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Fifth Meeting of the Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication, Manila, Philippines, 25-29 April 1994, : report

31 décembre 1994 Organisation mondiale de la santé

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(WP)EPI/ICP/EPIIOO2-A Report series number: RS/94/GE/ll(pHL) English only

REPORT -FIFTH MEETING OF THE TE'tHNICAL ADVISORY GROUP ON THE EXPANDED PROGRAMME ON IMMUNIZATION AND POLIOMYELITIS ERADICATION

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 25-29 April 1994

'fIfHo/wppn LfHRAR) U{!.'I1i!" }, hililJinntl"

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines September 1994

NOTE

The views expressed in this report are those of the participants of the fifth Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization.

This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for the participants in the fifth meeting of the Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication in the Western Pacific Region, which was held in Manila, Philippines, from 25 to 29 April 1994.

CONTENTS

SUMMARY 1. INTRODUCTION................... .......... ............................ .......................... 1.1 Objectives. . . . . . . . . . . . . . .. . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. ...... . .. . 1.2 Organization.................................................................................... 1.3 Opening ceremony............................................................................ 2. PROCEEDINGS............................................................................ ......... 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 3. 4. Global overview............................................................................... Regional overview............................................................................ Country reports ........................................................................... ..... Poliomyelitis Eradication.................................................................... Neonatal tetanus elimination................................................................ Measles control..... ................................... ....... ................................. Cold chain and logistics.............................. .......... .............................. Report of small group meeting on laboratory issues........................... ......... Report of small group meeting on cross-border activities ............................. Report of small group meeting on vaccine quality issues .............................. Closing of the meeting....................................................................... 2 2 2 3 3 3 5 16 25 32 36 37 39 40 41 42

SUMMARY REPORT OF THE FOURTH MEETING OF THE REGIONAL INTERAGENCY COORDINATING COMMITTEE ........................................ 43 SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS ....................... 44 4.1 Executive summary ........................................................................... 44 4.2 Progress since the last TAG meeting ...................................................... 45 4.3 Major issues and recommendations ........................................................ 46

Key words: Immunization I Poliomyelitis - prevention and control I Western Pacific I Philippines

- II -

TABLES: TABLE 1 - EPI COVERAGE IN POLIOMYELITIS-ENDEMIC COUNTRIES OF THE WESTERN PACIFIC REGION, 1992-1993 (EXPRESSED AS A PERCENTAGE)........................

TABLE 2

- CONFIRMED POLIOMYELITIS CASES AND PROPORTION OF PROVINCES OR REGIONS WITH CONFIRMED POLIOMYELITIS CASES IN POLIOMYELITIS-ENDEMIC COUNTRIES OF THE WESTERN PACIFIC REGION, 1991-1993 ............................... II - IMMUNIZATION DAYS HELD IN THE WESTERN PACIFIC REGION DURING WINTER SEASON, 1993-1994, AND PLANNED FOR 1994-1995 ................................................... 12 - RESULTS OF IMMUNIZATION DAYS HELD IN THE WESTERN PACIFIC REGION, DURING WINTER SEASON, 1993-1994 AND PLANNED FOR 1994-1995................................................... 13 - AFP SURVEILLANCE INDICATORS, WESTERN PACIFIC REGION, 1992-1993 CASE INVESTIGATION COMPLETENESS AND TIMELINESS BY COUNTRy................... ..................... 14 - AFP SURVEILLANCE INDICATORS, WESTERN PACIFIC REGION, 1992-1993 LABORATORY SPECIMEN COMPLETENESS AND TIMELINESS BY COUNTRy ........................................ 14 - FINAL CLASSIFICATION OF CONFIRMED POLIOMYELITIS CASES FOR THE WESTERN PACIFIC REGION, 1991-1993 ............................... 25 - STOOL SAMPLES FROM AFP CASES RECEIVED IN NATIONAL LABORATORIES, 1993 .................................. 29 - REPORTED LABORATORY RESULTS FOR POLIOMYELITIS-ENDEMIC COUNTRIES, 1993 ...................... 30

TABLE 3

TABLE 4

TABLE 5

TABLE 6

TABLE 7

TABLE 8 TABLE 9

TABLE 10 - INTRATYPIC DIFFERENTIATION RESULTS ......................... 31 TABLE 11 - PROGRESS MADE IN NEONATAL TETANUS ELIMINATION IN SELECTED COUNTRIES, WESTERN PACIFIC REGION, 1992-1993 ............................... 34

- iii -

FIGURES: FIGURE 1 - IMMUNIZATION COVERAGE (CHILDREN < 1 YEAR AND PREGNANT WOMEN FOR TI'2), WESTERN PACIFIC REGION, 1984-1993 ......................................................................... FIGURE 2 - REPORTED DIPHTHERIA CASES, WESTERN PACIFIC REGION, 1983-1993............................... FIGURE 3 - REPORTED PERTUSSIS CASES, WESTERN PACIFIC REGION, 1983-1993 ............................... FIGURE 4 - REPORTED POLIOMYELITIS CASES AND OPV3 COVERAGE, WESTERN PACIFIC REGION, 1980-1993 ...................... ................................... ...... .......... FIGURE 5 - REPORTED MEASLES CASES, WESTERN PACIFIC REGION, 1974-1993 ............................... FIGURE 6 - REPORTED TUBERCULOSIS CASES, WESTERN PACIFIC REGION, 1983-1992............................... FIGURE 7 - TETANUS AND NEONATAL TETANUS CASES, WESTERN PACIFIC REGION, 1983-1993 ...............................

5 7 7

8 8 9 9

FIGURE 8 - CONFIRMED POLIOMYELITIS CASES, WESTERN PACIFIC REGION, 1993 (pROVISIONAL DATA AS OF 16 APRIL 1994) ........................ 10 FIGURE 9 - STATUS OF AFP CASE INVESTIGATION IN THE WESTERN PACIFIC REGION, AS OF 15 APRIL 1994 ......................................................... 14 FIGURE 10 ANNEXES: ANNEX 1 - TIMETABLE.................................................................... 53 ANNEX 2 - LIST OF PARTICIPANTS .................................................... 55 NATIONAL LABORATORY PERFORMANCE ......................... 29

SUMMARY

The fifth meeting of the Technical Advisory Group (TAG) on the Expanded Programme on Immunization (EPI) and poliomyelitis eradication initiative (PEl) in the Western Pacific Region was held in Manila, Philippines, from 25 to 29 April 1994. The meeting was attended by 114 participants and observers, including six TAG members, EPI managers from six poliomyelitis-endemic countries within the Region and one country with cases of poliomyelitis in 1992 and 1993, EPI managers from the neighbouring countries in the South-East Asia Region of Bangladesh, India, Indonesia, Myanmar and Thailand, representatives from national and regional poliovirus laboratories, WHO staff from the South-East Asia Regional Office and Africa Regional Office, as well as representatives from multilateral, bilateral and nongovernmental organizations. The purpose of the meeting was to review progress in EPI and poliomyelitis eradication in order to make recommendations for 1994 and 1995, to disseminate information on the latest EPI developments, to coordinate technical support, to improve coordination among present and potential EPI donors and national governments, and to exchange epidemiological information and promote interregional cooperation with the South East-Asia Region. Significant progress has been made in EPI and in poliomyelitis eradication and neonatal tetanus elimination. A revised system for calculating EPI antigen coverage has been used in China, resulting in a lower calculated Regional coverage. Despite this change, routine coverage of the six antigens remains high, and the total number of reported EPI target diseases continues to decline. There has been an increase in activities for neonatal tetanus elimination, and a Regional plan for accelerating neonatal tetanus elimination has been developed. The lowest ever Regional total of 1214 poliomyelitis cases was reported for 1993, a reduction of almost 40% from the 1992 level. This reduction has largely been the result of large-scale supplementary immunization with OPV in China, Philippines and Viet Nam. During the winter season of 1993/1994 national immunization days (NlDs) were held in China, Lao People's Democratic Republic, Philippines and Viet Nam, and Cambodia held subnational immunization days in two provinces. The NlDs were the largest single public health activities ever to be held in the respective countries, and in the case of China, where over 83 million children were given OPV, probably the largest public health activity in history. Surveillance activities are continuing to make progress, with Cambodia being added to those countries carrying out AFP surveillance. Surveillance indicators continue to show improvements in completeness and timeliness of case investigation. The Regional Interagency Coordinating Committee met for the fourth time and demonstrated its continued commitment to accelerating EPI and poliomyelitis eradication progress by pledging further funds for vaccines and operations. Vaccine supply was adequate in 1993, but donor support will again be required if countries are to conduct NlDs during the 1994-1995 winter season.

-21.

INTRODUCTION

The goal of Global Eradication of Poliomyelitis by the year 2000 was adopted by the Forty-first World Health Assembly in May 1988. In September 1988, the Regional Committee for the Western Pacific adopted a resolution calling for poliomyelitis eradication by 1995 within the context of strengthening the overall Expanded Programme on Immunization (EPI). The first meeting of the Technical Advisory Group (fAG) on EPI and poliomyelitis eradication in the Western Pacific Region was held in Tokyo, Japan in April 1991 with the second, third and fourth meetings being held in 1991 in Cebu, Philippines, in 1992 in Beijing, China and in 1993 in Ho Chi Minh City, Viet Nam, respectively. 1.1 Objectives

The TAG held its fifth meeting at the WHO Western Pacific Regional Office in Manila, Philippines from 25 to 29 April 1994, with the following objectives: (1) to review the EPI and poliomyelitis eradication situation in the Western Pacific Region with particular reference to the six countries where poliomyelitis is endemic; (2) to make further recommendations for 1994 based upon the review of progress made since the fourth meeting of the TAG; (3) to disseminate information on the latest EPI developments. including all disease reduction initiatives; (4) to improve coordination among present and potential EPI donors and national Governments and determine the present and future contribution that each can make to the programme; and (5) to exchange epidemiological information with South-East Asia Region countries to promote interregional cooperation particularly in the area of AFP surveillance. 1.2 Organization

The meeting was attended by 114 participants and observers. including the six members of the Technical Advisory GrouP. EPI managers within the region from six poliomyelitis-endemic countries and one country with cases of poliomyelitis in 1992 and 1993, EPI managers from the neighbouring countries in the South-East Asia Region of Bangladesh, India, Myanmar, and Thailand, representatives from the regional reference laboratories, international organizations, WHO staff from the South-East Asia Regional Office and Africa Regional Office, and a secretariat. Annex 1 shows the timetable of the meeting and Annex 2 contains the list of participants.

-31.3 Qpening ceremony

Dr S.T. Han, Regional Director, WHO Western Pacific Region, opened the meeting and welcomed the participants. He stated that in the three short years since the first TAG meeting, significant progress had been made with the number of poliomyelitis cases in 1993 reduced to a mere 1214. He reported that all the countries reporting poliomyelitis cases had conducted very successful supplementary immunization activities, with China conducting national immunization days which were the largest immunization activity in history. Viet Nam, Philippines and Lao People's Democratic Republic also conducted national immunization days, and Cambodia commenced subnational immunization days (SNIDs) in two provinces. Dr Han stressed the importance of each country having rapid and accurate surveillance systems to detect every case of poliomyelitis. He also emphasized the importance of coordination between regions. He stated that the goal of poliomyelitis eradication was in sight and if the efforts already made could be continued and even accelerated, then 1995 should witness the end of poliomyelitis. He welcomed Dr Robert Hall as a new TAG member and expressed his appreciation for the efforts that Professor A. Radford,the previous TAG member, had made. The following TAG members were appointed to serve as officers for the meeting: Chairman Vice-chairman Rapporteur Dr Isao Arita Dr Kenneth Bart Dr Robert Hall

PROCEEDINGS

2.1

Global overview

In 1993 Global Programme for Vaccines (GPV) co-sponsored by WHO and UNICEF was created. This programme will be coordinated with the Children's Vaccine Initiative (CVI). The aim of the new programme is to ensure a reliable supply of high quality vaccine when and where needed. At regional and country level there has been a strong impetus to accelerate activities towards the disease reduction goals. Increased number of countries are now committed to conducting supplementary immunization activities that are essential to achieving poliomyelitis eradication. Globally by mid-March 1994, 46 countries were committed to supplementary immunization, while 60 countries had established surveillance for AFP. There is evidence of decline of immunization coverage in some large populous countries, although it is difficult to interpret year-to-year changes in levels of immunization coverage. On a national basis, EPI reviews should be conducted to confirm more accurately coverage and, where appropriate, to identify the causes and take action on any deteriorating situation.

-4During the previous year important progress was made towards establishing and strengthening disease surveillance. WHO in close coordination with UNICEF and Rotary International conducted 24 surveillance assessments, in which expert tearns focused on the system and performance of surveillance, identifying strengths and weaknesses. These assessments were followed with workshops where the findings of assessment teams were translated into practical steps for improving the situation. These steps, most important, always included the strengthening of reporting and case investigation. Equally, the feedback to reporting units has been strengthened from global to regional levels and most critically, within countries. The production of newsletters has stimulated information feedback to health staff at all levels. Progress in introducing new vaccines has been disappointing. While 48 countries have now started routine hepatitis B immunization, many of the poorest countries possessing the greatest disease problems are far from affording its introduction. Similarly, re-emergence of yellow fever as a significant problem must be tackled. About half of the countries at risk in Africa have policies for yellow fever vaccine delivery as part of their routine immunization. The coverage of the under-one age group in the countries at risk is 10 %. The laboratory network has improved significantly. The five specialized laboratories have now been networked to IS regional laboratories and 48 national laboratories. As training has been conducted, the functioning of the network improved. Although initially aimed at providing diagnostic Services for poliomyelitis eradication, these laboratories have potential for providing services for a range of disease control programmes in the future. WHO expects to meet the goals of 95% reduction in measles deaths and 90% reduction in measles cases by 1995. However, this will depend upon the ability of countries to identify and provide immunization services to the population groups and areas where measles immunization is not available, and to the places where coverage has decreased. In 1993, an estimated 45 million cases of measles occurred globally. Coverage with measles vaccine was estimated at 78% globally. Over 600 000 neonatal deaths due to tetanus are prevented annually mainly through tetanus toxoid immunization, though more than 500 000 cases are still occurring worldwide. Global TT2+ coverage is rising slowly, reaching 43% in 1993. To meet the 1995 goal, acceleration of tetanus toxoid immunization activities must take place, especially in high-risk districts in every country. A continuing success for EPI has been the increased number of countries with a zero or a low incidence of poliomyelitis: 141 countries reported no cases in 1993. In the Western Hemisphere no cases have been reported since 1991. The number of poliomyelitis cases reported from endemic countries in 1993 was 7898; however, reports from some of these countries are incomplete and it is estimated that 100 000 poliomyelitis cases still occurred worldwide in 1993. The incidence of the EPI target diseases has markedly declined over past few years. It is estimated that 2.9 million deaths are being prevented each year, as a result of immunization. The urgent need to maintain and increase immunization coverage levels is exemplified by the cases and deaths still occurring, estimated in 1993 to be 2.1 million deaths, predominantly from measles, neonatal tetanus and pertussis. Also of major concern is the reappearance of diseases thought to have been well controlled: in 1993, over 15 000 cases of diphtheria were reported from the Russian Federation, with significant increases in reported cases from other newly independent States of the former Soviet Union. The control of this already extensive epidemic is a challenge to be faced by the affected countries, with heightened awareness required by other countries to avoid this epidemic becoming a more widespread problem.

-52.2 Regional overview

In 1993, the Regional coverage was 85% for BCG, 81 % for DPT3, 83% for OPV3 and 89% for measles (see Figure 1). The Regional coverage for the EPI antigens has fallen for the first time owing to the use of a new, larger denominator in China, where a revised system for calculating coverage has been put into use. The Regional coverage for tetanus toxoid for pregnant women increased in 1993, but still remains low at 12%, as no coverage data for this antigen are yet available from China. In spite of the improvement of the overall regional immunization coverage for the EPI target diseases, there are still large contrasts between the countries of the Region (see Table 1).

Figure 1. Immunization coverage (children < 1 year and pregnant women ror IT2), Western Pacific Region, 1984 - 1993

PER CENT IMMUNIZED 100.---~~--------------------~~------------------------------,

BeG

OPT 3

OPV 3

MEASLES

TT 2 (Preg. women)

D 1984

[] 1988 01990 E;31991 .1992

D 1993

DATA AVAILABLE CEIS/wPRO 11 April 1994 (1993 data provisional)

-6Table 1. EPI coverage in poliomyelitis-endemic countries or the Western Pacific Region, 1992-1993 (expressed as a percentage)

BCG Country

DPT3 1992 32

OPV3 1992 32

Measles

TTr 1992 6 ."

