Sixth Pacific Immunization Programme Strengthening (PIPS) Workshop, Nadi, Fiji, 27 September to 1 October 2010 : report

Sixth Pacific Immunization Programme Strengthening (PIPS) Workshop .

27 September to 1 October 2010 Nadi, Fiji {@~~\ World Health --'7~

~~§ -Organization - Western Pacific Region

(WP)/ICP/IVD/1.1/001-A . Report series number: RS/2010/GE/47(FJI) English only

REPORT 7~~~

.~ PACIFIC IMMUNIZATION PROGRAMME STRENGTHENING (PIPS) WORKSHOP

Nadi, Fiji 27 September- 1 October 2010

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Not for sale Printed and distributed by: W o:dd Health Organization Regional Office for the Western Pacific 11anila,Philippines August2011

WHOIWPRO LIBRARY !HANfLA. PHILIPPINES

21 fee 2012 ·

NOTE The views expressed in this report are those of the participants of the Sixth Pacific Immunization Programme Strengthening Workshop and do not necessarily reflect the policies of the World Health Organization·.

•

Keywords:

I Vaccines, immunization, partnership This report has been printed by the Regiona,l Office for the Western Pacific of the World . Health Organization for the participants of the Sixth Pacific Immunization Programme · Strengthening Workshop, which was held in Nadi, Fiji, 27 Septembe r- 1 October 2010.

CONTENTS

List of Acronyms ... ......... .... .... ..... ................ .. ........... .............. .. .. ..... ....... ... ... .iv Summary ......................... ............................................................................ vi

1. INTRODUCTION ........ .. ........................ ........................... .... .................... 1 1.1 Objectives . . . . . . . . . . .. . . .. . .. . . .. . . . . . .. . . . . .. . . .. . . . . .. . .. . . . . . . . . .. . .. . ... . . . .. . . . .. . . .. .. .. .. 1 1.2 Opening remarks ......... ......... .......... ............ ... ................ .... ........... ... 1 2. PROCEED.INGS ....................................................................................... 4 2.1 Workshop objectives and implementation of 2009 PIPS workshop recommendations ................... ....... .............. ..... ........ ............. .. ......... 4 2.2 Regional overview ofEPI .................................................................. .. 5 2.3 Progress review ofEPI in Pacific Island countries and areas .......................... 6 2.4 Communication and advocacy .............................................................. 7 2.5 Measles elimination ... ............. ... ... ..... ...... ... ... .................. .. .. ....... ...... 9 2.6 Pandemic (H1N1) ........................................................................... 12 2.7 Outbreak response .............. ~ ... ... ... ............ .. ........................ ............. 13 2.8 Service delivery ........................................... ~ ................................. 14 2.9 Country poster presentations, progress, challenges and planned activities ......... 17 2.10 New vaccines .............................. ." ........... ." ............ .......... .. ......... .... 17 2.11 Immunization supply chain management ................................................. 19 2.12 HepB contro1. ................... ............ ........................................ ......... 19 2.13 Monitoring and VPD surveillance ...................................... ; ................. 22 2.14 Immunization safety ......................................................................... 23 2.15 Policy and strategy ............................... .".. ....... ... ........... .. .. ......... ... .. . 24 2.16 Vaccine procurement and the Vaccine Independence Initiative (Vll) ................ 25 2.17 Maintaining poliomyelitis-free status in Pacific Island countries ..................... 34 2.18 Review_ of Japanese support to PIPS (I-PIPS) and next steps ......................... 36 2.19 Independent progress report of AusAID/UNICEF multi-country programme, immunization component ................................................................... 37 2.20 Closing session .................. .............................. .. ........... ...... ....... .... 38 3. ACTION POIN"TS ........................ ..... .... ............. .... .... ............ .... .. .... ........ 39 3.1 Vaccine procurement and VII ............................................................. 39 3.2 Cold chain/vaccine/logistics management ............................................... 39 3.3 Service delivery ......................................................... , ...... : ............ 39 3.4 · Coverage monitoring .. ... ... .... .. ... .. ............ .. ...... .. .. .. .. ... ..... .. ............. . 39 3.5 VPD surveillance ......... ..... ... ...... ... ... ......... .......... ..... .. ...... . .... ..... . .... 40 3.6 Polio eradication ............................................................................. 40 3. 7 Measles elimination ......................................................................... 40 3. 8 HepB control ............. .... .... .... ....................................... .... .... .. ....... 41 3.9 New vaccines ............ ...... .......... ... ............... .............. ; ........... ......... 41 3.10 Injection safety and waste management ................................................. .41 3.11 Immunization safety......................................................................... 41 3.12 Training and capacity building ............................... ·.......................... ~ .. 42 3.13 Linkage to other health interventions and programmes ................................ 42 3.14 Communication and advocacy, ................................ : ........................... 42 3.15 Pandenlic (HlNl) 2009 ....... ::............................................................................................. :.. 42

ANNEXES ANNEX 1 - PROGRAMME OF ACTIVITIES ANNEX2 LIST OF PARTICIPANTS

ANNEX 3 - MINUTES OF THE PIPS PARTNERS CO-ORDINATION MEETING NADI, FIJI, 1 JANUARY 2010 ANNEX 4 - PROGRESS ON PIPS 5.(2009) ACTION POINTS ANNEX SA- 6TH PIPS EVALUATION QUESTIONNAIRE ANNEX SB- SUMMARY OF 6TH PIPS EVALUATION RESULTS

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List of Acronyms AEFI adverse events following immunization acute flaccid paralysis acute fever and rash Australian Agency for International Development

AFP. AFR AusAID BCG bOPV cMYP CRS cVDPV BPI ERP EVM

Bacille Calmeite-Guerin bivalent oral polio _vaccine· costed multiyear plan Congenital Rubella Syndrome circulating vaccine derived poliovirus Expanded Programme on Immunization expert review panel effective vaccine management effective vaccine and storage management Fiji Health Section Improvement Programme fmancial rules and regulations Global Alliance for Vaccines and Immunization Global Immunization and Vaccine Strategy ·Government line agency hospital-based active surveillance Hepatitis B

EVSM FHSIP

FRR GAVI GIVS GLA HBAS HepB

Hib HIV

Haemophilus influenzae type B human immunodeficiency virus human papilloma virus information, education and communication Integrated Management of Childhood illnesses inactivated polio vaccine Japan International Cooperation Agency Japanese support for Pacific Immunization Programme Strengthening . joint reporting form letter of guarantee maternal and child health measles containing vaccine Millennium Development Goal mid-level management

HPV IEC IMCI IPV JICA J-PIPS

JRF LOG MCH MCV MDG MLM

- v -·

MMR MNCH MNT mOPV MOD

measles/mumps/rubella vaccine maternal-neonatal-child heaLth maternal and neonatal tetanus monovalent oral polio vaccine memorandUfn of understanding measles/rubella vaccine Ministry of Women, Community and Social Development ·National Immunization Programme National Regulatory Authority neonatal tetanus New Zealand's International Aid and Development Agency oral polio vaccine pneumococcal conjugate vaccine Pacific Immunization Programme Strengthening Regional Certification Committee rubella-containing vaccine Regional Verification Committee Reaching Every District Supplementary Immunization Activity Secretariat of the Pacific Community Subregional Committee for the Certification of Poliomyelitis Eradication in Pacific Island Countries and Areas Subregional V eriflcation Committee Technical Advisory Group trivalent oral polio vaccine United Nations Children's Fund United States Centers for Disease Control and Prevention Vaccine Independence Initiative vaccine derived poliovirus va~cine preventable

MR MWCSD

NIP . NRA NT NZAID OPV · PCV PIPS RCC RCV RVC RED SIA

SPC SRCC SRVC TAG tOPV UNICEF US CDC

VII VDPY VPD VMA

disease

vaccine management assessment village women's committee World Health Organization

vwc WHO

-vi -

SUMMARY

The Sixth Pacific Immunization Programme ~trengthening (PJPS) Workshop was convened by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) from 27 September to 1 October 2010 in Nadi, Fiji. Participants included representatives from 16 Pacific Island countries and areas, as well as from PJPS partners including Australian Agency for International'Development (AusAID), Japan International Cooperation Agency (JICA), New Zealand's International Aid and Development Agency (NZAID), the Secretariat for the Pacific Community (SPC) and the United States Centers for Disease Control and Prevention (US CDC). The programme for the workshop is attached as Annex 1. The list of participants is attached as Annex 2. · The objectives of the workshop were: (1) To review technical updates and implementation status, share information on national immunization programme (NIP) status and identify major obstacles in each country and area with regard to: 0

strengthening the NIP including achieving or maintaining high routine immunization coverage, promoting good management practices and appropriate training, and maintaining vaccine security; achieving the regional twin goals of measles elin1ination and hepatitis B (HepB) control, and maintaining poliomyelitis-free status and preparedness for response to importation of wild poliovirus; accelerating introduction of new and underutilized vaccines based on rational decision-making; and achieving or sustaining high-quality vaccine preventable disease (VPD) surveillance .

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. (2)

To agree upon practical recommendations, commitments and plans necessary to address the above four areas. At the close of the workshop, the following action points were agreed:

(1)

vaccine procurement and the vaccine Independence Initiative (VII) 1.1. All countries participating in VII are encouraged to improve accuracy of annual forecasting to minimize the need to place supplemental orders and rely on the regional buffer stock. 1.2. All countries participating in VII should advocate with national decision makers to ensure appropriate annual budget allocations for vaccine procurement, timely budget release to ensure availability of funds, and ensure payment within 60 days of receipt of each individual invoice. Furthermore, VII participating countries should sign and return new/updated Memoranda of Understanding and new Letters of Guarantee to UNICEF within a month of receipt to ensure continued access to UNICEF vaccine procurement.

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1.3.

UNICEF will improve the invoicing process to ensure timely issuance to countries, taking into consideration, wherever possible, the individual country's annual fiscal calendar, and develop a monitoring tool to report to countries and partners on invoicing and payment response times .

(2)

Cold chain/vaccine/logistics management

All countries/areas in the Pacific Region should have trained personnel for vaccine, cold chain and logistics management. Countries should regularly update their cold chain ~ventory and conduct proper maintenance/replacement of cold chain equipment and conduct a WHO-UNICEF Effective Vaccine Management assessment where needed to identify strengths and weaknesses of their current immunization supply chain management system. (3) . Service delivery All countries should strive to implement all five components of the Reaching Every District strategy to reach every child: re-establish outreach; conduct supportive supervision; develop community linkages; monitor and use data for action; and improve planning and ma.hagement. For United States jurisdictions, the equivalent US CDC policy should apply. (4) Coverage monitoring 4.1 The national Expanded Programme on Immunization (BPI) team should work closely with subnational BPI focal points (if applicable) to actively monitor reporting status of BPI data and ensure timely follow up of all missing reports. A simple · report monitoring form is recommended. The national BPI team should train and require staff at health facilities (where BPI services are provided) to utilize coverage-monitoring charts and take rapid action when needed. Countries should conduct provincial/national BPI reviews to identify areas of concern and provide feedback to local programme managers.

4.2

4.3

(5)

VPD surveillance 5.1 Countries should improve sensitivity and timeliness of acute flaccid paralysis (AFP), acute-fever and rash (AFR), and maternal and neonatal tetanus (MNT) case reporting through: 1.

VPD surveillance training, use of standard case investigation forins and dissemination of information, education and communication (IEC) materials in all health facilities;

ii. Monitoring of surveillance using recommended indicators and feedback to all health facilities and staff through various means including print and electronic media, meetings, etc.; 111.

Designating administrative assistants. at sentinel surveillance sites to assist hospital coordinators.

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5.2

National notifiable disease surveillance systems should be used to identify and respond to reported AFR and MNT cases in addition to hospital-based active surveillance (fffiAS), and merged when possible. Radio-telecommunication or cell phone may be used for case notification from remote areas, with proper registration of contents of verbal messages or SMS. Community-based key informants should be used to increase case notification.

