Telephone: 63 2 528 8001 • Facsimile: 63 2 521 1036 • Mobile: 63 9278330672 • E-mail: fujin@wpro.who.int WHO CAMBODIA Mr Richard Duncan, Technical Officer, Expanded Programme on Immunization, WHO Representative Office in Cambodia No. 177-179 corner Streets Pasteur (51) and 254, P.O. Box 1217, Sangkat Chak Tomouk, Khan Daun Penh, Phnom Penh Telephone: 855 23 216610 • Facsimile: 855 23 216211 • E-mail: duncanr@wpro.who.int Dr Lawrence Rodewald, Team Leader, Expanded Programme on Immunization, WHO Representative Office in China 401, Dongwai Diplomatic Office Building, Chaoyang District, Beijing 100600. Telephone: 86 10 6532 7189 to 92 • Facsimile: 86 10 6532 2359 • E-mail: rodewaldl@wpro.who.int Dr Zuo Shuyan, National Programme Officer, Expanded Programme on Immunization, WHO Representative Office in China 401, Dongwai Diplomatic Office Building, Chaoyang District, Beijing 100600. Telephone: 86 10 6532 7189 to 92 • Facsimile: 86 10 6532 2359 • E-mail: zuos@wpro.who.int Dr An Zhijie, National Programme Officer, Expanded Programme on Immunization, WHO Representative Office in China 401, Dongwai Diplomatic Office Building, Chaoyang District, Beijing 100600. Telephone: 86 10 6532 7189 to 92 • Facsimile: 86 10 6532 2359 • E-mail: anz@wpro.who.int WHO LAO PEOPLE’S DEMOCRATIC REPUBLIC Mr Keith Feldon, Technical Officer, Expanded Programme on Immunization, WHO Representative Office in Laos, Ban Phonxay, That Luang Road, Vientiane. Telephone: 856 21 353902 • Facsimile: 856 21 353-905 • E-mail: feldonk@wpro.who.int Mr Alejandro Ramirez-Gonzalez, Technical Officer (VPD Surveillance) Expanded Programme on Immunization, WHO Representative Office in Laos, Ban Phonxay, That Luang Road, Vientiane. Facsimile: 856 21 353-905 • E-mail: gonzaleza@wpro.who.int WHO MONGOLIA Dr Sodbayar Demberelsuren, National Professional Officer, Expanded Programme on Immunization, WHO Representative Office in Mongolia Ministry of Public Health, Government Building No. 8, Ulaanbaatar Telephone: 976 11 320183 • Facsimile: 976 11 324683 • E-mail: demberelsurens@wpro.who.int
WHO CHINA
WHO PAPUA NEW GUINEA
Dr Siddhartha Datta, Technical Officer, Expanded Programme on Immunization, WHO Representative Office in Papua New Guinea 4th Floor, AOPI Centre, Waigani Drive, Port Moresby Telephone: 67 5 325 7827 • Facsimile: 67 5 325 0568 • E-mail: dattas@wpro.who.int Dr Salim Reza, Technical Officer, HSD, WHO Representative Office in Papua New Guinea, 4th Floor, AOPI Centre, Waigani Drive, Port Moresby. Telephone: 67 5 325 7827 • Facsimile: 67 5 325 0568 • E-mail: rezam@wpro.who.int
WHO PHILIPPINES
Ms Maricel Castro, Technical Assistant for EPI, World Health Organization in the Philippines, National Tuberculosis Centre Building Second Floor, Bldg. 9, Department of Health, San Lazaro Hospital Compound, Sta. Cruz, Manila. Telephone: 63 2 338 7479 • Facsimile: 63 2 338 8605 • E-mail: castrom@wpro.who.int Dr Jayaprakash Valiakolleri, Technical Officer, Expanded Programme on Immunization, WHO Representative Office in the South Pacific Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva Telephone: 679 3 304 600 • Facsimile: 679 3 304 631 • E-mail: valiakollerij@wpro.who.int Dr Kohei Toda, Medical Officer, Expanded Programme on Immunization WHO Representative Office in Viet Nam, 63 Tran Hung Dao Street Hoan Kiem District, Hanoi. Telephone: 844 3 943 3734 • Facsimile: 844 3 943 3740 • E-mail: todak@wpro.who.int Dr Jean-Marie Okwo-Bele, Director, Family and Community Health Immunization, Vaccines and Biologicals, World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Telephone: 41 22 79 12779 • Facsimile: 41 22 79 13111 • E-mail: okwobelej@who.int Dr Peter Strebel, Medical Officer, Expanded Programme on Immunization World Health Organization, Avenue Appia 20, CH-1211 Geneva 27 Switzerland. Telephone: 41 22 79 11338 • Facsimile: 41 22 79 13111 • E-mail: strebelp@who.int Dr Lidija Kamara, Technical Officer, Immunization, Vaccines and Biologicals, World Health Organization, Avenue Appia 20 CH 1211 Geneva 27, Switzerland. Telephone: 41 22 791 2145 • Facsimile: 41 22 791 3111 • E-mail: kamaral@who.int
WHO SOUTH PACIFIC
WHO VIET NAM
WHO HEADQUARTERS, GENEVA
WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA
Dr Arun Bhadra Thapa, Coordinator, Immunization and Vaccine Development, WHO Regional Office for South-East Asia World Health House, Indraprastha Estate, Mahatma Gandhi Marg New Delhi 110 002, India. Telephone: 911123370804 • Mobile: 91 9910699080 • E-mail: thapaa@searo.who.int
WHO NEPAL
Dr Walter William Schluter, Medical Officer Programme for Immunization Preventable Diseases, WHO Country Office for Nepal, United Nations House, Pulchowk, Lalitpur, Kathmandu Telephone: 977 1 526 0831 ext. 105 • Facsimile: 977 1 526-0490 • Mobile: 977 98010 10007 • E-mail: schluterw@searo.who.int