Thirteenth Meeting of the Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication in the Western Pacific Region, Manila, Philippines, 4-7 November 2002 : report

(WP)IICPIEPII5.2/00 I-A

Report series number:

RS/2002lGEJ lO(PHL)

English only

REPORT THIRTEENTH MEETING OF THE TECHNICAL ADVISORY GROUP ON THE EXPANDED PROGRAMME ON IMMUNIZATION AND POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 4-7 November 2002

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines January 2003 WHV/\\ •. JL• . "

\

MANILA, PHlLIPlllNEi

o MAR 2003

. NOTE

The views expressed in this report are those of the participants of the thirteenth meeting of the 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. The Expanded Programme on Immunization, WPRO would like to thank Japan Government Voluntary Contribution (JGVC), who provided fmancial support for the meeting including the production of this document.

Keywords: Poliomyelitis - prevention and control I Epidemiologic surveillance - standards I Immunization programmes I National health programmes I Certification I Western Pacific This report has been printed by the Regional Office for the Western Pacific of the World Health Organization for the participants in 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 4 to 7 November 2002.

SUMMARY

The thjrteenth meeting of the Technical Advisory Group (TAG) on the Expanded Programme on Immunization (EPI) and Poliomyelitis Eradication in the Western Pacific Region was held from 4 to 7 November 2002 in Manila, the Philippines. This was attended by the members of the TAG, Chairman, Vice Chairman and three other members of the Regional Certification Commission (RCC), EPI and surveillance managers from countries within the Western Pacific Region, representatives from regional and national poliomyelitis reference laboratories, international organizations, other partners in poliomyelitis eradication, and a secretariat. The TAG provides the World Health Organization (WHO) technical advice in relation to all aspects of EPI in the Region. Presentations and discussions were held covering four main areas: maintenance of poliomyelitis-free status, measles elimination, hepatitis B control, maternal and neonatal tetanus elimination (MNTE), and developing comprehensive EPI systems. Now that the Region is maintaining its poliomyelitis-free status, new flagships are needed to provide the engine to drive EPI in the Region. The TAG recommended the twin flagships of measles elimination and hepatitis B control. Both diseases are one of the main causes of death and disability in the Region, and in the case of measles, elimination is possible in the medium-term. The TAG endorsed the recommendation of the Meeting of Technical Experts on Measles, Seoul, Republic of Korea, 30 April-2 May 2002, that measles elimination is the appropriate goal for measles control. The target date for elimination will be set througb an annual review process, hOd requires the political commitment engendered by a Regional Committee resolution. Hepatitis B, with its important disease burden in the Region, provides an appropriate twin control initiative to measles. Improving hepatitis B control requires strengthening of routine services, including the quality for routinely reported coverage data (including for a timely birth dose, where scheduled). While strengthening of routine immunization is also important for measles, there is a need for special focus so that both initiatives help to establish the foundations for a comprehensive development of EPI systems for the long-term. Maintenance of poliomyelitis-free status remains a priority, as does achieving MNTE in the six countries of the Region where it is still a public health problem. Achieving all these aims requires a broad strengthening of EPI in all countries and areas of the Region. Changes in global vaccine supply mean that new emphasis is also needed to ensure vaccine security in the Region. Since the twelfth TAG meeting in August 2001, progress has been achieved in the maintenance of poliomyelitis-free status in the Region; at the same time, significant progress has been made towards strengthening routine immunization, controlling and eliminating measles, controlling hepatitis B, conducting safe immunization, eliminating MNTE and introducing new or under-utilized vaccines. The TAG made detailed recommendations on these issues to help guide and strengthen the EPI in the Region. The challenge now is for WHO to help countries and areas to effectively implement these recommendations.

CONTENTS

1. INTRODUCTION ................................................................................................................... 1 1.1 Objectives ..................................................................................................................... 1 1.2 Organization ................................................................................................ ,................ 2 1.3 Opening ceremony ........................................................................................................ 2

2 PROCEEDINGS ...................................................................................................................... 3 2.1 2.3 2.4 2.5 2.6 Regional EPI overview ................................................................................................. 3 Measles: moving towards elimination ........................................................................ 16 Hepatitis B control ...................................................................................................... 25 Maternal and neonatal tetanus elimination ................................................................. 26 Developing comprehensive EPI systems .................................................................... 30

2.2 Poliomyelitis eradication initiative ............................................................................... 8

3. INTERAGENCY COORDINATION COMMITIEE .......................................................... 36

4. NATIONAL MANAGERS' SESSION ................................................................................ 37 5. CONCLUSIONS AND RECOMMENDATION .................................................................. 37 5.1 Overall EPI ................................................................................................................. 37 5.2 Poliomyelitis eradication initiative ............................................................................. 38

5.3 Measles: moving towards elimination ....................................................................... 40 5.4. Hepatitis B control ...................................................................................................... 42

5.5 Maternal and neonatal tetanus elimination ................................................................. 43 5.6 Developing comprehensive EPI systems .................................................................... 44 5.7 Immunization Safety ................................................................................................... 45 5.8. Vaccine Security ......................................................................................................... 46

6. ACKNOWLEDGEMENTS .................................................................................................. 47

ANNEXES: ANNEX I ANNEX 2 ANNEX 3 TIMETABLE ................................................................. .49 LIST OF PARTICIPANTS ................................................. .51 PROGRESS REPORT ON COUNTRIES NON-ENDEMIC AT THE BEGINNING OF THE INITIATIVE ........................... 63 GLOBAL ALLIANCE FOR VACCINES AND IMMUNIZATION AND REGIONAL WORKING GROUP FACT SHEET...................................................... 69

ANNEX 4

1. INTRODUCTION

The Technical Advisory Group (TAG) on the Expanded Programme on Immunization (EPI) and Poliomyelitis Eradication was established in 1991. Its technical guidance was a critical element for the Western Pacific Region achieving certification of poliomyelitis-free status on 29 October 2000. The twelfth meeting of the TAG (Manila. I3 to 15 August 2001) resulted in further recommendations on maintaining poliomyelitis-free status. in addition to providing guidance on measles control. maternal and neonatal tetanus elimination (MNTE) and safe immunization. The Region continues to maintain its poliomyelitis-free status and make progress in control of other vaccine preventable diseases. A recent milestone was the inclusion of hepatitis B vaccine in every national immunization programme (NIP) in the Region. In addition. regional plans for safe immunization and MNTE were developed in 200 I and reviewed and endorsed at the last TAG meeting. As EPI in the Region enters a new era of post-poliomyelitis eradication. it is now time to build for the long-term strengthening of routine EPI systems as an essential foundation for control of all the EPI diseases. Therefore. the focus of the TAG meeting was to be on strengthening and developing comprehensive EPI systems building upon the successes and great infrastructure of the poliomyelitis eradication activities. and on identifying a replacement flagship for EPI that poliomyelitis had been until certification of poliomyelitisfree status. 1.1

Objectives

The TAG held its thirteenth meeting at the WHO Regional Office for the Western Pacific in Manila, Philippines from 4 to 7 November 2002. with the following objectives: (1) to review the situation of the EPI in the Western Pacific Region. including poliomyelitis eradication following the Region's certification of poliomyelitis-free status;

(2) to make recommendations for sustaining the poliomyelitis-free status of the Region. including prevention of circulating vaccine-deriVed poliovirus (cVDPV) and spread of importation of wild poliovirus. and continuation of laboratory containment; (3) to make further recommendations on objectives and strategies towards the reduction of vaccine-preventable diseases. including the control and elimination of measles and neonatal tetanus. based upon review of the epidemiological situation and the progress made since the twelfth TAG meeting; (4) to make recommendations on strategies for achieving and/or sustaining high quality NIPs in the Region. including immunization safety. management of vaccine supply and cold chain. and introduction and expansion of new vaccines; and (5) to disseminate information on the latest developments in EPI and disease control and elimination.

- 21.2 Organization

The meeting was attended by 117 participants and observers. These included six TAG members; five members of the Regional Certification Commission (RCC); and 106 representatives from 15 Member States including 23 national EPI managers and surveillance managers, 14 from the national and regional reference laboratories, 13 representatives of international organizations, two from WHO's Regional Office for South-East Asia, 22 from other partners in poliomyelitis eradication and 32 from the secretariat. The timetable of the meeting and list of participants are in Annexes I and 2, respectively. 1.3 Opening ceremony

Dr Shigeru Omi, the WHO Regional Director, welcomed all the participants, especially the many colleagues who had been involved with EPI for so many years. He commented on the perception by some that those 'polio times' were the peak for BPI, with less emphasis being given to EPI compared to other communicable diseases and increasing emphasis on non-communicable diseases. However, he countered that this is only a perception and the WHO Regional Office for the Western Pacific maintains EPI as an important priority. Dr Omi discussed the reason for this perception and the need to reinvigorate EPI. Until the historic moment in Kyoto on 29 October 2000, when the Region was certified as poliomyelitis-free, the Polio Eradication Initiative (PEl) was the flagship for the EPI. The PEl engendered and delivered the highest level of political commitment throughout the Region. Of course, maintaining poliomyelitis-free status remains a priority until global certification, but EPI needs a new flagship to generate political commitment; to be the engine to power EPI and continue preventing BPI disease and improve the health of children in the Region.

Dr Omi asked the TAG members to help WHO to identify the new flagship to guide and reinvigorate EPI throughout the Region. A proposed new flagship would be a dual attack including measles elimination and hepatitis B control. There is adequate scientific evidence to support these two accelerated disease control initiatives, but this evidence needs to be translated so that the public can understand the feasibility and benefits of these initiatives and political support can be obtained. Both measles and hepatitis B control need consistently high immunization coverage through routine EPI services, but each has some additional requirements that complement each other. Measles is the next disease being targeted for global control and eventually eradication. The Region has already made considerable progress in the control of measles, including elimination in some countries and areas. However, measles remains an important preventable cause of death and disability in the Region. Hepatitis B causes about as many deaths in the Region as does tuberculosis (TB) (estimated at about 800 and 1000 per day, respectively). However, hepatitis B control has not been given the same attention as TB because of the failure to advocate for it and to explain the magnitude of the health burdens caused by hepatitis B. The failure to promote awareness about this health burden is complicated by the fact that the consequences of hepatitis B infection are often delayed and indirect and thus, the disease impact is not as readily visible as the impact of other diseases. Innovative approaches to inform the international community are needed to increase the attention and investment in hepatitis B disease control initiatives. As well as the maintenance of poliomyelitis-free starus, MNTE needs to continue, as does safe immunization. Again. Dr Omi reiterated that the new flagship could strengthen EPI and this improved EPI would allow for disease control and elimination initiatives to be effectively delivered.

- 3-

Dr Omi closed his speech by reminding the TAG members and meeting participants how the poliomyelitis initiatives had obtained its high profile through the passing of the resolution by the Regional Committee. He then expressed his willingness and interest in introducing the new EPI flagships to this Regional Committee through a similar process, emphasizing however, that in order to gain this political commitment, there needs to be careful technical consideration and agreement on their feasibility and appropriateness as regional initiatives. Dr Omi encouraged a fruitful TAG meeting discussion and thanked the TAG in anticipation for establishing new flagships and for helping WHO establish the solid technical foundation needed for these flagships to gain political commitment. The following TAG members were selected to serve as officers for the meeting: Chairman Vice-chairman Rapporteur Dr Isao Arita Dr Robert Hall Dr Steve Cochi

2 PROCEEDINGS

2.1

Regional EPI overview

Since the twelfth TAG meeting (August 2(01), maintaining the Region's poliomyelitisfree status remains the highest priority of national EPI programmes. At the same time, more efforts have been given to strengthening routine immunization, accelerating measles control, eliminating MNTE, conducting safe immunization, and introducing new/under-utilized vaccines. For the meeting, country reports were developed using a new approach: a standardized questionnaire that included requesting comment and checking of country information previously submitted to the EPI Unit of the WHO Regional Office for the Western Pacific as well as asking additional questions to cover the breadth of EPI. The aim was to improve the quality and range of the data held by the EPI Unit of the WHO Regional Office for the Western Pacific and to improve data use for managing programmes. The Region has 37 countries and areas divided into two blocks: the 21 Pacific island countries and areas (PICs) and the other 14 countries and two areas. In this report, information from the 16 countries and areas (excluding the PICs) are presented and for the sake of simplicity the two areas are referred to as countries. Thus, 14 of the 16 countries replied to the question on the priority that EPI is given within health services; of these 12 replied that it was of high priority and two that is was of medium priority. Some key indicators for the 16 countries are presented in Table I, showing the wide diversity of the Region. One of the issues brought out by the country reports was the difference between different sources of data on the number of births - a critical number as the denominator for coverage (Table 1). The key source of population data are the regular censuses, and these are undertaken every five or 10 years in most countries.

-4-

Table 1. Country basic data, ranked by per capita gross national product

Coontry

~bodia Lao People's Democratic RB!lublic Vietnam MonQolia China Papua New Guinea Philippines Malaysia ~blic 01 Korea New Zealand Brunei Darussalam Maceo ~ustralia

GNP 260

Year Last Next Births Births (As EPIINIP popu'ation population Births (2001 used for Difference IMR started census census 1%) StatisticsI coveraeel in births 9f 1986/ 1998 3.8% 49777! 40954.< 88231

35( 37 39 78( 51( lOS( 339< 849< 1399< 1418( 1418! 209s( 241S( 2507 32030

a; ~

Sf

1982 1981 1962 197E 1977 197E 19801 196C 195C 198' 199, 1931

1995 1999 2000 200( 200(

200s 2009 2004 2010 2010 200s 2010 2005 2006 2011 2011 2006 2011

3' 7f 2f lC

200c 200(

, E

f ,

f

200c 2001 2001 2001 2001 200(

Sin08DOre Hono Kono Japan

,

,

2001 2000

2002

3.4% 179 sa; 188 195 -8613 2.0°(. 1559748 1486472 73276 1.9% 48634 48~ 0 18118 11489 1.4% 105 731 6628374 2.4% 129741 15896C -29219 2.6°(. 2005406 2316977 -311 571 2.2% 504 716 518100 ·13384 1.3% 602483 636 78C ·34297 1.4°(. 52170 7363 2.1% 7363 0 392! 0.7°,\ 3241 ·684 1.3% 249636 245 59~ 4043 4188( 41880 1.0'% 0 0 49144 49144 0.7% 0.9'% 1171 482

GNP = Gross national product per capita in US$. IMR= infant mortality rate per 1000 live binhs. Binhs (%) = Number of 2001 binhs as percentage of total population from statistics data. Difference in binhs = Number of binhs recorded in the WHO Regional Office for the Western Pacific database (statistics) minus number of binhs reported in the WHOlUnited Nations Children's Fund (UNICEF) Joint Reporting Form as used for coverage calculation. Note: Hong Kong and Macao are special autonomous regions of China, but treated as 'countries'. Reported immunization coverage has been consistent!y high in the Region since the late 1980s, at around 95% for BCG, OPT3, OPV3 and measles vaccines. The 2001 reported immunization coverage was 93% for BeG, 95% for OPT3, 94% for OPV3, 95% for measles and 72% for 172+ for pregnant women. Recognizing the limitations of reported coverage, since 1999 countries have also been asked to report on the 'official estimate' of coverage. For most countries there is no difference between coverage reported and the official estimate. However, China (whose large population drives the regional average) reports a difference leading to the estimated 2001. Thus, using the 'official estimate' leads to a 2001 Regional coverage of 77% for BeG, 80% for OPT3, 79% for OPV3, 81 % for measles, and 72% for 172 (Figure 1 shows OTP3 coverage.).

-5Cases

45000 -411,000 35,000

--------

:;--=::::;=~ll-

eov.r...

)0 . 000

25,000 20,000 15.000

.... 20%

10,000 5,000

M

~

n

n n

~

•

81

~

"

"

e

~

~

Figure 1. Regional reported DPT3 coverage and diphtheria cases It is preferable to use the best estimate for monitoring coverage. although this has created a problem of apparent decline in coverage - not in fact considered to be a true decline, but merely using more realistic estimates. The TAG commended those countries that had the courage to use estimates that were more accurate even though it then gave the appearance of declining coverage. The Region's countries can be categorized into three groups: (1) sustained high immunization coverage [Australia, Brunei Darussalam, China, Hong Kong, Japan, Macao, Malaysia, Mongolia (Figure 2), New Zealand, Pacific island countries, Republic of Korea, Singapore and Viet Naml; gradually increasing coverage [Cambodia (Figure 3) and possibly Lao People's Democratic Republic - but recent trends indicate a decline]; and declining coverage [papua New Guinea (Figure 4) and the Philippines]. Philippines coverage has been declining since the early 1990s, with a further drop in 2001 due to vaccine shortages.

•

n

~

~

~

n

~

~

~

~

~

~

00 01

(2)

(3)

Of the 10 countries with recent coverage surveys, half found coverage surveys with similar results to the administrative method, two had higher coverage in the survey (because immunization delivered in the private sector is not always captured by administrative reporting) and three had lower coverage, indicating problems with the administrative reporting system for monitoring coverage. Many countries expressed concern about data quality and delays in receipts of routine reports. Renewed efforts are needed to improve the quality of routinely reported data in many countries.

- 6-

=c~~,~ ~ I. =n~n... nn mm. nnm:!.'_f~:__ .....{.n. ~ i··~·_::.········-··········)·. ~::::·i:··~··Jl'.-............

.........n......... .......... n..

.

I . '"I . '

e:l l;;:J

I .;/.............................................................. .

i

Figure 2. Reported BCG, DPT3, HepB3, and Measles Coverage, Mongolia

mo..

"'" n .... n ................ nnnn...................... n.................

jT~----- -,----.. _---- . . -'-n •••• : . . . . . . . . . . . . . . ..

.......,.

I..I.· ..........• ..•.........•....••........:c.,c......•.......... n

"'" j. . . . . . . . . . I ~~m

~ ~: :~ ... n ...

. n .. ,"

-

"-

... ---,...-- ....

............... .

~. L . . . . . . . . . . . :. ~. n..... . . .........: ....... ,........................................... ..... ~~---.. ~ -

I n

.... m .. m ...mm ... mnm .. nn .. mm..... m ... mm .. mm ....... nm ........... m .. nn........ nm

Figure 3. Reported BCG, DPT3, and Measles Coverage, Cambodia

100"" ...-.,.

I .... n ............. n ...............

j

: . ,. t .. · ~+

.. .. n .............. n .. n .......I 1 1

: i

i. . .-.--- . . . ...

mm...:~..mm .....m . . ~/. nm· ......~'·. ;,::·~. ·:...... ·~....·. . '. r--"

l'~'\ ~.a--....

.• . I I lm;.:.::::'~:JI' r~'-;;:BC:OO"-'

"'.. f.....n ............ :/.~>C;;:..·:....................n....L>. ~:1. i ----.-.....___ /" ,/ Xl'llo

-'

.... n ...... n ... , ~ I j .

---DTP3 Me..'e,

_..

~,•••••••...• -•••••••• : ••••

/

•

!:. . ....... . . . . . . . . . . . . . . . . . . . . _ . . . . . . . . . . . ._ . . . . . . . . . . . .

Figure 4. Reported BCG, DPT3, and Measles Coverage,Papua New Guinea

-7A key aspect to improving national coverage is to review and act on sub-national coverage data. Countries reported reviewing coverage data annually (5), quarterly (4), every two months (1), and monthly (1) - the five other countries did not respond to that question. Only seven countries reported 2002 coverage data to be available by the first quarter of 2003 (when it is needed for the WHOIUNICEF Joint Reporting Form), highlighting the problem of timeliness. A key indicator for immunization coverage is DPT3. Its relation to disease incidence at the regional level is.shown by the decline in reported diphtheria cases (Figure), although the data depend on surveillance quality. Outbreaks of diphtheria were reported in Mongolia with 128 cases in 1995 and Lao People'S Democratic Republic with 319 cases in 1996. Large-scale immunization responses controlled diphtheria outbreaks in Mongolia in 1995 and Lao People's Democratic Republic in 1996. Another outbreak was reported from Lao People's Democratic Republic in 2002, which is not surprising given the low DTP coverage. Papua New Guinea also has low DTP coverage and reported 645 diphtheria cases in 1998 and 311 cases in 2001. Although Viet Nam has very high reported coverage, there were 133 reported cases from Viet Nam because of areas of low coverage. There were also 73 reported diphtheria cases from the Philippines in 2001. Country reports highlighted similarities and differences between EPI services: • All but five countries plan to develop a new multi-year strategic plan between 2002 and 2006, and all but one country reported an annual workplan was in place for 2002. Eight countries plan an EPI review in 2002 or 2003. Immunization services are provided primarily by nurses in nine countries, doctors in three countries, and health workers in three countries. Most countries deliver immunization mostly or exclusively in the public sector, but over half of EPI immunizations are delivered in the private sector in Australia and the Republic of Korea. No user fees are charged for traditional BPI vaccines delivered in the public sector in any country except in China; user-fees are charged for hepatitis B vaccine in Singapore (but covered by health insurance) and for locally-procured hepatitis B vaccine in the Philippines (government supply has been inadequate to cover the entire country). Four countries provided information on the percent of health services expenditure that is spent on EPI, ranging from 0.1 % (the Philippines) to 9% (Cambodia); but nine countries provided information on total EPI spending. Dividing that total by the number of births provides an estimate of spending per birth ranging from US$3 (Philippines) to $129 (Japan). Adequacy of funding is a major issue for BPI in several countries, but II countries had vaccines as a line item in the national budget, and 10 countries a budget line item for injection supplies. Six countries provided estimates of the cost to fully vaccinate a child, which varied from US$2 in the Philippines to US$150 in New Zealand (but New Zealand did not provide a figure on total BPI spending); this range reflecting different cost structures and inclusion of different costs in the estimates. Costing studies were undertaken in Cambodia, Lao People's Democratic Republic, and Mongolia in 200 1 or 2002, and yielded similar estimates of the cost to fully immunize a child at U5$17. U5$18, and U5$22, respectively.

• •

•

•

•

•

-8-

•

Priority needs for EPI programmes were wide ranging, but common themes were: increased funding and financial sustainability, maintaining high immunization coverage, disease control activities, cold chain maintenance and improvement, introduction of immunization registers, and injection safety disposal.