5.3

5.4 (6)

Polio eradication 6.1 The Subregional Committee for the Certification of Poliomyelitis Eradication in Pacific Island Countries and Areas (SRCC) urges Pacific Island countries, · particularly those with relatively large populations and frequent international population movements, to develop or update national plans of action to quickly detect and respond to importation of wild poliovirus. Countries should maintain coverage with three doses of polio vaccine at 90% or more. Supplemental doses may be added when supplementary eradication activities ·(SIA) targeting other diseases are being conducted. Countries should improve their BBAS and case investigation through training of hospital coordinators and physicians. Countries should increase community awareness of the signs of AFP (as well as measles and MNT) through development and distribution ofiEC materials.

6.2

6.3

6.4 (7)

Measles elimination

Countries and areas should review the 2009 WHO Position Paper on Measles ·r:vveekly Epidemiologic Record, 2009; 84:349-360) and consider applying its guidelines with specific reference to: (i) optimal age of administration of the first dose ofmeasles~containing vaccine (MCV1) and the second dose of measles-containing vaccine (MCV2); (ii) criteria for introduction ofMCV2 (for the Solomon Islands and Vanuatu only); (iii) use of school entry immunization requirements to ensure high population immunity by the time of school entry; and (iv) appropriate intervals between SIAs (i.e. before the accumulation of susceptible children reaches the size of one birth cohort). (8) HepB control 8.1 . If not recently done, consider an immunization coverage survey to assess the reliability of routine immunization coverage reports. 8.2. Consider whether a HepB serosurvey (as stand alone or as part of a possible Pacific Island multicountry survey) is appropriate to be undertaken in 2011 to establish the current level of HepB control. Identify and implement options to improve 90verage and timeliness ofHepB vaccine birth dose and subsequent doses. Train and regularly supervise maternity staff for delivery of birth dose and ensure that timely birth dose coverage is at least equal to that of births delivered in institutions.

8.3.

8.4

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8.5

Health workers should be protected against HepB virus infection through immunization programmes.

(9)

New vaccines 9 .1. Local data on pneumococcal, rotavirus and human papilloma virus (HPV) disease burden should be collected and analyzed to assess the potential impact of vaccines against S. pneumoniae, rotavirus and HPV. Data sources may inClude hospital admissions or outpatient consultations for pneumonia, meningitis and diarrhoea (among children under five years old) and admissions for cervical cancer. These data may serve to help prioritize vaccine introduction and to mobilize additional resources.

9.2. Factors that countries should consider before introducing new or underutilized vaccines include programmatic capacity (staff, cold-chain capacity, etc.), cost of introduction, future fmancing and timing of administration in consideration of the existing BPI schedule. 9.3. All countries and areas should make efforts to mobilize resources for introduction of pneumococcal conjugate vaccine (PCV) and rotavirus vaccines in p.ccordance with WHO recommendations for universal introduction of these vaccines. Efforts should be made with donors to set up a subregional fund or project to support the Pa.cific Island countries in .introduction of high-priority new vaccines (PCV, rotavirus and HPV vaccines) in selected Pacific Island countries based on a model similar to the Pacific Hepatitis B Project in 1996.

(10) Injection safety and waste management All countries/areas in the Pacific Region should ensure safe injection practices and waste management, including procurement of appropriate equipment as part of their national waste management plan. (11) Immunization safety All Pacific Island countries should ensure access to and use of a national regulatory authority (NRA) with capacity in licensing and post-marketing surveillance, including high-quality sUr\Teillance of adverse events following immunization (AEFI) complete with guidelines. (12) Training and capacity buildirrg 12.1 All countries should review training needs at national and subnationallev els and develop a training strategy to further develop skills in delivery, monitoring and maintenance of _high-quality BPI services. 12.2 PIPS partners should consolidate technical, training and other needs for Pacific Island countries/areas and harmonize partner support through a Joint Pacific Islands Strategic Plan.

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(13) Linkage to other health interventions and programmes All countries should link and/or integrate EPI activities with Mother and Child Health (MCH) programme activities where appropriate and sustainable with support from all partners, including civil society. (14) Communication and advocacy 14.1. Countries should participate in the first Regional Vaccination Week in the Western Pacific (24-30 Apri12011) and use this initiative as a way to gain visibility and political support for immunization at all levels. Countries should explore bilateral opportunities with traditional and non-traditional donors (private sector) in support ofEPI activities.

14.2.

(15) Pandemic (H1N1) 2009 15.1 In accordance with WHO recommendations, during the post-pandemic period, countries should vaccinate high-risk individuals with monovalent Pandemic (H1N1) 2009 vaccine or a trivalent seasonal influenza vaccine (that includes the HlNl 2009 strain) contingent on supply availability.

15.2

Countries should document lessons learnt from the Pandemic (HlNl) 2009 vaccine deployment and vaccination implementation and prepare accordingly for the next pandemic. This may include incorporating pandemic vaccine deployment plans into_national pandemic preparedness plan.

1.

INTRODUCTION

The Sixth Pacific hnm.unization Programme Strengthening (PIPS) Workshop was convened by the World Health organization (WHO) and the United Nations Children's Fund (UNICEF) from 27 September to 1 October 2010 in Nadi, Fiji. Participants included representatives from 16 Pacific Island countries and areas, as well as from PIPS partners including Australian Agency for International Development (AusAID), Japan International Cooperation Agency (ITCA), New Zealand's International Aid and Development Agency (NZAID), the Secretariat for the Pacific Community (SPC) and the United States Centers for Disease Control and Prevention (US CDC). The programme for the workshop is attached as Annex 1. The list of participants is attached as Annex 2. 1.1 Objectives The objectives of the workshop were: (1) To review technical updates and implementation status, share information on national immunization programme (NIP) status and identify major obstacles in each country and area with regard to: • strengthening the NIP including achieving or maintaining high routine immunization coverage, promoting good management practices and appropriate training, and maintaining vaccine security; achieving the regional twin goals of measles elimination and hepatitis B (HepB) control, and maintaining poliomyelitis-free status and preparedness for response to importation of wild poliovirus; accelerating introduction of new and underutilized vaccines based on rational decision-making; and achieving or sustaining high-quality vaccine preventable disease (VPD) surveillance.

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•

•

(2)

To agree upon practical recommendations, commitments and plans necessary to address the above four areas.

1.2

Opening remarks

The opening ceremony was chaired by Dr David H. Sniadack, Acting Team Leader, Expanded Programme on hnmunization (EPI), WHO Regional Office for the Western Pacific, and started with a devotional service led by Ms Litiana Volavola. Dr Salanieta Saketa, Permanent Secretary for Health in Fiji, brought greetings from the Ministry of Health to representatives and participants, and particularly to Pacific Island neighbours and those visiting Fiji for the first time. Dr Saketa informed the meeting that Fiji has implemented two major vaccination campaigns since the 2009 PIPS meeting in Japan. More than 41 000 high priority people had been vaccinated with the Pandemic (H1N1) 2009 vaccine since April 2010 and the vaccine is still available for those at the next level of need. In addition, Fiji embarked on a typhoid fever immunization campaign when a major outbreak emerged after parts of Fiji were devastated by Cyclone Tomas. With the much appreciated assistance of

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AusAID and WHO, over 53 600 people in the most affected areas were vaccinated, achieving campaign coverage of 98%. Fiji has also completed its successful mop-up vaccination campaign using Gardasil against the Human Papillomavirus (HPV) with a coverage rate for the third dose ofHPV vaccine of 65% of the 18 338 girls that consented. EPI has been a key element of health systems in the Pacific Region whose focus is to achieve a fully immunized child by his or her first birthday. It is hoped that the Fiji Cabinet will accept a proposal for a further US$ 5.8 million dollars to top up Fiji's commitment to routine EPI through the Vaccine Independent Initiative (VII) and also allow introduction of rotavirus, pneumococcal and HPV vaccines. While there has been a decline in the burden ofVPDs, there is no room for complacency and the Pacific Region must work together to ensure coverage of over 95% against measles and other potentially serious infections . Dr Saketa noted that the Sixth Regional PIPS meeting reflected the importance that island nations and partners place on training and capacity building and is a great opportunity to strengthen knowledge. PIPS activities throughout the Pacific Region have had a huge impact on child survival and well-being, and in_ conjunction with the Integrated Management of Childhood illnesses (IMCI) and other child survival strategies, have helped reduce under-5 mortality and morbidity. Fiji plans to put more funding toward interventions that will have a positive impact on the achievement ofMillenium Development Goals (MDG) 4 and 5. She concluded by thanking all development partners on behalf of Pacific Island nations for their huge resource contribution and encouraged the participants to use their new skills to continue their positive work in improving the lives of Pacific Island children. Dr Chen Ken, WHO Representative in the South Pacific, delivered the remarks on behalf of Dr ShinYoung-Soo, WHO Regional Director for the Western Pacific, who apologized that he was unable to attend the meeting due to other pressing commitments. After warm greetings to dignitaries and participants, Dr Chen noted that EPI continues its successes in the Pacific Island countries and areas. All Member States have remained poliomyelitis free, endemic measles virus transmission has likely been interrupted, chronic HepB infection rates among children have been substantially reduced and other VPDs have become rare. Pacific Island countries as a whole are proactive in assessing the need for and introducing other new or underutilized vaccines. Vanuatu will introduce Haemophilus influenza type b (Rib) at the beginning of2011 making the Western Pacific Region the first WHO Region in which all developing countries are using Rib. Despite financial difficulties, several Member States are actively considering introducing pneumococcal, rotavirus and HPV vaccines into their NIPs, which would substantially impact child mortality and morbidity and also reduce cervical cancer rates in the future. He noted that sustaining and building on these successes requires even greater efforts. Follow-up supplementary immunization activities (SIA) for measles were carried out in five countries between 2009 and 2010 and will need to continue until routine coverage increases or the risk of measles virus importation disappears. Routine immunization strengthening requires good local level micro-planning to organize a combination of service delivery approaches; community participation to ensure acceptance; improved monitoring of coverage and identification of children that drop out; supportive supervision and regular assessment of EPI staff performance; and an adequate cold chain, safe vaccine and logistics management. Vaccine security is crucial and is therefore a major focus of this year's workshop. Increased efforts are needed to improve the quality of surveillance for acute fever and rash (AFR) and acute flaccid paralysis (AFP) to ensure that any potential measles, polio or rubella case is identified. Partners and Member States need to work together to address weaknesses and to increase the public health impact of immunization services. Wherever possible, primary care services should be integrated and synergies utilized at every level. This workshop is an opportunity for Member States, partners and experts to discuss relevant issues, agree upon needed actions, and coordinate future plans. Dr Chen expressed appreciation for the relentless efforts of all PIPS partners in

