(WP)CDS(S)/ICP/CDS/OO8-E
20 October 1989
ENGLISH ONLY
REPORT ~RKSHOP
('
ON HEPATITIS B IMMUNIZATION IN THE SOUTH PACIFIC Convened by the
REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Suva, Fiji
3-5 April 1989
Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines
October 1989
NOTE
The views expressed in this report are those of the participants of the Worskhop on Hepatitis B Immunization in the South Pacific and do not necessarily reflect the policies of the World Health Organization.
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Region and for those who participated in the Workshop on Hepatitis B Immunization in the South Pacific and the Informal Consultation on Hepatitis B Control in the South Pacific, held in Suva, Piji, from 3 to.S April 1989.
CONTENTS
1.
INTR.ODUCTION •••••••••••••••••••••••••••••••••••••••• PROCEEDINGS ••••••••••••••••••••••••••••••••••••••••.
1 2 2 6 7
2.
2.1 2.2 3.
Country reports ••.•••••••••••••••••...••••....• Discussions on country reports •••••••••••••••••
INFORMATION AND VACCINATION PROGRAMMES •••••••••••••• 3.1 3.2 Target groups ...•..........•••...••.........•.. Education ................••..••••••.•... , .•••.
It
7 8 8
4.
CONCLUSIONS ANNEXES:
........................................ .
ANNEX 1 - WORKSHOP ON HEPATITIS B IMMUNIZATION IN THE SOUTH PACIFIC - AGENDA ••••••••••••• ANNEX 2 - FINAL LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERS AND SECRETARIAT ••••••• ANNEX 3 - INFORMAL CONSULTATION ON HEPATITIS B CONTROL IN THE SOUTH PACIFIC - AGENDA ANNEX 4 - LIST OF MEMBERS, OBSERVERS AND SECRETARIAT •••••••••••••••••••••••••••••••
9 11 17 19
1.
INTRODUCTION
The Workshop on Hepatitis B Immunization in the South Pacific was held in conjunction with the Informal Consultation on Hepatitis B Control in the South Pacific, in Suva, Fiji, from 3 to 5 April 1989. Dr A. Kurisaqui1a, Minister of Health, gave the welcome address, and Dr S.T. Han, Regional Director, WHO Western Pacific Region, opened the meeting. Dr Han pointed out that in the South Pacific, most countries had HBsAg carrier rates of 10% or more. Immunization with hepatitis B vaccine was the most effective approach to preventing the development of the carrier state. At present, fourteen of the twenty-one South Pacific countries had already started hepatitis B immunization, and it was expected that the other seven would start the immunization programme in collaboration with WHO and other countries before the end of 1989. Dr Han said that the high cost of hepatitis B vaccine remained a major obstacle. In the South Pacific, WHO had initiated a high-titre HBsAg plasma collection scheme, which began in 1985. Locally collected plasma was sent by the countries involved to Japan, where the Kitasato Institute processed it into vaccine. The vaccine was then returned to the countries which had collected the plasma. The collection scheme had been established in Fiji, Papua New Guinea, Tonga, and Western Samoa. Tonga and Fiji had begun immunizing the newborn with the plasma derived vaccine in 1988, and Papua New Guinea would commence in the second quarter of 1989. This system was in the process of being expanded to other countries. Dr Han noted that other Pacific countries were using donated or purchased vaccine. As yet there was no overall plan for hepatitis B vaccine supply for the South Pacific.
The Group selected Dr Supeleo Foliaki as Chairman, Dr Laisa Naivalulevu as Vice-Chairman and Dr Roro Daniel and Mr Chris Maher as rapporteurs. The objectives of the Workshop were: 1. 2. 3. 4. to review the epidemiology of hepatitis B infection in the South Pacific; to review the high-titre HBsAg positive plasma collection scheme; to develop a distribution scheme for HB vaccine; to determine the best strategy for immunizing the newborn with HBV vaccine and to study the possibility of integrating it into the EPI programme.