2.1.1 Global developments relevant to the Region At the global level, WHO is involved in every stage of preventing disease through immunization from basic research to delivery to the child. This includes advocacy to make vaccines less expensive and adapted to developing country needs; establishing norms and standards for vaccines; strengthening national regulatory authorities assure vaccine quality: and supporting programmes to reach every child with needed vaccines. A major milestone for the Global Alliance for Vaccines and Immunization (GAVI) in its goal of reaching every child is for 80% of developing countries to achieve at least 80% in all districts by 2005. In 200 I, 36 million children were not immunized with three doses of DTP, 5.2 million of whom were in the Region. It is estimated that it will cost an average of about US$35 per year to immunize these children, suggesting a global shortfall for investment in immunization of over US$1 billion every year. This compares to just over US$1 billion in GAVI's Vaccine Fund to cover a five-year period, with well over half of that money going to new vaccines as opposed to strengthening services. These figures outline the extent of the shortfall even after taking into consideration the GAVI investment. As well as starting to address some of this shortfall, GAVI has a milestone of introducing hepatitis B vaccine in 80% of all countries with adequate delivery systems by 2007. Hepatitis B vaccine was part of the national immunization schedules in 20 countries in 1990; 136 countries by 2001; and in 153 in 2002. Despite this achievement, the global coverage remains relatively low at under 40% for three doses of hepatitis B vaccine. However, in the Region, hepB3 coverage is relatively close to that of DTP3 and reported at 68% in 2001. The uptake of Haemophilus influenzae type b (Rib) vaccine has been slower, in part because of the vaccine's cost, and in part because there is limited evidence to show that it is a public health problem in Asia and Eastern EUrope. 2.2 Poliomyelitis eradication initiative

2.2.1 Global status Global progress in 2001 continued with a reduction in the number of countries with endemic transmission from 20 to 10 [under conditions of adequate acute flaccid paralysis (AFP) surveillance]; and an 80% decline in the number of cases (2979 to 483). It has now been three years without poliovirus type 2 globally; and Bangladesh and Democratic Republic of Congo have been poliomyelitis-free for more than two years. In 2002, wild poliovirus transmission continues in three high transmission areas (India, PakistaniAfghanistan and NigerialNiger) and three low transmission areas (Hom of Africa, Egypt and Angola). Despite the challenge brought on by the geopolitical events, Afghanistan and Pakistan have improved both AFP surveillance and supplementary immunization activities during the past two years. In both countries, the resources and infrastructure for poliomyelitis was also used to provide broader humanitarian relief, and has managed to not only prevent resurgence, but brought both countries close to interrupting wild poliovirus transmission.

- 9-

The fifth documented outbreak of poliomyelitis from cVDPV was reported from Madagascar in 2002. As with previous outbreaks, this was the result of low immunization coverage (<37% OPV3 coverage in 1999) and poor AFP surveillance (reporting rate of 0.4). The outbreak again emphasizes the importance of maintaining surveillance and immunization coverage. On 21 June 2002, the WHO European Region was the third Region (after Americas in 1994 and Western Pacific in 2000) certified as poliomyelitis-free. An estimated 3.4 billion people (56% of the world's population) now live in 134 countries and territories certified poliomyelitis-free.

2.2.2 Progress of poliomyelitis eradication in the South-East Asia Region AFP surveillance in Bangladesh, India and Nepal is facilitated through a network of surveillance medical officers (SMOs) who receive specialized training and are responsible for assisting the local health authorities in a defined area. As of June 2002, India had 239 officers, Bangladesh had 33, and Nepal had 14. Since 2000, Bangladesh, India and Nepal have exceeded non-polio AFP rates of 11100 000, with adequate specimens taken from > 80% of AFP cases, thus achieving certification-quality AFP surveillance at the national level. Since the last wild poliovirus positive cases occurred in Bangladesh (August 2000) and Nepal (November 2000), India has been the only country in the South-East Asia Region with indigenous wild poliOVirus transmission. India reported a total of 268 wild-virus confirmed poliomyelitis cases in 2001 compared to 265 cases in 2000. From January through October 2002, India reported 854 wild-virus confirmed poliomyelitis cases. As of 5 November 2002, 790 type 1 wild poliovirus confirmed cases and 62 type 3 wild poliovirus confirmed cases from 107 districts were reported with intratypic differentiation (ITO) for 97 cases still pending. The basic strategies of AFP surveillance and intensive OPV campaigns to supplement routine immunization programmes have proved successfnl in eradicating poliomyelitis in nearly all states of India, the other nine countries of the South-East Asia Region and around the world. In order to interrupt transmission in northern India, innovative measures will be needed to increase community involvement and improve the quality of supplementary immunization activities (SlAs). The principal reasons for failing to immunize children during immunization campaigns are: (1) failure of immunization teams to correctly identify all eligible children; (2) poor or non-existent field supervision in many areas; and (3) poor participation of families in underserved communities. New approaches were implemented in India from late 2001, including: (I) deploying follow-up vaccinator teams to find and immunize children missed by primary teams; (2) increasing the number of SMOs working in high-risk districts; (3) changing the ratio of supervisors to vaccination teams during SIAs from 1:5 to 1:3 in selected high-risk areas; (4) creating a network of social mobilization persons at the district, block and village levels to generate demand and promote acceptance of immunization; (5) re-training of vaccinators and supervisors to improve interpersonal communication skills; (6) forming a national operations group comprised of Ministry of Health and national and international partners to facilitate rapid implementation of strategic decisions; and (7) increasing the number of field monitors and more extensive analysis of available data on SIA quality.

- 10-

2.2.3 Update on situation in the Western Pacific Region The Regional Commission for the Certification (RCC) of the Eradication of Poliomyelitis in the Western Pacific Region submitted its' progress report on the Region maintaining poliomyelitis-free status to the Global Commission (GeC) for the Certification of the Eradication of Poliomyelitis. During its seventh meeting, held in Geneva on 12 April 2000, the GeC reviewed and endorsed the report of the RCC. The GeC commended countries of the Western Pacific Region on their achievement and concurred with the Regional Commission's rmding on countries' successful efforts to sustain and document poliomyelitis-free status following regional certification, but urged all countries that have not yet completed phase I laboratory containment activities to reach this important milestone by the end of 2002. The eighth meeting of the RCC immediately followed the TAG meeting from 7 to 8 November 2002. 2.2.3.1 AFP surveillance performance

As of 2 November 2002 a total of 5125 AFP cases were reported (compared to 3958 reported for the same period in 200 I) - an annualized regional AFP reporting rate of 1.3 per 100 000 population aged under 15 years (under-ISs). All except one recently poliomyelitis-free country meet the AFP reporting target of I per 100 000 under-15s per year. Papua New Guinea has an annualized rate of 0.48 for 2002. For countries that were poliomyelitis-free at the start of the initiative, all except Australia, New Zealand and Singapore, are meeting the AFP reporting target. Regionally, 87% of AFP had adequate stool collection rates, exceeding the 80% target. China, Mongolia, the Philippines and Viet Nam also met the target, and Cambodia, Lao People's Democratic Republic and Malaysia had rates above 60%. Regionally, 79% of AFP cases with inadequate stool sample collection had the 6O-day follow-up for residual paralysis - just short of the 80% target set by the Global Technical Consultative Group (TCG). Australia, Cambodia and Papua New Guinea were below target. During its last meeting, the TAG recommended that countries should track AFP cases pending final classification after 90 days of onset of paralysis. Currently 5% of the overall number of AFP cases have not yet been classified after 90 days following onset; with no country reporting rates above 20%. As requested by the TAG during its last meeting, presumptive diagnoses are now assigned for all AFP cases reviewed by the expert panels. Several countries (mainly the ones poliomyelitis-free at the start at the initiative but also Malaysia and the Philippines) aim to have a final diagnosis available for all AFP cases. Several expert panels review all AFP cases to ensure that clinical information is concise and case documentation complete. This provides important clinical information for causes of AFP other than poliomyelitis; particularly when adequate stool sample collection is below required standards. There were five poliomyelitis compatible AFP cases (from China) reported in the Region in 2002 through October. Potential cases of vaccine associated paralytic poliomyelitis (VAPP) were investigated in Cambodia, China, Japan, Malaysia, the Philippines and Viet Nam. All poliovirus isolates are supposed to be subjected to two lTD methods, one antigenic and one molecular. ELISA testing capacity has been established at all Regional Reference Laboratories (RRL) and reporting to the WHO Regional Office for the Western Pacific by

- 11 individual lTD method has commenced. Poliovirus isolates with non-conclusive lTD results are subjected to sequencing of the VPl region. Searches for potential VDPVs included retrospective virological analysis. Almost all ITD results (99%) are available within 28 days of receipt ofisolates at the laboratories but the required 80% of lTD results available within 60 days of onset is not yet reached. although significant improvements to 79% in 2002 to date (compared to 47% in 2(01) have been made. particularly in China. AFP surveillance in the Philippines improved in 2002. following the 2001 VDPV outbreak. with all regions except one reporting at least 1 per 100 000 under-ISs. Adequate stoOl collection exceeds 80% in all but two regions. 2.2.3.2 Laboratory network

The poliomyelitis laboratory network continues to function at good quality levels. with 87% of laboratory results available within 28 days of specimen receipt at the laboratory in 2001. and 91 % in 2002 (up to 31 October). Reporting timeliness lower than 80% is noted in the National Poliovirus Laboratory (NPL) in New Zealand and four sub-national laboratories in China. Ninety-five percent of lTD results were available within 14 days after receipt at the RRL and 99% lTD results were available during the current standard of 28 days after receipt. In 2001. all RRL have been visited and fully accredited. All NPLs have also been reviewed in 2001; seven were fully accredited (Hong Kong. Malaysia. New Zealand. Papua New Guinea. Philippines. Singapore and Viet Nam South). one was provisionally accredited (Viet Nam North) and for two laboratories (Mongolia. Republic of Korea) accreditation was kept pending until the first quarter of 2002. The NPL in Korea was subsequently fully and the NPL in Mongolia provisionally accredited. All but one (Tibet) of the 31 sub-national laboratories in China were shown to be operating at WHO accreditation standards in 2001. In 2002 to date. two RRLs [China Centres for Disease Control (CCDC). Beijing; and the National Institute for Infectious Diseases (NIID). Japan] were already visited and reviewed and fully accredited. The review of the third RRL [Victorian Infectious Disease Research Laboratory (VIDRL). Australia] is planned for December 2002. Six NPLs were visited and reviewed (Hong Kong. Malaysia. Mongolia. Philippines. Singapore. Viet Nam North) and fully accredited. The review of the NPL in New Zealand is scheduled for December 2002. The NPL in Viet Nam South was also visited but accreditation is pending as a passing score was not achieved in the most recent isolation and identification proficiency test (PT). A detailed action plan was developed and specimens are currently tested in parallel at the RRL in Australia. As the NPL in Papua New Guinea did not achieve a passing score in the most recent PT. arrangements continue for parallel testing at the RRL in Australia and have been made for performance review and recommendations towards repeat PT and accreditation in November 2002. with the review planned either at the end of 2002 or in early 2003. All other laboratories passed the isolation and identification PT during the first distribution. Technical support was provided in close collaboration with the Centers for Disease Control and Prevention in Atlanta (CDC) and NIID in Tokyo to the RRL in Beijing to conduct genetic sequencing procedures; phylogenetic analysis of sequence data; and facilitate introduction and use of the screening enzyme-linked immunoassay (EIA) developed by RIVM.

- 12 In order to increase lTD capacity in the Region, the NPLs in Hong Kong and Singapore were reviewed and found to be operating at very high quality standards; accreditation is still pending, however, as new P3 EUSA reagents were only recently received and the PI still has to be passed once testing methods are fully established. 2.2.3.3 Immunization

Supplementary immunization activities with OPV were conducted in 200112002 in Cambodia, China, Mongolia, Philippines, and Viet Nam. In Cambodia, OPV was included in the measles supplementary immunization activities (see Measles country report). China conducted two rounds of sub-national immunization days (SNIDs) in December 200l and January 2002 in 27 provinces targeting almost 29 million children under four years of age and achieving a reported coverage of 98%. Two additional rounds, with emphasis on reaching unimmunized children in high-risk and low coverage areas, were conducted in MarchiApril 2002 in 105 counties and 12 prefectures in the provinces of Xinjiang and Tibet These rounds targeted 900 000 children of the same age group also aChieving a reported coverage of 98%. Following identification of a cluster of AFP cases and suspected transient circulation of VDPV in Sichuan in mid-2002, two rounds of supplementary immunizations are being implemented in eight prefectures in Sichuan, Guizhou and Yunnan Provinces. Viet Nam conducted supplementary immunizations in November and December 2001 in 36 districts in 12 provinces along the southwest border of the country. Over 550 000 children under five years of age were targeted and a coverage of 97.8% reported. In response to the isolation of a poliovirus type 1 with 0.8% divergence from Sabin strain (still Sabin-like under the current definition) in an AFP case in Da Nang supplementary immunization has been implemented in two districts targeting about 13 000 children under five years old. 2.2.3.4 Laboratorv containment

Further progress was made in laboratory containment of wild poliovirus infectious/potentially infectious materials with Australia and the Philippines having completed a national inventory of wild poliovirus infectious/potentially infectious materials. Australia is planning to reorganize its containment database before the end of 2002 to also have types of laboratories included which will serve as an important step towards assessment and validation of the containment process. Although close to completion of the national inventory in 2001, Malaysia validated its denominator figures of institutions and laboratories and identified additional ones to be included in the search, which prolonged the completion of the national inventory (now expected to be completed by the end of 2(02). China and Japan still require more time due to the large number of laboratories to be searched. As the second edition of the global containment action plan (GAP II) is now available, important modifications have been incorporated into the regional action plan (previously amended in 1999). Progress has also been made at the global level in developing quality assessment tools for confirming the quality of poliomyelitis laboratory containment activities and the draft validation tools could successfully be tested in two countries in this Region.

- 13 -

2.2.4

Country reports on sustaining poliomyelitis-free status 2.2.4.1 Cambodia

A recent cluster of Sabin-3 positive AFP cases has led to concerns about the possible emergence of VDPV(not yet confirmed), particularly since routine OPV 3 coverage remains a problem. Therefore, OPV supplementary immunizations will be given with the measles and tetanus toxoid (IT) supplementary immunization activities, and also in stand-alone OPV immunization activities in selected high-risk areas. The same successful techniques used in previous SNIDs and high-risk response immunization (HRRIs), such as a rolling schedule to ensure adequate supervision and use of mobile tearns continue to be employed in all supplementary immunization activities. The stool collection is reasonable (between 70% and 80%), but has never surpassed the threshold of 80% because of the relatively underdeveloped health and transport infrastructure. To compensate, AFP active searches are undertaken in low performance areas, and AFP clusters monitored and investigated. Central level monitoring of surveillance activities in low-performance areas and expanding private sector into AFP surveillance network are also being undertaken. 2.2.4.2 China

During 200 I and the fIrst eight months of 2002, 634 polioviruses were isolated from 9000 AFP cases. No wild polioviruses or VDPVs with >1 % base-pair differences from Sabin reference strains were detected. A cluster of three cases of paralysis was detected in 2002 in Panzhihua and Luzhou Prefectures in Sichuan Province. The cases and three contacts all had a Sabin virus with three identical base-pair changes in the VPI sequence and one additional identical basepair change in the contacts. No additional unreported AFP cases were found. Coverage in residents was found to be 83% but only 63% in floating children. The cases and contacts involved in the Sichuan cluster do not fIt any of the current case defmitions; there is a need to clarify the defInition of, and appropriate response to, cases of VAPP, contact VAPP and circulating VDPV. Two rounds of high-risk response immunization were conducted in eight prefectures in October and November 2002 in response to the cluster. In all, 28 million children 0-3 years of age will be targeted for SlAs during the winter of 2002 through the spring of 2003. China plans to continue large-scale SlAs to prevent circulation of imported and vaccine-derived poliovirus.

2.2.4.3

Lao People's Democratic Republic

Lao People's Democratic Republic maintains its AFP surveillance performance and has strengthened it with supplementary activities in 2001 and 2002. These activities have succeeded in fInding missed cases that invariably have inadequate stools, and thus reduce the adequate stool rate. Reporting completeness and timeliness from provinces to the central level is good, but there is a lack of information about AFP reporting completeness and timeliness from districts to provinces. The new performance requirement for 2002 that at least 80% of AFP cases be classifIed within 90 days of onset is a challenge for Lao People's Democratic Republic, but the performance for 2001 and so far in 2002 has been close to 80%. The most important areas for improvement relate to the timeliness of 6O-day follow-up investigations, and the frequency of

- 14-

National Certification Committee (NCe) meetings (to conduct expert review for pending cases). Clustering of AFP cases continues to be monitored. Thus far, clustering of cases does not raise concerns about circulating poliovirus. Similarly, poliomyelitis-compatible cases are not a cause for concern in Lao People's Democratic Republic. Laboratory results for 200 1 and to date in 2002 confirm good surveillance performance. The proportion of specimens yielding non-poliomyelitis enteroviruses is above 20% for both years. Only one poliovirus isolate has been isolated in the past two years. VDPV currently does not appear to be a problem in Lao People's Democratic Republic. Coverage for OPV3 has declined steadily since 1997. The decline is related to the reduction in frequency and scope of SlAs, underscoring the reality that routine immunization coverage is not presently capable of maintaining high coverage levels on its own. 2.2.4.4 Malaysia

Despite overall adequacy of AFP surveillance, adequate stool specimen collection rate of 80% has yet to achieved. Expert panel review of all AFP cases is therefore undertaken to ensure a final diagnosis other than poliomyelitis. An analysis for possible VDPV of all poliomyelitis isolates from AFP cases since 1997 found only Sabin-like isolates. National coverage for OPV3 has been maintained at over 90% since 1996 and this rate has also been achieved by all 130 districts in 2001. The national coverage further improved to 96.7% in 2001. Reported lower coverage in Kuala Lumpur attributed to a large proportion of immunizations given by the private sector and not included in the coverage reports has been assessed by a coverage survey conducted in 2000 and the results confirmed that 89% of children had completed their third dose of OPV and DPT before the age of one. The process of laboratory containment of wild poliovirus infectious and potentially infectious materials is progressing well. Survey forms were sent to 447 agencies and institutions involved in the search, and out of these, 423 agencies replied returning 513 questionnaires. To assess the containment process, inspection visits have been made to 24 government and private laboratories. 2.2.4.5 Mongolia

In provinces with sub-optimal surveillance indicators for the past five years, special stool surveys were conducted to evaluate the sensitivity of the surveillance system. All polioviruses detected in 2001 and 2002 (n=8) were Sabin-like. Catch-up immunization campaigns with OPV were conducted in May and October 2001 and 2002, despite very high routine coverage, as children of migrant populations do not usually register in new areas they settle in and as a result, about 5% to 6% of children (3000 to 4000) each year do not receive routine immunization. The national inventory of wild poliovirus infectious/potentially infectious materials was established in 2001. Materials were only identified in one facility (a NPL) and were destroyed. In addition, research materials consisting of 189 vials of non-polio enterovirus (NPEV) isolates were destroyed since there was no record that these samples had tested negative for poliovirus.

- IS -

2.2.4.6

Papua New Guinea

The AFP reporting rate decreased from 1.62 per 100 000 under-ISs in 1998 to 0.77 in 200 I and 0.2 in 2002. The lack of commitment and understanding of the need for continuing AFP surveillance after certification is the main reason for the decline in AFP surveillance. Late reporting and investigation of the cases remains a problem, leading to delay in stool collection. No case has been followed up yet in 2002, after the improvement to 88% in 2001. The situation has been affected by other factors including a worseuing socioeconomical situation and lack of operational funds for disease control and EPI; law and order problems and increased safety risks for health workers; frequent turnover of the trained staff in health facilities and provincial health offices; communication and transportation problems; and diluting of commitment to the AFP surveillance by other duties and priorities. The NPL performance declined due to personnel, management and structure problems, so it was not able to achieve a passing score in the 2002 PT, first distribution reaching a final score of 60%. Several basic organizational steps have been taken to improve the situation and the head of the RRL in Australia will visit in mid-November 2002 to review in detail the work practices at the laboratory and make recommendations on required improvements towards accreditation. When performance levels are confirmed as good again, a repeat PT will be provided and once a passing score has been achieved, the next accreditation visit will be scheduled. Shipping stool samples regularly to the RRL for parallel testing has commenced. The NPEV isolation rate is 10%, and 90% of all laboratory results in 2002 were available within 28 days of receipt. There were no polioviruses isolated from AFP cases but two P3 isolates from the aseptic meningitis study were confll1Iled as Sabin-like by the RRL. Both the National Immunization Policy and National Policy on Cold Chain and Logistics were published in 2000, giving priority to improving the routine immunization coverage. The new system of distribution of vaccine has been introduced and 90% of cold chain equipment changed over the country. However, in spite of this, the routine coverage has been falling since 2000, outreach services have collapsed and the situation is made even more difficult with deteriorating infrastructure and the government's inability to financially support the programme due to financial crisis. The programme further faced personnel problems recently when the national EPI manager left the position without notice and financial shortcuts and telecommunication problems let to the cutting of all telephone lines in the Department of Health. Finally the loss of the vertical structure significantly affected the performance. The coverage for OPV3 dropped to 30% in 2001 and is expected to continue its fall in 2002 due to election problems. 2.2.4.7 Philippines

The Philippines effectively responded to the 2001 cVDPV outbreak with a successful house-to-house operation countrywide (pPFMIC - Philippines Polio Free Maintenance Immunization Campaign) reaching 12.1 million children under five years of age with two doses of OPV in February and March 2002. The nation-wide door-to-door strategy was implemented in high-risk areas where circulation of VDPV might be happening, while others not considered high-risk adopted the fixed site approach. Major steps taken by the Department of Health following PPFMIC are (1) signing an agreement with UNICEF securing a continuous supply of vaccines to the Philippines (already on-going); and (2) establishing a five-year Strategic Plan proposed and developed with WHO and UNICEF as a major initiative to strengthen and facilitate coordination of all immunization activities in the country for the next five years.

- 16The national inventory of wild poliovirus infectious/potentially infectious materials was completed but the laboratory containment data in its present fonn require considerable validation to ensure completeness and accuracy of the national inventory. Laboratory visits need to be conducted to validate responses of laboratories claiming to have potentially infectious materials in storage or claiming to have none or have already destroyed them. 2.2.4.8 Viet Nam

Supplementing the AFP surveillance system that is meeting all targets, active search in all provincial and district hospitals identified a total of 25 previously unreported AFP cases. Training programmes for health care workers and follOW-Up visits by regional and national staff are been carried out regularly to ensure all cases are reported. In 2001 and 2002, a total of nine AFP cases with Sabin poliovirus isolates were reported from eight different provinces. Regional staff conducted an active search in theses reporting provinces to look for potential unreported AFP cases related to the cases. Following visits to major laboratories, no new infectious or potentially infectious materials for poliovirus have been identified to date. 2.2.4.9 Non-endemic countries

For progress report for countries that are non endemic at the beginning of the initiative [Australia, Brunei Darussalam, Hong Kong (China), Japan, Macao (China), New Zealand, Pacific island countries and areas, Republic of Korea, Singaporel, please refer to Annex 3. 2.3 Measles: moving towards elimination

2.3.1 Regional overview Measles continues to be an important cause of death and disability in Cambodia, Lao People's Democratic Republic, Papua New Guinea, Philippines, Viet Nam and parts of China. Papua New Guinea reported over 7000 cases during the 200 112002 epidemic resulting from low immunization coverage. Measles is estimated to cause at least 17 000 deaths and 177 000 cases in the Region. This represents a reduction in mortality and morbidity of over 95% and 90%, respectively compared to the pre-vaccine era. The challenge is to now complete the task and obtain the full potential that measles immunization offers: elimination (interruption of indigenous transmission). Several countries in the Region have already established measles elimination targets, and Australia, Mongolia, the Pacific island countries, and the Republic of Korea have all probably achieved elimination - at least for some time. Elimination is only temporary if high levels of population immunity are not maintained (see below for definition of elimination). In Mongolia, low immunity among young adults has allowed re-establishment of virus transmission after several years of elimination (see Mongolia's report). As it is much easier to achieve elimination for a short period, the role of globally or regionally coordinated activities needs future consideration. During 2001 and 2002, 11 of the PICs conducted nationwide campaigns following up their 1997-98 campaign; Cambodia, Lao People's Democratic Republic and Viet Nam have conducted sub-national campaigns as part of the multi-year implementation of a nationwide campaign. The Philippines also conducted a campaign in the National Capital Region, the area with the highest incidence of measles.