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providing fmancial, technical and logistical support to Pacific Island countries and in supporting this workshop. He thanked the Government of Fiji for hosting the workshop and gave special thanks to all of those participating. Dr Chen finished by noting that the recent United Nations Millenium Development Goal (MDG) summit emphasized the importance and success ofEPI in effecting good child health. Mr Tim Sutton, Deputy Representative, UNICEF Pacific Regional Office, highlighted a number of significant meetings during the previous week in association with the global summit on MDGs, including the launching of a Global Strategy for Women's and Children's Health that has EPI as a central focus. In addition, a side meeting at the summit for Small Island and Developing States recognized their special needs and the need to mobilize the donor community and achieve solidarity. Discussions at the global MDG summit focused on progress; globally, the world is on track to reach the MDGs. UNICEF advocated the achievement of equity targets, thus ensuring that the needs of the hard-to-reach and marginalized are met. UNICEF research shows that if we target the hardest to reach, 60% more lives are saved. EPI has spearheaded efforts to reach every child through the Reach Every District (RED) strategy and microplanning. To this end, UNICEF joins WHO and Pacific Island Ministers of Health in calling for the revitalization of primary health care through the Pacific Healthy Islands Strategy endorsed by Pacific Island leaders. The PIPS workshop also coincides with a number of significant UNICEF activities including the mid-term review of the 2008-2012 UNICEF multicountry programme of cooperation with Pacific Island countries. Significant changes have been made including replacing annual work plans with multiyear plans so that UNICEF is more aligned and harmonized with government planning and budget cycles. UNICEF will therefore be seeking guidance on the development of a joint strategy for enhancing EPI in the Pacific Region including the possibility of developing one EPI programme for the Pacific Region using the PIPS mechanism. Effective programme communication and linking EPI programming to other maternal, child and newborn interventions will be critical. Mr Sutton informed the meeting that the UNICEF Executive Board has approved the extension ofthe VII for another five years and further feedback on this issue will be invited from participants later in the week. Comments would also be invited later in the week when a brief overview, key recommendations and fmdings would be shared on the immunization component of an Independent Progress Report of the AusAIDIUN1CEF multi-country programme 2005-2010. In closing, he thanked PIPS partners and country delegates for taking the time to attend the Sixth PIPS Workshop and emphasized that the building blocks of a healthy society are achieved by working together. Mr Yukata Fukase, Deputy Resident Representative of ITCA, made opening remarks on behalf of Mr Juichiro Sasaki, ITCA Resident Representative, who was overseas at the time of the meeting. He reviewed the Japanese Support to the Pacific Immunization Programme Strengthening (J-PIPS) project including supporting PIPS workshops, regional training programmes and domestic training programmes in each country including training 83 EPI nurses and 54 cold chain technicians, and provision of equipment. J-PIPS is fortunate to be associated with Nagasaki University, a highly recognized institute with a long history of cooperation in the field of public health. ITCA will continue to support the EPI programme in the Pacific Region through J-PIPS phase-2 for the next three years focusing primarily on Kiribati, Samoa, the Solomon Islands, the Federated States of Micronesia and Vanuatu. The next ITCA project will provide capacity development for trainers and workers in the areas of vaccine management, logistics and cold chain management and maintenance. Building on the training from phase 1 activities, regional refresher training courses will be a major focus of Phase 2 and Fiji is expected to take a lead role in the training courses that will be conducted.

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Dr Orner Pasi, Medical Epidemiologist, US CDC, conveyed warm greetings from Dr Brenton Burkholder, Director of the Global Immunization Division of the Centers for Disease Control and Prevention in Atlanta. He reiterated US CDC's commitment to supporting Pacific Island Countries in their quest for maintaining poliomyelitis-free status, eliminating measles and controlling HepB by 2012, eliminating MNT as a public health problem and strengthening the foundation of all routine immunization systems. He expressed sincere thanks to the Government of Fiji for hosting the meeting. He reminded the meeting participants of a great proverb quoted recently by Dr Kevin DeCock, Director of the newly created Center for Global Health, "Ifyou want to go fast, go alone; ifyou want to go far, go with others" and reminded participants that everyone is in this together and wants to go as far as reaching the last child.

2. PROCEEDINGS

·2 .1

Workshop objectives and implementation of 2009 PIPS workshop recommendations

Dr Eliab Seroney Some, Chief of Health and Sanitation, UNICEF Pacific Regional Office, presented an overview ofthe 2010 objectives (as outlined in section 1.1 above). He thenlisfed the specific topics the meeting would be covering and presented the major actions recommended at the conclusion ofthe 2009 PIPS Workshop attended by 11 countries: (1) Countries should consult their relevant government ministries on options for vaccine supply beyond 2010. Countries should allocate available and new funds more efficiently and effectively to address bottlenecks in routine immunization coverage. Countries should systematically review gaps in achieving and sustaining measles elimination, ensure good implementation of the effective strategies recommended, and strengthen AFR surveillance. Countries yet to conduct a national HepB serosurvey should schedule a national survey in the next one to three years among children five years or older to determine the rate of hepatitis B surface antigen (HbsAg) positivity in line with WHO guidelines. Countries should strengthen their human resources, cold chain and logistics management systems to prepare for rapid vaccine deployment (<7 days) should a pandemic occur. Donors should support Pacific Island countries with the introduction of high priority new vaccines based on a model similar to the Pacific Hepatitis B project in 1996.

(2)

(3)

(4)

(5)

(6)

The 56 specific recommended actions covered 14 areas. These were largely standing recommendations to improve EPI, and countries had identified their priorities among these. He asked that each country review the recommendations so that a summary of the implementation status of the 2009 recommendations could be presented later in the week.

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2.2

Regional overview of EPI

Dr David H. Sniadack, Acting Team Leader in EPIIWHO Regional Office for the Western Pacific, gave an update on the Western Pacific Regional Immunization Programme. The Region has continued to make progress towards achieving global and regional goals of measles elimination and using this to prevent congenital rubella syndrome (CRS), controlling chronic HepB infection and maintaining poliomyelitis-free status. Regional routine immunization rates have continued to climb but have not yet achieved their targets. To strengthen routine immunization and achieve the Global Immunization and Vaccine Strategy (GIVS) goal of ::90% coverage nationally and ;;::80% coverage in every district, the Technical Advisory Group (TAG) on Immunization and Vaccine Preventable Diseases in the Western Pacific Region has recommended implementation of RED strategies and school-entry requirements and/or verification ofimmunization status. TAG further endorsed the first Vaccination Week in the Western Pacific Region in 2011 and encourages all countries and areas in the Region to participate. No Pacific Island country has an NRA, and the TAG recommended that all Member States have an NRA functional in at least two areas to ensure vaccine quality and immunization safety: licensing and post-marketing surveillance, including high-quality surveillance for adverse events following immunization (AEFI). Member States were also strongly encouraged to use the new Effective Vaccine Management (EVM) assessment tool, and to implement the indicated improvements, such as training, updating cold chain equipment inventories for repair and replacement.

2.2.1

Measles elimination and rubella control, and HepB control

All Pacific Island countries are likely to meet the 2012 goal of measles elimination, and periodic SIAs are needed in those Pacific Island countries with inadequate routine two-dose coverage. Thirty (83%) of all countries and areas in the Region are usmg rubella containing vaccine (RCV); among the Pacific Island countries, only the Solomon Islands and Vanuatu have not yet introduced RCV. Reported rubella incidence for the Region in 2009 was 41 per million population; 21 countries and areas reported rubella incidence <1 per million population and another eight reported incidence of 1-9 per million population. Only two countries have been verified as reaching the 2012 HepB control goal ofless than 2% of five-year-old children seropositive for HepB surface antigen. Among the Pacific Island countries, four have low HepB coverage and are not ready for verification; nine might be ready but lack seroprevalence data; seven have seroprevalence data but need further guidance from the HepB Expert Review Panel (ERP).

2.2.2

Poliomyelitis-free status

All countries in the Region have maintained poliomyelitis-free status for more than nine consecutive years; to prevent potential outbreaks from importations of wild poliovirus and vaccine derived poliovirus (VDPV), Pacific Island countries must achieve and/or maintain high polio vaccination coverage, sensitive and timely AFP surveillance and have national importation preparedness plans set in place that focus on surveillance and immunization response to wild poliovirus importation or circulating VDPV (cVDPV).

2.2.3

Tetanus, Hib, rotavirus, Pandemic (HJNJ) status

All but five countries in the Region, including all Pacific Island countries, have achieved maternal and neonatal tetanus elimination. Of the newer vaccines, 30 countries and areas in the Region have introduced Hib vaccine and, with Vanuatu introducing the vaccine in 2010-11, all Pacific Island countries will have included Hib vaccine in their routine schedules; three countries use Hib vaccine in the private sector and two (China and Japan) have not yet decided on Hib

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vaccine use. Pneumococcal Conjugate Vaccine (PCV) is in use in 14 countries, including Australia, New Zealand and nine Pacific Island countries; HPV vaccine is in use in Australia, New Zealand, Malaysia, Fiji and six more Pacific Island countries and rotavirus vaccine is being used by Australia and six Pacific Island countries. Sentinel surveillance networks for invasive bacterial diseases caused by S. pneumoniae, H. influenza b, and N. meningitidis exist in five countries and for rotavirus in eight countries in the Region; among the Pacific island countries, only Fiji is included in the rotavirus surveillance network. Following the onset of the pandemic from the influenza A(H1N1) 2009 virus, five large countries in Asia and 11 Pacific Island countries received and distributed vaccine donated by WHO to vaccinate high-risk individuals and learnt lessons that will be helpful to prepare for the next pandemic.

2.2.4

Regional Technical Strategic Framework/or EPI

The WHO Regional Office for the Western Pacific has developed a Regional Technical Strategic Framework for BPI in line with the GNS, with the overall goal of reducing mortality, morbidity, and disability from VPDs. Approaches include: strengthening national immunization programmes; targeted VPD control, elimination and eradication; introduction of new and underutilized vaccines; monitoring, surveillance and laboratory network support; and coordination and partnerships. Dr Sniadack concluded by stating that while the Western Pacific Region spent US$ 20 million in 2008-09 on immunization, estimated requirements for 2010-11 are over US$ 40 million. 2.3 Progress review of BPI in Pacific Island countries and areas

Dr Raul Bonifacio, Temporary Appointment Professional, WHO Regional Office for the Western Pacific, started his presentation by stati..itg that while the Pacific Island countries continue overall to have good immunization coverage, Chuuk State of the Federated States of Micronesia, Kiribati, Samoa, the Solomon Islands and Vanuatu have persistently remained well below 90% during the last three years, although there had been good improvement in 2009 in Kiribati and Vanuatu. Fiji's decline in performance in 2009 also raises concerns. The HBAS reporting rate in 2010 substantially improved to >70% compared to 25% in 2009 and this was largely due to regular reporting by Fiji, French Polynesia, the Federated States of Micronesia, Tonga and Vanuatu. HBAS sites increased from 58 to 61 in 2010 with the addition of two sites in Vanuatu and one in Kiribati. Fiji launched a mobile phone network to support VPD reporting, thus allowing rapid reporting of AFP, AFR and neonatal tetanus (NT) cases from remote areas. Specimens can be analyzed rapidly at Mataika House, which was accredited by WHO as a Measles Reference Laboratory in April2010. Only three countries reported AEFis. National authorities need to develop better monitoring mechanisms at the district level. Measles SIAs were conducted in Kiribati, the Solomon Islands and Vanuatu in 2009 and in Chuuk State of the Federated States ofMironesia and Tuvalu in 2010. They were integrated with vitamin A administration, hand washing education and birth registration in Kiribati, and bed net distribution in Torba Province, Vanuatu. The WHO Pandemic (H1N1) Vaccine Deployment Initiative was undertaken in 11 countries. Six countries (Fiji, Kiribati, Samoa, the Solomon Islands, Tuvalu and Vanuatu) focused on high-risk groups (10% of the total population) while five countries (Cook Islands, Nauru, Niue, Tokelau and Tonga) opted for whole population vaccination. In Guam, mass vaccination outreach was implemented in a housing complex with a cluster of mumps cases (172 confirmed and 89 suspected cases). Almost 55 000 doses of typhoid vaccine were rapidly administered in Fiji in seven outbreak hot spots. A change in vaccination schedule was noted in French-affiliated countries with PCV no longer administered during the third month. All Pacific Island countries submitted the WHOUNICEF Joint Reporting Forms (JRFs) in 2009. Effective Vaccine Storage and Management