1992 Cambodia China Lao P.D.R. Papua New Guinea Philippines Viet Nam Rel!:ional coveral!:e 1993

1993 57 84 42 65 90 94 85

1993 35 80 25 37 87 91 81

1993 36 83 26 35 88 91 83

1992 33 94 46 58 90 90 92 !

1993 37 91 46 18 87 93 89

1993 22 ... ..-

50 94 34 63 94 91 93

94 23 62 92 88 92

95 27 63 92 89 92

17 38 70 35 9

24 1----'-

, ~ I

I 12

data are provisional as of September 2. 1994 data not available

The total number of reported cases of EPI target diseases continues to decline as a result of sustained high immunization coverage (see Figures 2 to 6), though measles remains a major cause of morbidity and mortality. Neonatal tetanus is greatly under-reported in countries where the disease remains a serious problem (see Figure 7). Household surveys and anecdotal data from selected districts indicate foci of neonatal tetanus that are not yet reflected in data from national reports. Efforts are being made to increase tetanus toxoid immunization coverage for women in areas at high risk for neonatal tetanus.

-7 -

Figure 2.

Reported diphtheria cases, Western Pacific Region, 1983 - 1993 Thousands of cases

14 12 10 8

90 91

92 93

" " DATA INCOMPLETE (SOURCE: CEISIWPRO Apr" t"4)

Figure 3.

Reported pertussis cases, Western Pacific Region, 1983 - 1993 Thousands of cases

83 84 85 86 87 88 89 90 91 92 93 t193: DATA INCOMPLETE (SOURCE: CEISIWPRO May 19.3)

-8Figure 4. Reported poliomyelitis cases and OPV3 coverage, Western Pacific Region, 1980 - 1993

Number of cases 12000

OPV3 coverage (%) 90

~--------------------------------------------------T-100

10000

ao 70

1000

ao 50

6000 40

4000

20 2000 10

80 81 82 83 84 85 86 87 88 89 90 91 92 93*

I_ *1993 data Figure 5.

Polio cases

-0-

0 PV31

provisional (111 AFP cases are stili under Investigation). (Source: CEIS/WPRO, Polio Surveillance Reports, 6 April 1994).

Reported measles cases, Western Pacific Region, 1974 - 1993

Thousands of cases 3500~---------------------------------------'

3000 2500 2000 1500 1000 500

O~~~~~~~~~~~~ 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 -0-

Region total

"* China

excluding China

1993 DATA INCOMPLETE (SOURCE: CEIS/WPRO APRIL 1994)

-9Figure 6. Reported tuberculosis cases, Western Pacific Region, 1983 - 1992 Thousands of cases

1200.---------------------------,

DATA NOT AVAILABLE FROM All COUNTRIES fOR YEARS .... TO t"2 (SOURCE: CEIS/WPRO JUNE t "3)

Figure 7.

Tetanus and neonatal tetanus cases, Western Pacific Region, 1983 - 1993

Thousands of cases

I0 TOTAL TETANUS. NNT I DATA INCOMPLETE (SOURCE: CEIS\WPRO April 1994)

- 10 The Region is making good progress and is on schedule to meet the 1995 poliomyelitis eradication goal: the provisional annual number of reported poliomyelitis cases in 1993 was 1214, a reduction of almost 40% from the 1992 level of 1912, though the data are still provisional. Five of the six poliomyelitis-endemic countries, Cambodia, China, Lao People's Democratic Republic, Philippines and Viet Nam continued to report cases. Papua New Guinea reported zero poliomyelitis cases for the third consecutive year, although it is still considered endemic since surveillance is not yet optimal and certain areas of the country remain inaccessible. The 1993 provisional total of 1214 cases is the lowest Regional total ever reported to WHO/wPRO. This reduction has largely been the result of large-scale supplementary immunization with OPV in China, Philippines and Viet Nam. This lower total number of poliomyelitis cases has occurred despite countries having further improved their surveillance systems for reporting and investigating cases of AFP. Figure 8 shows the distribution of confirmed poliomyelitis cases. Cambodia reported 135 cases in 1993, but this is a considerable underestimate of the poliomyelitis situation in the country. As the AFP surveillance system in Cambodia undergoes further development, the number of reported confirmed poliomyelitis cases is expected to rise in the future (see Table 2). Throughout the Region, the majority of poliomyelitis cases were either partially immunized or not immunized at all, indicating good vaccine efficacy. China and Viet Nam still have widespread poliomyelitis transmission (see Table 2), though the number of cases has been reduced. At this stage, cross-border notification of poliomyelitis cases and control activities have not yet been implemented. As the number of cases declines, it will become important to develop a system of rapid notification among countries in the Region, and neighbouring countries of other regions.

Figure 8.

Confirmed poliomyelitis cases, Western Pacific Region, 1993 (provisional data as or 16 April 1994)

POUOMYEUTIS CASES ~O 01to1O

k:::::::1 •

11 to 500

501 AND OVER

D Nam

NON-lYPR COUNTRIES

~hiliPPines , , "4'

i=(J

~c~

~apua

New Guinea

- 11 -

Table 2.

Confirmed poliomyelitis cases and proportion or provinces or regions with confirmed poliomyelitis cases in poliomyelitis-endemic countries or the Western Pacific Region, 1991-1993

1991 Country % of regionsl

1992 % of regionsl

1993'

Polio cases

provinces reporting confinned polio 57 100 6 0 29 89

Polio cases

pro"inces reporting confinned polio 71 100 24 0 36 74

Polio cases

% of regions! pro"inces reporting confinned polio 71 83 24 0 20' 77

Cambodia China LaoPDR Papua New Guinea Philippines VietNam WPRTOTAL Notes:

84 1926 2 0 11 612 2635'

146 1191 7 0 8 557 1912

135 653 7 0 6' 413 1214

I: Including imported cases in non-endemic countries. 2: 1993 data provisional as of August 3 I, 1994. 3: To be confmned by expert pane\.

During the winter season of 1993/1994, China, Lao People's Democratic Republic, Philippines and Viet Nam held two rounds of national immunization days (NIDs) during which all children under the age of 5 years (under 4 years in China) throughout their respective countries were targeted to receive supplementary doses of OPV. Cambodia held subnational immunization days in two provinces (see Table 3).

- 12 Table 3. Immunization days held in the Western Padnc Region during winter season, 1993-1994, and planned ror 1994-1995

1992f1993 Country Anligea. Target ace croup (monlh.) Dole. Anllgen.

1993f1994 Torgel 0," ,roup (monlh.) 0-59 0-47 0-59 0-23 9-23 0-59 12-59 12·59' 15-44 }TS 0-59 6-59 9-23 12-35\TS' Datel

Planned (or 1994/1995 Anllcen. Torgel 01" Croup (month.) 0-59 0-47 0-59 0·23 9-23 0·59 12-59 12-59 15-44 yn 0-59 6-59 9-23 15·)5,'13 Plonn"d dol.. II Feb 95 II March 95 5-6 Dec 9~ 5-6 Jon 95 2 periods in JanlFeb 95

Cambodia China

... OPV OPV OPT' Measles ' OPV Vit.A Measles· 0-47 0-59 0-23 9-23 0·59 6-59 9-23 15-49 yrs

OPV OPV OPV OPT' Meash:s' OPV Vit.A Measl-.:s

FeblMar 1994 5-6 Dec 93 5-6 Jon 94 IS JII194 19 Feb 94

OPV OPV OPV OPT' Me..I..'

OCI92Apr 93 14 NOl' 92 26 Dec 92

LaoPDR

Philippines

21 Apr 93 19 May 93

16 Feb 94 16Mu94

OPV Vit.A Me..l.. IT

ISFeb95

IS Mar 95

TT' VietNam

TT Ocl-No,' 1992

OPV

0-35

OPV Vit.A Mcules' IT'

13-15 Nov 18-20 Dec 1993

OPV VilA Meuleo' IT'

12-14 Nov 94 17-19 Dec 94

NOles I: In selected high-risk or accessible areas only. 2: In high-risk ore..: 1 to 10 ye.... 3: In 1993-1994 in Viel Nom, IT was given 10 all pregnanl womc-o and 10 all women 121035 years in high-risk ore...

(TT given to women only.)

The results were very encouraging_ In all the countries involved the NlDs reflected well on their governments' planning and organizational abilities, and their skills in social mobilization_ Very high coverage with OPV was achieved, and in some countries other antigens and vitamin A were offered to specific age groups (see Table 4),

- 13 -

Table 4.

Results or immunization days held in the Western Pacific Region during winter season, 1993-1994 and planned ror 1994-1995

1992-1993 NwnberoC provIM.. ordbtrkts

1993-1994 Tarzot poplllalion rorOPV (mlWol1l)

Planned 1994-1995 Tal'lot poplllalion forOP\' (mIIIIoas)

eoverHI

Co,"enp foriwo ...... of OP'-

NwnberoC pro\iftcH or districts ~o"em

Eatlmated co\"erace Coriwo ....... of OP\-

NwnloeroC pro.-lDc:a or"lstrlcts COCO\'C'r

Tal'lot poplllalion forOP\' (mlIIIoas)

Cambodia China LaoPDR Philippines VietNam NOI$:

... 29130 pro\inces 481128 districts

... ... 77"4 90°-

... ... 0.33 9.5

2121 pro\inc..

88% 80~.

0.3 100

NID NID NID NID NID

1.7

NID \04'\29 districts

100

> 80~·. >90% >90~.

0.6 9.5 9.8

0.8 9.5 10

NID 81'3 uro\inces

NID NID

90°4

1.3

NID = National lnununization Day, covering entire country. • : The lowest coverage figure of the two rounds is shonn as an estimate of the coverage for two doses ofOPV.

It is particularly noteworthy that the NIDs were the largest single public health activities ever held in their respective countries, and in the case of China, where over 83 million children were given OPV, probably the largest public health activity in history. Surveillance activities are continuing to make progress in the five countries that have established AFP surveillance nationally. Cambodia has commenced AFP surveillance in Phnom Penh, and the system will be extended to all provinces in 1994. Table 5 shows progress in 1993 compared with 1992 for the surveillance indicators that are reported to WPRO. Case investigation completeness is very high in all countries, and case investigation timeliness has improved during 1993. Table 6 shows that there are still deficiencies in laboratory specimen completeness and especially laboratory specimen timeliness in all five countries reporting, though the situation has improved since 1992. Figure 9 gives the status of AFP case investigation in the Western Pacific Region for 1993.

- 14-

Table S.

AFP surveillance indicators, Western Pacific Region, 1992-1993 case investigation completeness and timeliness by country

.,.. t1

LMPDR

I'NG

_N_

INDICATOR

" CASE INVESTIGATION COMPLETENESS p~., AFP Q I f t ..... anllwesdp1e4

" , ..... , ..... I'" S%

') P~" AFP lUeS ..... an rellewetlup aft... " . , .

CASE INVESTIGATION TIMELINESS a) Percabpel AFP cues ~""'bID.' .......... """"" .. ...,..,

I'"

j j..

'I Bj"

" 9l%

" ,..... ,..... 'I 7N

.... ." 0% 11)%

" .... ,..... ." ,..... 'I 'I

1S%

.. ... "..

)1%

<2%

28';

,,, "'"

') P.ra.... ., AFP c:uu 1Iwnttp&e4 wit... 1 "" ef'"""",1 .. ,.,...

6'"

.... ...

)1%

j j..

.....

<2%

.....

Table 6.

AFP surveillance indicators Western Pacific Region, 1992-1993 laboratory specimen completeness and timeliness by country

c_.... INDICATOR

ChI. .

LMPDR '1

I'NC

...... " t1

... .. ~

'1 LAMORA TORY SPECIMEN COMPU:T[NESS Perana.• ., AFP catH ror whIdI aI ,pHinwn ha.IMftI .... t. thr lahorat...,. (or "Vftflnftoll

'1 4~;e

" o-r,.

"If .......

....

,..... .,.,.. 10% b~.

'1 J"'~

'2%

.... 44'!.•

" 0':\-,.

.,.,., 35·,.

LABORA TOR." SPECIMEN TIMELINESS Tht peruntap" At'P dil'l llaaillad., "'lone ., ... .ptdllMtll bbn wtthl •• 4 da\'l'" on .... .rpuahcll.

'''''

4«>.;.

'''~

J"~

~l·/.

. .;,

Figure 9.

Status or AFP case investigation in the Western Pacific Region as or IS April 1994

AFP 2644

I Conllnned poliomyelitis 1214

I I Discarded as nonpollomyeUtis 1319

I Pendln, 111

- 15 The bulk of the resources for the Expanded Programme on Immunization and Poliomyelitis Eradication continue to come from the countries themselves. There were some positive developments in 1993 in mobilizing funds, especially as regards procurement of poliovirus vaccine. Additional funds were received from Australia, Canada, Japan, the United States of America and Rotary International. Hepatitis B vaccine has been incorporated into the routine immunization schedule for infants, in 29 countries of the Region, though on a limited basis in some countries. In areas of high prevalence of hepatitis B, effective protection is achieved by immunizing infants with three doses: at birth, one month and two months of age. Incorrect EPI sterilization and injection practices during routine immunization sessions and supplementary immunization activities are a major concern. The potential transmission of hepatitis B and HIV through unsterile injections become potentially even more important when large numbers of women are immunized with tetanus toxoid. Ensuring correct EPI immunization and sterilization is very often a management issue concerning training and the supply and distribution of needles, syringes and steam sterilizers. Indicators to monitor the performance of cold chain and logistics systems are becoming increasingly important, and national EPI programmes are beginning to devote more attention to reviewing these systems. The use of locally produced equipment in the cold chain is increasing, particularly for national immunization days. Work has now commenced on tield trials of modifications to domestic refrigerators, to enable their use for vaccine storage. Since the fourth TAG meeting in Ho Chi Minh City in June 1993. national immunization days for poliomyelitis eradication conducted by four countries have been a highly visible achievement for the countries of the Region. However, there are still many constraints and problems that must be addressed. (1) Surveillance and laboratory

Countries still have low rates of reporting of AFP cases that fall short of the expected rate of 1 per 100 000 population under 15 years of age. Case investigation is not always adequate, there are deficiencies in timeliness of case investigation, and in completeness and timeliness of stool specimen collection for virological investigation. There are delays in processing laboratory specimens. Countries that are not endemic for poliomyelitis do not yet have sufficiently well-developed surveillance systems for AFP. (2) Supplementary immunization

A shortfall of OPV for supplementary immunization still remains. There are pockets of low coverage during NIDs. (3) Cross-border coordination

There is insufficient interregional coordination in poliomyelitis surveillance and immunization services. (4) Coverage with routine EPI antigens

Low coverage with EPI antigens for routine immunization of infants remains a problem in Cambodia, Lao People's Democratic Republic and Papua New Guinea. All countries have pockets of low coverage for routine EPI.

- 16 (5) Neonatal tetanus elimination

Coverage for tetanus toxoid for pregnant women remains low. Surveillance for NNT is not yet well developed in countries where NNT is a problem, and there is a shortfall of tetanus toxoid vaccine for supplementary immunization in some countries. (6) Measles control Measles case fatality rates remain unacceptably high in many countries. (7) Safe EPI sterilization and injection practices In many areas, safe EPI injection and sterilization practices are not yet assured. The WHO Regional laboratory network for poliomyelitis eradication was developed in 1992 and is now functioning reasonably well. The laboratories involved in the network are two Regional Reference Laboratories; one in the National Institute of Health, Japan, the other in Fairfield Hospital, Australia; ten National Laboratories, in New Zealand, Hong Kong, Singapore, Philippines, Republic of Korea, Viet Nam (one in Ho Chi Minh City and one in Hanoi), Malaysia, China and Papua New Guinea. There are also 28 provincial laboratories in China. Following the recommendations of the fourth Meeting of the Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication, national laboratories have been required to submit monthly data reports to WPRO. With the increase in the number of countries approaching poliomyelitis-free status within the Region, each suspected case of poliomyelitis requires complete laboratory investigation, and the timeliness and accuracy of laboratory services become more important. Data received at WPRO suggest that although laboratory performance has been generally improving, there remain some considerable deficiencies with respect to timeliness and completeness of reporting laboratory results. Three WHO laboratory proficiency tests have now been carried out, in July 1992, June 1993 and February 1994; the results have generally been good. 2.3 2.3.1 Country reports Cambodia

Achievements in relation to recommendations from the fourth TAG meeting The EPI in Cambodia is beginning to accelerate, after a decline in immunization activities during the second quarter of 1993. Immunization coverage of infants has increased well in the third and fourth quarters of 1993 and the first quarter of 1994. Coverage of infants in 1993 was 57% for BCG, 36% for OPV3, 35% for DPT3, and 37% for measles vaccine. Cambodia has conducted subnational immunization days for the first time in February and March 1994, in Kandal Province and Phnom Penh Municipality, which comprise 20% of the national population. Coverage of children under five years of age with OPV was 88 % and 93% in rounds 1 and 2 respectively.