- 17 While surveillance activities progress and continue at the country level, the WHO Regional Office for the Western Pacific is only now starting to coordinate and develop a regional measles surveillance system and database. A measles surveillance database for country level has been developed and installed in Cambodia, China, Lao People's Democratic Republic and Viet Nam. The Regional Measles Laboratory Network is not yet fully operational, but close to being so as the accreditation and coordination details are being finalized. Already, 36 (97%) of the 37 countries/areas of the Region have access to an officially designated National Measles Laboratory. There is also one officially designated RRL (VIRDL, Melbourne), with CCOC in Beijing, and NIID in Tokyo soon to be designated. 2.3.2 Meeting of Technical Experts on Measles As recommended by the twelfth TAG meeting, a Meeting of Technical Experts on Measles in Seoul, 30 April to 2 May 200 1 addressed several issues related to measles control. The main conclusion was that the Region should aim for measles elimination, but that it is premature to establish a regional target date for elimination. l Therefore, annual reviews of progress in measles control should be undertaken in order to establish a regional measles elimination target date. However, national elimination can be achieved and maintained, and is worth doing without waiting for regional elimination; just as regional elimination is worthwhile ahead of global elimination. There is global consensus on the key strategies needed for measles control:

1. deliver the first dose of measles vaccine to children by 12-15 months of age; 2. provide a second opportunity for measles immunization through either routine services or SIAs; 3. conduct active, case-based surveillance; and 4. ensure access to an accredited laboratory for confirmation of diagnosis. The Seoul Expert Meeting also concluded that the current measles vaccines are safe and effective. A single dose of measles vaccine is inadequate to control measles, as it only protects about 85% of vaccinated children, if given at age nine months. A second dose given after the age of 12 months is needed to protect 99% of children. Therefore, all countries need to provide a second opportunity in a manner where practically every child is given measles vaccine. 2.3.3 Role of campaigns For countries that can achieve high coverage with routine services, the second opportunity can be through a second scheduled dose. For other countries, pulse immunization or periodic supplementary activities will be needed. The key point is that practically every child must be reached by the second opportunity - both for disease control and equity. A wide-age range national measles campaign increases population immunity rapidly, and is thus the preferred strategy to prevent disease where it is still prevalent. In countries where older children have less than 95% population immunity, there is a need for campaigns to include them to prevent cohorts entering adulthood with low population immunity that is difficult to address subsequently (see the Australia report). There are limited data comparing the cost of delivering the second opportunity as a scheduled dose in the immunization schedule as opposed to regular campaigns. The Pan American Health Organization estimates that routine one-dose delivery costs US$2.09 per vaccinated child while campaigns cost US$0.99 per vaccinated child.

- 18 -

Studies have been undertaken to estimate the cost of a fully immunized child (FIC) in Cambodia, Lao People's Democratic Republic and Mongolia, with results ofUS$17, US$18, and US$22, respectively. These estimates are in line with estimates from other developing countries. As measles immunization is given at one of five visits in infancy, its cost can be estimated to be about one-fifth of the cost for FIC, or about US$3 to US$4. In Lao People's Democratic Republic, the cost of the measles campaign was estimated at US$0.57 per vaccinated child, using similar methods as had been used to estimate the cost for a FIC. An estimate from Tanzania's measles campaign was similar at US$0.74 per vaccinated child. Thus, the available data suggest that campaigns are less expensive. In addition, campaigns may be able to reach children not reached by routine services. However, campaigns should not be thought of as special events separate from routine services, but a necessary complement for some countries or parts of countries, that is part of the package of routine services, and are better thought of as 'episodic' as opposed to the 'continuous' delivery. Campaigns are also opportunities to strengthen the routine ('continuous') delivery of EPI. Thus, each country needs to develop the appropriate strategies to reach every child rather than debate the merits of 'campaign' versus 'routine'. 2.3.4 Definition of measles elimination and impact of importations The definition of elimination is the same for measles as it was for poliomyelitis: sustained interruption of indigenous virus transmission. But, there are differences in the viruses and surveillance that change the 'battle orders', and global surveillance indicators for certification of measles elimination have not yet been established. Only about one in 200 poliovirus infections in a fully susceptible population leads to paralytic illness, whereas practically every measles infection leads to rash and fever illness. Therefore, a single case of poliomyelitis reflects the same level of virus transmission as about 200 cases of measles. In addition, measles is more infectious than poliomyelitis, so that an importation of measles virus will lead to more secondary infections than with poliomyelitis for the same level of population immunity. Finally, if population immunity is not maintained following elimination, measles circulation may be re-established after an importation. Thus, importations are easier to detect after interruption of indigenous transmission for measles than for poliomyelitis. Measles importations are also more common, so countries will continue to experience measles cases even after elimination is achieved. However, there is no need to respond to a single (or even several) measles cases as would be needed for a single wild polioviruS case, for the reasons given above. Mathematical modelling shows that as long as population immunity to measles remains above 93%, importations will only lead to limited spread (see Figure 5).2 However, as population immunity drops below this level the likely size of the outbreak resulting from an importation increases exponentially. The size of an outbreak arising from an importation can be used as a rough guide to the likely level of population immunity. An outbreak involving less than about 50 people indicates that population immunity is likely being maintained at the level needed to sustain elimination.

• 19·

60

!

It! u 40 ...... 0 ..... 30

ID Ul

50

E 20 ~

z

10

o~r=~~~~~~~~~~ 100.0 98.9 97.9 96.8 95.7 94.7

93.6

Percentage Population Immune Figure S. Percentage of the Population Immune to Measles as a Function of the Number of Cases in a Measles Outbreak (equilibrium point 93.6% for this model).

Guam provided evidence that if a country is able to maintain high levels of population immunity. importations are of limited consequence (see below). Paradoxically. maintaining high population immunity becomes more important as measles is controlled. Otherwise. there will eventually be a large measles outbreak for which neither clinicians nor healtb services are prepared. as measles had been relatively well controlled (as happened in New Zealand in 1984/85. 1991. and 1997). 2.3.5 Measles as an indicator of coverage Measles is the most infectious of the EPI diseases. and measles surveillance provides the ideal indicator on the validity of reported coverage. Measles is so infectious that even poor quality surveillance is likely to identify measles transmission. as it will spread explosively in susceptible populations. Surveillance is vital to control efforts. as the age distribution of cases can identify the susceptible age groups. Epidemiological analysis of the age distribution of cases can provide the same quality of information on the age distribution of population immunity as does a well· conducted serosurvey. 2.3.6 Cross cutting issues The TAG noted that obtaining political and financial support to fully implement the strategies is one of the greatest challenges for measles control in the Western Pacific Region. At least US$16.6 million will be needed just to fund activities that are already planned until 2005. This will be a highly cost effective investment not just for measles control for but also for overall EPI and other health services that need to reach the entire population. Measles provides an opportunity to strengthen all aspects of EPI. including developing the best strategies to ensure that every child is systematically and consistently reached for immunization (as well as other essential public health services). Identifying the appropriate

- 20approach for each country will not only eliminate measles, but also strengthen routine EPI, and can be used for other population health services. For immunization in general, and measles in partiCUlar, there are increasing returns as coverage reaches around 95%, as 'herd immunity' leads to greater reduction in disease than suggested by the increase in coverage, up to the point of elimination. Thus, for measles equity and efficiency are not opposing values that have to be balanced, and developing the infrastructure to reach the population for measles immunization can be used for other health services that aim to disproportionately reach the poor. Measles has already advanced the issue of safe injection in the Region, through the use of auto-disposable (AD) syringes in campaigns. The disposal and destruction of the large volume of used injection materials poses a challenge that needs to be solved from both a health and environmental perspective. Measles also provides an opportunity to strengthen the monitoring of vaccine qUality used in the Region - not only in relation to manufacturing quality of vaccine as it leaves the plant, but also in relation to protecting children in the field. 2.3.7 Setting a regional measles elimination target date The setting of an elimination target date is simply the culmination of work undertaken in the Region over the past several years. The TAG has ensured that the technical preconditions are met to go for measles elimination; now it is up to the Regional Committee to make the political commitment so that elimination can be achieved. Implementation of the key strategies provides a framework for assessing the readiness of the Region to establish a target date for elimination:

Not ready for elimination Ready for elimination (all elements planned) L--=--I- Elimination mode

- 21 2.3.8 Country reports on measles 2.3.8.1 Australia

Measles vaccine, which was introduced in 1968, is now given as MMR vaccine at rwo sCh.edulc:ct episodes and is ~hieving .high coverage. To prevent a predicted epidemic, a natlonwlde measles campaign targeting all primary school children was conducted in 1998 at the same time the second dose of MMR was brought forward from age 12 years to school-' entry (age five years). As a result of the campaign, immunity in school-children was raised from 84% to 94%, and measles effectively e1iminated. In 2001, 135 cases were reported, most with a proven link to an importation, giving an incidence of less than I per 100 000 total population. The major challenge, partly the result of the failure to include older school-aged children in the 1998 campaign, is the spread of measles in young adults. As a result, there has been a nationwide campaign to immunize 18 to 30 year-olds starting in 2000. However, accessing this age group for immunization campaigns is not easy. Maintaining high population immunity in pre-schoolers and school children has meant that importations have not led to large outbreaks, despite the susceptible young adults. 2.3.8.2 Camb<Ktia

Cambodia was the last country in the Region to introduce measles vaccine (in 1986), but intensified measles control from 1999 is already showing dramatic results. Reported measles cases have dropped from 13 827 in 1999 to only 1300 in 2002 (as of October 2002), and surveillance has been improving. Measles is being controlled through a progressive national measles immunization campaign covering the country over three years. The progressive implementation of the national campaign allows adequate supervision to ensure high quality, despite the lack of trained staff. Phase II of the campaign was completed in 2002; Phase ill (the fmal one) will be completed in March 2003. Phase II reached 2 412 141 children aged nine months to 14 years, immunizing 98% of the target population - the largest immunization activity ever undertaken in Cambodia. The cost per vaccinated child was US$I.87, US$2.42, and US$0.S9 in the pilot, Phase I and Phase II respectively. The much lower cost in Phase II reflects the more remote populations having been covered in Phase I, whereas more populous areas were covered in Phase II. Cambodia aims to improve routine coverage and surveillance; consider future options for the second opportunity; and deliver a follow-up campaign in 2006, probably for children aged nine to 59 months. 2.3.8.3 China

Measles incidence in China is now at a historic low as a result of the implementation of the 1998 National Plan of Action for Accelerated Control. Provinces are categorized into three groups based on measles incidence over five years: measles elimination; outbreak prevention; and measles control. An increasing number of provinces in eastern China have moved to a measles elimination or outbreak prevention goal. China currently has a national rwo-dose measles schedule at eight months and seven years of age. There is a plan to realign the EPI schedule and move the national second dose to 18-24 months of age, as well as strengthen monitoring and evaluation of routine second dose

- 22-

measles coverage. A national measles active surveiIlance system integrated with AFP surveiIlance is being established. with training in measles control and surveillance. 2.3.8.4 Guam

Since the 1994 epidemic (228 cases and three deaths reported). Guam has only had sporadic measles cases - all linked to importations. Guam is at risk of importations from tourists (Japan) and migrants (philippines). In 2002. an importation led to an outbreak among unvaccinated pre-school children. The response to the outbreak included active surveillance in the areas around the residence of known cases and outreach vaccination in clinics and villages. An island-wide vaccination campaign was also conducted. targeting children 12-59 months of age. and was successful in reaching over 5000 children. The outbreak was limited because of the high level of population immunity to measles in school-age children. The remainder of the Pacific remains free of measles circulation since 1998. with no spread from Guam. 2.3.8.5 Japan

Japan introduced measles immunization in 1966. changed to MMR in 1989. and discontinued MMR in 1993 because of aseptic meningitis from the mumps component. returning to monovalent measles vaccine. recommended at 12 to 90 months of age. The results have been significant reductions in measles incidence and deaths, with estimates from NIID that there are between 100 000 and 200 000 cases annually and somewhere between 20 and 80 deaths per year. There are about twice as many cases in one year olds compared to two year oIds, and 50% and 80% of cases are immunized in these two age groups, respectively. These data as well as serological data show that the relatively high incidence of measles is the result of delayed immunization as reported coverage has been over 90% since 1994. To improve measles control, it is planned to promote the importance of delivering measles vaccine as soon as possible at the child's first birthday and consider adding a second dose of measles to the immunization schedule. 2.3.8.6 RepUblic of Korea

The Republic of Korea experience demonstrates how an effective national measles immunization campaign conducted in the setting of good control can eliminate measles. Measles vaccine was introduced in 1965, MMR in 1980 and following an outbreak in 1994, a second dose in 1997. The result was a steady decline in measles incidence to very low levels. A measles outbreak started in 2000 because the school-aged population had only been given a single dose of vaccine and had relatively low population immunity. The outbreak caused over 50 000 cases before it was ended by an immunization campaign (using MR vaccine) from May to June 2002. targeting all children aged seven to 16 years (second year primary school through first year high schOOl). Over 97% of the 5.8 million-target population were reached and either immunized (83%) or provided certification of two doses of MMR (14%). In addition a law now requires all children to have documented proof of two doses of MMR for school entry. Surveillance and laboratory data since the campaign indicate that measles may have been eliminated. with only sporadic cases now appearing - likely to have been imponed.

- 232.3.8.7 Lao People's Democratic Republic

Measles. vaccine was introduced at the same time as EPI was initiated in 1982. Reported measles cov~rage ~or children aged nine to 23 months reached a peak of 73% in 1996 as a result of the mciuslOn of measles vaccine during the poliomyelitis NIDs. By 2000, ~overage had fallen bel~w 50~. A national measles campaign was conducted in two phases m 2000 and 2001 targetmg children aged nine to 59 months .. In 2000, a pilot campaign was undertaken in two provinces (about 10% of the target population), and in the remaining provinces in 2001. Reported coverage was over 90% and 85% in 2000 and 2001 respectively. Actual 2001 coverage was more likely 60% to 70%. ' Despite the relatively low coverage, some impact has already been demonstrated by measles surveillance that has been progressively improving since 1995 when it was integrated into the active AFP surveillance system. A national measles laboratory was officially designated in 2001, enabling enhanced outbreak investigation and response from 2002 with collection of blood specimens at selected hospitals and at several outbreaks. Until 1995, reported measles cases and coverage demonstrated only a loose correlation, suggesting deficiencies in the reporting system. Improved surveillance since 1995 shows a three-year epidemic cycle, with an epidemic expected in 2001. However, reported cases in 2001 declined, presumably as a result of the measles campaign. Possible reasons for the campaign's impact despite relatively low coverage and the narrow target age group include reaching previously unreached children; greater impact in areas of low population density; and perhaps relatively good coverage in urban, and other major population areas where most disease transmission occurs. The limited impact of the campaign was demonstrated by two large outbreaks in 2002, but the remainder of the country has continued to have relatively few cases of measles. 2.3.8.8 Mongolia

Mongolia introduced measles immunization in 1973 for 13-month old children. In 1986, it was changed to age eight to 12 months, with a second dose to be given six to 10 months after. A pilot measles campaign in 1994 reached 75% of three- to seven- year-olds in selected area. A national campaign in May 1996 reached 98% of nine month. to IO-year olds; and a followup campaign in October 2000 reached 96% of nine months to eight-year olds. Active measles surveillance was integrated into AFP surveillance in 1996. As a result of high routine coverage, measles had been declining, and following the 1996 campaign transmission was interrupted until an outbreak of rash and fever started in November 1999. This was diagnosed by the national laboratory as measles, but found to be rubella by the reference laboratory. Subsequently, cases of measles have been confirmed by both national and reference laboratories. Over 80% of cases are in 16 to 25 years old - the age group that were too old to have been covered by the initial national campaign as that only targeted children up to age 10 years. Most of the remainder of cases are under one year old, as the rest of the population has high immunity. Mongolia is unusual in having sustained this epidemic in the young adult group.

2.3.8.9

Papua New Guinea

Measles contrOl in Papua New Guinea has deteriorated because of a general decline in EPI. The 2001 EPI review recommended that the government give EPI its highest health priority and the resources to meet the EPI objectives.3 Unfortunately, nothing substantial was achieved before the elections of June-July 2002. The result has been a large measles outbreak in 2001 - 2002.

- 24-

Measles vaccine was introduced in 1982 at nine months of age. Another dose of measles vaccine was added at age six months following the 19S6 epidemic (19 024 reported cases) because many cases and deaths were in children under nine months old. In 1997, a measles vaccine was given to children nine to 59 months old as part of round 2 of the poliomyelitis NID; with a repeat campaign in 1998 for the four provinces with particularly poor coverage; and for Bougainville in 1999. A large measles outbreak started in 2001 in Milne Bay and Port Moresby and has severely affected most of Papua New Guinea. The outbreak has been confIrmed serologically in several provinces and the virus characterized as a D3. From I January to 25 July 2002, there were 3279 reported cases and 167 reported deaths: a 5% case fatality rate. In Mount Hagen Hospital, only 8% of 438 children were immunized; age distribution of 485 admissions was 11 % aged 0 - 5 months old, 36% below age one year, and 54% in the second year of life. Plans for the future include a reassessment of the measles immunization schedule, perhaps stopping the six-month dose and instituting a two-dose schedule at nine months and 12 to 15 months and a school entry requirement. 2.3.8.10 Philippines The Philippines has set a goal of measles elimination by 2008, with the initial "catch up campaign" conducted in 1998 targeting all children from nine months up to 15 years of age. It was reported that 26.5 million children, 96% of the target popUlation, was immunized. However, measles surveillance data in the years following the campaign showed that results were uneven, with poor coverage mainly in overcrowded urban depressed areas of Luzon (the National Capital Region of Metro Manila (NCR]) and other high-risk areas of the country (e.g., Mindanao). The Philippines now plans a Measles Follow-Up Campaign in late 2003 or early 2004, targeting all children from nine months to less than eight years of age (age range selected based on available surveillance data). A bilateral aid grant from the Government of Japan is the basis for securing vaccine requirements for the Measles Follow-Up Campaign. 2.3.8.11 Viet Nam Viet Nam continued to experience measles outbreaks despite achieving and maintaining coverage over 93%, as only a single dose is scheduled at age nine months. Reported cases declined 95% in 1997 compared to 1985, but with enhanced measles surveillance, reported cases have increased since 1997 to a peak of 16000 cases in 2000. Cases have since declined as a result of the campaigns to deliver the second opportunity, using surveillance data to set the target age of nine months to 10 years. An initial pilot campaign was undertaken in 1999, followed by pilots in the other regions leading to a campaign in the 28 northern provinces achieving 99% coverage of nine months to 10- year-olds in March 2002. The campaign used 35 145 vaccination teams (29 092 fIxed teams and 6053 mobile teams) and 224 913 volunteers (People's Committee, Women's Union and Youth's Union). Injection safety was given emphasis during the campaign, including successful use of AD syringes and safety boxes, and only 1% wastage of AD syringes. Approximately I 500 000 doses of measles vaccine with a vaccine vial monitors (VVM) were used in six northern provinces and an assessment of the impact of the VVM was conducted in two mountainous provinces. The VVMs allowed an increase in the average number of doses per delivery from central stores and thus the number of deliveries required; and increase in the number of outreach sessions; and assurance that vaccine was not heat-damaged. No measles

- 25 -

vaccines were discarded due to VVM past discard point. Similarly, no cold chain breakage occurred at the study sites, thus any information on unopened vials to be saved due to the VVM is not available.

In 2003, the remaining 33 southern provinces, targeting about 10 million children, will be covered. In 2005, a second dose will be added to the immunization schedule at age five years. Surveillance is also being enhanced, in addition to the existing integration with AFP surveillance. This is demonstrated by 45 (74%) of the 61 provinces submitting samples to the two national measles laboratories in 2001; 75% of 1337 samples tested positive for measles. 2.4 Hepatitis B control

Hepatitis B vaccine is the only vaccine proven to prevent cancer. Unlike other EPI diseases, the consequences of hepatitis B virus (HBV) infection in childhood do not usually manifest until adult life, from chronic HBV infection. Liver cancer and cirrhosis are the main consequences killing 15% to 25% of people with chronic HBV infection. A safe and effective vaccine has been available for 20 years that can prevent infection and its consequences. Nearly all countries of the Region have moderate to high rates of chronic HBV infection. The Region has about one quarter of the global population, but nearly half of those with chronic HBV infection, and over half of the annual global death toll from HBV, amounting to about 800 deaths every day in the Region. To address this important disease burden, every NIP in the Region had included hepatitis B vaccine in their programme by the end of 2001. However, more work is needed to ensure that the full potential benefits of hepatitis B can be obtained. The EPI Unit of the WHO Regional Office for the Western Pacific developed a draft regional plan to improve hepatitis B control through immunization. A Working Group meeting was convened in Tokyo, 26-28 June 2002, to review the issues and guide the development of the regional plan. The meeting and its conclusions and recommendations together with the latest draft of the regional plan were presented and discussed. Improving hepatitis B is largely about improving routine EPI, as the key to hepatitis B control is achieving high coverage with three doses of hepatitis B vaccine, as delivered through routine services. As such, it provides a suitable engine for reinvigorating routine EPI services throughout the Region. Hepatitis B is particularly appropriate as an EPI flagship for the Western Pacific Region with about a quarter of the global population and nearly half of all the estimated people with chronic HBV infection (carriers). In addition, the Region is estimated to have more than half of the deaths caused by HBV (an estimated 280 000 deaths in 2000 alone). Preventing HBV infection in infancy and early childhood now will have major consequences for the health and economy of the Region as these children enter middle life.