-7 -

(EVSM) assessments were conducted in Fiji, the Solomon Islands and Vanuatu, and procurement of cold chain supplies including introduction of Solar Chills in Vanuatu was undertaken through UNICEF. A joint WHO/UNICEF Vaccine Procurement Assessment was undertaken in March 2010, and procurement of vaccines for 14 countries continues through the VII. Vanuatu will introduce Hib in January 2011, thus establishing use of the vaccine in all Pacific Island countries. PCV is used mainly by the American- and French-affiliated countries; Fiji and Kiribati are considering introducing PCV along with HPV. WHO and UNICEF conducted the first mid-level management (MLM) training course in six Pacific Island countries (Fiji, Kiribati, Samoa, the Solomon Islands, the Federated States of Micronesia, and Vanuatu). Follow-up training at the national level is being planned. J-PIPS completed its five-year project support in February 2010, a programme that focused on immunization policy and programme, vaccine and cold chain management, injection safety, disposal management and outreach activities, and also provided regional training. Vanuatu appointed six BPI supervisors at the provincial level. Kiribati will graduate from Global Alliance for Vaccines and Immunization (GAVI) support, leaving the Solomon Islands as the only GAVI-eligible Pacific Island country. 2.4 Communication and advocacy

2. 4.1

Five steps to effective communication promoting immunization and the 5 P's

Mr Tomas Jensen, Communication Specialist, UNICEF Pacific Regional Office, facilitated an interactive discussion on effective communication outlining the five key steps: Step 1: Be clear about what you want to communicate and to what effect. Step 2: Research the communication situation and plan your communication. Step 3: Produce relevant and interesting communication materials. Step 4: Communicate with and monitor your participant groups. Step 5: Assess effects/impact and use lessons learnt to improve your communication skills. A number of basic assumptions underlie these five steps including the fact that the communication environment is complex; that communication needs to be strategic and planned; that communication effects or impacts are not guaranteed by well-planned strategic communication; that communication should be kept simple and flexible; and that communication is a long-term ongoing process: for example, communication campaigns need at least six hits per day, five days a week, for three months to be effective. He went on to illustrate and explain further the five steps and then discussed the five cross-cutting principles of communication: (1) (2) communication is linked to Programmes and delivery of services; ensure standardization of messages and activities and minimize duplication to achieve greater impact of coordinated activities among key Partners working in the same field; communication is well Planned with behavioural and communication results and indicators identified beforehand, and delivery via multiple channels and approaches;

(3)

-8-

(4)

consultation with and involvement of Participant group representatives will ensure that the message is relevant; and Persistence and continuity is required to support this process for as long as necessary because social and behaviour change takes time.

(5)

2.4.2

Regional Vaccination Week

Mr Gabriel Anaya, Programme Management Officer, EPJJWHO Regional Office for the Western Pacific, gave a presentation on Regional Vaccination Week, an event highlighting the importance of protecting infants from VPD and celebrating the achievements of immunization programmes and partnerships that promote healthy communities. WHO's Region of the Americas, Eastern Mediterranean Region, European Region and many countries observed vaccination week jointly from 24 April to 1 May 2010 in a call to action to ensure that infants around the world are fully immunized. Vaccination Week events included vaccination activities, social mobilization and media campaigns, public statements by high-ranking officials and advocacy meetings. The WHO Regional Office for the Western Pacific plans to join these efforts in the 2011 Vaccination Week. The Region's TAG has endorsed the First V!lccination Week in the Western Pacific Region and countries are being assessed for their willingness to participate in the event and on the feasibility of conducting suggested activities or modified versions. Activities range from a proclamation letter at the village level to a full-scale vaccination campaign. The regional office will continue to work with country offices to guide and facilitate the observance of Vaccination Week in the Western Pacific Region.

2.4.3

Update on the first Regional Mid-Level Manager's Training in Immunization

Ms Diana Chang-Blanc, Regional Immunization Specialist, UNICEF East Asia and Pacific Regional Office, made a presentation on the first MLM training conducted in the Pacific Region in Nadi, Fiji, 9-16 August 2010. Key objectives were to provide immunization managers with up-to-date technical information, strengthen national and provincial capacity for management and technical oversight of immunization, and promote learning across countries through sharing of experiences. There were 32 participants from six countries, including Fiji (3), Kiribati (5), Samoa (3), the Solomon Islands (12), the Federated States of Micronesia (2) and Vanuatu (7). The Solonion Islands and Vanuatu were selected because these countries had recently instituted a second level of BPI management (provincial) and appointed new staff in these positions. The majority of participants were drawn from this second level or "middle level", variously titled as provincial, divisional, state, district or regional coordinators for EPI, depending on the classifications of the second level of the health system in each country. Facilitators were drawn from UNICEF, WHO and Fiji Health Sector Improvement Programme (FHSIP). Course content was adapted from MLM modules launched by WHO in 2010 (WHO/IVB/ 08.07). The eight modules could not be covered in their entirety because of the short seven-day duration of the course but key topics of each module were extracted and reviewed. A mixture of methodologies was applied including illustrated lectures, small group exercises and hands-on practical exercises, plenary discussion and field practice. The training course was preceded by a pre-test questionnaire and concluded with a post-test. Based on post-course evaluation, 82% of participants felt the MLM course achieved its objectives and 79% reached their personal objectives. The pace of the course was perceived as too fast however, and this should be addressed in future training. The sessions on surveillance, planning, vaccine management and supportive supervision were perceived·as most useful.

-9-

Ms Chang-Blanc emphasized that the follow up to the MLM will need to be specific to country needs, but should nevertheless fit into an overall strategy for capacity building of mid-level managers rather than translated into a series of national cascade training courses. Specifically, she felt it was essential to establish job descriptions for second-level BPI managers, annual planning and monitoring systems at mid-level, and supervision mechanisms and guidelines. At the regional level, consensus should be reached with the main technical partners on a common strategy for the MLM BPI training in the Pacific Region. Encouragingly, a number of countries have expressed their desire to participate in the next phase ofMLM. 2.5 Measles elimination

2.5.1

Process ofverification of measles elimination and TAG recommendations, WHO Regional Office for the Western Pacific

Dr David H. Sniadack presented information on measles elimination progress in the Region and the Pacific Island countries. As a result of increasing routine coverage with MCV2, SIAs and improving case-based surveillance, there has been a 92% reduction in the number of reported measles cases in the Region from 2000 to 2009. Overall vaccination coverage with MCVl was 96 % in 2009. Measles incidence in 2009 was 34 per million population, with China and to a lesser extent Japan, the two most populated countries in the Region, contributing the majority of the cases. More than 16 countries now have school entry immunization requirements for measles. Overall, there has been an improvement in completeness and timeliness of country reporting to the WHO Regional Office for the Western Pacific although measles surveillance performance in Pacific Island countries remains poor. Potential importation of measles virus into Pacific Island countries (as well as other countries) is a challenge to sustaining measles elimination. For example, in 2008-2009 measles virus entered Australia from at least 13 countries representing all six WHO regions. Greater political commitment and fmancial resources are needed to achieve the goal, with an estimated US$ 25 million required and US$ 19.4 million funding gap in 2010-2012 to support priority countries. An additional US$ 6.7 million is needed to sustain measles elimination through 2015 and another US$ 9. 7 million to sustain measles elimination from 2016 to 2020, suggesting that measles elimination is a worthwhile investment. Pacific Island countries are among the 25 Western Pacific Region countries and areas that have either already achieved or are Close to achieving measles elimination by 2012, but verification of measles elimination is yet to be initiated. A Technical Consultation on the Verification of Measles Elimination in the Western Pacific Region was held 15-16 June 2010 during which a Subregional Verification Committee for Pacific Island Countries and Areas (SRVC) was recommended with a timetable for completion of regional verification by 2015. This committee should report to the Regional Director through a Regional Verification Commission (RVC); the SVRC should also inform the Ministers of Health of21 Pacific Island countries and areas of measles elimination progress and status. The WHO Representative Office for the South Pacific will serve as secretariat to the SRVC. The five components for documentation to verify measles elimination were proposed as: (1) (2) (3) high population immunity in all birth cohorts since measles vaccine introduction; incidence and epidemiological analysis for as many years as possible; high-quality epidemiological surveillance using standard indicators and targets;

- 10-

(4) (5)

virological analysis of measles chains of transmission; and sustainability of measles elimination in the context of a well-functioning NIP.

The RVC would be given discretionary authority to allow verification of countries or areas unable to provide data satisfying the core and/or complementary indicators in the above areas, so that alternative yet comprehensive evidence of measles elimination may be admissible for verification purposes. Dr Sniadack also presented recent TAG recommendations for measles and rubella. These include endorsement of the strategic approaches contained in the revised Plan for Achieving and Sustaining Measles Elimination in the Western Pacific Region 2010-2020, and the revised Regional Plan for Control ofRubella and Prevention of Congenital Rubella Syndrome in the Western Pacific Region, 2010-2015. hnproving epidemiological surveillance and laboratory networks, more extensive and complete suspected case investigations that include contact tracing, and moving the verification process forward were included among the recommendations. TAG also urged countries and areas to commit the human and financial resources necessary to achieve and sustain measles elimination and reaffirmed its recommendation to use measles elimination activities to accelerate rubella control and prevention of CRS.

2.5.2

Measles SIA in Chuuk State, the Federated States ofMicronesia

Ms Louisa Helgenberger, Programme Manager, hnmunization and Vaccine Preventable Diseases, the Federated States of Micronesia, described the measles SIAs undertaken in Chuuk State in May-June 2010. Of the four states of the Federated States of Micronesia, Chuuk is the most populated with 53 000 people, based on the 2000 census. It presents geographical challenges as it is comprised of outer islands and one of the largest enclosed lagoons in the world covering an area of 832 square miles encircled by 140 miles of barrier reefs. With measlesmumps-rubella (MMR) coverage·rates of only 75% oftwo-year-old s and 82% of six-year-olds in 2009, a campaign was needed to increase measles coverage and prevent transmission of the measles virus. In 2004, a measles/rubella (MR) campaign was conducted, targeting children one to 14 years old and women of reproductive age. Another campaign had been planned in February-March of 2010 but this was deferred due to the H1 N1 outbreak. When funds for operational costs and vaccines became available through the American Recovery Re-investment Act, campaign planning started with the formation of a Working Group in Chuuk. WHO provided technical assistance; 8000 doses of MMR vaccines were secured through US CDC and 16 vaccine carriers were donated by UNICEF. Although social mobilization activities were planned to start at least four weeks before the campaign, there were delays and activities actually started two weeks before the campaign with information and fact sheets sent to the mayors, and radio information, church and megaphone announcements to the public before and throughout the period of the campaign. The campaign started in May and integrated routine and MMR vaccination with de-worming using mebendazole. The target population was one- to six-year-olds, with the total number estimated to be 6762 based on the 2000 census; 12 nurses from the other three Federated States of Micronesia states assisted. The immunization age was extended up to 14 years during part of the campaign because of an outbreak of mumps in Wino. There were eight teams of four members who received a two-day training course; vaccination teams wore t-shirts and caps for identification. Rental cars and boats were used for transport in the lagoon islands and the Federated States of Micronesia Surveillance/Patrol boat was used for the outer islands.

-11-

Final MMR coverage was estimated to be 90.9% with lack of parental awareness of vaccination opportunities as the most common reason for children being missed. A total of 1485 seven to 14 year olds were immunized in the outer islands after the mumps outbreak. Many factors contributed to the success of the campaign including strong commitment and ownership by the Department of Health Services, full funding by the Government through US CDC, good support from other states, fully committed team members and good access to supplies upon request to the NIP. Challenges included poor roads, ongoing road construction work, bad weather and rough seas that led to travel delays, tracking children of highly mobile families, the unreliable Patrol boat sched:ule and the mumps outbreak during the campaign. The total cost of the campaign was US$ 150 000.