- 17 Disease reduction initiatives (l)

Poliomyelitis eradication

A total of 135 cases of poliomyelitis were reported in 1993, from 17 out of 21 provinces. The AFP surveillance system is stlll weak, but some improvements are being made. In 1993 four cases were confirmed by poliovirus isolation at the Pasteur Institute in Ho Chi Minh City. A national workshop for AFP surveillance and NID planning will be held in July 1994. Following the success of the SNlDs in Phnom Penh and Kandal, full NIDs are being planned for February and March 1995. This will present major organizational challenges for the Ministry of Health, but if adequate resources are available the Ministry is confident of a good result. (2) Neonatal tetanus elimination

Progress has been made in NNT elimination. Coverage of pregnant women with two doses of tetanus toxoid was 22 % in 1993. This is the first year that it has been possible to calculate coverage, with the introduction of new reporting forms. There have also been positive developments in surveillance, with 88 NNT cases being reported separately from total tetanus cases for the first time. However, surveillance is still very weak and many more cases of NNT are suspected to be occurring. (3) Measles control

Measles immunization coverage increased slightly to 37% in 1993. A total of 1262 cases were reported in 1993, but most cases are not reported. Major problems and constraints Poliomyelitis eradication: there is continued low routine coverage for OPV nationally, and AFP surveillance and investigation of cases are not yet well developed. Causes of these include programme management problems and lack of funds, and lack of training in surveillance at all levels. Neonatal tetanus elimination: there is low coverage of pregnant women with TT, and most cases of NNT are not reported. Causes of these problems include low attendance of pregnant women at health facilities and little awareness of the NNT problem. Measles control: there is low coverage nationally for measles vaccine, and high case fatality rates. Causes of these problems include difficulties in sustaining routine immunization sessions, and lack of resources for both immunization and case management.

- 18 -

2.3.2

China

Achievements in relation to the recommendations of the fourth TAG meeting In 1994-1995, national immunization days were conducted in which 87 million children received two doses of OPV 30 days apart. AI! provinces synchronized their rounds to occur on 5-6 December 1993 and 5-6 January 1994. Approximately 10 million children received their first ever OPV doses during the NIDs. Virological surveillance for wild poliovirus was increased in some provinces. Nearly 3000 stool samples were collected from either AFP patients or contacts. At least one stool sample was collected from 64% of AFP cases. The National Laboratory received approximately 200 isolates for intratypic differentiation. Vaccine supply During the NIDs, approximately 200 million doses of OPV were used. Approximately 140 million doses were funded by donor agencies and 60 million (33%) from local funding. Surveill ance The rate of non-poliomyelitis AFP for children less than 15 years old remained at the same low level (0.37 per 100000 children less than 15 years) in 1993 as in both 1992 and 1991. This was again due to very little reporting of non-poliomyelitis AFP in children 5 years of age or older (93% less than 5 years, 7% 5+ years). The rate of non-poliomyelitis AFP in the population with 95% of the reported confirmed cases (less than 5 years) was 0.8 per 100 000 (less than 5 years). The main obstacle to timely reporting was that doctors were not promptly reporting AFP cases to the public health department. Delayed notification of the results of case investigation to the national level remained a problem - the number of confirmed cases of poliomyelitis was not known throughout 1993 until March 1994 because the status of the residual paralysis examination was not known. Although at least one stool was collected on 64% of AFP patients, only 22% had two stools collected within 14 days of onset of paralysis. Immunization strategies Because of limited vaccine supply, NIDs were conducted in children aged 0-47 months. There will be a continued focus on the previously unimmunized children during the forthcoming NIDs. Regarding the routine immunizations, the number of measles cases declined in 1993 compared to 1992 indicating that the routine immunizations programme had not deteriorated in 1991 and 1992. Laboratory Wild virus was detected from isolates from Fujian, Guangdong, and Xinjiang; however, at the time of this report there were many type 1 poliovirus isolates from Guangxi, Guizhou, Qinghai, and Shandong awaiting intratypic differentiation.

- 19 Constraints Selected provinces may need additional supplementary rounds in 1994 besides the NlDs in December 1994 and January 1995. At the present time the high-risk provinces of Fujian, Guangdong, Guangxi, Hainan, Guizhou, Xinjiang, and Qinghai may need extra supplementary rounds, for which additional vaccine will be required. However, the NlDs remain the priority activity and additional supplementary rounds should not compromise them. It is difficult and expensive to get stool specimens from the county to the provincial laboratory and isolates from the province to the national laboratory. In addition, if all AFP under 15 years are investigated, then the workload of the laboratory will triple in 1994. If these items are to be improved quickly, additional funds are needed. 2.3.3 Lao People's Democratic Republic

Achievements in relation to the fourth TAG meeting Increased political commitment There was a marked increase in political commitment led by His Excellency the President Nouhak Phoumsawan. Other major achievements were: the passing by the National Assembly of a resolution in 1993 on EPI and its importance in the development of the country; the Prime Minister issuing a decree in April 1993 on EPI and the role of ministries and mass organizations in its implementation; and a national meeting on EPI attended by governors and representatives from concerned ministries and mass organizations in June 1993. Provincial and district commissions for the mother and child were also established in all provinces. Supplementary immunization activities (1) National immunization days were successfully conducted in 104 districts of the 129 districts in the country in January and February 1994 targeting 87% of the total population. Coverage of OPY for children under five was 79 %. Measles and DPT were also administered to eligible children. The excellent results of the NlDs were achieved through the strong support of provincial and district administrations and the mass organizations. Over 91 % of targeted villages were reached, even those in very remote areas which could only be reached by walking for several days. (2) Extended outbreak response was conducted in five districts in 1994 which did not conduct NIDs but where surveillance demonstrated that there was active transmission of wild poliovirus in the province. Surveillance A new national surveillance system of selected notifiable diseases has been established and is being introduced in 1994. This system initially will focus on four diseases which include acute flaccid paralysis, measles, and neonatal tetanus. The reporting network will extend to village level through the inclusion of vaccinators into the reporting network. Ouality of immunization services A marked improvement in immunization and sterilization practices has been observed following a nationwide training of health workers in 1993. Adequate steam sterilizers and syringes and needles have been supplied to health workers.

- 20 -

Constraints and problems The constraints are: the geographical nature of the country - it is very mountainous, difficult terrain with a low population density and lack of roads; the lack of an adequate health infrastructure and the wide variation in skills of health personnel; EPI services are still generally not well established.

The major problems continue to be: - the national surveillance system is not yet operational; 2.3.4 weak managerial capacity at all levels; lack of manpower; inadequate financial support. Malaysia

Routine EPI services have continued to provide quality services, maintaining high coverage for all antigens, including hepatitis B. Except for measles and diphtheria, the reported number of cases of EPI target diseases decreased further in 1993 compared to 1992. The increase in reported measles and diphtheria cases is largely due to an increase in cases reported from the east Malaysian state of Sabah. Although there is no regular zero reporting network, 19 cases of acute flaccid paralysis were reported in 1993. Stool specimens were collected from all cases, and the results were negative, except for one case from the border area with a neighbouring country, from whom poliovirus type 2 and 3 was isolated. Intratypic differentiation revealed that the virus was Sabin vaccine strain for both types. Follow-up information is not available for any of the 19 AFP cases, including the case with vaccine virus isolation. Good AFP surveillance is needed particularly in border areas. Since poliomyelitis is endemic in Thailand and Indonesia, which both have land borders with Malaysia, importations of wild virus into Malaysia are likely to occur. In order to maintain its poliomyelitis-free status and be confident about the continued absence of the circulation of wild poliovirus, more importance should be given to the surveillance of children with AFP, especially in border areas. Also, contact should be made with public health and surveillance officers at central and provincial levels in neighbouring countries to coordinate cross-border notification procedures and to establish pathways of communication between the two countries to facilitate the exchange of surveillance data. 2.3.5 Papua New Guinea

Achievements in relation to the recommendation of the fourth TAG meeting Indicators for surveillance have been improving since the last TAG meeting; however there is still scope for further improvement, especially in timeliness of reporting, investigation and specimen collection procedures, as they do not meet requirements.

- 21 Disease reduction initiatives Surveillance The country has a fairly well-established communicable disease surveillance system called the EPINT system. Surveillance of poliomyelitis or AFP, measles, neonatal tetanus and diphtheria is an integral part of the urgently notifiable diseases procedure in the EPINT system. However, many resources and adequately trained manpower and reorganization are still needed to make the system function with the required sensitivity and specificity. Work is now going on under the sponsorship of the Asian Development Bank to improve the disease surveillance and reporting system. The National Health Department staffing structure is now being reorganized to optimize the use of scarce trained manpower. Immunization activities Immunization activities in the country have decreased in the 1991-1993 period owing to problems with the health services. In most parts of the country immunization activities are only taking place in urban and town clinic areas. Rural areas where over 80% of the population live are no longer adequately served. The coverage level is perhaps the lowest it has been in the last ten years. Laboratory There is strong and continuing collaboration with the office of the national epidemiologist who is managing the poliomyelitis surveillance system and the Papua New Guinea Institute of Medical Research with the use of laboratory facilities. Stool collection is still a problem. Constraints/problems Major contributing problems are inadequate government funding, political instability, high staff turnover and the lack of visibility in the planning and implementation processes. The Government of Papua New Guinea has declared this situation a serious crisis and has launched the PNG Child Survival Crash Programme in February 1994 to improve the situation. 2.3.6 Philippines

Achievements in relation

to the fourth TAG meeting

The Philippines conducted their second two-round national immunization days in February and March 1994. The activity was again very successful, with more than 90% of target children reached during both rounds. Measles vaccine was included during round 1 (target: children 9-59 months) and tetanus toxoid was given to women 15-44 years of age during both rounds. Vitamin A was again given to 75 % of the target population during round 2. More than 6 million doses of measles vaccine were given, for a coverage of 86% of the expanded target age group. Tetanus toxoid was given to more than 6 million women during the first round and to more than 4 million women during the second round. Again, multisectoral social mobilization and a short but intense tri-media campaign were key to the success of NIPs. Support in cash and kind again came from a multitude of government and nongovernmental organizations, including more than 150 private business corporations. Although with less of a "fiesta" atmosphere than the previous year, operations at the immunization posts went smoothly, profiting from the experience gained during the 1993 NIPs. NIP vaccines had been supplied well ahead of time, in part supported through the new revolving fund set up as part of the vaccine independence initiative supported by UNICEF.

- 22 The Government of the Philippines paid for a large share of NID vaccine as well as for a sufficient supply of disposable needles and syringes. Rotary International, the Canadian International Development Agency (CIDA) and the Australian International Development Assistance Bureau (AIDAB) were again major contributors to the campaign. Acute flaccid paralysis surveillance The zero reporting network grew to 358 AFP reporting units (most of them Department of Health hospitals at all levels) by January 1994. Completeness and timeliness of reporting was satisfactory in 1993; 57 AFP cases were reported and investigated. As of April 1994, 14 of the 1993 cases were confirmed as poliomyelitis and 43 were discarded. Of the confirmed cases, wild poliovirus was isolated in five (Metro Manila, Metro Cebu, Misamis Occidental) and nine were confirmed through residual paralysis. All five cases confirmed through wild virus isolation had onset of paralysis before the 1993 NlDs, which might indicate that NlDs have already had the desired effect of stopping wild virus transmission. However, two-thirds of all 1993 AFP cases were reported during the first five months, indicating that underreporting was more severe during the second half of the year, when true poliomyelitis cases may have been missed. Underreporting of AFP is the main remaining problem for AFP surveillance. Only about 20% of the expected non-poliomyelitis AFP cases (based on a rate of 1 non-poliomyelitis AFP per 100 000 population under 15) are being reported. Several active searches in hospitals found that many AFP cases had not been reported from hospitals during 1993. It is thought that further promoting AFP surveillance in hospitals, may be the most effective means to encourage more complete reporting of AFP cases. The backlog in laboratory work-up is being addressed by two new medical technologist positions in the enterovirus laboratory, funded by Rotary International. A significant decrease in processing time in the laboratory can already be noted. Rotary International is also supporting one position for the surveillance unit at the Field Epidemiology Programme Office, Department of Health central office. The reporting of neonatal tetanus (NNT) cases has formally been included in the AFP reporting network. NNT is presently underreported from hospitals, and it is thought that this will result in more complete reporting, although NNT cases in the community will not be captured by the new system. NNT data available from the existing sentinel surveillance system will be used to delineate high-risk areas to target with tetanus toxoid during next year's NlDs. Routine immunization activities Routine immunization levels have slightly fallen for all antigens, with 89% of infants being fully immunized in 1993. However, Tf2+ coverage for pregnant women was maintained at 70%. The decentralization of health services (devolution) is considered mainly responsible for the lower performance in 1993. Health services, at provincial and lower levels, have now become the responsibility of local government units. The Government of the Philippines, through the new vaccine-finance mechanism set up with UNICEF, is now the biggest contributor to vaccine funds needed for NlDs and for routine activities.

- 23 2.3.7 Viet Nam

Achievements in relation

to the recommendations of the fourth TAG meeting

Routine immunization coverage of 80% nationwide has been maintained and monitored by district and 83% of the 53 provinces achieved a coverage of ~ 80% in 1993. Coverage of pregnant women with Tf2+ was raised from 43% in 1992 to 71 % in 1993. Completeness and timeliness of monthly reporting and AFP case investigation, including stool specimen collection and follow-up visits, continued to improve. National immunization days have been conducted in the whole country in November-December 1993, targeting children less than five years of age. Additional immunization days are planned for the 1994-1995 winter season. Disease reduction initiatives Poliomyelitis In 1993, 641 cases of AFP were reported, and 425 were confirmed as poliomyelitis, in 41 (77%) of 53 provinces and in 163 (29%) of 552 districts (provisional data). This compares with 677 AFP cases reported in 1992, with 577 confirmed poliomyelitis cases. Incidence is the highest in the Mekong delta area in the south. Type I poliovirus was isolated in stool specimens from 164 cases, and 75 sample isolates were confirmed as Type 1 poliovirus, wild strain (provisional data). Of 413 children with confirmed poliomyelitis, 349 (82 %) were less than five years of age. Of 279 children 1-4 years of age with confirmed poliomyelitis, 193 (69%) were inadequately immunized. The decrease in the number of confirmed poliomyelitis cases between 1992 and 1993 is explained in part by the sharp reduction of the characteristic summertime increase, from 168 confirmed cases in 1992 to 42 in 1993, in six provinces where provincial immunization days took place for the first time in 1992 (Hai Hung, Nam Ha. Binh Dinh. Dong Nai. Tien Giang and Can Tho). National immunization days (NIDs) were conducted on 13-15 November and 18-20 December 1993, with two doses of OPV administered, five weeks apart, to all children under five years of age in the country. Accord ing to reports of doses administered, 9.7 mill ion children received two doses of OPV. As there is evidence that 10-15% of OPV recipients were five years of age or older, coverage is estimated as 83-88% of children under five years of age. In addition, 7 million children between 6 and 59 months of age received one dose of vitamin A. The central and local governments contributed an estimated US$1.15 million. Vaccines were made available by Rotary International, UNICEF, AIDAB, JICA, CIDA (Canada), SmithKIine Beecham Biologicals (Belgium). and Pasteur-Merieux Serums and Vaccines (France). Measles Measles remains a serious cause of morbidity and mortality, resulting mostly from low coverage or delayed immunization in remote areas. In 1993, reported coverage with measles vaccine was 93 %. A total of 12 015 cases of measles were reported in 1993, of which 5583 (46%) were in 16 mountainous provinces. Of 2687 cases for which information was available, 92% were older than one year and 96% were unimmunized. Action has been taken to improve the measles situation; during the 1993 NIDs, 201 000 children aged 9-23 months in selected low coverage districts received measles vaccine.