In addition to fully integrating hepatitis B vaccine into the EPI and strengthening EPI, there are two additional key strategies to improve hepatitis B control: • • timely birth dose; and monitoring and evaluation.

Special efforts are also needed for social mobilization and advocacy for hepatitis B because of the nature of the disease. However, the promotion of hepatitis B immunization should be undertaken as part of, and to strengthen, these promotion activities for routine EPI.

- 26Transmission from mother to child is known to be a major source of chronic HBV infection in the Region (estimated at about 40% for China). Hepatitis B vaccine will protect up to 95% of infants from infection; but a timely (within 24 hours) birth dose is needed for greatest efficacy. The fIrst step is for countries to establish systems to monitor timely delivery and then to develop and meet targets for timely delivery, recognizing that many births in the Region occur not only outside hospitals but also are not attended by a health worker. A timely birth dose is the ideal, but it is never too late to give a birth dose. Hepatitis B vaccine should be given at fIrst contact with a health worker, if not given at the time of birth. Unlike other EPI diseases, the impact of immunization on the disease cannot be monitored readily in the short-term by disease surveillance. Therefore, the primary method to monitor is through evaluation of coverage (including for a timely birth dose). A secondary method, and one that will validate that actual benefIts are in line with coverage, is to undertake a serosurvey in those children born after routine hepatitis B immunization was started. The Hepatitis B Working Group proposed that every country should undertake at least one such serosurvey and that chronic HBV infection (HBsAg positive) should be less than 1% in these cohorts. Monitoring coverage for hepatitis B control requires both improving the quality of routinely reported coverage data and using those data so that unreached populations can be identifIed and strategies developed to better serve them. This provides another part of the engine that hepatitis B can provide to routine EPI services: data use and management. Hepatitis B works well as the partner for measles in the new flagship. It relies on routine coverage data for monitoring, and requires systematic analysis and response to coverage data that can complement the response to measles disease surveillance data. As noted above, measles disease is the most sensitive outcome indicator of coverage. In addition, focussing on more than one disease provides a potential bridge to the integration between vertical and horizontal approaches to developing the programmes. The addition of hepatitis B as a flagship requires an attention to the delivery of routine services, and the potential to add other packages of health services as part of the EPL 2.5 Maternal and neonatal tetanus elimination

2.5.1 Regional overview The joint strategy towards MNTE between the UNICEF Regional Office for East Asia and the PacifIc (EAPRO) and the WHO Regional Office for the Western Pacific has led to steady and measurable progress in affected countries. The collaborative approach has proven successful to date and is perceived as being able to serve as a model for other joint activities. In 2001, 3261 cases of neonatal tetanus (NT) were reported from the six countries in the Region where NT remains a public health problem (Cambodia, China, Lao People's Democratic Republic, Papua New Guinea, Philippines and Viet Nam). These countries have not yet achieved the goal ofless than one NT case per 1000 live births at district level. Two thousand six bundred eight cases were reported from China, 283 cases from the Philippines, 165 cases from Cambodia, 104 cases from Viet Nam and 75 cases from Papua New Guinea. Lao People's Democratic Republic reported 17 cases but a survey conducted in 2001 estimated that the NT prevalence is much higher, at least eight cases per 1000 live births.

Since the regional plan of action for MNTE was endorsed during the twelfth TAG meeting in 2001, Cambodia and Viet Nam have developed or updated their national plans of

- 27-

action for MN1E a.nd conducted 11 SlAs for child-bearing aged women. According to the country plan of action and based on progress of implementation, Viet Nam may be targeted for a comprehensive review to validate elimination of MNT by the end of 2003 .. . During a c~mp~hensive international review of the national immunization programme ~ Papua ~ew G~ea 10 Nove~ber 2~1, the MNTE situation was also assessed. Although 10cluded 10 the national health information system (NHIS), surveillance for NT cases appeared to be incomplete and no case investigations and/or immunization response appear to take place if a case is reported. There is no mechanism in place to obtain information on neonatal deaths. In 1998,49 NT cases were reported in 14 provinces. In 1999,73 NT cases were reported in 16 provinces. Most cases (44%) were reported in we national capital district, which may be due to relatively better access to health facilities. particularly hospitals. In 2000, 138 cases were reported in 15 provinces but these figures may contain a data error. The number of reported NT deaths was 23 in 1998.26 in 1999 and 14 in 2000. a fatality rate that appears too low under given case management conditions. There are no case-based data available at the national level.

Reported 112+ coverage for pregnant women was 31 % in 1998, 32% in 1999 and 31 % in 2000. Assessment of reported coverage appears difficult, as the denominator cannot be clearly defined. Limited. supplementary immunization activities for 11 were included during the OPV supplementary immunization activities in 1997 and 1998 but coverage achieved was reported to be very low. In 2000. reported coverage for the first visit of antenatal care (ANCl) was 64% but it must be assumed that figures provided are usually based on women having access to health services. and it is difficult to assess the total number of pregnancies as well as births as birth registration does not exist and most birth registers at health facilities have been abolished.

Of the 164 306 births estimated in 2000. 43% (70 105) took place in bealth facilities. Assuming that all deliveries reported to have taken place at health facilities were attended by trained staff, over 50% of all deliveries were unattended. The Demographic and Health Study of 1996 indicated that most women in urban areas gave birth in health facilities (87%) and had professional assistance (89%). whereas only 43% of deliveries in rural areas had received professional assistance. Unsupervised deliveries Significantly contribute to maternal mortality rates, Which are among the highest in the Western Pacific Region, with bleeding during childbirth being the most common cause of death. The Philippines have conducted a national workshop with the purpose of reviewing the national MNTE initiative in September 2002. A revised plan of action for MN1E is under preparation since the workshop and targeted to be finalized in the first quarter of 2003. The plan will address important issues such as the underreporting of NT cases and deaths and the proper identification of high-risk areas (down to municipality or sub-municipality level), which will be the target for supplementary 11 immunization activities for child-bearing aged women. 2.5.2 Country reports on MNTE 2.5.2.1

CambcKtia

NT is a serious public health problem in CambcKtia due to > 90% of births taking place outside of health facilities. harmful traditional birth practices, low antenatal care coverage, and low routine TT2+ coverage in pregnant women. Two types of NT surveillance have been introduced in Cambodia: facility-based active NT surveillance and community-based

- 28-

surveillance. The NIP has expanded the integrated NT surveillance with the existing surveillance systems for cases of AFP and measles to 40 operational districts by August 2002 . out of 73 opemtional districts in the country. The flrst pilot NT surveillance community-based activities were initiated in 1999 in Chhouk opemtional district in Kampot province. The surveillance activities were mainly focused on the neonatal death case reporting system by health staff and non-health staff (tmditional birth attendants, village chief). The NT surveillance system was expanded with fonnal !mining to staff at provincial, district and health centre levels to flve opemtional districts in 2000, to 11 opemtional districts in 2001 and to 23 operational districts in 2002.

In 2001, 165 NT cases were reported and 85 NT cases in 2002 (up to 10 August 2002). Line listing of NT cases has been developed and maintained at central and provincial levels. The format needs to be updated by the provincial and NIP surveillance officer. A computer database programme was established at the central NIP for management and analysis of the NT situation in the country, including spot mapping, and NIP staff was !mined on data entry, analysis and reporting. A recent review of the current neonatal death and NT surveillance system recommended to conduct better screening of the initial neonatal death reports in order to investigate only the suspected NT cases. The first IT SIAs targeting all child-bearing aged women were implemented in 19992000 in one opemtional district. In 2001-2002 the activities were expanded to cover eight remote operational districts and 225 gannent factories as well as selected slum areas. In 2002 IT SIA are being expanded to eight additional operational districts and seven more opemtional districts will be targeted in 2003. The selection of the operational districts targeted by the SIA has been based upon their identiflcation as high risk opemtionaI districts for NT. In 75 % of the IT SIA rounds, a coverage above 80% of the targeted child-bearing aged women was achieved. The reported IT2+ immunization for pregnant women and child-bearing aged women during the routine ANC or EPI sessions have been mther low for the past seveml years although increasing gradually to reach in 2001 a covemge for IT2+ of 48% for pregnant women and of 29% for child-bearing aged women. A home birth kit was intrOduced after being tested in 1999-2000. Its use has been expanded to more than 150 out of 939 health centres nationwide. 2.5.2.2 China

China has made signiflcant progress in MNTE since 1995 when a national plan of action was developed with three strategies for MNTE: promotion of clean and hospital delivery, NT surveillance and IT immunization for child-bearing aged women (18-35 years old) in high risk areas. In 2001, the State Council issued the National Programme on Children's Development in China for 2001-2010, in which the goal of achieving NT incidence mte at county level of less than one case per 1000 live births by 2010 was set. Increased clean and hospital delivery is the main strategy to achieve MNTE goal in China, and the clean delivery mte and hospital delivery mte at national level in 2000 improved to 95% and 65% respectively. However, high rates of unattended home births in some areas limit this strategy. In 2000-2001, a maternal and child health (MCR) project. with a total budget of US$24 million was funded by the Government to reduce maternal mortality and achieving NTE.

In addition to the MCH Reporting System, NT was made a class B reportable disease in the Notiflable Disease Reporting System (NDRS) in 1996 that legally requires reporting by all health facilities every month. To improve case detection and investigation, the active NT

- 29-

Surveillance System (NTSS) with zero case reporting was established in 1999, requiring reporting units to conduct active search for NT cases every 10 days, often in conjunction with active surveillance for cases of AFP. Since 1996, the numbers of NT cases reported from both the MCH Reporting System and the NDRS have been decreasing. Although the NTSS did not yet yield significantly more cases than the NDRS, the quality of the active NT surveillance system is improving. In 2001, a total of 2386 NT cases were reported from the active NT surveillance system with the majority of them occurring in southern provinces such as Hainan, Guangxi and Guizhou. Based on the data available from both the MCH Reporting System and NTSS, a total of 134 counties with an incidence rate of over one case per 1000 live birth were identified in 2001. IT SlAs for child-bearing aged women were carried out in more than 300 high-risk counties in 1995 and an estimated 23 million child-bearing aged women aged 18-35 years old were vaccinated. IT immunization was also provided to child-bearing aged women under several MNTE projects supported by international organizations, including the first Australian Agency for International Development (AusAID)-supported NTE and safe injections project in three provinces (1995-1996), the UNICEF (Hong Kong)-funded NTE project in five provinces (1998-2000), the World Bank Health Project 7 in ten provinces, and the AusAIDWHO NTE and safe injections project in four western provinces (1999-2003). A new Ministry of Health-UNICEF project on NTE (2003-2005) with a main component of IT SlAs is currently being developed. Although China has made significant progress in MNTE since 1995, there are still some problems encountered, including low hospital and clean delivery rates in poor rural areas, sub-optimal active NT surveillance, women's fear of IT reactions and rumours that the injections are for family planning and difficulty in management of the floating population. 2.5.2.3 Lao People's Democratic Republic

Adequate data were not available to document NT as a public health problem, but all the risk factors were present. Therefore, a survey was conducted in November 2001 in nine rural districts of three provinces. The survey design called for 80 clusters of 22 live births each to be conducted by four two-person survey tearns and two supervisors. A total of 7919 households were visited. Because some of the recorded live births did not meet age eligibility requirements, only 1623 live births were accepted for analysis but this smaller number of live births had only a minor impact on the statistical Validity of the survey results. Among the 1623 eligible live births there were 33 neonatal deaths, of which 14 were determined to be caused by NT, for a point prevalence of 8.6 NT cases per 1000 live births. The survey also confirmed the presence of high-risk factors such as low proportion of births in a health facility (15%), low proportion of births delivered by a trained attendant, low IT coverage among the mothers and low proportion of mothers who had received ANC. The survey results provided the basis for developing an MNTE plan of action which was endorsed by the Interagency Coordinating Committee (ICC) in September 2002 and has been submitted to the Ministry of Health for approval. Upon receipt of ministerial approval, the plan will be submitted to UNICEF for approval and funding. It is anticipated that funds could be made available soon enough to allow pilot work to begin during the first quarter of 2003. There are several issues for plan implementation: UNICEF funding guidelines of US$1.2 per targeted child-bearing aged women may not be enough for Lao People's Democratic Republic; demographic information on the number of child-bearing aged women may underestimate the actual number; and Lao People's Democratic Republic is unlikely to achieve MNTE by the end of 2005.

- 30 -

./

2.6

Develooing comprehensive EPI systems

2.6.1 Vaccine security The increasing gap in vaccines used in the developing and industrialized world has resulted in a shift by many manufacturers to the production of the more expensive and profitable vaccines. Between 1998 and 2001, 10 of 14 manufacturers partially or totally stopped production of the traditional EPI vaccines, leaving only three to four manufacturers offering these vaccines for UNICEF supply. As supply declines, costs are likely to increase. The narrowing between vaccine availability and demand means there are no safety margins for variations on vaccine yields, batch failures and slow regulatory release. If these difficulties, which are inherent in the production of biological products, occur or other problems arise, it has the real potential to seriously compromise UNICEF's ability to procure vaccines. Quantities of DPT for supply by UNICEF are barely sufficient for 2003, and some programme activities will have to change timing to ensure supply. TI demand in 2003 exceeds availability, meaning reduction in demand is required, and some SIA activities will have to be scaled back or delayed. UNICEF is addressing this situation by strengthening the forecasting and monitoring of vaccine estimations and supply and the implementation of vaccine arrival reports for UNICEF recipient countries. 2.6.1.1 Vaccine Provision Project

The Vaccine Provision Project has been developed to assist with the forecasting of demand of vaccines for the years 2004 to 2006 for countries that have been or are likely to be supported by GAVIIVaccine Fund. A project team that includes programmatic, finance, and vaccine supply expertise will work with Vaccine Fund-eligible countries to get an accurate forecast of needs and preferences. This information will be used to enable the supply of vaccine in a situation where the preferred combination vaccines remain in short supply and the demand for Hib vaccine relatively low. Even though the project relates to vaccine supply more than a year in the future, the final forecasts will be needed in the near future to allow for sufficient time for planning and contracting. 2.6.2 Vaccine stock management, wastage and cold chain With the introduction of new vaccines and injection safety supplies, vaccine logistics systems are facing additional and new challenges. To meet these, NIPs should ensure that logistics systems are functioning optimally. The key areas are: accurate estimates of vaccine requirements for all levels of vaccine supply, good stock management practices, monitoring the quality of vaccines on arrival, during storage and during distribution (using monitors such as vaccine vial monitors, cold chain cards and freeze watch monitors), functioning cold chain that is managed through an inventory system, and the monitoring of vaccine wastage (in opened and unopened vials). Vaccine logistics within the Region can be strengthened, with 31 % of countries reporting stock-outs at the national level during the last three years and only 56 % of countries reporting availability of vaccine wastage data. While 62% of countries reporting forecasting vaccine stock requirements for future years, only one of 16 countries reported having projections beyond 2005. The situation for the vaccine cold chain is similar. Eighty-seven percent of countries have a national cold chain policy, but only 56% of countries reported having a budget for the cold chain equipment and 37% having a cold chain inventory and replacement programme. The lack of focus placed on the cold chain was further highlighted by the fact that most countries have not conducted a cold chain assessment since before 1999.

- 31 -

IS an appropnate area of future activity along three main fronts: supply (vaccine p~uction), demand (~accine forecasting and stock management), and funding. The EPI U~t ~~ the ~O ReglOnal O~ce for the Western Pacific is planning to build on all these

. v:accines are a. global cOmmodity. Nevertheless, developing vaccine security in the

ReglOn

aCtivlties· c An unportant area 10 supply is strengthening the national regulatory authorities (NRAs) in vaccine producing countries so that their vaccines can be supplied to other countries. 2.6.3 Immunization safety Immunization safety is being addressed in the Region through the development and implementation of plans of actions for safe injection and disposal, adverse events following inununizations and vaccine quality through strengthening of NRAs.

In addition to national policies for injection safety, Cambodia, China, Lao People's Democratic Republic and Viet Nam currently have functioning injection safety working groups that address specific country needs and build upon national strategies for implementing activities and coordinating donor contributions (see also GAVI). In 2002, China and Viet Nam undertook several activities to strengthen their NRAs. This has included an assessment undertaken by WHO and the development of plans with milestones to achieve the required standards to lead to pre-qualification of vaccine suppliers. Enabling China and Viet Nam to produce pre-qualified vaccines for UNICEF supply should substantially improve the Region's vaccine supply. 2.6.5 Update on the Global Alliance for Vaccine and Immunizations (GAVI) activities GAVI, through its Vaccine Fund, started providing new vaccine supplies for NIPs in the Region in mid-200!. Infonnation on GAVI and the Regional Working Group (RWG) was presented at the last TAG meeting. An updated fact sheet is appended (Annex 4). 2.6.5.1 GAVJJVaccine Fund supPOrt to Region: Hepatitis B vaccine

Cambodia and Lao People's Democratic Republic were among the first round of 13 countries to be awarded funding from the GA VI Vaccine Fund. They were both awarded a five-year supply of hepatitis B vaccine (as combination DTP-HepB vaccine). As both countries are phasing in the introduction over several years, the duration of support should be longer than five years. The first new vaccine supplies were received in May and July 2001 and the pilots started in September and December 2001 in Cambodia and Lao People's Democratic Republic, respectively. As a result of GAVI, every NIP in the Region has now included hepatitis B vaccine in their programme. Both China and Viet Nam had successful GAVI applications for hepatitis B vaccine in 2001, with the case of China being a 'special arrangement' requiring a memorandum of understanding (MOO) that was signed on 1 June 2002. Viet Nam has been using GAVI hepatitis B vaccine since January 2002. (Local production of hepatitis B vaccine had been only adequate for about 15% of the birth cohort). '

In China, the Vaccine Fund is providing US$38 million to cover half the costs for five years supply of hepatitis B vaccine and AD syringes and safety boxes for all EPI vaccines in the 12 western provinces and all the official poverty counties (amounting in total to 37% of the birth cohort). The Government of China is providing the other half of the funding.

- 32-

2.6.5.2

GAVI Immunization Services Sub-Account (ISS)

For countries with DTPJ <80%, the ISS provides US$20 for each additional child who received DTP3. Both Cambodia and Lao People's Democratic Republic successfully applied for the ISS in October 2001. Both countries had been advised by WHO against applying for the ISS with their initial application because of uncertainty and concerns about the ISS, and its possible implications for immunization programmes. However, WHO assisted with the applications when the countries chose to apply. The funds were received in the countries by early 2002, but to date the flow of funds has been limited and it remains uncertain how effectively the funds will be used to strengthen the programme. Additional human resource at all levels is one of the key needs for the NIPs, but as government workers do not receive a living wage in these countries, there are limitations to how the money can be used effectively to strengthen the programme. 2.6.5.3 GAVI injection safety sUJlPOrt

A new GA VI policy in 2001 enabled the provision of three years of safe injection supplies (AD syringes, reconstitution syringes, and safety boxes) to countries with a GAVI award. To obtain this support, governments needed to have national pOlicies and plans for injection safety as well as a commitment to continue to provide these safe injection supplies after the three years of support. Both Cambodia and Lao People's Democratic Republic were successful in their October 2001 application, and are in the process of transition to exclusive use of AD syringes for all EPI vaccines. The GAVI support does not address the issue of safe disposal. However, by obtaining part of the support as cash instead of supplies (by phasing introduction), as well as the support of partner agencies, the countries are able to construct at least one incinerator in each province before introducing the AD syringes in both Cambodia and Lao People's Democratic RepUblic. Viet Nam applied for injection safety support in September 2002. 2.6.5.4 Other Vaccine Fund eligible countries

Mongolia submitted an application in May 2002 for new vaccine introduction (Rib vaccine as DTP-HepB-Rip and/or for DTP-HepB), ISS, and injection safety support. Mongolia was advised that it was ineligible for ISS; that the application for new vaccine introduction should be resubmitted; and that the injection safety support was contingent upon approval for new vaccine introduction. Another application was prepared for DTP-HepB in September 2002, despite advice from WHO that such an application would not be considered until the government could show that the supply combination DTP-HepB vaccine, replacing monovalent HepB vaccine would enable the current funding for DTP and HepB vaccines to be used in other ways to support the programme. WHO has provided technical support and supplies to Mongolia to enable assessment of Rib disease burden through laboratory surveillance for meningitis and Rib cases. In addition, a consultant was sent in July 2002 to assess the costs and feasibility of doing a vaccine probe study to determine the Rib pneumonia disease burden. As the study would take five years and cost US$2.5 million, it is not feasible. On the other hand, the laboratory-based surveillance should provide good disease burden data by next year for an application to be submitted in April 2003. Two other eligible countries in the Region have not yet applied: Papua New Guinea and Solomon Islands. It is not certain that either of these countries will benefit from a GAVI application, but WHO and the RWG will support them if they choose to apply. It is expected

- 33 -

that the last round for applications will close on 2 May 2003; however, further rounds remain possible. 2.6.5.5 Implementation

The new vaccine introduction is relatively straightforward, especially for Cambodia and Lao People's Democratic Republic, as all that is required is changing from one vial (DTP) to a virtually identical one (DTP-HepB). However, in both countries, the introduction is being phased in slowly to enable the introduction to also enhance the immunization services.

In Viet Nam, hepatitis B vaccine has already been in use for over five years, but only in very limited areas of the country. The extension to all provinces happened smoothly in the first half of 2002. In 2002, only about half the districts in 44 provinces will get the hepatitis B vaccine; the other half will introduce the vaccine from 2003. The remaining 17 provinces are using the locally produced vaccine. The major effort with hepatitis B was ensuring a timely birth dose - within 24 hours for those born in a health facility and within three days for those born outside. The availability of hepatitis B vaccine with a vaccine vial monitor (VVM) will enable selective use of vaccine beyond the cold chain to improve timely delivery of the birth dose. At present it is early in the implementation of the China GAVI project, and also relatively early in the use of ISS funds in Cambodia and Lao People's Democratic Republic. 2.6.5.6 Implications for BPI in the Region

The GAVI Initiative has brought additional funds and interest to immunization programmes in the Region. In addition, some of the processes that are required by the GAVI process are ones that all countries should consider: review of the BPI to develop a strategic multi-year plan and annual workplans, an ICC, a fmancial sustainability plan, and data quality audit of reported immunizations. 2.6.6 Using and managing data to strengthen EPI systems Data can be used to improve the quality of any service, to the extent that data gives accurate feedback on the key parameters of the service. For NIPs, the data that describe the key parameters are immunization coverage, disease incidence, adverse events following immunization (AEFl), vaccine utilization (wastage) and resources (financial and human) used to deliver the service. 2.6.6.1 Managing data

It is imperative to collect reliable and accurate data. Only once this has been achieved can the management and analYSis of data produce informed interventions. Data needs to be carefully managed so that is can be used to guide the NIP. This includes developing and enhancing the system for data collection. Once data are collected, they need to be actively managed starting with the processes of data cleaning and validation.