The list of participants and agenda for the Workshop and Informal Consultation are attached as Annexes I, 2, 3 and 4 respectively.
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2. 2.1 2.1.1 Country reports American Samoa
PROCEEDINGS
In January 1985, the Center for Disease Control (CDC) initiated a hepatitis B project. This is geared towards eliminating the transmission of hepatitis H virus and preventing the development of hepatitis related chronic liver disease later in life. One study carried out in American Samoa indicated that 62% of the 221 persons studied had anti-HBc markers with 50% of the population having been infected bv age 5-9 years. A second study showed an HBsAg prevalence of 18% and a prevalence of anti-HBs of 66%. The current situation is that newborns are immunized at birth with hepatitis B vaccine. Locally donated blood is routinely screened for hepatitis B infection and screening is routine in prenatal care. Hepatitis B immunization has been included in American Samoa's EPI programme since January lY~8. 2.1.2 Republic of Palau
The Republic of Palau has started a preventive programme for hepatitis B. After the donation of vaccine from CDC Atlanta, vaccination was aimed at newborns and children up to age 9 years as the donated vaccine was only sufficient for that population. The coverage during the first administration was 100% of the children, the second reached 96% and the last dose will take place in September or October 1989. The only adults that have been included in this immunization programme are the health care workers. 2.1.3 Commonwealth of the Northern Mariana Islands
The hepatitis B vaccination programme was implemented on 3 December 1988. The target group includes newborns, children through fifth grade, staff and government employees-at high risk. The HBV programme will be incorporated in the normal childhood immunization programme. The vaccine was obtained through the CDC, USA. 2.1.4 Cook Islands
Hepatitis B vaccination is available in the country at a very high cost (NZ$77.22); therefore only those who are well off can afford to have their children vaccinated. The vaccination is only given to those infants whose parents request immunization and the poor, who are more at risk of being infected, cannot afford to buy it.
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In 1987 a sero-survey of a sample constituting 7% of the population in Rarotonga, the main island, was carried out. This survey shows that 10.1% of the sample were HBsAg positive and an additional 60.4% had detectable levels of anti-HBc. Altogether a total of 70.5% of the studied population showed serologica.l evidence of infection with hepatitis B virus. Studies by Gust and others (Fairfield Hospital, Melbourne) in 1979 had shown similar results. The Cook Islands Health Department hopes to schedule vaccinations for newborns at birth, 1 month and 6 months but this cannot be done at present because affordable vaccine is not available. 2.1.5 Federated States of Micronesia
Three studies investigated the prevalence of HBV infection in Federated States of Micronesia (FSM). The first non-age specific survey in 1979 estimated a prevalence rate of 41%. Another survey in 1985-1986 demonstrated a 68% positivity of all Hepatitis B markers. A recent survey of the State of Truk on prenatal clinic patients demonstrated a 10% carrier rate, and 80% of all pregnant women's serum demonstrated past exposure to HBV. In December 1988, on receipt of donated HB vaccine, Federated States of Micronesia began a mass immunization campaign to vaccinate all 0-6 year-olds against HBV. This programme was coordinated with the existing EPI programme. 2.1.6 Fiji
Studies on the prevalence of hepatitis B virus infection conducted from 1976 to 1978 showed that more than 80% of ethnic Fijians (Melanesians) were positive for hepatitis B markers by the end of childhood, and more than 12% of those tested were positive for HBsAg. The Fiji Indians showed low rates of infection, with hepatitis B markers present in 10% and HBsAg positive blood present in less than 1%. Another stud:" in 1982 showed similar results. HBV i~nunization was started on 1 January 1989. This was ext.ended to all newborns in the Suva subdivision. This programme will be extended to other divisions and tinally throughout the country once vaccine supply is sufficient. Fiji {,bta:i.ns vaccine through the WHO plasma collection scheme. 2.1. 7 Guam
A sero-prevalence study carried out in Guam in 1983 showed that 48% of the sampled population had HB markers as evidence of current or past infection, while the prevalence of anti-HBc was 41.3% and that of HBsAg was 5.2%.