- 24 Neonatal Tetanus Elimination Coverage of pregnant women with tetanus toxoid vaccine was raised from 43 % in 1992 to 71 % in 1993, and 21 (40%) provinces have a coverage of over 80%. An estimated 1.1 million pregnant or childbearing-age women received two doses of IT vaccine, before or during the NIDs, in 57 high-risk districts. Unsafe injection practices have been reported during routine immunization and NlDs. Surveillance for neonatal deaths and neonatal tetanus is improving, but neonatal tetanus is still widely underreported. Efforts are in progress to improve surveillance, immunization strategies and injection practices, and decentralized planning at provinciallr.-vel. Priority objectives in 1994 include 80% coverage with IT for pregnant women and 85% for women of child-bearing age in 140 high-risk districts. Constraints and problems Major constraints and problems include the following: (1)

Ensuring an adequate supply of OPV for NlDs. Total OPV requirements for 1994 are 36 million doses. A total of 20 million doses have been committed by Rotary International, AIDAB, JICA, and the United States Centers for Disease Control. The remaining 16 million doses are expected from local production, pending resolution of quality control and packaging issues. (2) NIDs strategies should include specific plans to reach unregistered children, particularly in the Mekong delta area. (3) Further improvement in poliomyelitis surveillance should emphasize the quality of investigation, stool collection and follow-up; sending case-investigation forms after initial investigation rather than after follow-up; monitoring of zero reporting at district level, including active searches for AFP cases in low-incidence areas; and support to laboratories for isolation of poliovirus and intratypic characterization of poliovirus isolates. (4) Full immunization coverage should be raised to greater than 80% for children under one year of age in mountainous districts and provinces, with special efforts to provide measles vaccine to all children as soon as possible after 9 months of age, and to unimmunized children 9-23 months of age during NlDs in mountainous districts.

(5) Neonatal deaths and neonatal tetanus surveillance, as well as measles surveillance, should be improved. (6) Injection and sterilization equipment should be supplied to mountainous districts and provinces, with special attention to the 140 selected districts where immunization of women of childbearing age with IT will be conducted during routine immunization activities and during NIDs. (7) Training, supervision, planning and monitoring of activities should be strengthened, with special efforts in 140 selected high-risk districts.

- 25 -

2.4 2.4.1

Poliomyelitis eradication Surveillance

Dr J. Bilous, EPI Medical Officer, reviewed the status of AFP surveillance in the Region, and described remaining constraints. R~presentatives of four countries (China, Viet Nam, Philippines, and Lao People's Demo.:ratic Republic) provided updates on surveillance activities and the results of reporting and investigations. Dr R. Tangermann, EPI Medical Officer in the Philippines, described the use of active search methods for AFP, with examples from the Philippines. While there have been improvements in AFP reporting and investigations (see Table 5 and Table 6), and in the proportion of cases providing stool specimens for laboratory testing, these have not reached adequate levels in any endemic country. The percentage of AFP cases lost to follow-up has actually increased (see Table 7).

Table 7.

Final classification or confirmed poliomyelitis cases ror the Western Pacific Region, 1991 - 1993

YEAR

CONFIRMED POLIO CASES

WILD VIRUS ISOL.

RESID. PARALYSIS

EPIDEM. LINKAGE

DEATH OF CASE

LOST TO FOLLOW UP 112 (4%) 266 (13%) 218 (18%)

UNKNOWN

1991

2635

... 49 (2%) 78' (6%)

1161 (44%) 1407 (67%) 782 (64%)

122 (5%) 1 (0.05%) 0

113 (4%) 112 (5%) 104 (9%)

1127 (43%) 252 (12%) 26 (2%)

1992

2087

1993

1214

... no data available • data incomplete

Reported AFP (other than poliomyelitis) still falls well below one per 100 000 children under age five in most countries, and an insufficient number have two stools collected within 14 days. While China has made significant progress, there is a need for improvement in completeness of stool sampling and laboratory methods, and in communication between laboratories and EPI divisions.

- 26Viet Nam has much improved its completeness of case investigations but AFP reporting remains somewhat low, especially in the north, and the high poliomyelitis ra~es and especially high case fatality rates remain a cause for concern in the Mekong delta area In the south. Major constraints in Lao People's Democratic Republic include limited access to and low utilization of health facilities, and generall} weak: institutional capacity. Thailand's offer of cross-border assistance in transporting laboratory specimens from Lao People's Democratic Republic to Bangkok was gratefully acknowledged. In contrast to immunization successes, AFP reporting remains low in the Philippines. The yield of active searches of hospital records in identifying unreported AFP was demonstrated in the Philippines and also in Shandong Province, China. Active search methods include retrospective hospital record reviews and other searches for AFP cases in existing medical records. This may be especially appropriate in areas where reporting appears inadequate. Once local cooperation has been obtained, the information gained has proved useful in identifying previously missed cases and, by comparing with previous reports, in assessing the sensitivity of the reporting system in detecting AFP. Identified cases may be further investigated to determine whether residual paralysis has resulted. Although labour-intensive, this process can significantly supplement AFP reporting, identify areas with special problems in reporting, improve collaboration between EPI staff and clinicians, and serve as a stimulus to future local efforts. Because intensive surveillance and case investigations have now assumed a high level of importance in the Region both for ensuring focused eradication efforts and for the eventual certification process, AFP case-finding and full evaluation of cases must be intensified. Timely stool collection and 6O-day follow-up need particular attention in the case investigation process. Close collaboration between field and laboratory staff will be required. Each country must continually reassess its resource needs and take the required actions to achieve adequate surveillance. 2.4.2 Supplementary immunization

Five countries (Cambodia, China, Lao People's Democratic Republic, Philippines, and Viet Nam) gave presentations on successful supplementary immunization activities in the 1993-1994 winter season. China, Lao People's Democratic Republic, and Viet Nam held their first national immunization days, while the Philippines conducted NIDs for the second year. The NIDs held in China were the largest single immunization activity ever reponed, with over 83 million children under the age of four years twice receiving oral poliovirus vaccine. In the Philippines and Viet Nam coverage of children under five years was over 90%, and in Lao People's Democratic Republic coverage was over 80%. In addition to OPV, in the Philippines tetanus toxoid and measles vaccine were widely offered, and in Lao People's Democratic Republic DPT was also used. In Viet Nam tetanus toxoid and measles vaccine were targeted to areas designated as high risk. Both the Philippines and Viet Nam also achieved high coverage with vitamin A, during the NIDs. In Cambodia subnational immunization days were held for the first time, in Phnom Penh Municipality and Kandal Province, which comprise 20% of the national population. Coverage with OPV was approximately 90% of children under five years in these areas. All five countries, including Cambodia, are committed to conducting NIDs in the 1994-1995 winter season.

- 27 In China there may be a need for subnational immunization days prior to the 1993-1994 winter season in selected areas where wild poliovirus transmission is expected to be continuing. However, during discussion the consensus was that NIDs remained the first priority and SNIDs should only be conducted if vaccine supply is not compromised. Following the country presentations there was active discussion of the successes achieved and the problems encountered. Countries reported a range of problems including difficulties with establishing population denominators, resource and funding problems, logistics and operational problems, and in countries using injectable antigens, problems with sterilization and injection practices. Dr J. Bilous presented a summary of operational issues identified from the experiences of countries conducting immunization days, and highlighted the following points: - the method used for estimating the eligible population should be simple, and should be set at the national level; - good logistics planning is essential and contributes greatly to well-organized NIDs; provincial and district preparations can be improved by being monitored through visits by staff from higher levels;

- special arrangements need to be made for marginal groups and urban populations; - particular attention should be paid to social mobilization, especially in urban areas, as it was a universal experience of countries that social mobilization contributed greatly to high coverage; - funds or other resources can be mobilized from local organizations and this can be put towards operational costs; NIDs can be evaluated usefully using simple methodology.

Mr C. Maher, EPI Technical Officer, gave a presentation on the inclusion of other antigens and other interventions, in addition to OPV, in NIDs. Based on the experience of countries, epidemiological and operational issues should be considered before deciding to incorporate other antigens or interventions. Particular care must be paid to logistics, manpower, and safe sterilization and injection practices. Vitamin A has been successfully used. Tetanus toxoid and measles vaccine are the other antigens most appropriate for use, but only in targeted high-risk areas, and only if safe injection practices are guaranteed. 2.4.3 Laboratory network

With the increase in the number of countries approaching poliomyelitis-free status within the Region, each suspected case of poliomyelitis requires complete laboratory investigation. and the timeliness and accuracy of laboratory services become more important. Laboratory isolation and identification of wild type polioviruses from AFP cases and the environment will be crucial to the poliomyelitis eradication campaign. Monitoring the efficiency and accuracy of the national laboratories within the Region is now of the utmost importance, to detect any shortcomings in the system and to identify any laboratories which require further technical support.

- 28 The following monitoring indicators for laboratory performance have been suggested for the evaluation of the laboratory surveillance system:

TImeliness of sampling at least 80% of stool specimens collected within 14 days of onset of paralysis

Completeness of sampling two stool specimens collected 24-48 hours apart from at least 80% of all AFP cases

Transport conditions at least 90% of specimens arrive with ice or at < 8°C no leakage of container or desiccation of specimen

Laboratory efficiency at least 80% of results reported within 28 days of receipt of specimen

Laboratory capability proficiency test score of at least 80% on virus test panels

Adequacy of transport and laboratory procedures enteroviruses isolated from at least 10% of all specimens received. Following the recommendations of the fourth meeting of the Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication, national laboratories have been required to submit monthly data reports to WPRO. Information supplied on these report forms has been used to monitor the number of cases for which two specimens were collected and the intervals between specimen collection and receipt in the laboratory, and specimen receipt and reporting of results. None of the six poliomyelitis-endemic countries in the Region met the indicator of collecting two stool samples from 80% of all reported AFP cases in 1993 (Table 8). In the Philippines, 75.4% of reported AFP cases had two stool specimens collected. In the other countries, less than 50% of the reported AFP cases had two stool specimens collected. For the Region as a whole, data on the number of AFP cases with two stool specimens collected is not available for years prior to 1993, but the number of reported AFP cases with one or more stool specimens collected has shown an increase from 39% in 1992 to 62% in 1993. The increase has been achieved mainly by the collection of stool samples from a greater proportion of cases in China. Criteria have been developed for monitoring the condition of specimens on arrival at the national laboratories. The information is being collected for specimens received in 1994 and will be used to improve specimen collection and transport procedures where required.

- 29 -

Table 8.

Stool samples (rom AFP cases received in national laboratories, 1993 Num~r

COUNTRY

JUportedAFP cases

810'" . , . . , _...

or AFP ....,. willa 1 or <OIIede4 % or ...ported

Nunl~'

of AFP _ Mth 2 .tool .,..,Intftu <OII«td %of ... port... .

nsn CAMBODIA CHINA PAPUA NEW GUINEA PIIILlPPINES LAOPDR VIETNAM TOTALS 135 4 lI7l

....,. 3.0 &.1.5 81.3 84.2

<Un

3.0

ISla 16 57 9 606

621

34.2 31.3 75.4

J3 48

5 43

6 389 1632

66.7 &.1.2

4 290 967

4U 47.9 36.6

2&.11

6 ...

None of the laboratories in the Region met the performance criteria with regard to reporting results (Figure 10), although the National Laboratory in Hanoi, Viet Nam, did achieve 70% of results reported within 28 days of receiving the specimens. Laboratories should be encouraged to streamline their virus isolation procedures, providing results within 28 days of receipt of specimens.

Figure 10.

National laboratory performance

WPRO reporting countries 1993 80-r----------------------------------------------------~-------

~70~---------------------------------,nLT------------------;:: GI

.. c c

:>60 ." ~50

+-------------------

+ __________________----1 +------------

"'40 GI

.5 30 +---------------GI Q.

=20 o >o!!:

+---------t---------Vial Nam (Ho Chi Minh City) Vial Nam (Hanoi) Papua Naw Guinea

• 10

o-L---'L....,--"----Cambodia

National Laboratory Performance criteria: • ~

samples arriving within 3 days results reported within 28 days of sample receipt

- 30 Three laboratory proficiency testings have now been carried out, in lune 1992, luly 1993 and February 1994. In 1992, 8 of the 10 laboratories tested achieved a proficiency score of 80 % or above. The mean proficiency score was 85 %. In 1993, 7 out of 10 laboratories scored 80% or above, with a mean score of 85.5%. Results are not yet available for the 1994 proficiency testing. In an independent assessment of the proficiency of 29 provincial laboratories in China, carried out by the National Laboratory Beijing, an overall proficiency score of 83.4% was achieved, with 21 of the 29 laboratories scoring 80% or above. Laboratory results for 1993 from poliomyelitis-endemic countries reporting to WPRO are shown in Table 9. Stool specimens from 1632 AFP cases were processed, an increase of 22 % over 1992 figures. A total of 434 cases (26.5 %) were found to be poliovirus positive.

Table 9. Reported laboratory results for poliomyelitis-endemic countries, 1993 Laboralory ....uJl5 (<Un) Number ofAFP c.... "Uh spuimens coO.n.d Nwuber ofAFP c.... posill.. for poUovlrus NUDlMr

COUNTRY

NWII"'r of AFP c...... posltl.. for .ach Iy~ of poUovlnu

ofAFP poIIII.. for pn'ero'Wtru

..... • (%) 0

Num"'r ofAFP pollth'e

..... (%)

Nrc

(%) CAMBODIA CHINA PAPUA NEW GUINEA PIIILlPPINES LAOPDR VIET NAM (Hanoi) VIETNAM (Ho ChI Minh ('1Iy) TOTALS 4 1172 13 48 6 172 217 3 (75) 254 (21.5) 0

III

PoUo

...11 0

PoOo EVS mil 0

for "'lnu

2 106 0

I 55 0

3(75) 365 (31) 2 (15.5) 14 (29) 2 (33.5) 68 (39.5) 112 (51.5) 566

I 807 II

59 0

32 0

2 0 I 0 4 0

113 (9.5) 1 (15.5.) 5 (10.5) I (16.5) 16 (9.5) I (0.5)

9 (19) I (16.5) 56 (32.5) 110 (51)

5 0 45 86

0 0 2 8

2 I I 6

I 0 4

34 4 104

lOS 1066

1632

434 (26.5)

244

138 (8.5)

(34.5)

Intratypic differentiation results for the period since the last TAG meeting are shown in Table 10. There was a 70% increase in the number of isolates typed in 1993 compared with 1992. Of polio I isolates 90% were wild type. No wild type polio II isolates were detected in the Region during 1993, and the proportion of wild type polio III isolates dropped from 35% in 1992 to 14% in 1993. In many cases there have been considerable delays between identifying poliovirus-positive specimens and the sending of isolates to r~gional reference laboratories.

- 31 -

Table 10. Intratypic differentiation results PoUol COUNTRY TIn.e period WUd

PoUo II WUd

PoUo III WUd

v...~In. 0 15

Vaccine

V...~lne 0 33

WUdand "H'tlM ndud

Pendlne

CAMBODIA' CHINA' LAOPDR PHILIPPINES' VIET NAI\1' (Hanoi) VIET NAI\1' (Ho ('1d Minh Oly TOTALS

1993 Oct 92·Oc:t 93 1993 1993 1993

0 87

0 47 0

0 14

0 0

0 4 29

0 2

0 I

I 0 0 16

0 0 0 0

0 0 0 47

0 S6

0 I 2

0 0 35

0 8 2J

1993

104 164

ISO

, Intratypic ditforenti.tion p<rfonned at N.tion.1 Institute of H••lth, Japan 2

Intratypic diff~enliation perfomled at Institute of Virology, Beijing

Communications between AFP case investigators and laboratories need to be improved to ensure that all specimens are accompanied by the correct epidemiological information, especially the case identification number and the date of specimen collection. Communications should be two-way, with laboratories informing case investigators of any problems with the specimens and of the results of laboratQry investigations. Results must be relayed back to the case investigators in a timely fashion so that appropriate action can be taken. Major obstacles in the timeliness of specimen testing and isolate characterization are the result of problems encountered with specimen transport. These problems have no obvious simple solutions. Solving specimen transportation problems will require considerable flexibility in dealing with specific local conditions. Virus isolation procedures in some laboratories need to be streamlined so that accurate results are available within 28 days of receipt of the specimen. Laboratories with poor scores in the proficiency tests need to carefully examine their laboratory procedures to identify sources of inaccuracy. All national laboratories should have clear and concise information on when and how to send specimens to the regional reference laboratories for intratypic differentiation. Great emphasis must be placed on the importance of receiving a final result of vaccine or wild type poliovirus as soon as possible after collection of the sample. Restricted availability of laboratory equipment, supplies and technical training are limiting the current quality of virus detection. These deficiencies need to be addressed in the immediate future, before demands on the network increase in line with the expected increase in AFP surveillance activities. The current capacity of the network, in terms of stool samples being processed, currently meets existing demands, but will have very great difficulties in meeting the expected demands as countries progress towards certification of poliomyelitis eradication. Substantially increased resources will be required to meet these demands, and support for these resources should be sought immediately.