The data that are received need to be checked for logical consistency and content. This includes data checks that can be applied automatically such as logical date checks (e.g., date of onset should be later than the date of birth) and checks that required information has been supplied (e.g., cases have a unique case identification number). Questionable data can also be manually filtered out and sent back to the source for verification. Examples include sudden large drops or increases in disease incidence or coverage and the incidence of NT or poliomyelitis in a non-endemic area.

- 34The data need to be stored in a standardized way. If all the data are received in a common format, then no additional work is needed. However, often data will come from different sources in different formats (e.g., maybe in paper format, or output from different types of computer programmes). As the data that are stored over time may evolve with the addition qr removal of fields, there needs to be some flexibility in establishing these systems. Once the data have been entered into the database, a set of routine reports that provide the first level of analytic processing takes place. After inspecting these reports, additional analysis may be needed. The data analysis provides the basis for action. It also needs to be fed back to those who provide the data in a way that is likely to be most meaningful, including comparing performance with their peers. 2.6.6.2 Current data processes in the WHO Regional Office for the Western Pacific

The WHO Regional Office for the Western Pacific currently collects routine data from countries and areas as provided on the WHOIUNICEF Joint Reporting Forms, the TAG and RCC country reports, and clinical and laboratory data on poliomyelitis, measles and maternaIlneonatai tetanus. These data are often received in different formats and in varying frequencies and completeness and have to be converted to a standard format before being merged into the regional database. Standard checks using data rules for logical consistency and data quality are applied to the data. These checks can be done automatically by the computer and should be done before the data are sent to the regionaileveJ. Questionable and erroneous data are also filtered out, often by manual checking, at the regional level. These data will be sent back to the source for verification. This process is repeated until the data at the country and the Regional Office have been completely reconciled. Standard reports are generated through computer systems at the Regional Office. These reports are used in routine publications and distributed to programme managers. Further analyses are done on the data and used in standard presentations and to satisfy ad hoc requests. Finally the data are forwarded to WHO Headquarters and posted on the WHO website. 2.6.6.3 Improving data management the WHO Regional Office for the Western Pacific

There are several problems affecting data quality and management at the WHO Regional Office for the Western Pacific. As the data are received in different formats, much effort goes into data conversion. Data conversion programmes have been developed for most of the routine data received in the Regional Office. However whenever the structure of the source data is changed, the conversion programmes must be updated. Furthermore, some of the data formats are significantly different enough or change often enough that it has been easier to re-enter them manually into the regional database. Both the data conversion process and re-entering of data are additional steps in which errors can occur. Data cleaning and validation is undertaken at the Regional Office. This centralized process is time-consuming and inefficient. Data has to be continually sent back to the source for verification. Improving the management of data in national EPI programmes will be the key to improving the above steps (data conversion, cleaning, and validation). As information

·35· technology advances, the options continue to increase, as does the ease of data collection, while the cost of the necessary hardware reduces. One critical feature is having standardized data definitions and formats (as well as associated. validation rules and data checks) that are consistently used in countries. Where a country cannot provide the kind of data needed, the WHO Regional Office for the Western Pacific can provide either a fully·functional database (as in the case of measles) or a data entry tool (as in the Joint Reporting Forms and TAGIRCC reports) that would provide data· entry level validation and take care of data transmission formats. Faster and better dissemination of data and closer collaboration on data cleaning between the regional offices will improve data qUality. This includes expanding data collection and information dissemination through the Internet to improve speed and quality of information transfer. The WHO Regional Office for the Western Pacific needs to consider how to best provide continued training and support to improve data management skills and systems in national EPI programmes. This is vital to ensure that the programmes can take advantage of available tools and software products that will enable them to do data collection, processing and analysis more rapidly and accurately so that data can be effectively used to improve the programme. 2.6.6.4 Using data to manage

Any data that is collected must be collected for a purpose. The ultimate purpose is programme monitoring. The information needs will differ at different levels, but in general, each level should ouly need a sub·set of the information needed at the lower level. There may also be needs driven by global requirements (as with polio eradication). 2.6.6.5 Reaching everv district

A key use of data is to improve coverage. This is the basis of the strategy currently being developed to "Reach Every District (RED)". This global initiative aims to provide a framework for improving routine coverage to 80% in every district. The potential is to use this framework to combine, coordinate, and pool resources between different programmes that all need to reach every child in every district. The RED strategy has five operational functions: re·establishment of outreach services, supportive supervision, community links with service delivery, monitoring and use of data for action, and planning and management of resources. This will require immunization programmes throughout all levels to combine, coordinate and pool limited resources, and integrate plans together with other health priority interventions. Clear coordination and roles in implementing this strategy for every level of the immunization programmes will be necessary. For each country, these roles will depend upon their own administrative structure and current coordinating efforts. Recommended for the national level is a focus on data management and analysis, coordination with other national health programmes and the coordination of technical assistance. At the sub·nationallevel, programme managers should provide support to districts, that is, any training, supportive supervision and monitoring and at the district level, there should be district micro-p1anning that includes the five operational components mentioned above.

- 36 -

3. INTERAGENCY COORDINATION COMMITTEE

The"meeting was opened by the Chair, Dr Peter Strebel, who welcomed the representatives of all partner agencies and introduced the rapporteur, Dr Maritel Costales. The Regional ICC provides details on past, present, and projected future funding status of the Region's EPI to discuss and coordinate future partner contributions to the programme. Financial summaries of the activities for each partner agency for the bienniums 19981999,2000-2001, and the fITSt year of the 2002-2003 biennium were presented, with a breakdown of donor contribution, both by country and by activity. Projecting to 2003 funding, a total of US$15 802 000 is needed. So far, US$8 589 000 of this amount has been identified, indicating a shortfall of US$7 213 000. AusAID reported its support for EPI activities in the Region would likely continue at similar levels in the near future despite concerns in the national government regarding the global security situation. Rotary International District 2650 summarized the strong support to the poliomyelitis eradication initiative provided by members of district 2650 and their intention to visit Cambodia in February 2003 to support the administration of routine EPI vaccine in outreach vaccination activities. In the future, District 2650 intends to support general BPI activities in the Region. Rotary International Polio Plus Committee remains committed to global poliomyelitis eradication by 2005. There is a global shortfall of US$275 million for completing poliomyelitis eradication. The Japanese International Cooperation Agency (JICA) indicated that it has been providing vaccines since 1989. JICA continues to be a major supporter of EPI in the Region. JICA places particular attention on safe injection practices with quality vaccines including safe disposal, vaccine self-sufficiency and the need to strengthen laboratory capacity as well as support for general immunization activities. JICA raised four areas for discussion at the ICC meeting: (1) increased need for accountability and documentation of results to justify future support; (2) uncertainty in the timeliness of vaccine delivery; (3) difficulties in prioritizing among the many programme needs (maintenance cf poliomyelitis eradication, measles control, introduction of new vaccines, MNTE, strengthening NRAs, and safe injection practices etc.); and (4) the need for safe disposal of injection equipment and exploration of alternatives to incineration. The Centers for Disease Control and Prevention (CDC), Atlanta, Georgia confirmed its commitment to EPI in the Region in the form of staff, procurement of OPV and measles vaccines, and technical support in disease surveillance, outbreak investigations, and the development of national plans of action for measles elimination. The German Federal Ministry of Economic Cooperation and Development has supported measles elimination in the Philippines and is providing specialized cold chain equipment for routine immunization programmes. There is a need to market the notable cost-effectiveness of immunizations as a public health intervention. However, in addition to raising more funds for immunizations, programmes should explore ways to improve operating efficiency. UNICEF is supporting MNTE through technical and financial contributions to the six countries in the Region where it remains a public health problem.

- 37 The Regional ICC congratulated the country programme managers and their staff for their outstanding achievements over the past year and commented that EPI was fortunate in being able to document success more easily than other public health programmes. The WHO Regional Office for the Western Pacific needs to support countries to improve documentation of progress toward achieving programme goals and explore ways to improve programme operating efficiency. Next year's Regional ICC meeting should focus on funding needs from a country perspective, reflecting both bilateral and multilateral support. The WHO Regional Office for the Western Pacific was requested to provide a detailed breakdown of the 2003 shortfall to the partner agencies. This will facilitate meeting the shortfall needs. The vision for revitalizing the EPI programme provided by Dr Omi was welcomed by ICC members who recognize the need to have highly visible programme goals such as measles elimination and prevention of hepatitis B deaths in order to develop the political commitment for immunization. The best way to maintain the poliomyelitis-free status in the Region is to adopt new challenges. The strategies for achieving routine coverage of >80% in all districts are essential for achieving success in the future and the need for partner coordination and programme integration is greater now than ever before. The meeting closed with a sense of optimism that ongoing progress in reaching programme goals combined with the new vision for EPI in the Western Pacific Region would lead to stronger support by the partner agencies in the future.

4. NATIONAL MANAGERS' SESSION

A separate session was held for national managers to work in small groups on three exercises. The first was part of a scenario being developed by the WHO Regional Office for the Western Pacific to teach the investigation and response to an AEFI incident. The aim was to assess the potential of the exercise in the countries and to sensitize managers to the issue of the mass psychogenic AEFI that is relatively common when vaccinating groups of older children, such as in the school setting. The second exercise involved the vaccine arrival report to emphasize the importance of completing this report as an important part of maintaining vaccine quality. Participants also did a shake test and were able to see the gel effect of sub-zero temperatures that did not cause freezing. The main part of the meeting involved reviewing each country's BPI report prepared for the TAG meeting to address issues of data quality and accuracy, and to discuss how best each type of information could be communicated with the Regional Office.

5. CONCLUSIONS AND RECOMMENDATION

5.1

Overall EPI Conclusions

1. BPI in the Region is entering an era of new opportunities, building on previous achievements. However, despite high national coverage there are still districts and

- 38 communities that are not regularly served. In addition, there is a perception that EPI no longer has the priority that was given for poliomyelitis eradication, now that the Region has been certified poliomyelitis-free. Maintenance of poliomyelitis-free status remains a priority, but ~ flagships to guide and strengthen BPI are needed. 2. The private sector is a major component of the health system in many countries, so private sector delivery of BPI vaccines and surveillance of EPI diseases should be incorporated. Recommendations 1. Revitalizing the priority that is given to BPI requires the identification of new 'flagships' in the way that poliomyelitis eradication was used in the past. The TAG concurs with the suggestion that regional measles elimination and improving hepatitis B control will become these new 'flagships'. 2. To successfully implement these two initiatives, routine EPI will need to be strengthened. In tum, the measles and hepatitis B targets will serve to support and strengthen the routine immunization services through the development of comprehensive, high quality and sustainable systems reaching every child in the Region. Immunization safety and adopting a data-driven approach at district level are key components. 3. Maintenance of poliomyelitis-free status should continue to be a high priority.

4. MNTE is another area where accelerated efforts are needed, as the suffering and deaths of newborns can be prevented with relatively simple measures, in collaboration with multilateral and bilateral agencies 5.2 Poliomyelitis Conclusions 1. The TAG expressed great concern that the global poliomyelitis eradication programme will not reach the target of interrupting global wild poliovirus transmission in 2002. Eradication of poliomyelitis in the Western Pacific Region remains a fragile success as long as there is poliomyelitis in neighbouring countries. 2. The TAG is impressed that generally national poliomyelitis eradication programmes continue to be very responsive to recommendations made both by the TAG and the RCC for maintaining the quality of surveillance and immunization activities. However, there are examples of reduced efforts to maintain poliomyelitis-free status once certification was achieved. In some cases these resulted either from the erroneous belief that surveillance for AFP cases was no longer required, or because of a reduction in funding. 3. In 2002, the regional annualized non-polio AFP rate in 2002 was 1.33 per 100 000 children under 15 years of age with 88% of the cases having adequate stool specimens taken. However, surveillance quality is not uniformly adequate across all countries and within countries. Due to active work of expert panels, final classification of AFP cases can now usually be obtained within three months after onset and less than 10% of cases remain pending after this period. 4. Surveillance for VDPV has been expanded, ELISA lTD capacity has been established at all regional reference laboratories and selected national laboratories, sequencing capacity has been strengthened and data management has been improved. AFP cluster analysis has also improved, with special attention for any case" potentially caused by VDPV.

- 39-

5. The requirement for at least 80% of lTD results to be available within 60 days of onset has not yet been reached although substantial improvements have occurred in 2002, particularly in China. Delays observed are partly due to late collection of stool samples but . can be mainly attributed to the long shipment times from the point of the collection to the national poliovirus laboratories, or from the national laboratories to the regional reference laboratories. 6. The performance of the poliovirus laboratory network in general remains high. Currently 91 % of virus isolation and identification results are available within 28 days of receipt of specimens and 98% of lTD results are available within 28 days of receipt of isolates at the laboratories. 7. Despite heightened AFP surveillance, no new cVDPV-associated cases have been detected in the Philippines since October 2001 following the nationwide immunization response to the cVDPV poliomyelitis outbreak. The TAG commends the Philippines on its successful immunization response that included house-ta-house OPV delivery. 8. Sub-optimal routine inununization coverage, especially among high-risk populations, remains a major challenge to maintaining poliomyelitis-free status in certain countries. Continuing supplementary inununization activities will be necessary to create a barrier against wild poliovirus and VDPV. 9. Further progress has been made in laboratory containment of wild poliovirus infectious/potentially infectious materials, with 33 countries now having established a national inventory. Furthermore, progress is also being made at the global level in developing quality assessment tools for confirming the quality of poliovirus laboratory containment activities and the draft validation tools have been tested in two countries in the Region. Recommendations 1. Routine immunization of infants is of highest importance in maintaining population inununity against poliomyelitis and the primary focus of all countries should be on achieving and maintaining the highest possible routine immunization coverage of each birth cohort. SIAs should be undertaken to maintain population immunity in areas of low coverage, recognizing the human and financial challenges that such activities impose. 2. Adequate resources for AFP surveillance need to be maintained. Countries are encouraged to integrate other surveillance activities, especially measles and neonatal tetanus, with AFP reporting as a means of strengthening the motivation to report AFP cases, and also to demonstrate that the reporting system has long-term value beyond poliomyelitis eradication. 3. Countries are encouraged to thoroughly investigate all potential vaccine associated paralytic poliomyelitis (VAPP) cases, applying definitions recommended by the Global Technical Consultative Group, and to report VAPP cases quarterly as part of AFP reporting. The national Expert Committee can serve in the role of review and final classification of such cases. The TAG requests WHO to provide definitions of V APP (including contact 4. V APP), VDPV, and c VDPV and guidelines on investigation and response to each of these and circulate to countries. 5. Those countries that have not yet completed the survey for laboratories holding wild poliovirus infectious/potentially infectious materials are urged to do their utmost to finalize the inventory as soon as possible.

- 406. The TAG urges the WHO Regional Office for the Western Pacific to support global poliomyelitis eradication at meetings of WHO governing bodies, emphasizing the importance of continued high political support. 5.3 Measles: moving towards elimination Conclusions 1. The countries of the Region have accumulated substantial measles control experience in recent years, and even achieved elimination in some areas, such that a regional measles elimination effort will be a natural extension of current activities. However, there is some concern about establishing a regional measles elimination target date because the global Polio Eradication Initiative (PEl) is not yet complete. In addition, in some countries there are concerns about vaccine safety and quality that also need to be addressed.

2. Measles elimination is an opportunity to strengthen immunization systems, particularly because every district will need to be reached with very high quality immunizations on a sustainable basis. For some countries, delivery of measles and other EPI vaccines through periodically implemented campaigns and/or sustained outreach activities may be the most effective way to strengthen the routine EPI in areas that are hard to reach and do not have regular health services. 3. Most countries have already adopted or have plans to adopt a two-dose measles immunization schedule (second dose through routine or supplemental). However, full implementation of the two-dose schedule and reporting on each dose remains incomplete. 4. The TAG recognizes that different immunization strategies may result in measles elimination when appropriately implemented. Some countries have achieved measles elimination by providing two opportunities for measles immunization solely through the routine immunization programme (e.g. Finland, United States of America), while others have combined routine and supplemental immunization to rapidly achieve very high population immunity and thus attain measles elimination in a shorter period of time (Australia, Canada, Republic of Korea, United Kingdom and others). 5. Some countries continue to experience large measles outbreaks due to inadequate measles immunization, both due to lowllate coverage with the first dose and lack of a second opportunity for measles immunization. Papua New Guinea reported 167 measles deaths and over 3900 cases in 2002. The high case fatality rate was due in part to stock shortages of basic therapeutic agents including vitamin A, intravenous fluids and antibiotics. 6. Evidence from three provinces in China and the Americas shows that placing greater emphasis on measles surveillance, as part of the AFP surveillance, helps to maintain high quality AFP surveillance. 7. Equity is an important argument for elimination, as poor children and countries suffer disproportionately from measles and its consequences. In addition, working towards measles elimination will require reaching practically every child thus providing a platform for delivery of other health services to disadvantaged and unreached populations. Cambodia provides a successful example of administration of OPV, vitamin A, mebendazole, and distribution of impregnated bednets as part of a measles campaign. 8. Measles elimination is defined as the situation in a large geographical area in which endemic transmission of measles cannot occur and sustained transmission does not occur following the occurrence of an imported case; continued intervention measures are required.

- 41 -

. 9. Among EPr diseases, measles is the most infectious, and surveillance for measles disease provides the best measure for validating reported coverage data, because measles outbreaks identify areas of low vaccine coverage. Laboratory confirmation of measles diagnosis for sporadic cases and outbreaks is essential, particularly when disease incidence is reduced to.low levels, as other viruses can also cause similar rash and fever illness, and it is essential to accurately track spread of the virus. Recommendations 1. The TAG endorses the principles and strategies of the Western Pacific Regional Plan of Action for Measles Elimination. Annual review of progress is needed to establish a target date at some time in the future. Careful implementation will be needed to ensure that measles is not seen as another project but will require a long-term effort that builds on and strengthens routine EPr services, including improving immunization safety (including safe disposal of used materials), introduction of rubella vaccine, and strengthening district services using a data-driven approach (see recommendation on overall EPI). Detailed and long-term estimates of resources required and available for the programme are needed. 2. Given the substantial progress already achieved towards measles elimination in most countries of the Region, regional measles elimination should be addressed at the next Regional Committee meeting in September 2003. 3. Measles elimination activities should be integrated with other disease control programmes, where appropriate, to avoid competing priorities among programmes. 4. Countries and areas should fully implement a two-dose measles immunization schedule and aim to achieve high coverage with each dose. The purpose of the second opportunity for immunization is to protect children who may have missed their first dose and to immunize those who failed to respond to their first dose. In line with the WHOIUNICEF Global Measles Strategic Plan, 2001 - 2005 and the Western Pacific Regional Plan for Measles Elimination. Each country needs to examine their own circumstances and use local knowledge and innovation to achieve the following outcomes: a. ensure and sustain very high coverage with a first dose of measles vaccine given on schedule; b. ensure that all children of each birth cohort have a second opportunity for measles immunization, either through the routine programme or supplemental immunization activities; c. establish or strengthen active, case-based surveillance of suspected measles cases with zero-case reporting, integrated with AFP surveillance where appropriate; and d. establish access to an accredited measles laboratory to conduct serologic testing to confirm suspected measles cases, including collection of clinical specimens for measles virus isolation. 5. Noting that many countries in the Region have achieved and maintained a very high first-dose coverage, the TAG recommends that options for achieving high two-dose coverage through the routine immunization programme be carefully explored, including those that require intersectoral cooperation (e.g. introduction and enforcement of school entry regulations). Countries and the Regional Office should monitor and report first and seconddose coverage.

- 42-

6. Countries should assess whether there is a need for supplementary immunization activities in part or all of the country to address gaps in population immunity among older cbildren andlor to accelerate measles control. Epidemiological analysis is needed to drive decisions about the scope of a campaign, including target age group, timing, and geographical location. 7. A regional laboratory network for measles needs to be formally established in order to correctly classify suspect measles cases, isolate and characterize measles viruses and standardize laboratory methods and procedures. 8. The TAG recommends the following milestones to assess progress, in line with the WHO/UNICEF Global Measles Strategic Plan, 2001-2005: a. by the end of 2003, all countries to have prepared measles elimination plans of action; b. by the end of 2005, all countries to have introduced a second opportunity for measles vaccination after 12 months of age through regular routine or supplemental activities. The TAG recognizes the potential challenges of reaching this milestone on time and encourages those countries that may miss this milestone to adopt an alternative plan; and c. by the end of 2005, all countries to have a surveillance system for measles in accordance with WHO guidelines and indicators and to be served by at least one accredited measles-rubella laboratory. 5.4. Hepatitis B control Conclusions 1. HB V is an important cause of clinical disease and death in the world, and even more so in the Western Pacific Region with over half of the global disease burden and only one quarter of the global population. The majority (90%) of the burden arises from chronic infection that primarily arises from mother to child transmission. Hepatitis B is the leading infectious cause of cancer-related deaths, and hepatitis B vaccine is the only vaccine that prevents cancer. 2. The primary objective is to prevent transmission from mother to child and child to child. A safe and effective vaccine is available. and through immunization the disease can be controlled and perhaps even eradicated after some generations. 3. Effectiveness of control is intimately related to quality of routine immunization services - especially coverage and injection safety. Hence, the most important aspect of improving hepatitis B control is to improve routine immunization services. There is potential to improve programmes in the Region. 4. There are other modes of transmission of hepatitis B, such as insufficiently sensitive blood donor screening, unsafe injection, and to a more limited extent unsafe sex that can be used to help define other target groups for immunization, according to country priorities. Recommendations 1. The TAG endorses the conclusions and recommendations of the Hepatitis B Expert Meeting as articulated in the Draft Regional Plan. In particular, the TAG recommends

- 43the following regional objectives/milestones to be used to monitor country and regional progress to improve hepatitis B control: ~. in~lude receip~ of three doses of hepatitis B for a child to be 'fully unmuruzed for BPI by 2003 - except where only babies of HBsAg positive mothers are offered immunization.

b. establish a system to monitor timeliness of birth dose (within 24 hours of birth) and a target date to reach a target of 80% coverage with a birth dose appropriate to the country, by 2004. c. five years after starting routine hepatitis B immunization, countries should achieve an HBsAg prevalence of < I % in those born after routine vaccination started. The TAG recognizes that a target of <2% among hard-to-reach populations could be an intermediate target. d. by 2003 establish a national hepatitis B control plan (as part of overall EPI plan) that includes a protocol to monitor health worker knowledge as an indicator of overall EPI practice; and e. as part of BPI implementation, achieve full BPI immunization (including three timely doses of hepatitis B) of at least 80%, and ideally 95%, of each birth cohort. 2. WHO should explore and recommend strategies towards increasing coverage for a timely birth dose, in collaboration with comprehensive child and reproductive health management groups. 3. Given that every NIP in the Region now includes hepatitis B vaccine, the considerable burden of hepatitis B disease in the Region, and the need to improve programmes to protect more infants from infection improving hepatitis B control through immunization, shonld be addressed at the next Regional Committee meeting in September 2003. 5.5 Maternal and neonatal tetanus elimination Conclusions 1. The TAG commends countries where NT is still a public health problem on the progress made. However, NT is still greatly underreported in .everaJ areas and where surveillance information is available, there is sometimes failure to take action with TT immunization in the high-risk areas where cases have been detected. A case of maternal or neonatal tetanus represents a triple failure of public health in terms of the routine immunization, antenatal care, and clean delivery/cord care services.