2.5.3

Measles SIA in Tuvalu

Ms Alaita Taulima, Public Health Sister, Tuvalu, made a presentation describing the measles SIAs and vitamin A distribution activity which started on 13 September 2010. The target population was children aged 12-71 months old. A media programme was initiated one week prior to the start of the campaign and included radio announcements to the general public in Tuvaluan and English languages, a radio interview on the campaign, IEC material distribution to child health clinics and pre-schools and increased awareness of all mothers, children and teachers in pre-schools by nurses on the outer islands. Letters were sent to all head teachers of pre-schools on Funafuti stating the intended date and time of school visits from nurses. Nurses undertook vaccination and vitamin A distribution at pre-schools in the mornings and during clinic hours for other children. House-to-house follow up was then undertaken. Challenges included managing competing health programmes, shortage of human resources to carry out the MR/vitamin A campaigns, challenges with the capacity and knowledge of nursing staff and lateness in receiving MR vaccines and vitamin A capsules due to air cargo backlogs. There were also campaign delays on the outer islands and late reports, plus communication problems due to telecommunication .breakdowns. Overall, coverage on each of the four islands ranged between 76.4% and 100% of the target population.

2.5.4

Mataika House measles reference laboratory and regional laboratory links

Dr Eric Rafai, National Adviser, Communicable Diseases, Fiji, described the rationale for and the process by which Mataika House was accredited as a WHO approved National (subregional) Measles Laboratory in Fiji in September 2009. High-quality surveillance is among the indicators to verify measles elimination and certain standards must be met including the : following: (1) more than two suspected measles cases per 100 000 population must be reported and discarded as non-measles per year; (2) at least 80% of suspected cases must be adequately investigated; (3) at least 80% of cases should have specimens collected for laboratory confirmation, unless already confirmed by epidein.iologic linkage; and (4) specimens for virus detection (i.e. genotyping) should be obtained from every chain of transmission. The WHO Measles/Rubella Labnet has a key role in confrrm~g suspected cases and identifying measles virus genotypes using standardized testing procedures. The Western Pacific Region Measles/Rubella.Labnet is therefore involved in monthly case-based laboratory reporting, genotyping data on recent strains, regional laboratory training, and offers financial support to cover operational costs, kits and equipment. There are four designated Measles/Rubella network laboratories in the Pacific Island countries but only Mataika House is WHO accredited based on an on-site review conducted in September 2009. Advantages to Pacific Island countries when they use Mataika House Laboratory include the following: (1) WHO accreditation ensures quality and proficiency; (2) an established relationship is useful for other diseases under surveillance, such as influenza or HIV; (3) freight options are broadened

- 12-

and this may mean fewer issues with customs clearance; (4) certified laboratory personnel; (5) quick tum around time within seven days of specimen receipt; (6) communication channels are easier as staff share the 'pacific language'; and (7) the laboratory can offer technical assistance and training. WHO has now recommended that the Mataika House Laboratory should receive AFR samples from other designated Pacific Island countries; samples are needed from neighbouring Pacific island countries to sustain its accreditation status. 2.6 Pandemic (H1 Nl)

2.6.1

Global and regional update on Pandemic (HINI) vaccine deployment and vaccination

Dr Md. Shafiqul Hossain, Technical Officer, BPI/WHO Regional Office for the Western Pacific, updated participants on Pandemic (H1N1) 2009 and WHO vaccine development activities. In response to the spread of disease across the globe, WHO declared on 11 June 2009 that the Pandemic (H1N1) 2009 was in phase 6 and that the overall severity of the pandemic was moderate. Shortly after notification of the first few cases of the new influenza A(H1N1) in April 2009, WHO collaborating centres started developing candidate vaccines and by July 2009, 13 candidate vaccine viruses had been developed and distributed in more than 400 shipments to manufacturers, regulatory authorities and research institutions; vaccine production from various manufacturing companies commenced in September 2009. To support developing nations, in July 2009 WHO assessed low- and middle-income countries globally that could not otherwise access pandemic (H1 Nl) vaccine and 17 were identified in the Western Pacific Region. Member States received technical and financial assistance from WHO including assistance with development of national deployment and vaccination plans. A total of 99 countries/areas were identified for WHO donation globally and 73 countries received the donated vaccine (72 570 990 doses) as of 10 September 2010 with a further nine countries due to receive 6 521 300 doses by 30 September 2010. Of the countries in . the Western Pacific Region, 16 countries requested vaccines from WHO and these countries have already received vaccines sufficient for 10%-oftheir total population. Eight among 16 countries (Cambodia, Cook Islands, Mongolia, Nauru, Niue, Tokelau, Tonga and the Lao People's Democratic Republic) have received additional doses as requested to cover a greater proportion of the population due to community demand. As of 25 September a total of 8 712 750 doses ofPandemic (H1N1) vaccine were deployed to 16 countries. A total of3 613 451 doses were administered as of25 September 2010 and vaccination campaigns are continuing in 14 countries. Almost 165 million doses of Pandemic (H1N1) vaccine have been distributed in the Western Pacific Region including Australia, Brunei Darussalam, China, Japan, Korea, Malaysia, New Zealand, Singapore, and 10 Pacific Island countries and areas. Finally, Dr Hossain shared WHO recommendations for post-pandemic vaccination. In the post-pandemic period when the virus is still circulating, vaccination against the virus is still the best protection. Depending on availability, Member States are encouraged to vaccinate high-risk individuals with a monovalent (single virus) Pandemic (H1N1) 2009 vaccine, or a trivalent seasonal influenza vaccine that includes the H1N1 (2009) strain, as well as seasonal strains H3 and B.

2.6.2

WHO Pandemic (HINI) vaccine donation initiative: Challenges and lessons learnt

Dr Raul Bonifacio discussed the challenges faced in the vaccine donation initiative. During the planning stage, the long preparation time (on average three to four months) was challenging in a situation where time was limited due to the rapid spread of the virus. Delay was partly due to competing health priorities but also the challenge of identifying the cohort of high-risk individuals as this age group is not part of national immunization programmes. Other

- 13 -

challenges included identifying the type of vaccine, the number of doses and date of delivery to countries and securing the funds for operational activities. During the vaccine deployment stage challenges included limited country experience in the use of the vaccine; varying levels of preparation and capacities in countries; uncertainty of vaccine shipment dates; ·the need to revise deployment plans; securing funds for the second phase; counteracting fears of AEFI caused by experiences in neighbouring countries; locating the target population with underlying chronic medical conditions in cities and towns; competing priorities, ensuring good documentation and timely reporting on the number of doses administered. It became clear that to achieve an effective response to an influenza pandemic, a number of factors are vital: international collaboration; good political commitment; consensus among partners on vaccine deployment; local government and community involvement as key social mobilization agents; efficient and effective use of the existing routine immunization system for Pandemic (HINI) vaccine deployment and implementation; and the national pandemic task force must be effective in preparation and implementation of activities. Greater success could have been achieved by better and more timely communication about the vaccine and its safety. The target of vaccine deployment within seven days was not achieved, perhaps partly because the 2009 pandemic was not sufficiently severe. 2.7 Outbreak response

2. 7.1

Mumps outbreak response in Guam

Ms Rita Oliva, CDC Coordinator ll, Guam, reported that there have been a total of 446 reported cases of mumps in Guam between 7 December 2009 and 11 September 2010, with no deaths and seven cases with complications, primarily orchitis. Cases have been reported from schools across the island and in many communities and among different racial/ethnic groups: the outbreak is considered to be ongoing. The Department of Public Health and Social Services Immunization Programme is taking appropriate prevention and control measures including releasing a Mumps Advisory to physicians, press releases to educate the community, media interviews and meeting regularly with community leaders and partners. Assistance has been sought from US CDC; intensive case investigation and contact tracing is underway, ~d active surveillance has been launched in day care centres and schools. Interventions have included a vaccination campaign at a housing complex, an MMR catch-up campaign, and an MMR third-dose intervention in May 2010. Evaluation of this intervention is now in progress.

2. 7.2

Typhoid fever control in Fiji

Ms Kylie Jenkins, Fiji Health Sector Improvement Programme (FHSIP), an AusAIDfunded initiative, informed participants of a Typhoid Fever Control Programme in Fiji that used vaccination as part of the control strategy. Typhoid fever is endemic in Fiji with many cases being laboratory confirmed annually. During March 2010, Fiji was hit by severe tropical cyclone Tomas and part of AusAID's assist~ce to the Ministry of Health after the cyclone was the funding of a Typhoid Fever Control Proposal. The Control Programme included a thorough epidemiological description to identify hyper-endemic areas, and improved case management that required a revision of the typhoid fever clinical guidelines to recommend the use of ciprofloxacin as the drug of choice (or treatment of cases. The main strategy for the control of typho~d was targeting of individuals living in areas with a high incidence of typhoid fever with the typhim-vi vaccination. The Typhoid Fever Control Programme has now successfully delivered over 53 000 doses of typhoid vaccine to people over two years of age across four subdivisions in Fiji. The vaccine was well accepted by the community and high coverage

- 14-

was achieved. Reported cases of typhoid fever appear to be declining but it is too soon to properly assess the success of the vaccination programme. The typhim-vi vaccine was also used to successfully stop another large outbreak of typhoid fever in a remote area of Fiji. During this outbreak, over 220 suspected cases were reported, among which 29 were confirmed. Since the vaccination programme was completed in June 2010, there have been no new cases of typhoid reported. The vaccination programme was coupled with hand washing demonstrations to encourage community members to wash their hands properly and avoid the transmission of typhoid fever. Other activities have included a nationwide IEC campaign including production of three television and radio advertisements, posters, brochures and bookmarks. A small-scale water and sanitation project was also funded targeting water and sanitation activities in areas offering vaccination. In addition, laboratory consumables were purchased to ensure that the testing for typhoid fever continues. It is likely that the typhoid fever vaccine programme has interrupted the transmission of typhoid fever in areas targeted with vaccination. Vaccination only offers protection for three to five years, however, and Ms Jenkins recommended that clean water and good sanitation are the keys to controlling typhoid fever in Fiji. 2.8 Service delivery

2.8.1

Improving vaccination in the Outer Islands of Kiribati

Ms Tikua Tekitanga, EPI Coordinator, Kiribati, described the Immunization Programme in this challenging environment comprised of 33 islands divided into six districts with a total land mass of 811 sq km distributed over 3.5 million sq km of water. The total population in 2005 was 92 533, with 2553 children less than one year and 60% of these children in the less accessible outer islands. Six senior nurses supervise each of the districts, 24 medical assistants work at the health centres and public health nurses staff each of the 77 dispensaries. Each village has Nurse's Aides paid by the local council and communities also have Village Welfare groups. There are either solar or main-powered refrigerators at each of the 24 health centres, plus an additional 12 distributed between the central level and the most remote Linnix group of islands. Communication to remote locations is by high frequency radios with 10 units supplied by the European Union and seven units from UNICEF. Transport is by motorbike, airplane or boat for the most remote locations with vaccine deliveries varying from monthly to every six months. Immunization is undertaken by various methods including daily fixed sites using Multi Dose Open Vial Policy, outreach at the Maneaba or meeting house two to three times per week and home visits for drop-out children two to three times a week by nurses and medical assistants. Records are maintained using a MCH Card, register book, tally sheets and monitoring charts. Mapping is also conducted in some places. A supervision checklist is used for oversight and a consolidated report is forwarded to the main office monthly. Kiribati showed improvement in vaccination rates in 2009 with 100% first dose pentavalent, 85% oral poliovirus vaccine (OPV) and 82% MRl coverage, but BCG is 70% and HepB birth dose coverage remains at less than 50%. Immunization coverage is still unstable, not uniform and drop-out rates are still more than 10% in many islands. Challenges include scattered islands with high transportation costs, limited monitoring and supervision at present and ongoing difficulties with cold chain management and maintenance. Improvement is likely if it is ensured that all solar fridges are functioning and this may mean replacement of outdated refrigerators, strengthening supportive supervision (using a revised checklist), ensuring all radios are working well, and implementation of vaccine stock management which is one of the follow-up actions from the Vaccine Management Training conducted 7-11 September 2010.