- 32 2.4.4 Certification

Dr M. O'Leary, Epidemiologist in WHO, South Pacific, reviewed the four primary criteria for certification of eradication: (1) verification of the absence of virologically confirmed indigenous poliomyelitis cases for a period of at least three years under circumstances of adeQuate surveillance; (2) verification of the absence of wild polioviruses in the environment, as indicated by testing of stools of normal children, and perhaps through waste-water testing or other environmental sampling; (3) (4) an on-site evaluation by an independent and authoritative certification commission; and the establishment of measures to deal with potential imported cases.

In selected settings, these may need to be supplemented by two other criteria: (5) (6) special immunization efforts in high-risk areas; and active case searches in areas of poor or suspect surveillance.

As the Region moves toward certification, the major constraint is likely to be inadequate surveillance, as indicated by failure to meet the benchmark of one non-poliomyelitis AFP case per 100 000 children under age five per year, insufficient zero reporting, and inadequate case investigations, especially with regard to timely stool collection and testing. The 20 Pacific Island countries were cited as an area already considered poliomyelitis-free, but with inadequate surveillance systems to allow certification. 2.5 2.5.1 Neonatal tetanus elimination Regional plan for the acceleration of NNT elimination

A Regional plan for the acceleration of NNT elimination activities was presented for the fifth TAG meeting. This plan describes three stages in attaining the goal of NNT elimination of under one case of NNT per 1000 live births per district, and assigns stages to countries according to their progress towards this goal. In WPRO, the term 'district' in the global NNT goal is interpreted as 'province', except in China where 'county' is the equivalent.

- 33 -

Stage 1 Countries and areas that have already achieved the goal of per year for every province (county in China) by 1995: American Samoa Australia Brunei Darussalam Cook Islands Fiji French Polynesia Guam Hong Kong Japan Kiribati Macao Malaysia Mariana Islands Marshall Islands

< 1 case per 1000 live births

Micronesia, Federated States of Nauru New Caledonia New Zealand Niue Palau Republic of Korea Samoa Singapore Tokelau Tonga Tuvalu Wallis and Futuna

Stage 2 Countries and areas expected to meet the goal of < 1 case per 1000 live births per year for the whole country by 1995: China Philippines Solomon Islands Vanuatu Viet Nam

Stage 3 Countries not expected to reach the goal of < 1 case per 1000 live births per year f2r....t!lll whole country by 1995: Cambodia Lao People's Democratic Republic Papua New Guinea (l) Countries in Stage 1 are required to maintain clean delivery practices, together with adequate coverage with IT where appropriate. They should ensure that they have a surveillance system that is capable of detecting and reporting cases of NNT.

(2) Countries in Stage 2 should focus their NNT elimination activities upon high-risk provinces to ensure that they attain Stage 1. (3) Countries in Stage 3 have a widespread NNT problem and should implement an NNT elimination plan throughout the country, the first priority being to raise coverage with at least two doses of tetanus toxoid for pregnant women.

- 342.5.2 Regional progress in NNT elimination

Table 11 shows the progress made by selected countries in the Region towards the 1995 goal of NNT elimination.

Table 11.

Progress made in neonatal tetanus elimination in selected countries, Western Padnc Region, 1992-1993

Reporttd eases Country

TT2+ co,'eraCe prepant women

con..c_ CBA "'omen

TTH

Hilb risk aRU 1d_..tUI...

National NNT ..0 .........

C ... 1n....tlC·IIOG

1992 Camb04la

1993 88

1992 6~· •.

1993 21~o

1992

1993

1992

1993

... ... 12 4~

... ...

...

... 300 counties

... Aug 1993 Sop 1993

ChIna' Looo PDR PNG Philippln..

... ~

... J1~. 38~·. 24~.

J8~.

26°.

... ... ... ... ... R.gional smtinel lites District 1,,·.1 1993·4

70 343

17C!,.

... ...

347

70%

.. 140 districts

Aug 1993 Apr 1993 ~Iar

VietNam

187

333

3S~o

71°.

...

86°-.1

$7 districts

1994

Solomon bland. '·anuatu

... I

6S~·-o

... ...

...

... ...

...

47~o

...

I Coverage and NNT case reports not yet available from China 2 Cov.....g• ...ren to high-risl< districts ... Data not available

(1)

Reported cases of NNT

Reporting remains incomplete. Most countries still only report a small proportion of the estimated cases of NNT. (2) Coverage for pregnant women

Coverage for pregnant women with at least two doses of tetanus toxoid (TT2 + ) has increased in Cambodia, Lao People's Democratic Republic and Viet Nam.

- 35 (3) Coverage for women of child-bearing age

All countries have carried out activities to immunize women of child-bearing age, but due to problems in estimating the denominator, coverage figures are not available for most countries. (4) Identification of high-risk areas

China has been conducting tetanus toxoid immunization and NNT surveillance in 300 high-risk counties, but data are not yet available nationally. Viet Nam has successfully achieved its target of 70% coverage for pregnant women and SO% coverage for CBA women aged 12 to 35 in 57 high-risk districts in 1993. In 1994 NNT elimination activities will expand.to 140 high-risk districts. (5) Training

China, Philippines and Viet Nam have conducted NNT elimination workshops at national and regional levels. (6) Surveillance

Remarkable progress has taken place in surveillance, particularly at the district, subdistrict and village levels in Viet Nam, where a system for reporting and investigating neonatal deaths and suspected NNT cases has been established in some high-risk districts. (7) Use of national immunization days to give supplementary doses of tetanus toxoid in the winter season 1993-1994 The Philippines gave tetanus toxoid to women of child-bearing age (15-49 years) throughout the country, delivering 5 681 934 doses in the first round and 4 004 423 in the second round. Viet Nam gave tetanus toxoid to pregnant women (293 481 received two doses) and non-pregnant women of child-bearing aged 15-35 years (446 404 received two doses), in high-risk areas. (8) Safe EPI injection and sterilization practices

All countries are aware of problems associated with safe EPI sterilization and injection practices, especially associated with the large-scale immunization of adults. Although NlDs are a convenient opportunity to immunize women with tetanus toxoid, there is a risk that the demand for injections may be greater than the ability to ensure sterility. Disposable syringes and needles are too expensive for most countries, thus supplies of reusable syringes and steam sterilizers and trained staff must be adequate at the peripheral level for the increased workload of routine and supplementary tetanus toxoid injections.

- 36 2.6 Measles control

Dr R. Tangermann, EPI Medical Officer in the Philippines, presented a paper on the current status of measles control in the Western Pacific Region, noting that measles continues to rank as one of the leading causes of childhood morbidity and mortality in the world and the Region. Although measles surveillance data are incomplete in most countries, the decrease in reported measles cases and deaths in several large countries in the Region has already reached or even exceeded the 1995 measles control goals. Outbreaks of measles continue to occur, especially among underserved and unimmunized populations in remote areas and urban slums. Case fatality rates can be high during outbreaks, especially if there is no access to medical care. The average case fatality rate for 18 measles outbreaks investigated in the Philippines during 1988 to 1991, mostly in remote areas, was 18%. High coverage of the primary target group, children aged 9-11 months, with one dose of measles vaccine remains the cornerstone of measles contro\. Efforts to increase measles coverage should be used to increase coverage for all EPI antigens. Special efforts may be needed to reach high-risk sections of the primary target age group, which may cluster in pockets of low coverage, with an increased risk of outbreaks and high case fatality rates. Such high-risk populations are found among the urban poor, ethnic minorities, refugees and those migrating, as well as those at risk of nosocomial transmission. Immunization alone will not be enough to meet the measles mortality reduction goal. Only improved case management will further reduce case fatality rates. Severe complications or death can be prevented in the majority of children infected with measles through timely, appropriate treatment, including high-dose vitamin A on admission to hospital. Measles vaccine was given to all children 9-59 months of age regardless of previous immunization status during the 1994 NIDs in the Philippines. Viet Nam also added measles vaccine to the NID, targeting children 9-23 months of age in selected low coverage districts. In the Philippines, 5.3 million doses of measles vaccine were given during the first round of NlDs. Assuming a coverage of 80% and an average vaccine efficacy of 85%, around 3.7 million (70%) of measles vaccine recipients probably were already immune (previously immunized); 1.6 million recipients were susceptible (unimmunized, primary vaccine failures). Considerable financial resources were needed to purchase measles vaccine as well as disposable syringes and needles. Although hospital admission rates for measles have dropped dramatically in several hospitals in Metro Manila, there is no representative and timely surveillance system for measles, and it will be difficult to assess the true effect of the measles mass campaigns. While recognizing the enormous effort made in the Philippines, WHO recommends that if multi-antigen NlDs are considered, measles vaccine during NlDs should be given to unimmunized children aged 9-23 months in high-risk, underserved populations.

- 37 -

2.7 2.7.1

Cold chain and loeistics EPI sterilization and injection practices

Mr A. Schnur, EPI Technical Officer, made a presentation on the problem of unsafe EPI sterilization and injection practices, noting that similar presentations were made at the third and fourth TAG meetings. Unsafe sterilization anJ injection practices, including those of EPI, still remain a major problem for health services in some countries. Inclusion of injectables in national immunization days is serving to further increase the seriousness of the problem for EPI. Successes have been achieved during the last year in Lao People's Democratic Republic and Philippines. These successes have been the result of the following: (I) obtaining high level awareness of the problem and commitment to work to solve it; (2) conducting practical training for peripheral level workers; and (3) providing sufficient quantities of injection equipment. High level awareness of the problem has been obtained in the Philippines and an injection practices survey has been conducted. National plans of action for elimination of unsafe EPI sterilization and injections practices are expected to be prepared in Cambodia and Viet Nam before the end of 1994. The five strategies contained in the Regional plan of action to eliminate incorrect EPI sterilization and injection practices were again endorsed for implementation by the countries. There was additional discussion on the importance of choosing the correct injection equipment. Disposable needles and syringes are expensive and present problems for proper disposal. It was also proposed to initiate routine monitoring and reporting of stock balances of injection equipment on standard reporting forms, as is currently done for vaccines, to improve the logistics situation for injection equipment. It was agreed that all countries should prepare national plans of action by December 1994, with fixed strategies and target dates and phasing in of operational areas. It was also agreed that the target date for elimination of incorrect EPI sterilization and injection practices in the Western Pacific Region should remain the year 2000, but that urgent action is required now. 2.7.2 Monitoring the cold chain and logistics system

Mr C. Maher, EPI Technical Officer, reported on progress in cold chain matters since the fourth TAG meeting. A field trial of modifications to domestic refrigerators for improving vaccine storage capacity is being held in the Philippines in April and May 1994. Countries are using more locally produced cold chain equipment, especially for NlDs, but no country has yet developed national cold chain standards. A presentation was given on the use of indicators to monitor the function of the cold chain and logistics system. EPIIWPRO is currently using a set of indicators to monitor the situation regionally, and these indicators show that many countries still have problems with stock control, the storage, handling, and distribution of vaccine, and sterilization and injection practices. To improve national management of the cold chain and logistics system, indicators were suggested for use by EPI managers in the following major areas: (a) (b)

ensuring appropriate amounts of vaccine are available; correct storage and transport of vaccines; adequate and appropriate equipment and supplies; adequate and appropriate sterilization and injection equipment.

- 38 In particular it was emphasized that all countries should: use standard formula to calculate vaccine requirements;

- develop cold chain plans, including standard equipment lists for each level; - develop standard supervisory check-lists for collecting information on indicators, and identifying and addressing problems. 2.7.3 Vaccine independence initiative (VII): the Philippine experience

Dr W. Varona, UNICEF, presented the experience of the Philippines with the vaccine independence initiative. In October 1993 the Government of the Phil ippines and UNICEF entered into a two-year agreement to establish a vaccine independence initiative. Under the terms of this agreement, UNICEF will procure vaccines on behalf of Government and make payments to suppliers from a revolving fund. Among the advantages of the vaccine independence initiative are the following: - strengthened planning and efficiency of vaccine procurement; improved coordination on vaccine matters among participating administrative units; Government obtains vaccines at lower prices available through UNICEF; Government can delay payment until vaccines are received; allows for payment in local currency by Government; ensures timely delivery of high quality WHO-approved vaccines.

The following preparatory steps were necessary to establish the VII in the Philippines: forecast of vaccine needs; calculation of budgetary estimates;

- joint Government UNICEF planning on procurement and delivery schedules; estimation of revolving fund capitalization requirement; determination of UNICEF capacity to absorb local currency; a letter of guarantee from Government; finalized vaccine independence initiative agreement signed.

Before the final vaccine independence initiative agreement was formulated Government and UNICEF representatives outlined a project strategy and plan of action for vaccine independence initiative in Philippines. A vaccine forecast was also formulated. The forecast took into consideration population growth, increases in immunization coverage, EPI strategies, vaccine wastage, local production, and the disease reduction initiatives. The total cost of forecasted annual vaccine requirements (in doses) for the next five years was determined using current vaccine cost estimates from UNICEF. The portion of the total vaccine requirement that would be procured through the vaccine independence initiative indicated the capitalization needed for the revolving fund.

- 39 In order to ensure an adequate supply of imported vaccines, the Government of the Philippines increased budgetary allocations for vaccines to the equivalent of USSII million annually for the period 1993-1995. The Government guaranteed availability of funds with a letter of guarantee or certification of available funds. The following operational steps are taken: Government sends to UNICEF its quarterly request (order) accompanied by a letter of guarantee. UNICEF then procures the vaccines on behalf of Government for shipment direct from manufacturer to Government. Payment to vaccine suppliers is advanced by UNICEF from the revolving fund. Relevant shipping documents and invoices are then sent to Government for payment to UNICEF. Upon receipt of payment from Government, UNICEF reimburses the revolving fund. 2.8 Report of small ~royp meetin~ on laboratory issues

The purpose of this meeting was to provide and compare accurate and timely information on the presence of wild poliovirus in the Region. It was also aimed to further strengthen the operation of laboratory services, including the laboratory reporting system, with emphasis on timeliness and completeness of laboratory diagnosis, up to and including the level of intratypic differentiation, and to advance towards a fully integrated, accessible laboratory and surveillance information database for the Region. Dr Sima Huilan, Regional Adviser, Health Laboratory Technology, WHOfWPRO, reported on progress made on the ten recommendations presented at the fourth TAG meeting in Ho Chi Minh City in 1993. Significant progress has been made in all of the recommendations from this meeting; work on most recommendations has been completed and the remaining are in progress. Poliovirus isolates from endemic countries are being characterized by intratypic differentiation at the regional reference laboratories in Japan and Australia, and intratypic differentiation services are being established in Ho Chi Minh City, Viet Nam. Mrs Margery Kennett, Virologist, Collaborating Centre for Virus Reference and Research, Fairfield Hospital, rapporteur, presented a brief report on the proceedings of the pre-TAG laboratory meeting which was held on Saturday, 23 April 1994. Discussions during the meeting and following on from the pre-TAG laboratory meeting identified the major areas of concern over the laboratory network as being: (I) limitations in the quality of virus detection due to restricted availability of equipment, supplies and training. This is may be demonstrated by less than optimal performance on laboratory proficiency tests achieved by several national and provincial laboratories; (2) limitations in the capacity of stool specimen processing and timeliness of results due to limited numbers of trained personnel, who may have divided responsibilities, and insufficient laboratory supplies. These limitations are making it very difficult to accurately assess the status and progress being made by the laboratory network. Although the network appears to be functioning reasonably well at present, its ability to meet the expected demands caused by improVed AFP surveillance, the collection of two specimens from every suspect poliomyelitis case, and negative stool confirmation, is in doubt. Adoption of standard proficiency indicators by all laboratories will enable the performance to be evaluated and will identify areas which require attention and increased support. The specific conclusions of the meeting were that: (I) accuracy and timeliness of the laboratory elements of wild poliovirus detection are adequate for some countries, but in need of significant improvements in some other countries and provinces; (2) the capacity of the laboratory network currently meets the existing amount of specimens for processing but may have difficulties in meeting increased demands with improved programmatic surveillance activities. A method of evaluating the ongoing situation and implementing action is required.