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Since 1985, all newborns of HBsAg positive mothers have been given hepatitis B vaccine shortly after birth and subsequent doses at one and six months. In 1988 Guam carried out a mass voluntary immunization programme for newborns and young children 6 years of age and below. This programme was made possible because of donated vaccines and is presently reaching approximately 60% of the target population. 2.1.8 Kiribati
A survey in 1984 of 615 subjects showed that 603 subjects (98%) had evidence of current or previous infection and 188 (31%) were HBsAg positive. Hepatitis is listed twenty-eighth among forty health priorities and no specific preventive strategies for hepatitis B control have been planned as yet. 2.1.9 Republic of the Marshall Islands
The Republic of the Marshall Islands would like to introduce HBV vaccine into their present immunization programme. Donated vaccine is available in the country. As EPI vaccines have not yet approached 100% coverage, it was felt that it would not be advantageous to add an additional vaccine to the programme. In the future perhaps hepatitis B vaccine can be made a regular part of the EPI. 2.1.10 New Caledonia
A number of surveys have been carried out in the country to establish the prevalence of hepatitis B virus. A first survey on 3000 pregnant women found that 5.4% were carriers of HBsAg and 57% of these carriers were also carriers of HBeAg. A second survey found the overall HBsAg carrier rate in adults and children for all ethnic groups to be 4%. Forty per cent of the adults from the Melanesian ethnic group were infected with hepatitis B virus before age 19 years. This survey also found that the Melanesian ethnic group had a HBsAg carrier rate of 6.6% and that 53.1% of them were anti-HBc positive. Since the beginning of 1984, babies born to HBsAg positive mothers have been systematically vaccinated. Other people who are currently being vaccinated are those in occupations where the risk of infection is high, patients undergoing haemodialysis, and haemophiliacs. Vaccine used is Pasteur plasma-derived vaccine. 2.1.11 Papua New Guinea
Papua New Guinea is involved in the WHO plasma collection scheme. There are 120 000 newborns per year in the country and 360 litres of high titre plasma is required for 360 000 doses of vaccine.
- 5 Currently Papua New Guinea has 2000 doses which were delivered in December 1988. The medical research centre at Goroka is holding a trial run to explore the possibility of reducing the dosage. 2.1.12 Samoa
No reliable information or statistics on HBV infection rates are available; however, it is believed that approximately 6.5% of the population are hepatitis B virus carriers (HBsAg positive). At present, hepatitis B vaccinations are not given because the vaccine is not available. Once it is available, it is hoped that hepatitis B vaccination will be integrated with the existing EPI programme. Samoa is involved in the WHO plasma collection scheme, and will shortly receive the first shipment of 2000 doses. 2.1.13 Solomon Islands
HBV infection is hyperendemiC in Solomon Islands. It is estimated that chronic liver disease accounts for 1%-3% of hospital admissions per year. Several studies carried out in populations in various areas of the country show that the prevalence rate of HBsAg varies from 10%-20%. Another study has determined that the prevalence of all markers of HBV is around 80%. The current activities undertaken to control HBV infection are the screening of blood and blood products, and vaCCination, where possible, of workers at risk. No HB immunization programme has been initiated; however this is being considered at present and a proposal is yet to be drafted. 2.1.14 Tonga
HepatitiS B surveys in Tonga show that 86.3% of all 1816 subjects tested are HBV marker positive. The results also suggest that Tongan children are exposed to HBV infection to a high degree early in childhood. Tonga has been able to get HBV vaccine from Kitasato Institute after providing the high HBsAg titre plasma. The target population for immunization is all the newborn babies in Tonga, a total of 3000 newborns per year. A total of three doses are given at birth. 2 months and 9 months, and HBV vaccination is coordinated with the current EPI schedule. Tonga has received 20 000 doses from the scheme, which is more than the amount required for the vaccination of 3000 newborn. Tonga is willing to provide its excess vaccine to countries without a source of vaccine.