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2.8.2

Improving vaccination in highly mobile populations in Vanuatu

Mr Leonard Tabilip, EPI Coordinator, Vanuatu, shared experiences in service delivery in very mobile communities in Shefa Province. This is one of the most populous provinces in Vanuatu, housing 29% of the national immunization target. Mobility is high as families travel from islands to Port Vila, becoming squatters and establishing illegal settlements. In addition, many mothers from nearby islands give birth in the Central Hospital. This situation creates many challenges for good planning and implementation of routine vaccination. A number of factors contributed to a substantial improvement in coverage from 2008 to 2009 with coverage of all antigens greater than 95%, except measles coverage, which was 79% in 2009. Coordination and teamwork has improved since restructuring of the Ministry of Health in 2009, which led to the appointment of six Provincial EPI Supervisors throughout the country and four Zone Supervisors in Shefa Province. There has been continuous capacity building of EPI staff at provincial-, zoneand health-centre levels including training and regular EPI reviews and supervision by zonal and provincial EPI supervisors. Planning and data management have improved and local area monitoring charts and detailed micro-plans are now in use. Health workers are communicating more effectively with their communities and fixed sites are open every day at the hospital, three health centres and 12 dispensaries. Outreach services are provided by health centre and dispensary staff up to three times a week to reach every child by tracking and finding defaulters. Good cold chain management and uninterrupted supply of vaccines and equipment have had a significant impact; effective supervision by the Provincial EPI supervisor has played a key role in the improvement of immunization services. The strengths of this approach have included strong commitment by the Provincial Health Manager; good planning with a better understanding of the target in terms of numbers, location and how to access them; development of a monthly implementation and monitoring system and monthly data collection by EPI; outreach mobile sessions which are essential in a suburban community; good motivation and incentives accompanied by supervision and monitoring: and sufficient support for transportation. Mr Tabilip reported that measles vaccination coverage remains unsatisfactory primarily due to movement of parents and children, but lessons have been learnt that will hopefully help address this. Future directions include production and distribution of IEC materials to raise awareness of mothers for the need to complete the immunization schedule and recognition of Shefa Province as "the model" for other provinces. Mr Tabilip concluded by stating "We can not stop until we reach every child".

2.8.3

Coordination with key agencies and community-based health committees/volunteers in Samoa

Ms Fuapepe lese Manuleleua, EPI Coordinator, Samoa, described the partnership that exists between health agencies and Village Women's Committees (VWCs) in Samoa. VWC were first established after the Spanish Influenza epidemic in 1918 that killed 22% of the total population of Samoa. Traditionally, these are powerful groups of women and all women who have left school are strongly encouraged to participate. A leader who acts as a focal point is elected, usually a wife of a high chief in the village, and committees are ultimately responsible to the village chiefs. VWCs freely contribute to community development including health issues. More recently the Ministry of Women, Community and Social Development (MWCSD) was established and there is regulation ofVWCs under the MWCDS Act. Some VWCs are under the umbrella of the MWCSD and fmancial incentives are now associated with activities and developments that were previously voluntary.

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Today, VWCs collaborate with village mayors. Mother and Child Health (MCH) clinics are organized by government health agencies in collaboration with VWCs and this includes visiting homes and working individually with parents. The National Health Service runs community health training and One Health Programmes in collaboration with other government ministries including MWCSD and the Ministry of Health, churches and the community. Challenges have included managing modernization of traditional structures, community participation and commitment, health system changes and reforms, and resource gaps. Ms Manuleleua believes the way forward includes strengthening existing collaborative systems with regards to policy making and programmatic implementation. There is a strong belief in Samoa that a healthy environment means a healthy child.

2.8.4

Linking EPI programming to other maternal neonatal child health (MNCH) interventions: Perceptions ofPacific Island countries and other development partners

Dr Eliab S. Some, Chief of Health and Sanitation, UNICEF Pacific Regional Office, presented the findings from an explorative study undertaken to determine the perceptions of EPI managers and partners in the PIPS partnership on linking EPI programming to other maternal, neonatal and child health (MNCH) interventions. Country delegates and PIPS partners attending the Fifth PIPS Workshop in May 2009 responded to a questionnaire on principles and operational issues for integrated programming. The questionnaire included questions on joint planning, joint reviews, integrated campaigns, integrated home visits, integrated improvement of data, integrated improvement of surveillance, integrated supportive supervision, master plans for continuing education for all staff, joint bottleneck analysis and performance-based incentives for all programmes. The questionnaire also included questions in a section labelled "operational issues" that included donor funding for integrated multi-intervention programmes; cold chain technicians servicing other equipment; micro-planning for all interventions targeting the same populations; integrated use of transport facilities; malaria active case detection to include other conditions (in the Solomon Islands and Vanuatu); integrated programme communication plans; communication to have both common and programme-specific elements with common communication elements delivered by all programmes; all well-funded programmes to include health system strengthening; and having multi-year, results-based, casted plans for all programmes. . Dr Some reviewed the results of a questionnaire administered to participants to the PIPS Workshop from the previous year. Among 58 country delegates and development partners invited to the Fifth PIPS Workshop in May 2009, 51 (88%) attended on the first day, and 49 (85%) remained on the fifth day, when the questionnaires were collected. Among these 49, 33 (67%) completed the questionnaires, including 14 (42%) country delegates, 17 (52%) development partners; and two (6%) of unknown category. Response rates for each item in the questionnaire ranged from 90.9% to 100%. Approximately 58% of respondents agreed that EPI programming should be linked to other MNCH interventions on both policy and operational issues. An additional29% "probably think so". A total of 87% therefore favour integration in general. However, for integration to be strongly supported, it seems that certain conditions need to be met, including feasibility and appropriateness of the proposed linkage. Development partners answered "Yes" to proposed items of integration less often than country delegates on all issues, excluding "joint integrated planning", for which 82.4% of partners vs. 69.2% of c-ountry delegates agreed. For country delegates, the least acceptable integration option was "performance-based incentives for all programmes" (63.6%); for development partners, "integrated improvement of surveillance systems" (47.1%) was least acceptable. There is therefore a general agreement among PIPS partners and country delegates that EPI programming should be linked to other MNCH interventions provided the linkages are appropriate and feasible. Special attention should be given to specific policy barriers and interventions with reduced effectiveness. These perceptions need to be explored further in specific country contexts and settings~

- 17-

2.9

Country poster presentations, progress. challenges and planned activities

Posters were displayed from all countries covering four themes: key achievements; innovative activities; challenges and constraints; and future plans and needs. Most countries are refining their NlPs and maintaining high vaccination coverage or have improved their coverage rates. Training was conducted in almost all countries and included MLM and EVSM training. Many had developed or reviewed cold chain inventories or immunization policies and handbooks, disease elimination and certification plans, and were implementing or developing requirements for full immunization at school entry. fucreasing numbers of countries are developing their electronic national immunization registries or the equivalent. Improvements in staffmg were mentioned and a number of countries held special campaigns, often integrating activities such as vitamin A and albendazole distribution. Transport, cold chain and/or waste-management infrastructures and systems had been strengthened with the assistance of regional partners in many countries. Countries had all been involved in Pandemic (H1N1) campaigns and many had made immunization schedule changes and had introduced a range of new vaccines. Many noted increased community education activities including immunization weeks or days, breastfeeding or health days. Many of the challenges and constraints highlighted by countries involve difficult geographic conditions (e.g. remote islands or communities) affecting communication, transportation, cold chain, waste management and outreach. Remoteness exacerbates the problem of locating children born outside clinics. Most countries lack human resources and have difficulty retaining trained individuals due to pressures to emigrate. Many countries mentioned difficulties with data management, documentation and reporting. Some countries noted interrupted vaccine supply due to delay in receiving their order. Priority activities common to a number of countries include refilling and improving routine immunization, particularly recording systems and computerized data management. Documentation such as inventories, protocols and handbooks will be reviewed or completed in many countries, and several countries are involved in developing combined multiyear plans (c-MYPs). Improving coverage by strengthening the cold chain infrastructure, addressing transport, waste disposal and communication needs, and increasing outreach and supervisory activities were mentioned by many. Other priorities identified by some countries included introduction/exploration of new vaccines and improving materials for community education. Countries require ongoing technical and fmancial support for training, supportive supervision activities, attending regional meetings, conducting coverage and seroprevalence surveys, printing materials, transport by cars and boats, computers and software, and introduction of new vaccines. 2.10 New vaccines

2.10.1

Regional status of new vaccine introduction

Dr Manju Rani, former Scientist with BPI/WHO Regional Office for the Western Pacific, described 2000-2007 as the golden years for vaccines as significant progress was made with many difficult and technologically complex vaccines. There is now the potential for significant impact on MDGs with vaccines available that attack important causes of under-five mortality. Pneumonia causes 13% of child deaths and is reduced by Hib vaccine and PCV; acute bacterial meningitis is another cause of child death and is also prevented by these vaccines. Diarrhoea causes 17% of child deaths and is reduced by rotavirus vaccine. These vaccines also reduce childhood morbidity, disability (e.g. from meningitis) and hospitalization from the same diseases. fu addition, premature adult mortality and morbidity is reduced by a vaccine against HPV, as

- 18 -

cervical cancer is the second most common cancer for women. All Pacific Island countries and areas are expected to use Rib vaccine in 2011, and many countries now vaccinate with PCV, rotavirus and HPV vaccines; much preparation work remains for the rest. Suitable PCVs come as 7-, 10- or 13-valent formulations that are WHO pre-qualified and may prevent 65o/o-85% of invasive pneumococcal infection. As pneumococcal pneumonia, meningitis and sepsis are important public health issues in the Pacific, it has been suggested that a Pacific Pneumococcal Project be established with support from AusAID, NZAID and TICA with technical support from UNICEF and WHO. Using UNICEF pooled procurement, the estimated cost would be US$ 20-US$ 25 per child (approximately US$ 700 000/year) for five years, with the cost likely to decrease in future years from declining vaccine prices. Sentinel hospital-based surveillance is ongoing in eight countries in the WHO Western Pacific Region, including Fiji. Surveillance data indicate that 30%-50% of all admissions of children under-five years of age for diarrhoea are due to rotavirus and that diarrhoea due to rotavirus is more severe and more likely to be associated with vomiting and fever, making oral rehydration therapy difficult. It mainly affects children six months to 23 months of age. New WHO pre-qualified fully liquid presentations ofRotavirus vaccines suitable in developing country settings are now available with effectiveness varying from 40%-70% in these settings. UNICEF is yet to procure the vaccine for developing countries and the exact market price is likely to be approximately US$ 15 per child. External support will be required for the remaining nine Pacific Island countries and this must be used in the context of other measures to control diarrhoeal disease. Studies in Tonga and Fiji indicate a very high HPV disease burden and case fatality rate. There are almost no screening programmes and treatment is difficult in almost all the Pacific Island countries when cervical cancer is diagnosed. HPV vaccine will prevent cervical cancer in cohorts of women yet to start sexual activity by preventing cervical cancer caused by HPV serotypes 16 and 18 that may account for 70%-80% of all cervical cancer. All these new vaccines are relatively expensive and this further emphasizes the importance of reducing vaccine wastage by more efficient vaccine management. The relevance and priority of different vaccines may vary in different countries and clear decision-making pathways to make informed and rational choices on vaccine introduction should be in place for use by countries. Dr Rani concluded by stating that timeliness of vaccination will become as important as coverage with some of the new vaccines. For example, the first dose ofrotavirus needs to be given before 12 weeks for safety reasons; the three doses ofHib and PCV should be given on time as most of the disease burden from these diseases is in the first six months of life, and a timely birth dose and subsequent timely doses ofHepB vaccine are needed to decrease the risk of chronic HepB infection to babies born to chronically infected mothers. Delaying vaccination may therefore reduce the public health impact of these expensive vaccines.