2. Current national plans of action exist in Cambodia and Viet Nam, with surveillance and supplementary immunization activities implemented accordingly. Lao People's Democratic Republic provides a good example of conducting a disease burden survey in order to document NT as a serious public health problem and using these data to develop a national plan of action. 3. The collaborative approach of UNICEF and WHO has proven successful to date and the TAG encourages its continuation and strengthening. This collaboration serves as a model for other joint activities.

- 44-

Reconnnendations 1. All countries where NT is still a public health problem and without a current plan of action or activity plan towards elimination of MNT should develop a plan of action to reach the target of less than one NT case per 1000 live births in every district, in close collaboration with UNICEF, WHO, and other partners. Cambodia, Lao People's Democratic Republic, Philippines and Viet Nam are encouraged to achieve the elimination target by 2005. 2. The TAG requests the secretariat to report on progress toward implementation of regional and national action plans during the next TAG. 5.6 Developing comprehensive EPI systems Conclusions 1. Vaccine logistics systems require active management and strong supervision to ensure the successful delivery of quality vaccine to vaccinators. Accurate estimates of vaccine requirements are best achieved using actual population numbers (or best estimate) in conjunction with true coverage and wastage rates, at the national, sub-national and health centre level. 2. Well-implemented procedures such as regular stock takes, cold chain inventories, monitoring vaccine quality via VVMs and other tools to identify heat/freeze damaged vaccines, and monitoring vaccine wastage rates for both opened and unopened vials, are essential components of a good logistic system. 3. GA VI is revitalizing innnunization through increasing support for eligible countries through the Vaccine Fund and by developing processes to strengthen immunization programmes. 4. Using and managing data is a critical function for NIPs. There are many aspects to this, including data checking, cleaning and most importantly using the data for managing the progrannne, including providing feedback to lower levels. Reconnnendations 1. NIPs should ensure vaccine availability through good stock management procedures at the national, sub-national and district level by: a. using actual birth numbers/target populations (or best estimates), accurate coverage, wastage rates and current stock balance to calculate vaccine requirements; b. calculating and making known maximum and minimum vaccine stock levels; c. keeping accurate stock records for vaccines/diluents and conducting regular stock counts; and d. implementing strategies that ensure sufficient injection safety equipment is supplied for immunization sessions. 2. NIPs should ensure a reliable and functional cold chain through the development/implementation of a cold chain and logistic policy that requires:

- 45a. a national (or provincial for China) inventory for cold chain equipment is kept, updated regularly and used to plan the placement, maintenance and replacement of equipment. The inventory should record location, model, power source, working condition, age and expected future life of equipment; b. that continuous operation of cold chain equipment be ensured by budgeting and providing sufficient finance for power requirements and transport of consurnables, such as gas bottles; c. that vaccine quality is assured by monitoring cold chain equipment temperatures twice a day, storing freeze-sensitive vaccines correctly in refrigerators and using conditioned ice packs (warm climates) or water bottles (cold climates) to transport vaccines; and d. VVM, cold chain cards, freeze watch, data logger, visual inspections and . the shake test are available, known and used to identify heat/freeze-damaged vaccines. 3. NIPs should monitor vaccine wastage rates to ensure accurate vaccine requirements estimates and identify programme areas requiring corrective action. Wastage should be monitored at all levels (or selected sentinel sites), including reporting of opened and unopened vial wastage. 4. NIPs with extensive outreach services in areas where the cold chain is difficult to maintain should consider using VVM to allow vaccines to travel beyond the cold chain in selected situations and with careful assessment on safe implementation, including consideration of the appropriate, limited time. 5. Countries not receiving GAVIlVaccine Fund support should consider adopting tools and processes developed for Vaccine Fund-eligible countries, such as financial sustainability plans, audit of immunization data quality, and coordination committees. 6. Countries need to develop information systems that provide them with the necessary data for managing the programme. The WHO Regional Office for the Western Pacific should assist countries by providing the data standards and processes, and providing a role model for countries on the use of data for managing programmes, as was achieved with the AFP surveillance system. 7. Internet based solutions and other strategies should be explored for data collection, sharing, and feedback, as part of an overall plan for improving the use and management of data by the Regional Office. 5.7 Immunization safety Conclusions 1. Several countries have made progress in the use of AD syringes, safety boxes, and appropriate waste disposal. Technology transfer for AD syringe manufacture in China and Viet Nam has been accomplished. 2. The appropriate use of incinerators allows the safe disposal of used EPI injection equipment. Safe disposal of EPI injection equipment is only a small part of the overall medical waste that needs to be addressed in a comprehensive manner.

- 463. Vaccine producing countries in the Region are ensuring vaccine safety and effectiveness through NRA strengthening. including the development of systems for dealing with AEFIs in selected countries in the Region. Recommendations Continued progress in implementing the Regional Plan of Action for Immunization Safety should be made through further technical assistance and introduction of AD syringes. safety boxes and appropriate disposal. 1.

2. Further installation of auto-combustion incinerators should be continued in areas of low population density with appropriate technical support; however. other appropriate methods of waste disposal should be explored. This exploration should include working with the WHO Environmental Health Cluster and others with the primary responsibility for environmental health concerns to develop an overall medical waste plan of action. 3. A regional review of injection safety and associated issues (including rates of unsafe injection and methods for disposal of used injection materials) should be undertaken by the Regional Office and the results reported to the next TAG meeting. 4. WHO should provide support to countries for developing systems to identify. report. investigate and respond to AEFIs. including building investigation and response capacity. This includes having the human resources who are adequately trained to undertake investigation of cases and clusters of AEFIs and to respond to the various types of AEFIs. 5.S. Vaccine security Conclusion

I. The supply of vaccines to countries is an emerging problem about which the TAG is concerned. Global vaccine shortages. arising from the divergence in products used between industrialized countries and developing countries. poor stock management. and inadequate forecasting have led to shortages and stock-outs of EPI vaccines in several countries in the Region. Recommendation I. Regional vaccine security - the uninterrupted sustainable supply of quality affordable vaccines - needs to be addressed. Countries need to have predictable demands and reliable funding for EPI vaccines. Donor countries are specifically requested to consider multi-year pledges for vaccine support. The Region should develop a vaccine security plan to best ensure that vaccines are readily available. The TAG calls on each country to: a. review its procedures for the procurement of EPI vaccines in the context of whether these are best suited to ensuring sustainable vaccine supply; b. enhance forecasting methods used to determine future vaccine demand. looking at requirements annually for five years into the future; c. advocate with ministries of finance and external donors the development of sure funding plans to cover vaccine requirements if possible over a three-year period; and d. provide a fair rate of return on investment for self-producing countries. to ensure long-term supply of quality vaccine.

- 47-

2. Regional EPI vaccine supply and quality (both locally produced and imported) should be reviewed by WHO with the aim of moving the Region towards an adequate and secure supply of high quality EPI vaccines. The TAG requests a report of this review to be presented at its next meeting. 6. ACKNOWLEDGEMENTS

The TAG gratefully acknowledges the Regional Director, Dr S. Omi, for the invitation to hold this meeting at the WHO Regional Office of the Western Pacific in Manila, Philippines. As in all previous meetings, the TAG gratefully acknowledges the outstanding contribution and participation of all the partners in the EPI and poliomyelitis eradication, including the national governments of the WHO member countries; the Government of Australia through AusAIO; the Government of Japan through nCA and Japanese Voluntary Contribution (JVC), through nCA; the Centers for Disease Control and Prevention, Atlanta, United States; Rotary International; Rotary International District 2650 and 2640; UNICEF; the World Bank, Shinnyo-en and Agency for Cooperation in International Health. In addition to funds, partner agencies have generously contributed technical, management and promotional expertise.

- 48 -

World Health Organization. [RSI2002lGEJ02(KOR)]. Manila: WHO, 2002.

Meeting

of

technical

experts

on

measles

2 Becker N et al. Measles Control: Gaining insights from transmission models. Report in preparation for the WHO Regional Office for the Western Pacific. 3 World Health Organization. Papua New Guinea Expanded Programme on Immunization (EPI) review, November 2001. Manila: WHO, 2002.

THIIITEEHTH MEETING OF THE TECHNICAL ADVISORY GROUP ON EXPANDED PROGRAMME ON IMMUNIZATION AND POLiOMYELmS ERADICATION IN THE WESTERN PACIFIC REGION TENTATIVE TIMETABLE TIme Mondav. 4 November REGISTRATION Opening ceremony TIme 4 T _ y . 5 November TIme Wedn......y.6 November TIme

M.nlla. Philippi"""

4-7 November 2002 Thuradoy. 7 November 8 National Ma""gers -ng

08OO-ll83O ~30

Measlas (a) (b) Regional overview Report 01 the Meeting 01 Technical Experts on Measles

5 _15 081~

HepatItis B (a) Report of the Working Group Meeting on Hepatitis B Regional overview and plan Country expectations and needs 10 meel regional objective

0800-1000

:_30 083Q.0900

• • •

• •

Opening speech SaK·introduciion

(b) (c)

EISCIion of offioers: Chalnnan. Vice Chairman and Rapporteur

~30

Administrative announcement Group photograph

0Il00-1000

(c)

Coonl/)' reports on measles: (i) (ii) (iii) (iv) Australia Cambodia China Guam

0930-1000

6

Operatt.....l l _ (a)

Vaccine security (i) VBccine

Provision Pmjootforecasting vaccine needs, 1000-1030 1030-1200 COFFEE BREAK

0930-1000

COFFEE BREAK

1000-1030 1030-1215

COFFEE BREAK (v) (vi) (vii) (viii) (Ix) (x)

1000-1030 1030-1100 1100-1130 113().12OO (b)

2004-2006, for Vaccine Fund eligible countrias COFFEE BREAK

1 Expe_ programme on Immunlzollon (EPI)

_

.....111._

Japan Vaccine stock management, wastage and cold chain financial sustainabHity Immunization safety

1000-1030 1030-1100 1 1100-1130 1130-1200 1200-1300 1300-1500

(a)

Regional overview Global overview Pollomyelltia eradication Regional overview

(b)

2 (a) (b)

Status of poliomyelitis eradication in South-east AsIa Region (SEAR) LUNCH BREAK

Lao PDR Malaysia Mongotla Papua New Guinea Philippines (xi) Repubtie of Korea (xii) Viet Nam

Mealing

(c) (d)

IP 1200-1300 1300-1500 9 LUNCH BREAK

1215-1330 1330-1400 1400-1430 l4:JO.15OO (d) (e) (~

LUNCH BREAK

1200-1330 1330-1400 1400-1500 (~

LUNCH BREAK

(c)

Coonii)' progress reports on status of poliomyelitis eradication In Western Pacific Region (WPR): (i) (ii) (iii) (iv) (v) (vi) . Cambodia China Lao PDR Malaysia Mongolia Papua New Guinea

Impact of importstion

(e)

Costing measles Regional plan 01 action

Global Alliance tor Vaccines and tmmunization (GAVI) update Using and managing data

Conclusions and recommendation Including _tatJon of ICC

1500

10 Closing ceremony

!7i~J Philippine.

1500-1530 3

vi. Viet Nam COFFEE BREAK

1500-1530 1530-1830 (g)

COFFEE BREAK ~iscussion

1500-1530 1530-1700

COFFEE BREAK

Maternal and neonaisltetanua ellmlnollon (IINTE)

7

Interagency Coordlnollng Commltlae _ n g (ICC) (a) (b) FUnding: Use. source and Mureneeds

1530-1545 1545-1830

(s) (b)

Regional overview Coonii)' reports on MNTE: (I) (n)

(iii) 1900 L-_____

Cambodia China Lao PDA

Statements from partners

I ....

Cocktails and Buffet attha Diamond Hotel

51

ANNEX 2

WORLD HEALTH ORGANIZATION

ORGANISATION MONDIALE DE LASANT~

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R~GIONAL DU PACIAQUE OCCIDENTAL

TlDRTEENTH MEETING OF THE TECHNICAL ADVISORY GROUP (TAG) ON THE EXPANDED PROGRAMME ON·IMMUNIZA TION AND POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION

WPRlICPIEPI(3)12002lIB12 02 November 2002

ManDa, Philippines 4·7 November 2002

ENGLISH ONLY

LIST OF PARTICIPANTS

1. TECHNICAL ADVISORY GROUP MEMBERS Dr Isao Arila, (Chainnan, EPI Technical Advisory Group), Chainnan, Agency for Cooperation in International Health (AClH), 4-11-1 Higashi-machi, Kumamoto 862-0901. Japan Tel: +81-9-6-367-8899, Fax: +81-9-6-367-9001, E-mail: arita@acih.com; acih@msa.biglobe.ne.jp Dr Robert Hall, (Vice Chainnan, EPI Technical Advisory Group), Director of Public Health and Chief Health Officer, Department of Human Services, Level 18, 120 Spencer Street, Melbourne. Victoria 3001. Australia, Tel: +61-3-9637-4200/4204, Mobile: +61-4-1835-3069, Fax: +61-3-9637-4250, E-mail: Robert.G.Hall@dhs.vic.gov.au Dr Stephen Cochi, Director, Global Immunization Division, National Immunization Program Centers for Disease Control and Prevention, Atlanta. Georgia 30333. United States of America Tel: +1-404-639-8476, Fax: +1-404-639-8573, E-mail: sic I @cdc.gov: scochi@cdc.gov Dr Nobuhiko Okabe', Director, Infectious Disease Surveillance Center National Institute of Infectious Diseases, 1-23-1 Toyama Shinjuku-lru, Tokyo 162-8640 Tel: +81-3-52851111, Fax: +81-3-5285-1129, E-mail: okabenob@nih.go.jp

Dr Yu Jingjin, Deputy Director-General, Department of Diseases Control, Ministry of Health, No. I Xizhimenwai Nanlu, Xicheng District, Beijing 100044. People's Republic of China Tel: +8610-6879-2331, Fax: +8610-6879-2514, E-mail: yujj@chsi3.moh.gov.cn Professor Dang Duc Trach, National EPI Manager, National Institute of Epidemiology and Hygiene, No.1 Yersin St., Ha Noi 10000. Viet Nam Tel: +84-4-821-4680 or 971-2989, Fax: +84-4-821-3782 or 821-0853, E-mail: trach@fpt.vn

I Dr Okabe will represent Dr Hiroyoshi Endo (Director, Division of Tuberculosis and Infectious Diseases Ministry of Health, Labour and Welfare, Japan Government), as new TAG member, who is unable to attend this year's meeting.

- 52-

Annex 2

2. REGIONAL CERTIFICATION COMMISSION Dr Anthony 1. Adams, (Chainnan, Regional Certification COmmission) Former Professor of Public Health, The Australian National University, National Centre for Epidemiology and Population Health, Canberra, A. C. T. 0200 New address: No. 612-4 Chapman Crescent, Avoca Beach, New South Wales 2251, Australia Tel: +612-4382-6516, Fax: nla, E-mail: aarr@netsoeed.com.au

Dr Shudo Yamazaki, (Vice-Chainnan, Regional Certification Commission) (Director Emeritus, National Institute of Infectious Diseases) 3-1204-3, Sayama, Higashiyamato-shi, Tokyo 207-0003, Japan Tel: +81-4-2-564-3630, Fax: +81-4-2-564-3640, E-mail: shudo@mxs.mesh.ne.jp Dr Aida M. Salonga, Head, Neurology Section, Department of Neurosciences University of the Philippines-Philippine General Hospital, Taft Avenue, Ermita, Manila. Philippines, Tel: +632-521-8450, local 2405, Fax: +632-525-4996, E-mail: RMS@wtouch.net; neuropgh@hotmail.com Dr Carlyle Guerra de Macedo', Former WHO Regional Director for the Americas and PAHO Director Emeritus, SMDB Conjunto 01 Casa 05 SHIS, Brasilia, DF.. Brazil 71680-010. Brazil, Tel: +614269595/ (55-61) 248-4245 (Res.), Fax: +5561321-1922, E-mail: macedo@bra.ops-oms.org Professor Nguyen Dinh Huong, Chainnan, Advisory Committee for Rational Use of Antibiotics, Ministry of Health, Secretary General, Red Cross Society of Viet Nam National Headquarters, 82 Nguyen Du Street, Ha Noi. Viet Nam Tel: +844-942-4868, Fax: +844-942-4285, E-mail: vnrchq@netnam.org.vn

Dr Olen M. Kew 3, Molecular Virology Section MSG-IO, Respiratory and Enterovirus Branch National Centre for Infectious Diseases, Centers for Disease Control and Prevention 1600 Clifton Road N.E., Atlanta. GA 30333. United States of America Tel: +1404639 1341, Fax: +1404 639 2648, E-mail: omkl@cdc.gov Dr Zhuang Hui, Professor, Department of Microbiology, Beijing Medical University 38 Xue-Yuan Road, Haidian District, Beijing 100083. People's Republic of China Tel: +8610-6209-8899, Fax: +8610-6209-1617, E-mail: zhuanghu@publica.bj.cninfo.net 3. EPI NATIONAL MANAGERSISURVEILLANCE OFFICERS, MINISTRYIDEPARTMENT OF HEALTH STAFF BRUNEI DARUSSALAM Dr Hajah Rahrnah Haji Mohd Said, Senior Medical Officer of Health and Head, Disease Control Unit, Department of Health Services, Ministry of Health Bandar Seri Begawan BB391O. Tel: +673-2382755, Fax: +673-2-382755 E-mail: rahmahms@brunet.bn CAMBODIA Professor Dr Sann Chan Soeung, Deputy Director of National MaternaI and Child Health Centre Manager, National Immunization Programme, Ministry of Health 531-153 Kampuchea Krom St., Phnom Penh. Tel: +855-23-426-257; +855-12-933-344 Fax: nla, E-mail: sannchansoeung@bigpond.com.kh Ms Ly Nareth, Deputy Director, Immunization Services, National Immunization Programme, 151 - 153 Kampuchea Krom Street, Ministry of Health, Phnom Penh Tel: +855-23-426-257; +855-012-620-481, Fax: nla, E-mail: immunization@bigpond.com.kh

2 3

Note: Unable to attend this year's meeting Note: Unable to attend this year's meeting

53

Annex 2

CIflNA, PEOPLE'S REPUBLIC OF Dr Bai Huqun Deputy Director, China Center for Disease Control 27 Nan Wei Road. Xuan Wu District, Beijing, 100050 Tel: +8610-6302-2935. Fax: +8610-6317-0894. E-mail:n!a

Dr Uang Xiaofeng. Director. Nationallrnmunization Program China Center for Disease Control. 27 Nan Wei Road. Xuan Wu District Beijing, 100050, Tel: +8610-6317-6737. Fax: +8610-6317-1724 E-mail: Iiangxf@hotmail.com Dr Lei Zhenglong. Deputy Director. Division of Vaccine Preventable Disease Department of Disease Control. Ministry of Health. No. 1 Xizhimenwai Nanlu Xicheng District. Beijing 100044, Tel: +8610-6879-2358 Fax: +8610-6879-2357. E-mail: EPIDDC@chsi3.moh.gov,cn Dr Lu Ming. Programme Officer. Division of Vaccine Preventable Disease Department of Disease Control. Ministry of Health. No.1 Xizhimenwai Nanlu Xicheng District. Beijing 100044. Tel: +610-6879-2356 Fax: +8610-6879-2357. E-mail: EPIDDC@chsi3.moh.gov,cn

HONG KONG (CIflNA) Professor Leung Nai-kong. Hong Kong College of Paediatricians Hong Kong Academy of Medicine. Room 808 Jockey Club Building 99 Wong Chuk Hang Road, Aberdeen. Tel: +852-2871-8842. Fax: +852-2785-1850. E-mail: hkcpaed@nelvigator.com

MACAO (CIflNA) Dr Lam Chong. Coordinator. Control of Communicable Diseases (CDC) Department of Health. Government of Macao. Ave. Sidonio Pais. No. 51 Edf. China Plaza. 3 Andar. Macao. Tel: +853-533-525 Fax: +853-533-524. E-mail: ndiv@ssm.gov.mo

JAPAN Dr Takeshi Tanaka, Deputy Director of Tuberculosis and Infectious Diseases Control Division Health Service Bureau. Ministry of Health. Labour and Welfare 1-2-2. Kasumigaseki. Chiyoda-ku. Tokyo 100-8916 Tel: +813-3595-2263. Fax: +813-3581-6251. E-mail: tanaka-takeshitt@mhlw.go,jp

LAO, PEOPLE'S DEMOCRATIC REPUBLIC Dr Somthana Douangmala, Deputy Director. National Center for Mother and Child Health and National EPI Manager. Ministry of Health. KM3. Thadeua Road. Vientiane Tel: +856-21-350027. Fax: +856-21-350067. E-mail: somthdm!@lao,com Dr Phengta Vongphrachanh. Deputy Director. National Center for Laboratory and Epidemiology Ministry of Health. Km 3. Thadeua Road. Vientiane Tel: +856-21-312351. Fax: +856-21-350209. E-mail: Phengta@ho!mail.com

MALAYSIA Dr R. Devan AIL K. Ramu. Principal Assistant Director of Health. Disease Control Division. Ministry of Health. Level 3. Block A. Health Offices' Complex. Jalan Cenderosari .. 50590 Kuala Lumpur. Tel: +603-2694-6601. Fax: +603-2694-6404 E-mail: devankurup@hotmail.com

MONGOLIA Dr Baldan-Osor Gerelsuren. Assistant of National EPI Manager. Ministry of Health Olimpic Street 2. Vlaanbaatar 51. Tel: +976-1-323111 Fax: +976-1-321278. E-mail: narangerel@moh.mng,net Dr Rentsen Tuul. Head of the National Measles Laboratory National Center for Communicable Diseases. Ministry of Health Olympic Street 2. Vlaanbaatar 51. Tel: +976-11-451183 Fax: +976-11-458699. E-mail: r tuul@yahoo,com

- 54Annex 2

NEW ZEALAND Dr Douglas Lush, Senior Adviser, Public Health Medicine, MinIstry of Health 133 Molesworth Street, Wellington. Tel: +6444954364, Fax: +644495-4401, E-mail: douglas lush@moh.govt.nz