- 40 The group meeting recommended that: (1) To achieve the goals set for the laboratory network, to improve timeliness, ~acity and accuracy of specimen testing, it is necessary to identify, assess, and evaluate the critIcal needs of the laboratory network. Appropriate performance indicators should be adopted in network laboratories to assist in the identification of needs and formulation of solutions.

(2) Major obstacles in the timeliness of specimen testing and isolate characterization are the result of problems encountered with specimen transport. Potential solutions for these problems need to be developed. (3) Continued improvement in reporting and communications of laboratory data and integration with AFP surveillance data should be accomplished through the gradual adoption of a computerized reporting system and the immediate and universal use of EPI case numbers in all communications. 2.9 Report of small group meeting on cross-border activities

A small group meeting was conducted on the coordination of poliomyelitis eradication activities among countries and regions. Dr Steve Cochi, CDC, Atlanta, gave a presentation on the underlying epidemiological principles. He pointed out that the transmission dynamics of poliovirus make intercountry and interregional coordination imperative - the virus does "not respect any borders". A key issue for effective coordination is the timely exchange of surveillance data, which should be used as "information for action". This is especially true for the results of virological surveillance, where the comparison of viral genomes can contribute to monitor pathways of transmission and to define the extent of ongoing circulation. He also noted that cooperation between countries can take various forms: sharing of information (surveillance); joint planning for supplementary immunization activities (synchronization of NlDs and SNlDs, particularly in border areas); and sharing of resources for specific purposes, such as the support for poliomyelitis reference laboratories. Dr Cochi described a two-stage process to improve cross-border coordination of poliomyelitis eradication activities. First, information has to be gathered to define epidemiological relationships among cases and outbreaks in different geographical areas, to define the pathways of transmission and to identify the population reservoirs sustaining transmission. Second, control strategies are developed and action is taken. Control strategies should take surveillance and virological findings into account, to interrupt pathways of transmission. Resources should be focused on remaining poliovirus reservoirs. He next described the experience in the Americas, where wild virus was found to cluster in several high-risk reservoirs, overlaying several national boundaries, while non-poliomyelitis AFP cases were more evenly distributed. Detailed molecular virological analyses showed epidemiological links among poliomyelitis cases, based on genetic relationships among poliovirus isolates. It was also possible for virologists to follow several major chains of poliovirus transmission, which were gentically related. Lineages not seen for over one year have never reappeared. This important observation is one of the reasons for believing that poliomyelitis eradication has been achieved in the Americas. As long as reservoirs of poliomyelitis endemicity remain in one part of the world, the absence of poliomyelitis in another region is an unstable condition, since reimportations can occur. Most recently, a wild type 3 strain associated with the 1992-1993 epidemic in the Netherlands was imported into Western Canada. In the Western Pacific Region, polioviruses from northern Viet Nam (Red River Region) represent a lineage distinct from viruses from the southern Viet Nam/Cambodia/Mekong delta region, which form a common zone of endemicity. Isolates from eastern Thailand closely match the Cambodia-southern Viet Nam strains, also indicating the need for interregional surveillance and cooperation.

- 41 -

Next, Dr Bernard Moriniere, EPI Medical Officer in Viet Nam, discussed the coordination of poliomyelitis eradication activities between Indochina countries. He pointed out that there is a significant amount of migration and cross-border traffic between Viet Nam and Cambodia in the southern Viet Nam/CambodialMekong delta area. Population movements include ethnic Vietnamese residing in Cambodia who frequently travel back and forth. Vietnamese and Khmer cross the border from Cambodia into Viet Nam to seek medical care in hospitals in Viet Nam. There are also ethnic Khmer living in areas in southern Viet Nam. who occasionally travel to Cambodia. There is probably less movement between Lao People's Democratic Republic and Viet Nam. Since Viet Nam is further advanced in the control of poliomyelitis than Cambodia, there is a major risk of importation of wild virus from areas in Cambodia with low coverage and high incidence into areas of Viet Nam with reduced incidence after NIDs. Also. unimrnunized children may enter Viet Nam, increasing the pool of susceptibles capable of sustaining local transmission of wild polioviruses. An important surveillance activity to coordinate would be the exchange of surveillance data for each country to know the situation on the other side of the border. Also, criteria should be found and agreed upon to define what constitutes an "imported" case. For "cross-border" cases, responsibilities for investigation, stool collection and follow-up should be clarified. Surveillance officers in each country should establish communication pathways into neighbouring countries. Names, telephone and fax numbers of surveillance officers at national/provincial level in each country should be known by their counterpart in the other country. Standard procedures of cross-border notification should be agreed upon. Staff involved in PE activities should go on exchange visits between countries to observe NIDs. for activities in border areas, etc. 2.10 Report of small group meeting on vaccine qual ity issues The small group was convened under the chairmanship of Dr Isao Arita. Chairman, Agency for Cooperation in International Health. Chairman of the fifth TAG, to discuss issues concerning oral poliovirus vaccine produced in Viet Nam and China. Dr Arita opened the meeting by reminding the group that the World Health Assembly has resolved that all vaccines used in EPI programmes should ultimately meet WHO standards. He noted that there was a process of development for vaccines produced in developing countries, and that the small group meeting was concerned with promoting quality of production, consistent with the WHA resolution. 2.10.1 OPV produced in Viet Nam

Three presentations were made. Professor Nguyen Van Man, Director of the newly formed Poliomyelitis Vaccine Research and Production Centre, Viet Nam, presented data on the production and testing of bulk OPV in Viet Nam, including information on the seed virus used which was supplied by the Institute for Poliomyelitis Research, Japan. Dr Doan Thi Tam, Director of the National Centre for the Quality Control of Vaccines, Viet Nam, presented data on the process being followed by the Ministry of Health in assessing the vaccine for release. Dr F. Chino from the National Institute of Health. Japan, presented data on virus marker tests and neurovirulence tests on the 16 million doses of bulk OPV originally produced in Viet Nam. Discussion followed, during which both Dr Chino and Dr M. Arita of NIH gave their opinion that the vaccine tested met WHO neurovirulence standards. Mr Maher gave a brief summary of two informal discussions held prior to the small group meeting to discuss the procedure to be followed to enable a decision on release of the OPV. The Ministry of Health, Viet Nam, has decided to perform neurovirulence tests on the second batch of OPV produced in Viet Nam, prior to deciding on the release of all that has so far been produced from the

- 42 Japanese seed virus. WHO will approach NIH Japan to provide technical observers for some parts of the test process, to collaborate with Ministry of Health and Poliomyelitis Vaccine Centre staff in ensuring that all necessary information is available for a decision on release. The following conclusions were reached: (1) The small group meeting was in agreement with the decision of the Ministry of Health, Viet Nam, on the process for deciding on the release of all OPV so far produced from the seed virus supplied by Japan. (2) Further necessary testing should take place as quickly as possible, and in the interim the process of bottling the 16 million doses originally prepared and tested should begin immediately, to ensure that vaccine is available for the NlDs if release is decided. (3) WHO and UNICEF should continue to provide technical support for the development of the national control authority in Viet Nam, and for the improvement of vaccine production. 2.10.2 OPV produced in China

Dr Mac Otten, EPI Medical Officer in China, presented a paper prepared by Dr Otten and Dr Yang Baoping (China) on the efficacy of OPV produced in China, based on data from field experience. Assuming a possible range of coverage levels from 70% to 90%, (since coverage may vary particularly in rural areas), vaccine efficacy ranged from 82 % to 95 %, which is well within acceptable levels. The following conclusion was reached: The small group meeting recommended endorsing the continued use of the dragee OPV produced in China, as data from field experience indicated good efficacy. 2.11 Closing of the meeting The meeting was closed by Dr Liu Xirong, Director of Programme Management, WPRO, speaking on behalf of the Regional Director Dr S.T. Han who was in Geneva to attend the World Health Assembly. In his remarks, Dr Han expressed his thanks to the TAG members for their continuing dedicated efforts. He gave particular praise for the country representatives and the quality of their presentations and, more important, for the progress reported which reflected the tremendous amount of work done in the countries and the impressive accomplishments achieved. All the countries reporting poliomyelitis were able to show improvements in surveillance and in successfully carrying out national immunization days. The great strides forward were significant because they were made not only towards poliomyelitis eradication but also towards elimination of neonatal tetanus and improving overall EPI activities. He noted that considerable problems and constraints still existed, particularly as regards the need to improve systems for epidemiological surveillance and the poliomyelitis laboratory network. Dr Han expressed thanks to members of the Interagency Coordinating Committee for demonstrating their continued commitment by pledging funds for vaccines and operations. AIDAB (Australia), Japan, Rotary International, and CDC (United States of America) were mentioned with gratitude for their generous donations. Dr Han strongly encouraged participants to make extra efforts as the initiative for eradication of poliomyelitis entered the final stages.

- 43 -

3. SUMMARY REPORT OF THE FOURTH MEETING OF THE REGIONAL INTERAGENCY COORDINATING COMMITTEE, 28 APRIL 1994

Dr B. Kean, Acting Director, Disease Prevention and Control, WHOIWPRO, made an opening statement in which he acknowledged the progress made in accelerating EPI and poliomyelitis eradication and the role played by the Regional Interagency Coordinating Committee. Mr B. Knowles of Rotary International was proposed and unanimously supported as Chairman of the Regional Interagency Coordinating Committee and Mr R. Keegan of the CDC was proposed and seconded to be Rapporteur. Presentations were made by the representatives from UNICEF (Dr Kayode Oyegbite), Rotary International (Dr E. Trainer), Government of Japan (Dr H. Hoshi), AIDAB (Mr A. March), CDC (Mr R. Keegan), and CIDA (Mr R. Baird). Dr E. Trainer (Rotary International) thanked the Regional Director and his staff, as well as the Governments of the Region for facilitating the association of Rotarians with EPI and the poliomyelitis eradication programme. Dr E. Trainer stated that the Trustees of the Rotary Foundation had committed US$33 143000 to date for poliomyelitis eradication in this Region. Rotarians in Japan had raised over US$700 000 for vaccine for China. Dr E. Trainer gave assurances that Rotary's interest and support would continue until poliomyelitis is eradicated. Ms M. Neal of Rotary International gave a presentation about the need for taking advantage of all public relations opportunities to engender additional support by government and nongovernmental organizations. Mr A. Schnur, EPI Technical Officer, presented the WHO Regional EPI/poliomyelitis eradication funding situation and then reviewed the vaccine needs of Cambodia, China, Lao People's Democratic RepUblic, Philippines, and Viet Nam. Given the commitments made by Rotary, the Government of Japan, AIDAB, CIDA, and CDC, significant shortfalls in the OPV supply for the routine programme and NIDs in 1994 appeared to have been avoided. The two most pressing unresolved issues involved the availability of 16 million doses of OPV produced by the Government of Viet Nam, but not yet approved for use, and the need for OPV for extended outbreak response immunization in China. Mr A. Schnur also presented a draft regional surveillance planning and budget document to identify the resources needed to accelerate activities to achieve the TAG recommendations for AFP and poliomyelitis surveillance. The ICC made the following recommendations: (I) The Ministry of Health of the Government of Viet Nam should proceed without delay to obtain final approval for the 16 mill ion doses of vaccine produced, and failing to obtain approval of the vaccine for use in the 1994 NIDS, the Ministry should seek funds from the Government of Vietnam for acquisition of the vaccine to ensure that this year's NIDs proceed as planned. (2) The Ministry of Public Health of the Government of the People's Republic of China, at the highest levels, should hold urgent discussions with the vaccine manufacturers in China aimed at ascertaining the maximum production capacity and increasing local production. Extra OPV is needed to cover ORI in the coming year but ORI should not be allowed to jeopardize the supply of vaccine to be available to the provinces as part of their commitment to NIDs this

year.

- 44 (3) In the event that the amount of vaccine used during China's NIDs in 1994 and 1995 is less than provided, the Government should inform the provinces that the balance should be applied against future NID requirements. (4) ICC discussions during the next TAG meeting should include discussion of long-term vaccine needs in addition to short-term needs. (5) The ICC recommends the establishment of a regional contingency fund for ORI vaccine requirements . (6) The ICC commended the effort by the Secretariat to rapidly develop a regional needs assessment and budget for surveillance activities. Under the guidance of the Secretariat, this draft plan should be reviewed, analysed, and modified in consultation with the country EPI officials and other experts. Following modification of the plan, the Secretariat should seek the endorsement of the TAG and then submit the plan to interested ICC members for their consideration. (7) All governments and WHO offices should use NIDs, EPI meetings, and other EPl/poliomyelitis eradication activities as opportunities to publicize the polio myel itis eradication initiative so that greater political and financial support in the Region and beyond can be mobilized.

SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS

4.1

Executive summary

The Technical Advisory Group (TAG) meeting reviewed progress in the implementation of the Expanded Programme on Immunization (EPI) and the Poliomyelitis Eradication Initiative since the last meeting. The TAG considered that good progress has been made, and that this was in large part due to the added political commitment and increased technical expertise which has been given to poliomyelitis eradication. There are now less than two years until the regional target date for poliomyelitis eradication, and accelerated activity is urgently required. The six poliomyelitis-endemic countries have continued to make substantial progress towards achieving the poliomyelitis eradication goal. Non-endemic countries remained poliomyelitis-free. The incidence of poliomyelitis has reached a historic low, four countries have conducted national immunization days (NIDs) and one country held subnational immunization days (SNIDs). Although surveillance for AFP has continued to improve, the TAG is concerned that more progress is required in the reporting and investigation of AFP cases and in the improvement of the laboratory network for isolation of poliovirus. Vaccine supply was adequate in 1993. Donor support will again be required if countries are to conduct NIDs in the 1994-1995 winter. The poliomyelitis-endemic countries are rapidly approaching the goal of poliomyelitis eradication.

- 45 4.2 Progress since the last TAG meeting

Twenty-nine countries and areas of the Region are now presumed poliomyelitis-free and the six remaining poliomyelitis-endemic countries are approaching that status. The provisional total of reported poliomyelitis cases fell to 1214 in 1993. The decrease in cases is largely due to a fall in the number of confirmed cases in China, following provincial immunization days in late 1992 and early 1993. One poliomyelitis-endemic country, Papua New Guinea, has reported zero cases for the three years 1991-1993. It is critical that Papua New Guinea maintains and extends AFP surveillance to document the continuation of this status. The EPI in the Western Pacific Region has maintained an overall immunization coverage of over 80% of infants in 1993, although there remain pockets of low coverage in countries with high overall coverage and the Regional coverage has fallen for the first time (due to the use of a new, larger denominator for calculating coverage in China). Evidence from poliomyelitis-endemic countries continues to show that poliomyelitis eradication activities have not adversely affected the EPI. The TAG has been impressed by the high level of political commitment displayed in all six countries. China, Lao People's Democratic Republic, Philippines, and Viet Nam conducted national immunization days in the winter season 1993-1994. In addition, Cambodia conducted subnational immunization days in two provinces, comprising 20% of the national population. The NIDs and SNIDs were extremely successful in all countries, achieving very high coverage of eligible children with OPV. Progress has also been made in AFP surveillance activities, with significant improvements in the proportion of AFP cases investigated and followed up, and the timeliness of case investigation. Laboratory specimen completeness and timeliness has also improved. However, considerable improvements still need to be made in surveillance and laboratory systems in all countries. Malaysia reported a poliomyelitis case in 1993. This follows three cases reported in 1992 and indicates the need to maintain a high level of AFP surveillance in countries considered to be poliomyelitis-free. There has been an increase in activity for neonatal tetanus (NNT) elimination. A regional plan for accelerating NNT elimination has been developed. China and Viet Nam are designating high-risk areas for NNT. Surveillance data for NNT and measles are still too weak to assess progress in reducing disease incidence since the last TAG. Experience has been gained with the integration of AFP and NNT surveillance in Philippines and Viet Nam. Funds mobilized for OPV from donors since the first TAG meeting, largely through the Interagency Coordinating Committee, now exceed US$20 million. Generous support and active participation by donors, particularly UNICEF, Rotary International, the Government of Japan, AIDAB, CIDA, and CDC, has been instrumental in the conduct of eradication activities in the Region.