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2.1.15
Vanuatu
Several surveys have been carried out on the prevalence of HBV markers and HBsAg in the population of Vanuatu. The overall infection rate is estimated to be 70%-80%, with 18%-20% being HBsAg positive. Mother to child and child to child transmission are considered to be the most important routes of infection. A pilot HBV vaccination programme began on 1 April 1989, using recombinant vaccine. The programme is integrated with the EPI in two regions of the country. The vaccine is given in three doses, and UiLly for newborns for the duration of the pilot programme, at birth, 6 weeks, and 6 months. If the programme is successful, the vaccine will gradually be introduced throughout the country. Evaluation of the programme will take place in 1989 and 1990. 2.2 Discussions on country reports
The following issues were raised in the question and answer sessions after the presentation of each country paper, and discussed both during the workshop and in the Informal Consultation sessions. 2.2.1 Vaccine supply
Discussion centred around the different sources of supply currently available, and possibilities for the future. The WHO plasma collection scheme was extensively discussed. It was clearly stated that the vaccine produced by this scheme was both safe and effective. There was no risk of the transmission of AIDS through the U3e of the vaccine. Difficulties in collecting plasma were addressed, given that only Tonga, out of the four countries so far participating in the scheme, had collected sufficient plasma. However, both Fiji and Samoa indicated that they believed they could collect sufficient plasma in the future. None the less, alternative sources of plasma were discussed and WHO was encouraged to continue efforts to obtain plasma from other sources since the plasma collection scheme was currently providing 100 000 out of 570 000 doses required annually in the Pacific. Since some countries were currently using donated vaccines, and some purchased vaccines, these sources too were discussed by the participants, and the general consensus of opinion wa3I.il<"L fi" source of vaccine could be ignored. It was agreed thQ~ an overall South Pacific vaccine supply plan, including all possible sources of vaccine, would be desirable. The plasma collection scneme was, however, strongly supported by many participants as a rel~able source of vaccine which would have a great deal of importance over the next few years. While future reductions in price of the recomD~nant vaccines were expected, the WHO scheme should be contmued tn ensure that vaccine supply took place in the intervening period, and to encourage self-reliance.
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3.
INFORMATION AND VACCINATION PROGRAMMES
A commonly expressed problem encountered during discussions was the lack of information about the use of vaccines in vaccination programmes. Information on where to obtain satisfactory vaccines, what schedule and what dosage to use was crucial. The possibility of having a single vaccine and a singe regimen for the whole of the South Pacific was discussed. It was noted that it was currently impossible to try to use a single vaccine for the whole region, and that dosages must vary according to vaccines. It was also noted that the EPI schedule in the South Pacific varied somewhat from country to country, but that general schedules giving broad outlines of when a vaccine should be given had been used before. The consensus was therefore that a general schedule for HBV vaccine was desirable, as it left a country sufficient latitude to develop its own schedule of immunization and integrate it into its health service while emphasizing that the first dose should be given soon after birth. Therefore, while uniformity in the use of vaccines in HBV control programmes was difficult, it was felt that the central gathering of information on suitable vaccines which fulfil particular operational criteria, and the setting of a general vaccination schedule, would go a long way towards standardizing the use of HBV vaccines. 3.1 Target Groups
Many of the recently initiated programmes have concentrated on newborns. Considerable discussion of the target groups for vaccination took place, and a strong concern was expressed that age-groups other than newborns should be targeted. It was felt that because of the pattern of transmission in many Pacific countries, much of the transmission of HBV could be curtailed by vaccinating older children as well as newborns. Participants of countries currently vaccinating newborns only in general agreed with the principal of wider target age-groups. However, they pointed out that the programmes were new and as such it was important to introduce the vaccine into the EPI in such a way that minimal disruption occurred. In addition, current vaccine supplies are not even adequate to cover all newborns in most countries. After discussion, it was clear that most participants favoured the introduction of the vaccine as the most important step, and that newborns were the best place to start. "Catch-up" vaccinations of older children were generally considered to be necessary as programmes became better established.