2.10.2

Introduction ofHPVinFiji

Ms Kylie Jenkins gave a presentation on the introduction ofHPV vaccine in Fiji. The HPV vaccine programme was made possible following a donation of short expiry 4-valent HPV vaccine in August 2008. The Government approved the donation in the first weeks of September 2008 and the campaign began three weeks later. School term dates and the need to deliver three doses within six months resulted in a short time for planning and raising community awareness. A national Ministry of Health campaign targeted 30 338 girls in the last four years of primary school. The campaign was met with negative media within the first week: this ran for a month and impacted on coverage despite the communication strategy that was implemented. At the end of the initial campaign, HPV vaccine coverage was 60% of eligible girls for dose 1, 46%

- 19-

received dose 2, and 39% received dose 3. A subsequent AusAID funded mop-up campaign was completed in July 2010 and was successful in increasing the number of girls completing the three-dose schedule. Ultimately, 18 880 (62%) girls aged nine to 12 received dose 1; 17 141 (57%) dose 2; and 16 560 (55%) received three doses during the HPV vaccination campaign. Ms Jenkins commented that vaccine donations could be successful, provided the shelf life is sufficient to allow for adequate planning and raising community and stakeholder awareness. Giving three doses of vaccine in six months is logistically and fmancially challenging in a resource-limited setting. 2.11 Immunization supply chain management

2.11.1

New EVM assessment tool for supply chain management

Dr Md. Shafiqul Hossain gave a presentation on the new EVM assessment tool. Experience shows that efficient and effective supply chain systems to store, transport and distribute vaccine products are one of the most crucial elements of an immunization programme. Many new vaccines and health technologies are available or close to completion, and most of these new vaccines are much more expensive and bulkier than traditional vaccines. With higher costs and the need for increased storage capacity at all levels of the cold chain, EPI managers must be able to effectively maintain lower stock levels, reduce wastage, accurately forecast vaccme requirements and prevent equipment breakdowns or malfunctions. Maintaining high standards of performance in these areas can only be achieved if all the links in the vaccine supply chain are effectively monitored, assessed and improved based on the latest principles of good storage and distribution practice. In past years, the Vaccine Management Assessment (VMA) tool and the EVSM tool had been used to help EPI managers and logisticians assess their vaccine supply chains and to improve vaccine management practices and procedures. It became apparent however that the overlap between the two approaches needed to be addressed and the new EVM assessment tool was developed in July 2010 to combine the strengths of the two earlier approaches and address weaknesses identified in each. The EVM therefore provides the tools and processes needed to demonstrate that good practices are in use and are being sustained. In addition, EVM includes many supplementary guida,nce materials such as EVM assistant and Standard Operating Procedures, and has several important new features such as planning tools, a report and improvement template and a web-based platform allowing for centralized updating procedures. EVM provides countries with a mechanism for comprehensive assessment, planning, monitoring and improvement of vaccine management systems, including cold chain equipment and capacity, stock control and transport systems. Dr Hossain concluded by encouraging countries to use the new EVM assessment tool, thereby assuring quality control of immunization supply chain management and good preparation for the introduction of an increasing number of new, bulkier and more costly vaccines. 2.12 HepB control

2.12.1

Regional updates on HepB control

Dr Tilman Ruff, Temporary Advisor and Associate Professor, Nossal Institute for Global Health, Melbourne, Australia, gave a regional update on progress in HepB control. Perinatal and early childhood infection is associated with the highest risk of chronic infection; timely administration of a birth dose of HepB vaccine, followed by at least two timely additional doses, is key to preventing mother-to-infant transmission. The completion of three timely HepB vaccine doses is necessary for protection against both perinatal and horizontal transmission.

-20-

Serological surveys are necessary to assess changes in HepB prevalence, as acute infection in children is most often subclinical. While the target for administration of a timely HepB birth dose within 24 hours of birth is most effective, the dose should still be given as soon as possible after that (preferably within one week) if health workers are unsuccessful in providing the vaccine within 24 hours of birth. HepB birth dose should be linked with essential maternity and newborn care. The target date of2012 has been set for the Western Pacific regional milestone of less than 2% prevalence ofHepB infection in children aged at least five years but a date has not yet been set for achievement of the final goal of <1% prevalence among children at least five years of age. Thus far, only two countries/areas in the Western Pacific Region (China, Macau Special Administrative Region and the Republic of Korea) have been verified as having achieved the regional milestone. China, Hong Kong Special Administrative Region and Malaysia are currently being evaluated for verification. Seven Pacific Island countries have prevalence data available and are likely to have achieved the milestone; nine are on-track to meet HepB coverage targets of ;;:65% timely birth dose coverage and HepB3 coverage of ;;:85% that are thought necessary to achieve the milestone, but lack current seroprevalence data; and in four priority countries (Kiribati, Samoa, the Solomon Islands and Vanuatu), immunization coverage remains below these targets and is therefore likely to be insufficient to achieve the 2% prevalence milestone. In 2009, at least five Pacific Island countries reported achieving less than 65% birth dose coverage, and at least seven reported less than 85% HepB3 coverage. A variety of ways to address increasing birth dose coverage were identified, whereas strategies to increase HepB3 coverage are essentially those related to improving routine immunization. It is expected that in February 2011, a HepB ERP will be convened by WHO Regional Office for the Western Pacific to provide further guidance.

2.12.2

Pacific Island countries' experience with HepB seroprevalence surveys

Dr Raul Bonifacio noted that the majority of Pacific Island countries are hyper-endemic with chronic HepB infection with seroprevalence of>8% among adults. Since incorporation of HepB into national immunization programmes in the early 1990s, multiple birth cohorts have been vaccinated with HepB vaccines and many countries in the Pacific Region may have achieved the HepB control milestone although none have been verified. To assess achievement of the HepB control milestone, the WHO Regional Office for the Western Pacific developed the following verification indicators: (1) at least one survey of representative data on seroprevalence ofHepB surface antigen (HBsAg) among children five years or older; HepB vaccination coverage to assess the maintenance and sustainability of verification status; and acute and chronic HepB surveillance data (optional) .

(2)

(3)

In measuring seroprevalence, however, the following criteria must be met: the sample must be representative of the nationwide estimate; the serological survey must be precise (with 95% confidence intervals of +/-0.5%); and standard laboratory procedures must be used. Since the inception of widespread HepB vaccine use, serosurveys have been conducted to measure vaccination impact in seven Pacific Island countries (American Samoa, Fiji, Marshall Islands, New Caledonia, Palau, the Federated States of Micronesia and Tonga). These were largely school based ~n design (six countries) or review ofMCH records (one country); the surveys in

-21 -

Fiji, Tonga and Vanuatu were a multi-country design. Seroprevalences were reported to be less than 2% in all except Chuuk State of the Federated States of Micronesia (2.5%). Challenges faced in conducting the serosurvey included working with small birth cohorts, far-flung outer islands and geographically heterogeneous HepB prevalence and coverage. TAG has recommended flexible serosurvey guidelines for HepB control/milestone verification in the small Pacific Islands and countries and these will be finalized in February 2011 by the HepB ERP.

2.12.3

TAG recommendations for ac'celerating HepB control

TAG meets regularly to monitor programme performance towards achievement of regional goals and objectives, to review technical and programmatic policies and strategies, and to recommend revised policies and strategies, if needed, for strengthening EPI. The TAG meeting agenda customarily includes technical updates and selected country updates. TAG acknowledges that many countries have made tremendous progress towards reaching the HepB 2012 milestone ofHBsAg prevalence <2%. However, nine priority countries have low vaccination coverage and will not reach the 2012 milestone. Data are needed on the prevalence of chronic infection in many other countries that have high HepB vaccination coverage to measure the impact of the vaccination programme. Only two countries have completed the verification process; improvement of the process may facilitate and encourage countries to initiate verification. Pacific Island countries in particular have had high coverage for many years but are not able to conduct verification-standard surveys due to small population sizes. A HepB ERP has been constituted to monitor and verify progress towards the HepB control goal and milestone. The ERP will also provide Member States with critical support and advocacy opportunities. In its 19th meeting in 2010, the TAG recommended that priority countries increase timely HepB birth dose (within 24 hours of birth) and timely three-dose coverage to levels needed to achieve the milestone by 2012 and beyond, through implementation of detailed action plans. TAG recommendations regarding verification include encouraging countries that have data suggesting that they may have achieved the HepB control milestone or goal to initiate the verification process with the WHO Regional Office for the Western Pacific and that by 2011, the ERP and the WHO Regional Office for the Western Pacific should develop regional guidance for conducting smaller scale seroprevalence surveys for verification including in some Pacific Island countries, programme assessment or post-verification monitoring. TAG has endorsed the development of the 2010-2011 Regional Plan of Action that recommends that countries consider adding or strengthening activities related to (1) establishment of a HepB birth dose as part of essential newborn care policies for facility births and maternal and neonatal care packages for home births, which may necessitate the use of vaccines outside of the cold chain; (2) implementation of standing orders for birth dose vaccination in facilities; and (3) vaccination of high-risk adults, especially health care workers. TAG further endorsed the development of the 2010-2014 Hepatitis B Strategic Plan. Also, in line with the 2010 World Health Assembly Viral Hepatitis Resolution, the WHO Regional Office for the Western Pacific should consider enhancing coordination across sectors including those responsible for injection safety, safe blood supply, screening of individuals for HepB, clinical treatment and HIV prevention. TAG recognized that additional funding is required to implement plans and ensure progress in ·regional HepB control, and partners were encouraged to provide technical and financial support for regional and country HepB control activities. Furthermore, TAG clarified the 2012 milestone, which was defmed as HBsAg seroprevalence <2% among five-year-old children, consistent with the 2005 Regional Committee resQlution. Achievement of the milestone and/or goal should be measured in terms of overall regional prevalence and prevalence achieved in each country (or for groups of countries with small populations where data are being pooled), consistent with the 2002 TAG recommendation. Although seroprevalence data are an essential element for

-22-

verification, timely birth dose and HepB three-dose vaccination coverage may be used as progress indicators. 2.13 Monitoring and VPD surveillance

2.13.1

Improving annual data process/content collection

Ms Rangi Tairi, EPI Manager, Cook Islands, described the geography of Cook Islands as a group of many widespread islands with the majority ofthe 19 569 population living either on the main island of Rarotonga or nearby Aitutaki. The Immunization Division is one of five sections under the control of the Chief Public Health Nurse. From the 1960s until2008, immunization data was recorded initially in the Maternity Registration Book, which was transferred into the Maternal Child Health Book to be kept by parents and finally into the Baby post-natal card retained by the Public Health Nurses. As part of improving annual data collection, a Registration Form is now filled out at birth by a receptionist and this data is then transferred into the Med Tech 32 System. The post natal card is delivered to the public health staff when mother and baby are discharged and has the following baby information: name, date of birth, gender, weight, length, chest circumference, head circumference, time of birth, etc., and all immunizations received while in hospital. The Well Child Book is also filled by midwives in the maternity ward and contains similar information including immunizations. Midwives ensure that parents understand the importance of taking the Well Child Book to the MCH clinic. Public Health Nurses undertake a post-natal check during home visits and transfer records from the Well Child Book into the MCH Child Health Card that is returned to the local MCH clinic. Clinics have an MCH Immunization Register Book with comprehensive vaccination records filled after each immunization. Public Health nurses have an important role in maintaining an Immunization Monthly Chart at each MCH clinic and an overall Immunization Chart is kept at the Public Health Main Office so that these can be viewed and discussed during monthly meetings. Med Tech 32 is used to update immunization status and allows nurses to identify double entry of names, unregistered names after birth and so on. If children do not tum up for immunization, child welfare representatives from the Cook Islands Child Welfare Organization assist the Public Health Nurses in follow up. This is a very strong group, consisting mainly of women who meet monthly and review MCH Clinic operations.