- 46 4.3 Major issues and recommendations

The TAG is confident that if its recommendations are carried out, poliomyelitis will be eradicated by 1995 in the Region. The momentum of the NIDs and SNIDs must be maintained and carried through to supplementary immunization activities in 1994 and 1995. Due to the success of the supplementary immunization activities in the Region, the number of cases of poliomyelitis can be expected to continue to fall. Improvements in the surveillance and laboratory systems are vital in ensuring that all poliomyelitis cases and circulating wild poliovirus are detected. Performance targets for surveillance and laboratory indicators must be adopted by national surveillance and laboratory systems. These systems, which are vital for the ultimate certification of eradication, require material and technical support in order to improve performance.

In addition to improvements in surveillance and laboratory systems, cooperation and information exchange between countries and regions will become increasingly important. Recommendations: (1)

A "mini-TAG" should be considered to address remaining issues of control, surveillance and investigation, and especially certification for both poliomyelitis eradication and neonatal tetanus elimination.

(2) China accounts for one-fifth of the world's population. In view of the critical importance of China to achieving the Regional eradication goal by 1995, the TAG strongly recommends that China undertake substantial immunization days in high-risk areas, including the five southern provinces (Fujian, Guangdong, Guangxi, Hainan and Guizhou) and Kasgar prefecture in Xinjiang province. Planning should take account of epidemiological and operational factors. Extra resources will be required. 4.3.1 Vaccine supply and quality

The poliovirus vaccine supply situation has improved dramatically since the first TAG meeting, but still remains an important concern. The TAG noted that there are still gaps in meeting vaccine requirements (particularly for China and Viet Nam) for the 1994-1995 NIDs. Potential shortages still remain for extended outbreak response immunization (EORI) in several countries. The TAG acknowledged with sincere thanks the excellent contribution of the ICC members in addressing the vaccine supply needs for poliomyelitis eradication and requests continued support to deal with remaining supply gaps. The TAG discussed the decision of the Ministry of Health, Viet Nam, on the process for deciding on the release of locally produced OPV. With the restarting of local production, there is good potential to ease the vaccine supply problems for Viet Nam. The TAG commended the efforts of WPRO in assuring provision of quality vaccines in collaboration with countries. The TAG favourably received the report from China on a field evaluation of vaccine efficacy of the locally produced OPV. The report documented that estimates of the vaccine efficacy ranged from 82 % to 95 %, which is acceptable.

- 47 Recommendations: It is critical to plan vaccine supplies for the Region to cover the increased activity which will be required over the next two years. The TAG recommends that: (1) Viet Nam should move rapidly ahead to complete the testing of the second batch of locally produced vaccine to enable a quick decision on release by the NCA. The process of bottling the 16 million doses currently availabie should begin immediately so that if release is approved this OPV will be available for use during the 1994 NIDs. (2) Efforts should continue to assure the continuation and improvement of in-country oral poliovirus vaccine production in China and Viet Nam, and the packaging of vaccine from imported bulk stock and the provision of automatic filling equipment in Viet Nam. (3) Field experience indicates that the dragee oral poliovirus vaccine used in China is effective. The recommendation of the fourth TAG meeting to continue to purchase the locally produced vaccine and to increase production as much as possible is reaffirmed. (4) The Ministry of Public Health of the Government of the People's Republic of China, at the highest levels, should hold urgent discussions with the vaccine manufacturers in China aimed at ascertaining the maximum production capacity and increasing local production. Extra OPV is needed to cover EORI in the coming year but EORI should not be allowed to jeopardize the supply of vaccine to be available to the provinces as part of their commitment to NIDs this year. (5) WPRO should prepare and implement a plan for vaccine production and quality control in the vaccine-producing countries. 4.3.2 Supplementary immunization

China, Lao People's Democratic Republic and Viet Nam held their first two-round national immunization days during the 1993-1994 winter season. The Philippines conducted its second national immunization day, while subnational immunization days were held in two provinces of Cambodia. China held the largest immunization campaign ever. Eighty-three million children under the age of four years were immunized twice with OPV one month apart in China. In Viet Nam, Lao People's Democratic Republic and the Philippines, more than 90% of children under the age of five years were immunized with OPV. In Cambodia, the campaign covered two provinces (more than 20% of the total population), with a coverage of around 90% of children under five. Key activities included intense social mobilization efforts, media campaigns, and the mobilization of hundreds of thousands of volunteers. All five countries (including Cambodia) are planning to hold full-scale NIDs again in 1995. Recommendations: (1) Cambodia, China, Lao People's Democratic Republic, Philippines and Viet Nam should undertake two-round NIDs in 1995.

(2) Extended outbreak response immunization should be planned and implemented in areas with low coverage and continuing transmission. These activities should only be done if they do not compromise the supply of OPV for NIDs. Surveillance activities have identified reservoirs in southern China, Viet Nam and Cambodia. Particular attention should be paid to those areas.

- 48 (3) NIDs in 1995 should be carefully planned in each country to assure the highest possible coverage of the target population with particular emphasis on children previously unimmunized. Immunization strategies may have to be adjusted based on experience gained during the previous NIDs. (4) Other antigens should be included in NIDs only after careful review. Issues to be considered are programmatic impact, including the ability to maintain safe injection practices, and additional financial and human resources needed. If a decision for multi-antigen NIDs is made, the following antigens and interventions are the most appropriate: vitamin A, measles vaccine and tetanus toxoid. Measles vaccine and tetanus toxoid should be targeted at high-risk areas, and given according to immunization status. (5) NIDs should be monitored and evaluated at all stages of planning and implementation. Process and outcome measures should be used. 4.3.3 Poliomyelitis eradication surveillance

Surveillance for AFP has improved remarkably since 1991. However, epidemiological and laboratory investigation for all AFP cases is still incomplete and delayed. All countries must ensure that they establish reliable systems for AFP surveillance. Some countries are still in the early stages of developing AFP surveillance, for these countries, training workshops, setting up a system with clear reporting procedures and responsibilities, together with monitoring and supervision, are required. Other countries with well-established systems still need support for surveillance activities, particularly case investigation and follow-up. The NIDs will rapidly reduce the rate of transmission of poliovirus, leading to a low level of poliomyelitis cases. As countries approach zero cases, it is essential that they detect, report and investigate all AFP cases so that a rapid response can be made to poliomyelitis cases. This requires raising awareness of poliomyelitis eradication, so that all clinicians and other health personnel understand the need to report and investigate AFP. Additional resources are needed for surveillance, including for active search activities, especially at the peripheral level. The activities needed to improve AFP surveillance as discussed are not expensive or difficult to undertake, and will also benefit other fields of public health. Recommendations: (1)

The rate of detection of non-poliomyelitis AFP should be improved. Countries should improve surveillance methods including active surveillance, to achieve this.

(2) Active search for AFP cases should be used to assess AFP surveillance. The methods used should be appropriate to the country, and should include community-based searches where use of heal th facil ities is low. (3) Greater support and supervision of surveillance personnel is required particularly at the peripheral level. Support should include provision of adequate funds to enable personnel to travel for the investigation and follow-up of AFP cases. (4) Poliomyelitis-free countries must be encouraged to develop AFP surveillance or an adequate substitute without delay, to detect imported cases and as preparation for the eventual certification of eradication. Non-endemic countries should have a surveillance system which will detect any cases of poliomyelitis.

- 49(5) Surveillance for AFP should be promoted through media publicity directed at health personnel and the community. All hospital doctors should be made aware of the necessity to report all AFP cases, regardless of whether or not poliomyelitis is suspected. (6) The following targets for AFP surveillance should be met by endemic countries within the next 12 months: (a) achieving a rate of non-poliomyelitis AFP of one per 100 000 children under 15 years of age; (b)

90% of AFP cases followed up after 60 days (30% for Cambodia);

(c) 80% of AFP cases investigated within 48 hours of report (30% for Cambodia and 60% for Papua New Guinea); (d) 80% of AFP cases with two stool specimens sent to the laboratory (30% for Cambodia); (e) 60% of AFP cases with two stool specimens taken within 14 days of onset of paralysis (20% for Cambodia). 4.3.4 Coordination between countries in areas of hi/:h transmission

It is imperative to coordinate poliomyelitis eradication activities among countries and regions. In the Western Pacific Region, coordination will become particularly important in countries of the Indochina Peninsula, where there are significant reservoirs of wild poliovirus which cross national borders. With the increasing success of poliomyelitis eradication in the Western Pacific Region, coordination will also be needed with other WHO regions, particularly SEARO, EMRO, and EURO. Timely surveillance data must be shared among countries and between WHO regions to allow effective cooperation and coordination. Surveillance results should be used as "information for action" to direct control and immunization activities. Attempts should be made to the extent possible to synchronize supplementary immunization activities between countries, in particular when conducting activities in border areas.

Recommendations: (1) To improve coordination, surveillance officers at national and provincial levels should establish means of communication (exchange of names, telephone and fax numbers). WHO should act as a focal point for the establishment of mechanisms to enable coordination of poliomyelitis eradication activities across borders between countries and WHO Regions. (2) WHO should collaborate in the establishment of standard procedures for cross-border notification of AFP and confirmed poliomyelitis, to coordinate case investigation, stool collection and follow-up. 4.3.5 Laboratory

The TAG notes the exemplary efforts made by the regional laboratory network in meeting the challenges set. There remains room, however, for significant improvement in some areas. The capacity of the laboratory network currently meets the existing demand for its services, but will have very great difficulties in meeting increased demands due to improved surveillance activities. Communication between laboratories needs to be further improved.

- 50Recommendations: (1) Laboratory surveillance performance indicators should be adopted in network laboratories as follows:

(a) speed of transport - at least 80% .,f stool specimens should arrive at laboratory within three days of collection of the second stool specimen; (b) transport conditions - at least 90% of specimens should arrive with ice; there should be no leakage or dessication;

(c) laboratory efficiency - for all laboratories, at least 80% of results should be reported within 28 days of receipt of specimen; (d) laboratory capability - it should score at least 80% on proficiency testing;

(e) adequacy of transport and laboratory proficiency - enterovirus should be isolated from at least 10% of specimens. (2) A computerized laboratory reporting system should be adopted and used for monthly reporting. (3) EPI cases numbers should be used in all communications.

(4) Increased resources are needed to support the laboratory network, particularly for training materials and transport of specimens, to intensify the capacity of the network. 4.3.6 Certification of poliomyelitis eradication

Twenty-nine countries of the Region are presumed poliomyelitis-free. The six remaining poliomyelitis-endemic countries are approaching that status. As the 1995 target date for eradication approaches, increasing attention must be given to meeting the criteria for certification of eradication. Recommendation: Countries presumed to be poliomyelitis-free should ensure that adequate surveillance, with zero reporting, is implemented. Supplementary approaches may include active AFP searches, active routine surveillance, or financial rewards for case-finding. 4.3.7 Neonatal tetanus elimination

Three countries (Lao Peoples' Democratic Republic, Philippines and Viet Nam) have made considerable progress in raising routine coverage for IT immunization for pregnant women; in addition, many women of child-bearing age were immunized with IT during immunization days in 1993. The Philippines and Viet Nam have improved reporting and investigation of neonatal deaths. Most NNT cases are still not reported. As NNT is a focal disease, efforts must be made to identify areas of high risk, and to immunize women of child-bearing age in those areas. For countries where NNT is a widespread problem, the first priority should be to raise coverage for pregnant women and non-pregnant women of child-bearing age through routine immunization sessions. Major improvements are required in NNT surveillance, while in all countries where NNT is a problem, IT immunization should be better focused on high-risk areas. Current operational problems in NNT elimination include ensuring safe sterilization and injection procedures, and ensuring clean deliveries at every level.

- 51 Recommendations: (1) Reaching the Regional NNT goal for 1995 of one case of NNT per 1000 live births per year at the provincial level requires a reliable system of NNT surveillance to be established. All countries in which NNT continues to be a problem must establish systems for surveillance that will report cases of NNT occurring at the subdistrict level in high-risk areas.

(2) The focus should be on high-risk areas particularly where clusters of NNT cases occur, or where there is low access to clean delivery when planning IT immunization activities. (3) The policy of one sterile syringe and needle for each injection of IT should be strictly adhered to. If IT is used during immunization days, adequate supplies and adequate time for sterilization must be given to immunization posts. (4) Countries must be prepared to provide adequate resources, supervision, trained staff, transport, equipment, and vaccine for those high-risk areas that are sometimes overlooked because of their distance from government centres. (5) All tetanus toxoid administered through routine or supplementary activities should be recorded by dose. 4.3.8 Measles control

Measles continues to be the EPI target disease with the largest impact on childhood morbidity and mortality in the Region. Outbreaks of measles, with high case fatality rates, continue to occur, especially among the unimmunized in high-risk areas and populations. Routine coverage with measles vaccine has decreased slightly in the Region in 1993 over 1992. Recommendations: (1) The highest possible routine coverage with a single dose of measles vaccine for children 9-11 months of age should be achieved and maintained.

(2) To reduce overall mortality due to measles, measles complications should be treated aggressively and in a timely way, including the use of vitamin A for cases of measles on admission to hospital. (3) Measles vaccine should only be included during national immunization days after careful consideration of the additional human and financial resources needed. If given during NlDs, measles vaccine should be given to children 9-23 months of age in high-risk areas. (4) Wherever possible, measles surveillance should be integrated with existing AFP surveillance mechanisms. 4.3.9 Cold chain and logistics

Progress in improving EPI sterilization and injection practices in several countries was reported, most notably Lao People's Democratic Republic, which has conducted practical training for peripheral level staff and provided additional injection equipment. However, while several countries have started planning activities, no country has yet prepared a national plan of action to eliminate incorrect EPI sterilization and injection practices. Field trials of domestic refrigerator modification are currently under way. However, despite the increased use of locally produced equipment, no country has yet developed national cold chain standards.

- 52 The importance of monitoring cold chain activities was emphasized and suggested methodologies presented. In particular, the use of standard formulae to calculate vaccine requirements and the development of standard equipment lists for each level and standard supervisory check-Iis~ were discussed. Recommendations: (1) Before the end of 1994, all countries should prepare national plans of action to eliminate incorrect EPI sterilization and injection practices by the year 2000, based on the Regional plan of action. (2) To improve injection equipment logistics, routine monthly reporting of needle and syringe stocks at all levels should be instituted on standard EPI reporting forms, as is done for EPI vaccines. (3) All countries should institutionalize routine collection of information on indicators for the cold chain and logistics system. 4.3.10 Additional support requirements

The TAG gratefully acknowledges the contribution of the Interagency Coordinating Committee for its outstanding support for EPI and poliomyelitis eradication activities. Without the contributions of Rotary International, AIDAB, ]lCA, the Government of Japan, CIDA, CDC, USAID, UNICEF and the many other multinational and bilateral agencies and NGOs the successes achieved to date would not have been possible. In the last year, additional resources have been provided by the countries themselves and members of the ICC, particularly for NIDs and OPV. Rapid improvement of surveillance systems in the countries and the laboratory network will be required for poliomyelitis eradication and certification. Additional funding is needed to effect these changes in the short time remaining before the 1995 target date. While the OPV supply situation is greatly improved, OPV shortfalls still exist for some countries. Continued and increased allocation of funds from national and international sources will be essential to continue acceleration of poliomyelitis eradication activities and to achieve the neonatal tetanus and measles disease reduction goals.