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3.2
Education
The issue of education about the importance of HBV immunization was discussed in depth. This education would not be for health personnel only but for politicians and other decision-makers as well. Many participants stated that this was essential to finance the introduction and continuation of HBV immunization programmes. For some countries, HBV immunization was not yet a priority because other health problems were considered more important. None the less, since the HBV vaccine was such an excellent tool for controlling HBV infection, and since the EPI already existed, this vaccine should not be ignored. The general consensus was that it was essential to educate decision makers in order to expedite the commencement of HBV control programmes, and that educational materials aimed at health professionals, decision makers, and the general public, should be developed as soon as possible. 4. (1)
CONCLUSIONS
All participants agreed that Hepatitis B control activities in the South Pacific must be strengthened. Those countries which had not yet started a programme should be encouraged to do so as soon as possible. A IffiO plan for vaccine supply to countries in the South Pacific region should be devel·)ped. .:'he current plasma collection scheme should be continiled and extended to those countries interested in joining, but als:. donations of vaccines and possible, purchase Jf low-cost vaccines should be included. To carry out this plan, collaboration with government and non-governmental organizations and agencies must be promoted. A central Hepatitis B vaccine stOrt~ for the South Pacific should be developed, either as part ,)f the existing EPI store or based on the same system. However, direct supply for those countries with adequate facilities should also be considered. Hepatitis B immunization programmes in individual countries should be monitored and evaluated, in collaboration with WHO, and the results made available for dissemination to all South Pacific countries. Educational material on hepatitis B for health workers and the general public should be prepared by WHO and individual countries. Information exchanges between countries involved in hepatitis B control activities should be promoted. A IffiO Task Force on Hepatitis B Control in the South Pacific should be organized with responsibility for the above activities.
(2)
(3)
(4)
(5)
(6) (7)
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ANNEX 1
WORKSHOP ON HEPATITIS B IMMUNIZATION IN THE SOUTH PACIFIC
AGENDA 1. 2.
OPENING CEREMONY OVERVIEW ON HEPATITIS B VIRUS INFECTION CONTROL PROGRAMME IN THE REGION COUNTRY REPORTS OF PARTICIPANTS INFORMAL CONSULTATION ON HEPATITIS B CONTROL IN THE SOUTH PACIFIC DRAFTING OF RECOMMENDATIONS FINALIZATION OF RECOMMENDATIONS CLOSING CEREMONY
3. 4.
5.
6. 7.
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ANNEX 2
WORKSHOP ON HEPATITIS B IHKUNIZATION IN THE SOUTH PACIPIC
FINAL LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERS AND SECRETARIAT
1.