PAPUA NEW GUINEA Dr David Mokela, Acting Chief Paediatrician, National Department of Health Port Moresby General Hospital, Free Mail Bag, Boroko. NCD Tel: +675-324-8200, Fax: +675-325-0342, E-mail: nla

Mr Barry Ropa, National Surveillance Officer, Department of Health P.O. Box 807, Waigani. NCD. Tel: +675-301-3938, Fax: +675-323-9710 E-mail: bropa@health.gov.og PHILIPPINES Dr Maria Consorcia Lim-Quizon, Officer-in-Charge, National Epidemiology Cener (NEC) Department of Health, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila Tel: (632) 711-9502/03, Fax: (632) 743-1829, E-mail: clquizon@doh.gov.ph Dr Joyce Ducusin, Medical Specialist IV, Center for Family and Environmental Health Department of Health, San Lazaro Compound, Rizal Avenue, Sta Cruz, Manila Tel: +632-712-81-18, Fax: nla, E-mail: clo fetp@doh.gov.ph

REPUBLIC OF KOREA Dr Young-Taek Kim, Deputy Director, Department of Infectious Disease Control National Institute of Health, 5 Nokbun-dong, Eunpyung-gu, Seoul 122-701 Tel: +822-380-1573, Fax: +822-354-2723, E-mail: ruyoung@nih.go.kr

VIET NAM, SOCIALIST REPUBLIC OF Dr Do Si Hien Manager, National EPI, National Institute of Hygiene and Epidemiology Ministry of Health, No. 1 Yersin Street, Ha Noi 10 000. Tel: +844-8214680, Fax: +844-821-3782, E-mail: dshien@fi?t.vn Dr Nguyen Van Cuong, National EPI Secretary, National Institute of Hygiene and Epidemiology Ministry of Health, No.1 Yersin Street, Hanoi 10 000 Tel: +844-971-9891, Fax: +844-821-3782, E-mail: vancuong@fi?t.vn

4. REGIONAL REFERENCE LABORATORY STAFF AUSTRALIA Dr Bruce Thorley, Regional Poliovirus Reference Laboratory, Epidemiology & Public Health Division, Victorian Infectious Diseases Reference Laboratory, 10 Wreckyn Street, North Melbourne 3051. Victoria, Tel: +61-39342-260712600, Fax: +61-39342-2665, E-mail: bruce.thoriey@rnh.org.au

CHINA, PEOPLE'S REPUBLIC OF Dr Zhang Libi, Director, National Reference Laboratory for Poliomyelitis Chinese Center for Disease Control, 27 Nanwei Lu, Beijing 100050 Tel: +8610-6317-1710, Fax: +8610-6317-1724, E-mail: chenliOlO2@hotrnail.com

JAPAN Dr Hiroyuki Shimizu, Department of Virology II, National Institute of Infectious Diseases Gakuen 4-7-1, Musashimurayama-shi, Tokyo 208-0011. Tel: +8142-561-0771, Fax: +8142-561-4729, E-mail: hshimizu@nih.go.jp

55

Annex 2

5. NATIONAL POLIOMYELITIS LABORATORY STAFF . HONG KONG (CHINA): Dr Wilina Lim Wei-ling. Consultant - Medical Microbiologist, Department of Health Hong Kong Government, 211F Wu Chung House. Wanchai. Hong Kong - SAR. Hong Kong Tel: +852-2855-4112. Fax: +852-2819-0704. E-mail: wllim@pacific.net.hk

MALAYSIA Dr Nor Shahidab Khairullab, Head. Virology Unit. Infectious Disease Research Centre Institute of Medical Research. Jalan Pabang. 50588 Kuala Lumpur Tel: +603-2693-5070; 4040-2345. Fax: +603-2693-6323. E-mail: norshahidab@imr.gov.my MONGOLIA Dr Sarankhuu Amarzaya, Head of National Polio Laboratory. Department of Virology Public Health Institute. Enkhtaivan Street-17. U1aanbaatar 49 Tel: +976-11-452-664. Fax: +976-11-452-664, E-mail: amarzs@yaboo.com

NEW ZEALAND Dr Qiu Sue Huang, Science Leader-Virology. Communicable Disease Group Institute of Environmental Science and Research, Kenepuru Drive Porirua. Tel: +64-4-914-0764. Fax: +64-4-914-0770. E-mail: sue.huang@esr.cri.nz PAPUA NEW GUINEA Dr Peter Max Siba, Assistant Director and Head, Microbiology and Virology Unit Papua New Gninea Institute of Medical Research. P.O. Box 60. Goroka, EHP 441 Tel: +675-732-2800, Fax: +675-732-1998. E-mail: general@pngimr.org.pg PHILIPPINES Ms Judy B. Bocacao4 • Research Analyst. National Poliomyelitis Laboratory Research Institute for Tropical Medicine. Department of Health Filinvest Corporate City Compound, A1abang. Muntinlupa City Tel: +632-809-7599; 807-2628 (Loc. 605). Fax: +632-842-224512828. E-mail:jbocacao@ritrn.gov.ph Ms Eichelle J. Lintag4. Research Assistant. Laboratory Containment for Wild Poliovirus Research Institute for Tropical Medicine. Department of Health. filinvest Corporate City Compound. A1abang. Muntinlupa City. Tel: +632-809-7599; 807-2628 (Loc. 605). Fax: +632-842-2245/2828. E-mail: eichelle@edsarnail.com.ph

REPUBLIC OF KOREA Dr Youngmee Jee. Senior Researcher. Laboratory of Enteroviruses Department of Virology, National Institute of Health. 5 Nokbun-dong. Eunpyung-gu. Seoul 122-701. Tel: +822-380-1493. Fax: +822-382-6542. E-mail: ymeejee@nih.go.kr

SINGAPORE Dr Chan K wai Pengo Consultant Virologist. Department of Pathology Singapore General Hospital. Outram Road. Singapore 169608 Tel: +65-6321-4940. Fax: +65-6323-4972. E-mail: !;lptckp@sW.com.s!;l VffiT NAM, SOCIALIST REPUBLIC OF Dr Nguyen Thi Hien Thanh. Chief of Enterovirus Laboratory. National Institute of Hygiene and Epidemiology. Ministry of Health. No.1 Yersin Street. Hanoi 10 000 Tel: +84-8-211-534. Fax: +84-8-213-782. E-mail: nththanh@fpt.vn Dr Phan Van Tu. Director. Laboratory of Enteroviruses. Pasteur Institute. Ministry of Health, 167, Duong Pasteur, Q3, Ho Chi Minh City, Tel: +84-8-8202878, Fax: +84-8-8231419, E-mail: phantu@hcmc.netnam.vn;pvtu@hcm.vnn.vn • Ms Bocacao and Ms Lintag attend as observers, to represent Dr Julia Fern Paladin, Head Virology

Department, Research Institute for Tropical Medicine (RITM), Muntinlupa City.

- 56-

Annex 2

6. TEMPORARY ADVISER

Dr Walter Dowdle, Director of Programmes, The Task Force for Child Survival and Development 750 Commerce Drive. Suite-400, Decatur, Georgia 30030, United States of America Tel: +1-404-687-5608, Fax: +1-404-371-1087, E-mail: wdowdle@taskforce.org Dr Tatsuo Miyamura, Director, Department of Virology II, National Institute of Infectious Diseases Ministry of Health Labour and Welfare, Toyama 1-23-1, Shinjuku-ku, Tokyo 162-8640. Japan Tel: +81-35-285-1111 (ext. 2500), Fax: +81-35-285-1161, E-mail: tmiyam@nih.go.jp Dr Mark Pallansch, Chief, Enterovirus Section, Respiratory and Enteric Viroses Branch Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases Centers for Disease Control and Prevention, 1600 Clifton Road E-05, Atlanta, Georgia 30333 United States of America, Tel: +1-404-639-2749. Fax: +1-404·639·4011, E-mail: mapl@cdc.gov Dr Mahomed Patel, Fellow, National Center for Epidemiology, and Population Health Australian National University, C/R Egglestone and Mills Road, Canberra 0200. Australia Tel. +61-2-6125-5619, Fax +61-2·6125-0740, E-mail: Mahomed.Patel@anu.edu.au

Dr Masato Tashiro, Department of Viral Diseases and Vaccine Control National Institute of Infectious Diseases, Gakuen 4-7-1, Musashi-Murayama, Tokvo. 208-0011. Japan, Tel: +81-4-2-565-2498. Fax: +81-4-2-565-2498, E-mail: mtashiro@nih.go.jp

7. OBSERVERS AUSTRALIAN AGENCY FOR INTERNATIONAL DEVELOPMENT (AusAlD) Ms Patricia Ludowyk, Austra1ian Embassy 63, Dona Salustiana Ty Tower, 104 Paseo de Roxas, Makati. Metro Manila. Philippines, Tel: n/a, Fax: +632754-6268, E-mail: Patricia.Ludowyk@dfat.gov.au BUNDESMINISTERIUM FOR WIRTSCHAFTLICHE ZUSAMMENARBEIT UN ENTWICKLUNG (BMZJGTZ) Dr Konrad Oberrnann, Component Adviser, GTZ Local Health Systems Development GTZ Health Program, GTZ Office Manila, P.O. Box 2218 MCPO, 1262 Makati City Tel. (6353) 323 8952; 323 8953, Fax: (6353) 323 9062, Email: gtz lhsd@mozcom.com CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC): Dr Peter Strebel, Chief, Global Measles Branch, National Immunization Program Global Immunization Division, Centers for Disease Control and Prevention 1600 Clifton Road (E05), Atlant!!, Georgia 30333, United States of America Tel: +1-404-639-8252, Fax: +1-404-639-8573, E-mail: pms4@cdc.gov

Dr Robert Perry, Branch Chief, Global Measles Branch, Global Immunization Division Department of Health and Human Services, Centers for Disease Control and Prevention Atlanta, Georgia 30333. United States of America Tel: +1-404-639-8224, Fax: +1-404-639-8573, E-mail: rrnp9@cdc.gov Dr Amra Uzicanin, Medical Epidemiologist, Global Immunization Division National Immunization Program, Centers for Disease Control and Prevention 1600 Clifton Road (E05), Atlanta. Georgia 30333. United States of America Tel: +1-404-639·8252, Fax: +1-404-639-8573, E·mail: aau5@cdc.gov

DEPARTMENT OF HEALTH (DOH), HONG KONG Dr Au Tak-kwong, Principal Medical and Health Officer, Department of Health Room 331 Shatin Government Offices, No. I Sheung Wo Che Road, Shatin. N.T., Hong Kong, Tel: +852-2158-5101, Fax: +852-2603-0523, E-mail: tkau@dh.gov.hk DEPARTMENT OF HEALTH (DOH), PHILIPPINES: Dr Juanita A. Basilio, Medical Officer VII, National Center for Disease Prevention and Control, Department of Health, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila. Tel: +632-732-9956, Fax: +632-781-8843, E-mail: nitzbasilio@hotmail.com

57 Annex 2 Dr Geraldine Anne Crimen, Medical Specialist IV, Center for Infectious Diseases Department of Health, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila Tel: +632-711-78-46. Fax: +632-711-78-46, E-mail: geraldineannecruz@yahoo.com Mr David Masiado, Supervising Health Program Officer, Bureau of International Health Cooperation, Department of Health, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila Tel: +632-917-8163400 (Mobile), Fax: +632-8843, E-mail: dave masiado@hotmail.com Ms Maricel de Quiroz, AFP Surveillance National Coordinator, ational Epidemiology Center, Department of Health, San Lazaro Compound, Rizal Avenue, Sta Cruz, Manila. Tel: +632 742 3945n43 1937, Fax: +632743 6076n41 7048, E-mail: dequirozm@yahoo.com

INTERNATIONAL MEDICAL CENTER OF JAPAN: Dr Kazuo Hikita, Expert Services Division, Bureau of International Cooperation International Medical Center of Japan, 1-21 ,Toyama, Shinjuku-ku, Tokyo 162-8655 Tel: +81-3-32027181, Fax: +81-3-3207-1038, E-mail: hikitak@it.imcLgo.jp Dr Makoto Kobayashi, Expert Services Division, Bureau of International Cooperation International Medical Center of Japan, 1-21, Toyama, Shinjuku-ku, Tokyo 162-8655 Tel: +81-3-3202-7181, Fax: +81-3-3207-1038, E-mail: koba98@mwb.biglobe.ne.jp

JAPAN INTERNATIONAL COOPERATION AGENCY (JICA), JAPAN Ms Saeda Makimoto, Programme Officer Planning Division, Medical Cooperation Department, Japan International Cooperation Agency Shinjuku Maynds Tower Bldg, 2-1-1, Yoyogi, Shibuya-ku, Tokyo. 151-8558 Tel: +81-3-5352-5683, Fax: +81-3-5352-5490, E-mail: makimoto.saeda@jicago.jp

JICA,CHINA Dr Toru Chosa, Chief Advisor, Japan International Cooperation Agency China EPI Strengthening Project, flCA Expert Room, China Center for Disease Control 27 Nanwei Lu , Beijing 100050 Fax: +8610-8315-9822, Tel: +8610-6304-2355, E-mail: tchosa@tkk.att.ne.jp

MINISTRY OF FOREIGN AFFAIRS, JAPAN: Mr Tamotsu Ikezaki, Assistant Director, Technical Cooperation Division Economic Cooperation Bureau, Ministry of Foreign Affairs 23" Floor, Shiba Keen Tower, 2-11-1, Shiba Keen, Minato-ku, Tokyo 105-8519. Tel: +81-3-3580-3311, Ext 3887, Fax: +81-3-6402-2106, E-mail: tamotsu.ikezaki@mofa.go.jp Dr Kuniaki Miyake, Second Secretary, Health and Welfare, Embassy of Japan 2627 Roxas Boulevard, Pasay City BOO, Metro Manila Tel: nJa, Fax: +632-551-5780, E-mail: miyake.kuniaki@mofa.go.jp Dr Atsuko Aoyama, Professor, Department of International Health Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku Nagoya 466-8550. Tel: +81-52-744-210812109 Fax: +81-52-744-2114, E-mail: atsukoa@med.nagoya-u.ac.jp Mr Yusuke Geto, Director, Earth & Human Corporation 8-3-23 Tarnagawagakuen, Machida, Tokyo 194-0041 Tel: +81-42-710-7661, Fax: +81-42-710-7665, E-mail: KYW05764@nifty.ne.jp

MINISTRY OF HEALTH, CAMBODIA: Dr Chea Kim Ly, Assistant Manager, National Immunization Programme 151-153 Kampuchea Krom Street, Ministry of Health, Phnom Penh Tel: nJa, Fax: nJa, E-mail: nJa Dr Svay Sarath, Assistant Manager, National Immunization Programme 151-153 Kampuchea Krom Street, Ministry of Health, Phnom Penh Tel: nJa, Fax: nJa, E-mail: nJa

- 58-

Annex 2

MINISTRY OF HEALTH, NIHE, VIET NAM Dr Ho Thi Min Ly; National Institute of Health and Epidemiology (NIHE) 1 Yersin Street, Ha Noi, Tel: +844 971-4669, Fax: +844 821-3782, E-mail: myconihe@fpt.vn Dr Nguyen Tu Yen, National Institute of Health and Epidemiology 1 Yersin Street, Ha Noi, Tel: +844 971-4669, Fax: +844 821-3782, E-mail: yentc@hn.vnn.vn ROTARY INTERNATIONAL Mr Oscar C. de Venecia, Chairman, Rotary National Polio Plus Committee 7"' Floor, Basic Petroleum Building, Carlos Palanca Street, Legaspi Village Makati City, Tel: +632-817-8596/97/98, Fax: +632-817-0191, Email: odv@mozcom.com Mr Mariano nano, Jr., Vice Chairman, Rotary National Polio Plus Committee 7th Floor, Basic Petroleum Building, Carlos Palanca Street, Legaspi Village, Makati City, Tel: +632817-3329, Fax: +632817-0191, E-mail: nla

ROTARY INTERNATIONAL DISTRICT 2650, JAPAN Mr Tatsuji Kondo, Rotary International District 2650 5-3 Fukuchiin-cho, NARA 630-8381 Tel: +81-7-42-25-2650, Fax: +81-7-42-25-2651, E-mail: ri2650go@galaxy.ocn.ne.jp Ms Yoshiko Kondo, Rotary International District 2650, 5-3 Fukuchiin-cho NARA 630-8381. Tel: +81-7-42-25-2650 Fax: +81-7-42-25-2651, E-mail: ri2650go@galaxy.ocn.ne.jp

UNITED NATIONS CHILDREN'S FUND (UNICEF) Dr Maria Otelia Costales, Senior Health Advisor, Global Polio Eradication Programme Health Section, Programme Division, UNICEF, New York Headquarters 3 UN Plaza (H 812), New York City, New York 10017, United States of America Tel: +1-212-326-7190, Fax: +1-212-824-6460, Email: mocostales@unicef.org Dr Paul Richard Fife, Immunization Plus Team, PDlHealth Section, UNICEF, New York Headquarters,3 UN Plaza (H 812), New York City, New York 10017, United States of America Tel: +1-212-326-7345, Fax: +1-212-824-6460, E-mail: pfife@unicef.org Ms Shanelle Hall, Contract Officer, UNICEF Supply Division, Freeport, 2100 Cooenhagen, Denmark Tel: +4535273084, Fax: +4535269421, E-mail: sehall@unicef.org

Dr Terrel M. Hill, UNICEF Representative, P.O. Box 1076, Makati Central Post Office 1250 Makati City, Philippines, Tel: +632 892-0611 to 25 (trunk lines) Tel: +632816-3935 (direct), Fax: +632-810-1453, E-mail: thill@unicef.or~:unicef@globe.com.ph Mr Stephen Jarrett, Deputy Director, UNICEF Supply Division Freeport, 2100 Copenhagen, Denmark Tel: +4535273084, Fax: +4535269421, E-mail: sjarrett@uni.cef.org Dr Marisa Ricardo, Project Officer, Expanded Programme on Immunization UNICEF, P.O. Box 1076, Makati Central Post Office, 1250 Makati City. Philippines Tel: +632-892-0611 to 25, Fax: +632-810-1453, E-mail: unicef@globe.com.ph Mr Basil Rodriques, Regional Immunization Officer, UNICEF Bangkok Office UNICEF East Asia and Pacific Regional Office (EAPRO), P.O. Box 2-154 Bangkok 10200. Thailand, Tel: +662-356-9499 Ext. 9512 Fax: +662-280-3563, E-mail: brodrigues@unicef.org Mr Chum Aun, (UNICEF-Phnom Penh), Assistant Project Officer National Immunization Programme, 151 - 153 Kampuchea Krom Street Ministry of Health, Phnom Penh, Cambodia, Tel: nla, Fax: nla, E-mail: nla Dr Pham Ngoc Len, Project OfficerlHealthlNutrition, UNICEF Ha Noi Office, 72 Ly Thuong Kiet St, Ha Noi, Viet Nam Tel: +844 935-0028 to 33 (ext 258), Fax: +844 935-0040. E-mail: pnien@unicef.org

59

Annex 2

8. SECRETARIAT WHOIWESTERN PACIFIC REGIONAL OFFICE (WPRO) Dr E. B. Doberstyn. Director Combating Communicable Diseases Regional Office for the Western Pacific. United Nations Avenue. 1000 Manila. Philippines Tel: +632528-8001. Fax: +632521-1036. E-mail: doberstyne@wpro.who.int Dr Yang Baoping. Regional Adviser. Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila Philippines Tel: +632-528-9747. Fax: +632-521-1036. E-mail: yangb@wpro.who.int Dr Yoshilruni Sato. Medical Officer. Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila. Philippines Tel: +632-528-9742. Fax: +632-521-1036. E-mail: satoy@wpro.who.int

Mr Wayne Antkowiak, Technical Officer, Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila. Philippines Tel: +632-528-9751. Fax: +632-521-1036. E-mail: antkowiak@wpro.who.int Dr Osman Mansoor. Medical Officer. Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila. Philippines Tel: +632-528-9748. Fax: +632-521-1036. E-mail: mansooro@woro.who.int

Dr Jeffrey McFarland. Medical Officer, Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila Philippines Tel: +632-528-9746. Fax: +632-521-1036. E-mail: mcfarlandj@wpro.who.int Dr Sigrun Roesel. Medical Officer. Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila. Philippines Tel: +632-528-9741. Fax: +632-521-1036. E-mail: roesels@wpro.who.int Dr Hiroko Tanaka. Technical Officer. Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila. Philippines Tel: +632-528-9744. Fax: +632-521-1036. E-mail: tanakah@wpro.who.int

Dr Stuart Blacksell. WHO Consultant. Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila. Philippines Tel: +632-528-8001. Fax: +632-521-1036. E-mail: sdb thai@hotmail.com Mr Richard Duncan. WHO Consultant, Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila. Philippines Tel: +632-528-8001. Fax: +632-521-1036. E-mail: Duncan ri@yahoo.com

Ms Susan Shin. WHO Consultant, Expanded Programme on Immunization World Health Organization. Regional Office for the Western Pacific United Nations Avenue. 1000 Manila. Philippines Tel: +632-528-8001. Fax: +632-521-1036. E-mail: susan@susanshin.com

-60-

Annex 2

WHO/CAMBODIA Mr Keith Feldon, Technical Officer, Expanded Programme on Immunization WHO Representative's Office, No. 177-179 comer Streets Pasteur (51) and 254 P.O. Box 1217, Sangkat Chak Tomouk, Khan Daun Penh, Phnom Penh. Cambodia Tel: +855-23216610, Fax: +855-23216211, E-mail: feldonk@cam.wpro.who.int WHO/CHINA: Mr Alan Schnur, Team Leader, Combating Communicable Diseases WHO Representative's Office - China, 401, Dongwai Diplomatic Office Building Chaoyang District, Beijing 100600. China Tel: +861065327189 to 92, Fax: +8610 6532-2359, E-mail: schnura@chn.who.int

Dr Lisa Lee, Medical Officer, Expanded Programme on Immunization WHO Representative's Office - China, 401, Dongwai, Diplomatic Office Building Chaoyang District, Beijing 100600. China Tel: +8610 6532 7189 to 92, Fax: +86106532-2359, E-mail: leel@chn.who.int Dr Li Ailan, Programme Assistant, Expanded Programme on Immunization WHO Representative's Office - China, 40 I, Dongwai, Diplomatic Office Building Chaoyang District, Beijing 100600. China Tel: +861065327189 to 92, Fax: +8610 6532-2359, E-mail: ailanl@chn.who.int WHOILAO, PEOPLE'S DEMOCRATIC REPUBLIC Mr David Bassett, Technical Officer, Expanded Programme on Immunization WHO Representative's Office, Ban Phonxay, That Luang Road, Vientiane. Lao People's Democratic Republic Tel: +85621413-431, Fax: +85621413 432, E-mail: bassettd@lao.wpro.who.int WHOIMONGOLIA Dr J. Mendsaikhan, Immunization Officer, Expanded Programme on Immunization WHO Representative's Office, Ministry of Public Health, Ulaanbaatar-13. Mongolia Tel: +976-11-327870, Fax: +976-11-324683, E-mail: mendsaikhan@mog.wpro.who.int WHOIPIllLIPPINES: Dr Jean Marc Olive, WHO Representative, Philippines, clo Department of Health San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila Tel: +632-338-7479, Fax: +632-731-3914, E-mail: OJivej@phl.wpro.who.int