FIFTH MEETING OF THE TECHNICAL ADVISORY GROUP ON EXPANDED PROGRAMME ON IMMUNIZATION AND POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Manila, Philippines 25·2' April 1994 Time Monday, 25 April Registration 1. Opening ceremony Tuesday, 26 April S. Introduction of the Vaccine Independence Initiative 6. Neonatal tetanus elimination

WPRIEPIIEPIII194.1·A 14 April 1994 ENGLISH ONLY TIMETABLE Wednesday, 27 April Thursday, 28 April 13. Presentation of conclusions of small group meetings 14. Interagency Coordinating Committee (ICC) Friday, 2' April 15. Draft swnma..,. of conclusions anCl recommendations 16. Presentation of R!:Iional ~Iiomy.elitis eradIcation Ield guide

0800 0830 to 0930

1l.Evaluation of national immunization days !a~ Introduction

b Country reports

09.30 • 10.00 10.00 2. Global EPI overview 3. Regional EPI overview (including Laboratory) 12.00 to 4. Country reports 12.00 • 13.30 13.30 to 15.00 7. Measles control 8. Cold cbain and sterilization practices

K 17. Finalization of summary report of conclusions and recommendations 18. Closing ceremony

II. Evaluation of national immunization days (b) Country reports (continuation)

14. ICC (continuation)

VI W

12. Small group meetings 4. Country reports (continuation) ,. Acute Flaccid Paralysis surveillance issues: bow to improve surveillance

PI C

GroUI! A DISCussion on Cambodia 2 Cross border coordination

14. ICC (continuation)

&~B issues (I) --tory 0 F F E E B

15.00 • 15.30 15.30 to

Country~

(continuation)

,. AFP surveillance issues: (continuation) 10. Brief introduction on certification of poliomyelitis eradication

12. Small Jlrou/: meeti:'i (continuatIon) Groups &: B) ~mllil ~ (I) -"ccUle quality is.~ues

14. ICC (continuation)

17.00

> Z >< m Z

18.30

Dinner hosted bt the Regional Direc or

- 55 -

ANNEX 2

LISf OF PARTICIPANTS

TECHNICAL ADVISORY GROUP (TAG) MEMBERS Dr Hokuto Hoshi2 Chief of Planning General Affairs Division Bureau of Health Policy Ministry of Health and Welfare Government of Japan 1-2-2, Kasumigaseld, Chiyoda-ku Thk)'.Q Japan Professor Nguyen Van Man 3 Director Poliomyelitis Vaccine Research and Production Center 135 Lo Duc Street Hanoi Viet Nam Dr Robert Hall National Center for Epidemiology and Population Health Australian National University Canberra, 0200 Australia

Dr Isao Arita Chairman Agency for Cooperation in International Health 4-11-1 Higashi-machi, Kumamoto-shi Kumamoto City 862 Japan

Dr Kenneth J. Bart Director National Vaccine Program Office Parldawn Building 5600 Fishers Lane Rockville, Maryland 20857 United States of America Dr Wang Zhao 1 Deputy Director Department of Epidemic Prevention Ministry of Public Health 44 Hou Hai Bei Yan Beijin~ 100725 China

ITo attend as representative of Dr Dai Zhicheng, Director, Department of Epidemic Prevention, Ministry of Public Health 2To attend as representative of Dr N. Sakai, Chief, Division of Health Promotion and Nutrition, Ministry of Health and Welfare, Japan. 3To attend as representative of Professor Hoang Thuy Nguyen, Director, National Institute of Hygiene and Epidemiology, Viet Nam.

- 56Annex 2

EPI NATIONAL MANAGERS MALAYSIA Dr Devan Kurup Assistant Director of Health Epidemiology Unit (EPI and ARI) Division of Disease Control Ministry of Health Kuala Lumpur Malaysia PAPUA NEW GUINEA Dr James Wangi Regional Epidemiologist Primary Health Services Division Department of Health P.O. Box 3991 Boroko Papua New Guinea PHILIPPINES

CAMBODIA Dr Oum Sophal Director National Centre for Hygiene and Epidemiology Ministry of Health Phnom Penh Cambodia Dr Mean Chhi Vun Deputy Director and National EPI Manager National Centre for Hygiene and Epidemiology Ministry of Health Phnom Penh Cambodia CHINA Dr Yang Baoping Chief of EPI Division Department of Epidemic Prevention Ministry of Public Health 44 Hou Hai Bei Yan Beijing 100725 China LAO PEOPLE'S DEMOCRATIC REPUBLIC Dr Somthana Douangmala Deputy Director National Institute of Hygiene and Epidemiology Ministry of Public Health Vientiane Lao People's Democratic Republic Dr Phengta Vongprachanh Department of Epidemiology National Institute of Hygiene and Epidemiology Ministry of Public Health Vientiane Lao People's Democratic Republic

Dr Ma. Otelia D. Costales Officer-in-Charge Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila VIETNAM Professor Le Dien Hong Director Department of Hygiene and Environment and National EPI Manager Ministry of Health 138A Giang Vo Street Hanoi Viet Nam Dr Doan Thi Tam Director National Centre for Quality Control Vaccines Hanoi Viet Nam Dr Nguyen Van Bien Medical Officer Expanded Programme on Immunization Ministry of Health Hanoi Viet Nam

- 57 Annex 2

REGIONAL REFERENCE LABORATORY STAFF

Ms Margery Kennett Virology Department Collaborating Centre for Virus Reference and Research Fairfield Hospital Yarra Bend Road Fairfield, Victoria Australia Dr M. Arita Director Department of Viral Disease and Vaccine Control National Institute of Health 4-7-1 Gakuen Musashi-Murayama Tokyo 208 Japan Dr F. Chino Director Department of Safety Research Center for Biologics Control and Research National Institute of Health 4-7-1 Gakuen Musashi-Murayama Tokyo 208 Japan Dr So Hashizume Director-General Japan Pol iomyelitis Research Institute 34-4, Kumegawa 5-Chome H igashimurayama-shi Tokyo 189 Japan Dr Tatsuo Miyamura Director Department of Virology II National Institute of Health 1-23-1 Toyama Shinjuku-ku Tokyo 162 Japan

Dr Zhang Ubi Chief National Laboratory for Poliomyelitis 100 Ying Xin Jie IQQQ52 Beiiine China Dr Mark Pallansch Enterovirus Section Respiratory and Enteric Viruses Branch Division of Viral and Rickettsial Diseases National Center for Infectious Diseases Centers for Disease Control and Prevention Atlanta, Georgia 30333 Vnited States of America Dr H. Yoshikura

V niversity of Tokyo Faculty of Medicine Department of Bacteriology 7-3-1 Hongo, Bunkyo-ku Tokyo 113 Japan

- 58 Annex 2

OBSERVERSI REPRESENTATIVES ASIAN DEVEWPMENT BANK Dr J. Jeugmans * Health Specialist Asian Development Bank 6 ADB Avenue 1501 Mandaluyon& Metro Manila Dr B. Loevinsohn Health Specialist Asian Development Bank 6 ADB Avenue 1501 Mandaluyon& Metro Manila AUSTRALIAN INTERNATIONAL DEVELOPMENT ASSISTANCE BUREAU (AIDAB) Ms Margaret Thomas Second Secretary Development Assistance The Australian Embassy Salustiana Ty Tower Ist to 5th floors 104 Paseo de Roxas Makati Metro Manila Mr Alan March Acting Director Pacific Island Section South Pacific and Training Branch Australian International Development Assistance Bureau AIDAB House, 62 Northbourn Avenue Canberra, A.C.T. 2601 Australia Dr Quentin Reilly AIDAB Consultant Austral ian International Development Assistance Bureau AIDAB House, 62 Northbourn Avenue Canberra, A.C.T. 2601 Australia

AFRICA Dr D. Barakamfitiye Director Disease Prevention and Control Regional Office for Africa Brazzaville The People's Republic of the Congo REGIONAL OFFICE FOR SOUTH-EAST ASIA Dr Kaushik Banerjee Assistant Commissioner (Immunization) Ministry of Health and Family Welfare Government of India Nirman Bhawan New Delhi - 110 041 India Dr Md Abdul Majid Project Director, EPI Directorate General of Health Services Dhaka, Bangladesh Dr Nyoman Kandun EPI Manager Directorate General of Communicable Disease Control and Environmental Health, Ministry of Health Jlo Percetakan Negara 29 Jakarta - Pusat Indonesia Dr Ye Hla c/o Deputy Director (Epidemiology)

Department of Health 36, Theinpyu Street Yangon, Myanmar Dr Supamit Chunsuttiwat Division of General Communicable Diseases Department of Communicable Disease Control Ministry of Public Health Samsen Road, Bangkok 10200 Thailand

*Unable to attend.

- 59 Annex 2

Ms lanine Constantine Senior Program Officer United Nations and International Programs International Organisations and Public Affairs Branch Australian International Development Assistance Bureau AIDAB House, 62 Northbourn Avenue Canberra, A.C.T. 2601 Australia

CANADIAN INTERNATIONAL DEVEWPMENT AGENCY Mr Robert Beadle Counsellor (Development) and Head of Aid Canadian Embassy Allied Bank Building 6754 Ayala Avenue Makati Metro Manila Mr Ronald Baird First Secretary (Development) Canadian Embassy Allied Bank Building 6754 Ayala Avenue Makati Metro Manila Ms Nide Marie Bombay CIDA Advisor Canadian Embassy Allied Bank Building 6754 Ayala Avenue Makati Metro Manila

CAMBODIA Dr Chea Kim Ly National Centre of Hygiene and Epidemiology Phnom Penh Cambodia Ms Ly Nareth Pharmacist/EPI Cold Chain Chief-Central Medical Store National Centre for Hygiene and Epidemiology Phnom Penh Cambodia

CENTERS FOR DISEASE CONTROL (CDC) Dr Stephen Lee Cochi Chief Poliomyelitis Eradication Activity Centers for Disease Control and Prevention Atlanta, Georgia 30333 United States of America Mr Robert Keegan Public Health Advisor Poliomyelitis Eradication Activity Centers for Disease Control and Prevention Atlanta, Georgia 30333 United States of America

JAPANESE GOVERNMENT Dr Norihiko Yoda Second Secretary The Embassy of Japan 375 Sen. Gil J. Puyat Avenue Makati Metro Manila

JAPAN INTERNATIONAL COOPERATION AGENCY (JICA) Dr Kazuo Kusumoto Chief Adviser Poliomyelitis Control Project in China Japan International Cooperation Agency Room No. 11 I, Beijing Fortune Building 5, Dong San Huan Bei-Lu Chao Yang District Beijin~

China Dr T. Chosa Japan International Cooperation Agency clo Embassy of Japan Vientiane Lao People's Democratic Republic

·60Annex 2

JAPAN PEDIATRIC ASSOCIATION Dr A. Amano Born-Shiba-Park-l102 2-12-6 Shiba-Daimon Minatoku, Tokyo 105 Japan NATIONAL MEDICAL CENTRE, JAPAN Dr Y. Chiba Medical Doctor International Cooperation Division National Medical Centre Tokyo Japan PASTEUR INSTITUTE, FRANCE Dr Radu Crainic Head WHO Collaborating Centre for Reference and Research on Poliomyelitis Institut Pasteur 28, Rue Du Dr Roux 75724 Paris CEDEX 15 France PHILIPPINES Ms L. Agripa Nurse VI Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila Ms J. Angeles Regional Nurse Coordinator Expanded Programme on Immunization National Capital Region for Health Department of Health San Lazaro Compound Sta. Cruz Manila Dr A. Benegas Medical Specialist II Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila

Engineer B. Bersola Engineer III Maternal and Child Health Service Department of Health San Lazaro Compound Sta.Cruz Manila Dr J. Ducusin Medical Specialist II Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila Dr E. Felarca Regional Immunization Offices National Capital Region for Health Department of Health San Lazaro Compound Sta. Cruz Manila Dr M. Ybanez City Health Officer Quezon City Dr A. Luz City Health Officer Manila Ms J. Libiran Statistician II Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila Dr C. Lucman Medical Specialist II Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila Ms A. Ma\lari Nurse VI Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila

- 61 Annex 2 Ms F. Mendoza Administrative Officer III Maternal and Child Health Service Department of Health San Lazaro Compound Sta.Cruz Manila Ms R. Niola Health Program Officer II Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila Ms F.J.E. Paladin Head Virology Section Department of Health Research Institute for Tropical Medicine Alabang, Muntilupa Metro Manila Dr G. Papa City Health Officer Caloocan City Mr A. Perez Sentinel Nurse Field Epidemiology Training Program Department of Health San Lazaro Compound Sta. Cruz Manila Dr P. Ubial Medical Specialist I Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila Dr G. Abad-Viola Medical Specialist II Field Epidemiology Training Program Department of Health San Lazaro Compound Sta. Cruz Manila Ms F. White Program Coordinator Field Epidemiology Training Program Department of Health San Lazaro Compound Sta.Cruz Manila

ROTARY INTERNATIONAL Dr E.G.P. Haran Regional Advisor Rotary International Polio Plus Program A-l/49, Safdarjung Enclave New Delhi - 110 029 India Mr Masami Hiraoka Regional Coordinator ASIA PolioPlus Task Force Rotary International 64-7-5 Ayazono, Takaishi-city Japan ~

Mr Brian Knowles 43/17 Bayview Street Runaway Bay 4216 Oueensland Australia Ms Mim Neal Manager Media Relations Rotary International One Rotary Center Evanston, Illinois 60201-3698 United States of America Dr W. Grattan O'Connell Regional Coordinator PolioPlus Task Force Rotary International 9 Stoneyroyd Gardens Auckland 5 New Zealand

- 62Annex 2 Mr Noraseth Pathmanand UNITED NATIONS CHILDREN FUND (UNICEF) Ms Riitta Poutiainen EPI Project Officer UNICEF Phnom Penh Cambodia Dr Alexander Malyavin EPI Project Officer UNICEF Vientiane Lao People's Democratic Republic Dr Wilfredo Varona Project Officer for EPI UNICEF 106 Amorsolo Street, Legaspi Village 1229 Makati Metro Manila Dr Kayode S. Oyegbite Senior Project Officer (Health) UNICEF Hanoi Viet Nam UNITED STATES AGENCY FOR INTERNATIONAL DEVEWPMENT (USAID) Ms Patricia Moser Chief Office of Population, Health and Nutrition United States Agency for International Development Roxas Boulevard Manila

clo Sinovest 7 IF Sibunruang I Building 283 Silom Road Bangkok 10500 Thailand Dr Sabino Santos Santos CliniC (Malolos) Inc. Malolos, Bulacan Philippines Dr William Sprague 2150 Lake Michigan Drive, N.W. Grand Rapids. MI 49546 United States of America Dr Edward Trainer PolioPlus Program Manager The Rotary Foundatiun of Rotary International One Rotary Center Evanston, Illinois 60201-3698 United States of America TASK FORCE FOR CHILD SURVIVAL AND DEVEWPMENT Dr Michael Heisler Director of Programs The Task Force for Child Survival and Development One Copenhill Atlanta, Georgia 30307 United States of America UNITED NATIONS DEVEWPMENT PROGRAMME Ms M. Wandel of the United Nations Development Programme in the Philippines P.O. Box 2865 1068 Manila

- 63 Annex 2 VIETNAM Professor Ha Ba Khiem Director Pasteur Institute Ho Chi Minh City Viet Nam Professor Nguyen Ai Phuong Director Hygiene Epidemiology Institute in Highland Viet Nam Professor Nguyen The Tram Director Pasteur Institute Nha Trang Viet Nam Mr A. Schnur Technical Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Ph ilipp ines Mr C. Maher Technical Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr V.M. Postila Medical Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr J. Kool Associate Professional Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr R. Sanders Short-term Consultant Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr Sima Huilan Regional Adviser Health Laboratory Technology WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr M. Otten, Jr. Medical Officer Expanded Programme on Immunization WHO Representative's Office United Nations Building 2 Dongqijie 9 Sanlitun, 100600 Beijing, China

SECRETARIAT

Dr B.P. Kean Acting Director Disease Prevention and Control WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr S. Omi Regional Adviser Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines DrJ. Bilous Medical Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines

- 64 Annex 2 Mr F.D. Rousar Technical Officer Expanded Programme on Immunization WHO Representative's Office 3rd Floor YWCA Sukuna Park ~

Dr l.W. Lee Director Global Programme for Vaccines World Health Organization Geneva Switzerland Dr F. Gasse Medical Officer Global Programme for Vaccines World Health Organization Geneva Switzerland Dr H.F. Hull Medical Officer Global Programme for Vaccines World Health Organization Geneva Switzerland Dr B. Hull Medical Officer Global Programme for Vaccines World Health Organization Geneva Switzerland Dr l. Milstien Scientist Global Programme for Vaccines World Health Organization Geneva Switzerland Dr Jon K. Andrus Medical Officer/Poliomyelitis World Health Organization Regional Office for South East Asia World Health House New Delhi India

Fiji

Dr M. O'Leary Epidemiologist WHO Representative's Office 3rd Floor YWCA Sukuna Park ~

Fiji Dr R. Nesbit Medical Officer Expanded Programme on Immunization WHO Representative's Office Vientiane Lao People's Democratic Republic Dr L. Kuppens Associate Professional Officer Expanded Programme on Immunization WHO Representative's Office Vientiane Lao People's Democratic Republic Dr R. Tangermann Medical Officer Expanded Programme on Immunization WHO Representative's Office San Lazaro Compound Sta. Cruz Manila Philippines Dr B. Moriniere Medical Officer Expanded Programme on Immunization WHO Representative's Office Hanoi Viet Nam Dr K. Toda Medical Officer Expanded Programme on Immunization c/o Pasteur Institute Ho Chi Minh City Viet Nam

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Technical Documents

Date d'adoption 31 décembre 1994

Source Organisation mondiale de la santé