PARTICIPANTS Dr Tof1ga L1a1ga Public Health Officer c/o Department of Health Services Pago-pago Tutuila Dr Anthony H. Polloi Senior Officer in Public Health Bureau of Health Services Ministry of Social Services P.O. Box 100 Koror Dr Roro Daniel Director of Public Health c/o Ministry of Health P.O. Box 109 Rarotonga Dr Laisa Naivalulevu Acting Assistant Director for Primary and Preventive Health Care (Technical) Ministry of Health Tamavua Mrs Vika Tikinitabua Assistant Director Nursing Community Health Ministry of Health Suva
AMERICAN SAMOA
REPUBLIC OF BELAU
-COOK ISLANDS
FIJI
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Annex 2
FEDERATED STATES OF MICRONESIA
Mr Kidsen Iohp National COllllunicable Diseases Specialist c/o Department of Human Resources Kolonia Pohnpei, E.C. 1. Dr Robert Leon Guerrero Chairperson, Pediatric C')lIIlDit.tee Department of Public Health and Social Services P.O. Box 2816 ~
GUAM
KIRIBATI
Dr Takaieta Kienene Acting Principal Medical Officer Curative Tungaru Central Hospital Bikenibeu Tarawa
REPUBLIC OF THE MARSHALL ISLANDS
Mrs Totha Arelong Director, Iaunlmization Programme Ministry of Health Services Republic of the Marshall Islands P.O. Box 16 Majuro 96960 Dr Terry Jack50n Medical Officer with U.S. National Health Service Corps. (U.S. Public Health Service) Commonwealth Health Center Saipan, liP (U.S. Zip 96950) Dr Denis Rellalod c/o Ministry of Health Noumea Dr Diro Babona Director Blood Transfusion Services Papua New Guinea Red Cross Deparment of Health P.O. Box 3991 Boroko Mr Tipasa Me Senior Health Planner and EPI Coordinator Health Department Apia
COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS
NEW CALEDONIA
PAPUA NEW GUINEA
SAMOA
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Annex 2
SOLOMON ISLANDS
Dr Ezekiel Nukuro Undersecretary, Health Improvement c/o Ministry of Health P.O. Box 349 Honiara Dr E.S. Faafoi Acting Director of Health c/o The Official Secretary of Tokelau P.O. Box 865 Apia Dr Supileo Poliaki Director of Health Ministry of Health Nuku'alofa Mr Chris Maher Responsible for Hepatitis B Programme c/o The Director of Health Services Vila 2.
TOKELAU
TONGA
VANUATU
TEMPORARY ADVISERS Dr Ron Lucas Macfarlane Burnet Centre for Medical Research Fairfield Hospital Yarra Bend Road Fairfield, Victoria Mr Y. Goto Research Associate The Kitasato Institute 5-9-1 Shirokane, Minato-ku Tokyo 108 Dr Michitami Yano Director Department of Clinical Research Nagasaki Chuo National Hospital Nagasaki Dr Shoko Nagaya
AUSTRALIA
JAPAN
Deputy Director Infectious Diseases Control Division Health Service Bureau Ministry of Health and Welf'lre Japanese Government Chiyoda-ku Tokyo 100
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Annex 2
Dr S. Oaura
Executive Vice President The Kitasato Institute Research Centre for Liver Disease 5-9-1 Shirokane, Minato-ku Tokyo 108 Dr Akio Ono Director Biologics and Antibiotics Division Ministry of Health and Welfare Tokyo 100 NEW ZEALAND Mr A. Milne Director Hepatitis Research Unit Public Health Whakatane Dr E. Hyock Kwon Chairman Korean Green Cross Corporation 1464-4, Seocho-dong Seocho-ku, Seoul Mr Steven D. Bice Department of Health and Human Service Region 9 Office of the Regional Health Administrator 50 United Nations Plaza San FranCiSCO, California 94102 Dr Gary Schatz Project Officer Hepatitis Branch Division of Viral Diseases Centers for Disease Control Atlanta, Georgia 3. OBSERVERS
REPUBLIC OF KOREA
UNITED STATES OF AMERICA
Dr Kwang-Soon Shin Research Manager Mogam Bio-Technology Research Institute 341 Bojong Ri, Kuo Sung Myun Yongin Gun, Kyonggido Republic of Korea
- lS Annex 2 Dr F. Bach South Pacific Commission P.O. Box D5 Noumea CEDEX New Caledonia Mrs Judy B. Otto Pacific. Programme Officer UNICEF Private Mail Bag Suva Fiji 4.