Dr Paulo Froes, Short Term Consultant, Expanded Programme on Immunization World Health Organization, Regional Office for the Western Pacific United Nations Avenue, 1000 Manila. Philippines Tel: +632528-8001, Fax: +632521-1036, E-mail: froesp@wpro.who.int WHOISOUTH PACIFIC Mr Frank Rousar, Technical Officer, Expanded Programme on Immunization WHO Representative's Office, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Sreet, Suva, Fiji, Tel: +6793-304600, Fax: +6793-304631, E-mail: rousarf@who.fii.wpro.who.int WHOtvIET NAM: Mr Angus Pringle, Technical Officer, Expanded Programme on Immunization WHO Representative's Office, 63 Tran Hung Dao Street, Hoan Kiem District, Ha Noi. Viet Nam, Tel: +844 943-3734, Fax: +844 943-3740, E-mail: pringlea@vtn.wpro.who.int Dr Rikke Schultz, Associate Professional Officer, Expanded Programme on Immunization WHO Representative's Office, 63 Tran Hung Dao Street, Hoan Kiem District, Ha Noi Viet Nam, Tel: +844 943-3734, Fax: +844 943-3740, E-mail: schuItzr@vtn.wpro.who.int

61

Annex 2 Dr Naosuke Asao, Short Term Professional, Expanded Programme on Immunization WHO Representative's Office, 63 Tran Hung Dao Street, Hoan Kiem District, Ha Noi Viet Nam, Tel: +844 943-3734, Fax: +844 943-3740, E-mail: asaon@who.wpro.who.int WHOIHEADQUARTERS, GENEVA: Dr Daniel Tarantola, Senior Policy Adviser to the Director-General Director, Vaccines and Biologicals, Health Technology and Pharmaceuticals World Health Organization, CH-U11 Geneva 27. Switzerland Tel: + 4122-791-2779/3920, Fax: + 4122-791-4227, E-mail: tarantolad@who.int Dr Julian Bilous, Coordinator, Expanded Programme on Immunization Vaccines and Biologicals, Health Technology and Pharmaceuticals World Health Organization, CH-l2ll Geneva 27, Switzerland Tel: +41 22791-2111, Fax: +4122791-3111, E-mail: bilousj@who.int Dr Pem Namgyal, Expanded Programme on Immunization Vaccines and Biologicals, Health Technology and Pharmaceuticals World Health Organization, CH-Ull Geneva 27. Switzerland Tel: +4122791-2111, Fax: +4122791-3111, E-mail: namgyalp@who.int

Mr David Featherstone, Coordinator, Vaccine-Preventable Disease Laboratory Network Vaccines Assessment and Monitoring, Health Technology and Pharmaceuticals World Health Organization, CH-Ull Geneva 27. Switzerland Tel: +4122-791-4422, Fax: +4122-791-4210, E-mail: featherstoned@who.int WHOIREGIONAL OmCE FOR SOUTH-EAST ASIA (SEARO) Dr Brenton Burkholder Regional Adviser, Vaccines and Biologicals Regional Office for South-East Asia, World Health House Indraprastha Estate, Mahatma Gandhi Road, New Delhi 110002. India Tel: +91-11 3370804, Fax: +91-11 3379707,0197,9395, E-mail: burkholderb@whosea.org Dr NaJini Withana, Virologist/Consultant, Regional Office for South-East Asia World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi 110002, India Tel: +91-113317804, Fax: +91-113318607, E-mail: withanan@whosea.org

- 63 -

Annex 3

Eighth Meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region (RCC) 7 to 8 November 2002, Manila, Philippines

PROGRESS REPORTS FROM COUNTRIES NON-ENDEMIC AT THE BEGINNING OF THE INITIATIVE Australia Surveillance for acute flaccid paralysis (AFP) is supported by regular meetings of the National ,Certification Committee (NCC). The Poliomyelitis Expert Committee (PEC) classified 45 of 61 AFP notifications in 2001 as eligible AFP cases, resulting in a non-polio AFP rate of 1.1 per 100 000 under15-year-olds ("AFP rate of 1.1"). Cases were excluded because: onset of paralysis in 2000 (2); non-AFP (2); non-residents of Australia (3), over fifteen years old (6); and no clinical information received (3). From January to 30 June 2002, the PEC classified 12 of 22 AFP notifications as eligible, given an AFP rate of 0.7 (annualized). Adequate stool collection rates remain low (29% in 2001 and 2002). A 2001 study by the Victorian Infectious Diseases Reference Laboratory (VlDRL), using a two-source capture-recapture method, estimated AFP incidence at 1.4 (95% CI 1.1-1.7); similar to the estimate of an earlier study in Victoria for 1995-1997 of 1.7 (95% CI 1.0-2.4). The secretariat for the PEC was transferred from the Commonwealth Department of Health and Ageing to the staff of the polio reference laboratory at VlDRL in May 2000. The PEC reviews and classifies cases prior to reporting data to WHO, and includes vaccine associated paralytic poliomyelitis (V APP) and (since 14 February 2002) vaccine-derived poliovirus (VDPV) cases in the same category. The PEC excludes non-AFP cases that have been misreported as AFP from the tally, Previously, there was inconsistency with classification of trauma cases notified, but the PEC resolved that all trauma cases with AFP would be considered as true AFP cases. The poliovirus reference laboratory at VlDRL retained full accreditation, It is the national poliovirus laboratory for Australia, the Pacific island countries, and Brunei Darussalam; as well as a regional reference laboratory (RRL), receiving specimens and virus isolates for intratypic differentiation (ITO) from the national laboratories of Hong Kong, Malaysia, New Zealand, Papua New Guinea, the Philippines and Singapore. The laboratory re-tested specimens from AFP patients from the national laboratories of Papua New Guinea and Mongolia and from cases of aseptic meningitis from Papua New Guinea between 2000 and 2002 as part of an ongoing assessment of quality control. Reported OPV3 coverage in 2001 was 92.1 % and 94.2% by June 2002 for children aged two years. No supplementary immunization was conducted. In January 2002 the Infection Management Section (IMS) of the Communicable Diseases and Health Protection Branch, Department of Health and Ageing was given responsibility to complete the national inventory of wild polioviruses. Completing the inventory was a challenging task because of the many potential sites where materials could be held, and including those not included in the initial process (e.g. defence laboratories). Extensive follow up has been undertaken of organizations previously identified that failed to respond, as well as to identify additional ones through professional and other organizations and advertisements in a range of professional journals. Using both the media and phone contact has been found to be the best way of Obtaining timely and accurate information and to explain the process to engage participation. The national inventory of wild poliovirus stocks and potentially infectious materials is now complete and contains 16 different organizations, The majority of samples are reference strains derived either from clinical specimens or vaccine strains, The database has been updated and reorganized, and holds entries for 2209 organizations and of these 2207 organizations have fully responded to the survey process. External experts will validate the database and process by March 2003.

- 64-

Annex 3

Brunei Darussalam The NCC continued its work, to ensure that all aspects of the post-eradication activities are sustained and conducted accordingly. . The AFP surveillance framework adopted prior to certification continued to be maintained with particular emphasis on coverage and completeness of the AFP surveillance from the various selected reporting sites. During the year 2001 and up till August 2002, the performance of the AFP Surveillance was found to be at certification standards. The zero report of AFP case during this period was substantiated by the absence of AFP case detection during the six monthly (JulylDec 2001; Jan/June 2002) and annual retrospective reviews (Year 2001) of the reporting sites. The national expanded programme on immunization (EPI) integrated its tenth antigen, the Hib vaccine, in April 2002. Coverage for all antigens including polio vaccine during 200 1 continued to be maintained at high levels both nationally and sub-nationally (OPV3 coverage 100%). In view of this, supplementary immunization activities are not currently deemed necessary. Nine laboratories identified during the initial screening for laboratory containment were all determined not to have any potentially infectious materials. Hong Kong (China) The AFP reporting rate was 1.5 per 100 000 belowr age 15 in 2001 and 1.1 in the first nine month of 2002 (annualized), with most other indicators also above target. The Government Virus Unit, the designated national poliomyelitis laboratory (NPL) for Hong Kong, has remained fully accredited since 1997. The immunization coverage rates for polio vaccine have been maintained at 90% and above. To ensure that prompt response can be elicited, an action plan on the response to importation of wild poliovirus has been prepared. Epidemiological data are also regularly exchanged with neighbouring areas. Hong Kong started the Phase I laboratory containment of wild poliovirus in 1999, and an inventory of laboratories has been established. Two laboratories had in their archives potentially wild poliovirus infectious materials and had destroyed the materials satisfactorily. Reminder letters have been sent to research laboratories reminding them to keep the National Coordinator for Laboratory Containment informed if clinical specimens are to be imported from countries where poliomyelitis is still endemic. Through this mechanism, six vaccine strains of poliovirus were identified from one research laboratory in 200 1, and they were destroyed under official witness.

The NCC met four times for discussions including on a possible vaccine-associated case in Kyoto and the adoption of inactive polio vaccine (IPV) for routine immunization in Japan. Members also discussed important aspects such as feasibility, how to get national consensus, how to keep high vaccine coverage and the possibility of combined vaccine with diphtheria-pertussis-tetanus (OPT). The NCC also analyzed the progress of the wild poliomyelitis containment survey. A questionnaire was distributed to 10 386 laboratories (clinical, teaching, research, etc), hospitals, private diagnostic companies, etc; 6535 responded as of March 2002. Forty-three laboratories reported having wild polioviruses or materials potentially containing wild polioviruses. Inquiries to non-responders by telephone are still ongoing, but to date the remaining institutions are all non-biological laboratories and are very unlikely to possess wild polioviruses. The national containment-coordinating group is going to examine the presence of polio viruses in "possibly containing materials". One specialist was assigned for this duty. In October 1998, a new "Law for Control of Infectious Disease" was established and poliomyelitis was designated as a second grade infectious disease requiring immediate reporting to health authorities and

- 65 -

Annex 3

strict investigation and control measures. This law does not presently cover vaccine associated cases but they may be included as part of the 2003 revision of the law. The Global Specialized Laboratory (GSL) at NIID, which also serves as a Regional Reference Laboratory and NPL, remains fully accredited. Routine OPV immunization is undertaken twice a year (spring and autumn) in Japan. In 2000, coverage dropped to 81 % after two cases of acute illness following OPV immunization in June 2000. One case died two weeks after immunization. Although investigation did not show that the vaccine was responsible, the local government, and subsequently the Ministry of Health stopped immunization until the safety of the particular lot of OPV was confirmed. In November 200 1, a 38-year-old man developed contact VAPP; but neither disease nor virus was detected in his contacts. Macao (China) Three AFP cases were reported from 1 January 2001 to 30 September 2002, achieving an annual AFP rate above 1. All cases had adequate stool samples taken which tested negative for poliovirus at the NPL in Hong Kong. The expert panel reviewed all AFP cases and assigned a final diagnosis. No poliomyelitis compatible case has been identified among them. A high level of oral poliomyelitis immunization coverage has been sustained two years after its poliomyelitis free certification. In 2000 and 2001 respectively, 91.8 % and 92.2% of all children around their first birthday were immunized with three doses of trivalent pOliomyelitis vaccine. Poliomyelitis immunization is part of the routine immunization provided throughout the health care system and the high coverage rate is expected to be sustained in future years. Under the containment effort, no new laboratory or any poliovirus infectious or potentially infectious materials have been identified since the national inventory was established. New Zealand The AFP rate was 1.29 per 100 000 aged under 15 in 2001, and 0.9 for January to July 2002 (annualized). The expected annual number of AFP cases is so low that it is hard to identify areas where the AFP reporting rate is less than would be expected. An audit of "missed" AFP cases from 2000 and 2001 identified only two cases that were not reported out of 27 AFP cases. In 2001, 54.5% of cases had adequate stool samples, and for the period January to July 2002 this figure was 75%. Ongoing work aims to improve the adequate stool rate. The NPL remained fully accredited. It is part of network comprised of five laboratories that covers the entire population. Untyped or untypable enteroviruses including polioviruses from non-AFP cases are referred to the NPL for identification. New Zealand changed from OPV to inactivated polio vaccine (IPV) in February 2002 as a combination vaccine with diphtheria, tetanus and acellular pertussis (DtaP-IPV). As a result, OPV isolation has been reduced from 6.9% of clinical samples to zero since March 2002, and from 86% of sewerage samples to a small but variable prevalence. New Zealand has not opted to retain stocks of OPV for the purpose of outbreak control in the unlikely event of an importation. The initial response would be limited use of IPV with further consultation with WHO.

- 66-

Annex 3

Under the laboratory containment effort. wild polioviruses stored at the NPL were destroyed on 28 March 2001 by autoclaving. Auckland Virology Laboratory has also destroyed some presumed Sabin strains after testing found them to be aberrant. Pacific island countries and areas Since certification of poliomyelitis-free status of the WHO Western Pacific Region. the Subregional Certification Committee (SCC) met twice on 18 to 19 October 2001 and on 10 to 11 October 2002 to review progress in maintaining poliomyelitis-free status after certification and review and make final classifications of all AFP cases reported since the previous review. Although 58 hospitals in all 20 countries continue to constitute the active AFP surveillance network of the Pacific island countries and areas. the required regular reporting to WHO has significantly decreased since 2000; 37 out of 58 hospitals failed to submit reports in 2001 and 28 hospitals failed to do so in 2002 so far (January to June). The SCC considers as possible reasons for this lack of reporting to be misconceptions that after certification of poliomyelitis-free status AFP surveillance is no longer required. low priority given to the continuation of poliomyelitis eradication activities after certification. high turnover of coordinators and key clinicians involved in the system. new staff who are not always aware of the requirements and insufficient prompting and follow-up. A non-polio AFP rate of 1 per 100 000 children under age 15 was achieved in 2001 but the annualized rate in 2002 (0.9 per 100 000 children under age 15) has not yet reached the minimum requirement. Retrospective record reviews conducted in Fiji. Samoa. the Solomon Islands and Tonga identified unreported AFP cases leading to the assumption of the system not yet being sensitive enough and thus missing cases. Adequacy of stool specimen collection remains very low with 36% in 200 1 and 29% in 2002 so far. Poliomyelitis immunization coverage for the Pacific sub-region remains at about 83% to 86% overall with some uncertainty due to inaccuracies in routinely reported data in a few countries. e.g. Vanuatu. Although poliovirus importation is unlikely anywhere in the Pacific. the SCC considers a few countries to be more vulnerable to local transmission based on population irnrnunization rates. These include the Federated States of Micronesia. the Marshall Islands, and the Solomon Islands. Coverage in the latter varies considerably by province. Thus. the areas of special concern to the SCC are: ~ ~ ~

Decline in routine monthly reporting from hospital surveillance sites Problems with adequacy and timeliness of stool collection Lower immunization coverage in a few countries AFP cases missed by the hospital-based active surveillance network

~

Because of the long interval since poliomyelitis was endemic in the Pacific, the low risk of poliovirus reintroduction and circulation, and the generally high irnrnunization coverage rates, the SCC continues to conclude even with sub-optimal performance of the AFP surveillance system that the Pacific continues to be free of indigenous poliomyelitis and to have sufficient and significant barriers to re-establishment of introduced wild poliovirus. Continued vigilance and achievement of high quality surveillance and immunization activities is required, at least until global certification is achieved. Republic of Korea The NCC continued to review all AFP cases detected through surveillance activities for the final classification and has met regularly to discuss issues related to the national documentation.

- 67-

Annex 3

The laboratory of enteroviruses designated as the NPL was fully accredited in 2000 and 2001 under WHO standards. The NPL is also operating nation-wide enterovirus surveillance and all polioviruses detected through the enterovirus surveillance mainly targeting aseptic meningitis patients will be isolated and identified at the NPL. Hand-foot-mouth diseaselherpangina surveillance commenced in 2001. In general, all polio samples regardless of source (AFP surveillance, enterovirus surveillance, environmental surveillance) are examined in the NPL and are also sent to RRL for ITO.

In 2001, 590 reports of monthly zero reporting, including 25 AFP cases, were reported from 70 hospitals nationwide. This makes 70.2% of completeness in reporting. When considering timeliness of reporting which means monthly reporting within the first week of the following month, 529 reporting (63%) were reported on time. Retrospective chart review was conducted in 2002 to review AFP cases in Busan and Gwangju from 2000 to 2002. Thirty-six AFP cases were found from retrospective record review and reviewed by the expert pane\. There were no polio-compatible cases identified. The RepUblic of Korea has completed phase I of laboratory containment of wild poliovirus infectious/potentially infectious materials. After sending screening forms, there have been replies from all places. Only three laboratories (of 244 sites identified in the initial survey) had relevant samples, and have completed an inventory form. All relevant samples are stored under at least BSL 21polio conditions. The national inventory will be regularly reviewed and updated until global certification of eradication is achieved. The poliomyelitis immunization level has been sustained at the level of 90% to 95% (estimated) since the 1980s. From 2002, the Association of Paediatricians recommended the possible use of IPV. The Division of Communicable Disease Control in the National Institute of Health has overall responsibility for immunization services in Korea and continues to recommend OPV, and to maintain high levels of coverage and population immunity. Singapore The NCC met annually to review AFP surveillance and cases. In 2001, nine AFP cases were reported (AFP rate of 1.3 per 100 000 under age 15), of which 44% had adequate stool samples taken and 78% had follow up examinations. From January to July 2002, three AFP cases were reported (annualized AFP rate of 0.7), of which 33% had adequate stool specimens collected and all had a follow up examination done. All AFP cases investigated in 2001 and 2002 were discarded as non-polio AFP cases. The Virus Laboratory, Department of Pathology, Singapore General Hospital, was designated as the NPL in 1995 and it is the only laboratory that performs enterovirus isolation and typing. It had continued to remain fully accredited, with a 100% score in the proficiency test. In addition to receiving stools from AFP or suspected AFP cases, the NPL also receives stool specimens from other sources for poliovirus isolation. Over the last four decades, immunization coverage has remained high. In 2000 and 200 1, the immunization coverage for poliomyelitis in infants was 91 % and 93% respectively. The National Coordinator implemented Phase I of the Action Plan of the Laboratory Containment in November 1999 and has completed the inventory oflaboratories. Only one laboratory (a diagnostic and research laboratory at the National University of Singapore) was identified to have stored infectious wild poliovirus material. The laboratory has since destroyed the infectious material according to WHO guidelines for destruction of such materials. The national inventory has been updated and three new research agencies have been included in the inventory.

- 69ANNEX 4

Global Alliance for Vaccines and Immunization (GAVI) and RWG Fact Sheet What Is GAVI?

•

The Global Alliances for Vaccines and Immunization (GAVI) brings together traditional and new partners: "To save children's lives and protect people's health through the widespread use of vaccines. " GAVI is not an organisation, but an alliance of all the partners involved in immunization including national governments, public health and research institutions, the Bill and Melinda Gates Children's Vaccine Program (CVP), the International Federation of Pharmaceutical Manufacturers Association (IFPMA), the Rockefeller Foundation, UNICEF, the World Bank Group, and WHO. GAVI has a small secretariat that is housed at UNICEF in Geneva, but has no field staff and no buildings or institutional existence other than through its partners. Why was GAVI formed?

The Alliance was developed because partners acknowledged the need to collaboratively address three primary gaps: ,/ stagnation/decline of immunization coverage, and regional discrepancies; ,/ lack of introduction of newly-developed vaccines into poorer developing countries ,/ limited investment in vaccine research for diseases with a high burden in developing countries. What are GAVl's alms?

In addition to trying to encourage the use of immunization coverage as a centrepiece in the design and assessment of international development initiatives, GAVI has outlined specific strategic objectives to respond to these problems. These include: ,/ Improving access to sustainable immunization services ,/ Expanding the use of all existing cost-effective vaccines ,/ Accelerating availability of new vaccines against developing country diseases How does GAVI work?

I

GAVI was formed in late 1999, and in January 2000 the partners created the Global Fund for Children's Vaccines (Fund) to fund poorer countries (annual per capita income less than US$I000). The fund has three sub-accounts: #1) to improve immunization services (ifDTP3 coverage <80%) #2) to introduce 'new' vaccines (ifDTP coverage >50%) #3) to accelerate development of new vaccines needed for developing countries The new vaccines currently supported are hepatitis B, Haemophilus injluenzae type b (Hib) and yellow fever vaccines. The third sub-account is not operational yet. From October 200 I, GAVI is also providing three years of support for Auto-Disable syringes (ADs) and safety boxes to countries that receive approval for new vaccine or services support. To apply for Fund support, a country must have: ,/ recent comprehensive assessment of the immunization programme; ,/ multi-year strategic plan ,/ an injection safety plan; and ,/ a functioning Interagency Coordinating Committee (ICC).

-70 -

Annex 4

What Is It?

The Regional Working Group (RWG) is an informal network of GAVI Partner Agencies at Regional level. Established in September 2000 to support Partners at country level, the RWG meets quarterly. Who is in It?

, 1

Asian Development Bank (ADB), the PATHiChildren' s Vaccine Program (CVP), United Nations Children's Fund (UNICEF), World Bank, and World Health Organization (WHO). How can It help countries?

RWG helps Vaccine Fund-eligible countries (Cambodia, China, Lao PDR, Mongolia, Papua New Guinea, Solomon Islands, Viet Nam) to obtain and use Fund support, by coordinating technical support from Partner Agencies. What else does It do?

Provides Regional-level feedback from countries and agencies to GAVI. Provides a forum to establish a united Regional position on GAVI-related issues. How does RWG differ from Its member agencies?

•

RWG provides no direct assistance to countries, but helps to coordinate the technical support of Partner Agencies on GA VI-related issues. Does It have money?

No. It can access resources for countries through its agencies. What Is Its basis/reason for existence?

RWG aims to maximise the benefit of GAVI for countries in the Region. It was formed to ensure that partner agencies develop and articulate a consistent position on GAVI-related issues, and to maximise the benefit that GAVI offers to National Immunization Programmes. How do countries contact It?

Access to the RWG to request support can be through any of the partner agency staff in the country. WPRO currently acts as the RWG secretariat (preparing the meeting agendas and undertaking specific work directed by the RWG). Email contact: mansooro@wpro.who.int

1 I

~

I