SECRETARIAT
Dr T. Umenai Director, Disease Prevention and Control WHO Regional Office for the Western Pacific P.O. Box 2932 Manila Philippines Dr H. Suzuki Regional Adviser in Communicable Diseases WHO Regional Office for the Western Pacific P.O. Box 2932 Manila Philippines Dr G. Cuboni Medical Officer (ICP HST 001) Office of the WHO Representative P.O. Box 113 Suva Fiji Dr K. Markvart Medical Officer Short-term consultant, ICP/HST/OOI Office of the WHO Representative P.O. Box 113 Suva Fiji Mr F. Rousar Technical Officer, lCP/HST/OOl Office of the WHO Representative P.O. Box 113 Suva Fiji
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Annex 2
Dr T. Akiba
Microbiologist, TON/CLR/OOl Office of the WHO Country Liaison Officer P.O. Box 70 NUku'alofa Tonga
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ARMBX 3
INFORMAL CONSULTATION ON HEPATITIS B CONTROL IN THE SOUTH PACIFIC
AGENDA
1. 2. 3. 4. 5. 6. 7.
OPENING CEREMONY OVERVIEW ON HEPATITIS B VIRUS INFECTION CONTROL PROGRAMME IN THE REGION COUNTRY REPORTS OF PARTICIPANTS INFORMAL CONSULTATION ON HEPATITIS B CONTROL IN THE SOUTH PACIPIC DRAFTING OF RECOMMENDATIONS FINALIZATION OF RECOMMENDATIONS CLOSING CEREMONY
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ANNEX 4 INFORMAL CONSULTATION ON HEPATITIS B CONTROL IN THE SOUTH PACIFIC
FINAL L IS'! OF MEMBERS, OBSERVERS AND SECRETARIAT
1.
MEMBERS
JAPAN
Dr Shoko Nagaya Deputy-Director Infectious Diseases Control Division Health Service Bureau Ministry of Health and Welfare Japanese Government 1-2-2, Kasumigaseki Chiyoda-ku Tokyo 100 Dr S. Omura Executive Vice President The Kitasato Institute Research Centre for Liver Disease 5-9-1 Shirokane, Minato-ku Tokyo 108 Dr Akio Ono Director Biologics and Antibiotics Division Ministry of Health and Welfare Tokyo 100
NEW ZEALAND
Mr A. Milne Director Hepatitis Research Unit Public Health Whakatane Dr E. Hyock Kwon Chairman Kor"ean Green Cross Corporation !464-4, Seocho-dong Seocho-ku, Seoul
REPUBLIC OF KOREA
- 20 Almex 4
UNITED STATES OF AK&RICA
Kr Steven D. Bice Depart.ent of Health and Huaan Servic •• Public Health Service Region 9 Office of the Regional Health Administrator 50 United Nations Plaza San Francisco, California 94102 Dr Gary Schatz Project Officer Hepatitis Branch Division of Viral Disease. Center. for Disease Control Atlanta, Georgia 2.
OBSERVERS
Dr Kwang-Soon Shin Research Manager Kogam Bio-Technology Research Institute 341 Bojong Ri, Kuo Sung Hyun YOngin Gun, Kyonggido Republic of Korea South Pacific Commission P.O. Box D5 NOUlllea CEDEX New Caledonia UNICEF East Asia and Pakistan Regional Office P.O. Box 2-154 Bangk.ok Thailand 3.
SECRETAllIAT
Dr T. Ak.iba Microbiologist. TON/CLR/OOI c/o WHO Country Liaison Officer Nuk.u'alofa Tonga Dr G. Cuboni ICP/HST/OOI Office of the WHO Representative ~
Fiji
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Annex 4 Dr K. Marltvart ICP/HST/OOI Office of the WHO Representative Suva Fiji Mr F. Rousar ICP/EPI/OOl Office of the WHO Representative Suva Fiji
Dr H. Suzuki Regional Adviser in Communicable Diseases WHO Regional Office for. the Western Pacific Manila Philippines