2.13.2

Strengthening HBAS using mobile phone technology in Fiji

Dr Josaia Samuela, National Advisor, Family Health, Fiji, described the recent introduction of mobile phone technology as an aid to improving HBAS activities. HBAS · provides active surveillance of three specific VPDs using syndromic case definitions for reporting measles, poliomyelitis and neonatal tetanus cases. Fiji has 21 sentinel sites at major government hospital facilities around the country. In addition, Fiji has a second system for VPD surveillance with weekly notifiable disease reporting from 97 health facilities, and this has created concerns regarding data management in terms of quality, laboratory diagnosis and the timeliness ofVPD responses. In early September 2010, Fiji launched a mobile phone network through WHO and Digicel to strengthen VPD surveillance using HBAS. The principles involved in this innovation are the same as for ordinary text messaging delivered by mobile phone technology. The difference is the application of a specifically designed template for the sentinel site to provide the required data. Towards the end of each month, an automatically generated message from the national centre is sent to all 21 sentinel sites reminding them of the monthly HBAS surveillance report and to respond with either "yes"(+ number of cases) or "no", as to whether any cases of AFR, AFP or NT were identified. If"yes", then a prompt message will be generated and sent to the sentinel

... -23r

site staff to follow up with case investigation, specimen collection and transport, and other assistance required. The overarching goal of this mobile phone technology is to strengthen timeliness and completeness of the national HBAS through closer supervision of prompt reporting and response measures by national programme managers. Use of text templates for syndromes like "Influenza-like illness" and "Prolonged fever of unknown origin" have had a positive impact during the pilot phase. Since the beginning of this year, HBAS e-mail reporting in Fiji has improved remarkably in terms of timeliness. It is hoped that this new mobile phone technology will further improve completeness ofVPD surveillance. 2.14 Immunization safety

2.14.1

How to ensure vaccine and immunization quality

DrYoshikuni Sato, Medical Officer, EPIIWHO Regional Office for the Western Pacific, opened his presentation by stating that all Pacific Island countries should assess their procedures for ensuring vaccine immunization quality in accordance with WHO guidelines. This includes monitoring vaccine quality via a regulatory pathway. WHO assists Member States to conduct NRA assessments using published indicators and standards. WHO prioritizes NRA assessments for vaccine-producing countries, for which a functional NRA is mandatory for pre-qualification. For non-producing countries, WHO conducts NRA assessments upon request. All countries and areas should have a national vaccine regulatory system. Six regulatory functions are included in the national vaccine regulatory system: (1) (2) (3) (4) (5) (6) product licensing and marketing authorization; post-marketing surveillance for AEFI; laboratory access; lot release; regulatory inspections; and authorization and supervision of clinical trials (if clinical trials are conducted).

In the Western Pacific Region, five countries produce vaccines and their NRAs should therefore fulfil all six of the above functions. Nine countries self-procure vaccines so their NRAs should fulfil functions 1 to 4 of the above list. For the 13 countries that procure vaccines through United Nations agencies, their NRA functions should fulfil functions 1 to 2.

According to annual country submissions of WHO-UNICEF joint reporting forms (JRF), 13 Pacific Island countries conduct AEFI surveillance, six do not and one did not report AEFI surveillance status. The quality of AEFI surveillance systems varies widely amongst the 13 countries although ideally all Pacific Island countries should have high-quality AEFI surveillance systems. Dr Sato closed by stating that in the past, Pacific Island countries have not given NRAs and AEFI surveillance adequate priority. In the present biennium, the first two NRA functions should be considered as national priorities especially in the wake of Pandemic (H1N1) 2009 vaccine deployment, and he encouraged countries to seek political commitment so that adequate financial and human resources may be used to support NRA functionality and therefore, vaccine quality and safety.

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2.15 Policy and strategy

2.15.1

Strategy for enhancement ofEPI in Pacific Island countries (2011-2013)

Dr Ingrid Hilman, Child Survival Specialist, UNICEF Pacific Regional Office and Dr Raul Bonifacio introduced their presentation by briefly reviewing the WHO-UNICEF agreement, implemented in 2005-2007, to support Pacific Island countries to improve EPI. They then presented the performance status of EPI in Pacific Island countries making the following points: (1) there are currently no multiyear strategic or master plans among partners to serve as a guiding mechanism to implement EPI strategies; sen,:ice delivery, vaccine management and procurement require continued support and four Pacific Island countries (Kiribati, Samoa, the Solomon Islands, Vanuatu) have persistent suboptimal performance while Fiji's performance declined in 2009; VPD surveillance remains hospital based and the regional laboratory needs strengthening; there are new and underutilized vaccines, although by January 2011, all Pacific Island countries will be able to immunize with Rib; the Pacific Islands have been poliomyelitis-free since 2000, measles transmission is likely interrupted and most countries have attained HepB control; and communication, linkage and advocacy remain underdeveloped in the Pacific Islands.

(2)

(3)

(4)

(5)

(6)

It was proposed that a master plan be developed for one EPI programme for Pacific Island countries 2011-2013 or 2011-2015. This would involve multiple stakeholders, serve as a roadmap to achieving goals and objectives and would provide great benefits to countries. The consolidated framework would allow better coordination among stakeholders thus avoiding duplication of support for some activities and lack of support for others, and would provide clarity for donors. The proposed Regional Strategic Plan would be in alignment with the GIVS framework, the ·wHO Regional Office for the Western Pacific TAG recommendations and regional and national priorities. Country representatives were invited to break into small groups to discuss the proposal and provide feedback on their ideas.

2.15.2 Results of group discussions on a strategy for the enhancement ofEPI in Pacific Island countries There was general agreement with the concept of a 2011-2015 multiyear plan while participants noted this should be casted. It was also noted that national ,plans exist within their own health systems and these would need to be taken into consideration. It was proposed that a subregional committee be developed. Representatives saw advantages in strengthening partnerships internationally and with donors and felt that there needs to be donor harmonization. One group felt that there are adequate in-country partnerships currently but other partnerships could be built such as external partnerships for fmancial and technical aid and also between countries such as "twinning" or locum type attachments. Another group felt more non-government organization involvement would be beneficial. Integration with the Global Fund to Fight AIDS, TB and Malaria was proposed to ensure adequate funding for EPI. Ongoing technical assistance and fmancial support are needed to support operational costs and special campaigns such as SIAs, new vaccine introduction and serosurveys. However, the substantial

·"·I

...

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issues resulting from the geographical challenges of delivering immunization to widely scattered islands need addressing. · Other aspects considered important for enhancing EPI in Pacific Island countries included:

•

Improved human resources with more training and capacity building covering the range ofEPI activities. Strengthened communication and social mobilization to persuade caregivers of the need for immunization, in addition to fmancial support for development of IEC and mass media communication materials. Strengthening of case-based VPD surveillance and more training in this .

•

•

• Enhancement of laboratory networks and mechanisms for specimen transport. AEFI surveillance also needs support. The role of new technologies such as mobile phones was mentioned.

•

The importance of integration of EPI with other health programmes was acknowledged although this is already occurring in small countries but could be strengthened. Harmonization of reporting would be enormously helpful to countries.

2.16 Vaccine procurement and the Vaccine Independence Initiative (Vffi Ms Diana Chang-Blanc started the day with an outline of objectives and expected outputs from the day's session. Objectives included providing technical updates on VII operations and performance trends; emphasizing linkages between forecasting, planning, budgeting and vaccine security; and sharing country experiences and lessons learnt. Expected outputs were: improved knowledge on global vaccine supply market and VII operations in the Pacific Region; an understanding of how VII performance affects sustainability of the regional procurement system; and proposed action steps to improve overall operations of vaccine planning and forecasting in the Pacific Region, with specific emphasis on VII.

2.16.1

Value of vaccination

The United Nations Millennium Summit in 2000 articulated eight international development goals to alleviate a range of global ills, among them poverty, hunger, disease and gender inequity; 192 Member States a:i:ld 23 International Organizations signed up to these MDGs. Immunization plays a key role in addressing MDG4: to reduce the under-five mortality rate by two-thirds between 1990 and 2015; and to MDG5: to reduce the maternal mortality ratio by three-fourths between 1990 and 2015. It is estimated that in 2008, the global number of deaths of children under five years old fell to just under nine million per year, from approximately 12 million in 1990 and it is estimated that more than half of the gains in reducing child mortality are attributable to immunization. Nevertheless, the primary causes of under-five deaths currently are neonatal causes (37%), pneumonia (17%), diarrhoea (16%) and malaria (7%), with measles deaths constituting 4% of all global deaths. VPD still cause 24% of under-five deaths. It is estimated that immunization saves three million lives per year, and without immunization countries see a clear trend in subsequent disease outbreaks due to the lack of protection conferred by vaccines. If coverage levels are high enough, immunization can also protect the unimmunized by interrupting disease transmission in a community.

,. -26-

..

Immunization is a core tool in the essential package for child survival (WHO/UNICEF Regional Child Survival Strategy) and in fact is one of the health interventions that demonstrate the highest success in reaching the previously unreached. Of the 68 priority countries considered 'off-track' for achieving MDG4, immunization is the only intervention that attains 80% median national coverage or higher. In contrast, other interventions achieve relatively low rates of success, e.g. skilled attendant at delivery (53%), care seeking for pneumonia (48%), malaria treatment (40%) or exclusive breastfeeding (28%). New vaccines remain underutilized and innovative vaccines under development such as those against malaria, HIV, dengue and TB have the potential to save more lives. With the recognition that 23.2 million infants currently remain unimm\mized, much work remains and as a further step it was announced at the World Health Assembly May 2010 that WHO and UNICEF, in close collaboration with the Gates Foundation, countries and partners, are developing a shared vision and global partnership for realising the potential of vaccines and immunization in this Decade ofVaccines.2.J6.2 Overview of global vaccine market Mr Robert Matthews, Contracts Manager, UNICEF Supply Division, Denmark, gave an overview of the global vaccine market as seen from a procurement perspective. Quality is an overriding criterion: as vaccines are highly sensitive products, maintenance of the cold chain from the manufacturer to the point of use is essential. Other risks to vaccine production stability include production failures. Mr Matthews explained that production of a dose of vaccine can take from six to 24 months. Increasing manufacturing capacity requires two to three years and building a new plant can take five to seven years, so accurate vaccine forecasting is critical to ensure adequate· supply. The global vaccine market is a multibillion-dollar business with five large multinational corporations providing up 85% of the global supply. The market is unbalanced: the greatest need is in developing countries whereas manufacturers focus on new and combination vaccines with higher returns in industrialized countries. The remaining 15% of supply comes from manufacturers from both developing and industrialized country suppliers and UNICEF procures about 50% of volume and 30% of value from developing country manufacturers. UNICEF vaccine procurement has seen considerable growth over the past 10 years, now procuring over US$ 800 million, mainly due to global eradication programmes and GAVI-supported new vaccine introduction. UNICEF procures immunization supplies on behalf of 80-100 countries annually, and procures over 40% of the world's vaccines by volume yet less than 5% by value. Procurement undertaken by UNICEF on behalf of 13 Pacific Island countries spans a range of vaccines and has increased significantly with the introduction of pentavalent vaccine. Pacific Island countries procurement through UNICEF represented 0.2% of UNICEF total value (in 2009) but Pacific Island countries get the same benefits as other countries from the pooled procurement and associated economies of scale. The market suffered a crisis period in the early 2000s with reduced availability of vaccines necessitating a change in approach. Thus UNICEF established the Vaccine Security Strategy to ensure an uninterrupted, sustainable supply of affordable, quality vaccines. Positive trends since then have been the broadening of the supply base, reducing the risk of supply interruptions and increasing competition. Large multinational manufactures provide access to new vaccines while developing country manufacturers provide longer-term sustainability and a lower cost base. Price increases have been seen, however, for the majority of traditional EPI vaccines although GAVI-funded support of Rib containing vaccines has enabled the 120-130 million dose pentavalent market to be established, with four pre-qualified suppliers, more in the pipeline and supply now outweighing demand. Vaccines available through UNICEF are still more affordable than other options. Mr Matthews concluded by outlining that the key to securing supply from a procurement perspective is a procurement strategy supporting vaccine security: accurate forecasting, timely and adequate funding and ensuring that appropriate procurement contracts or agreements are in place. The UNICEF pooled procurement mechanism provides a win-win situation for both countries and manufacturers by providing countries with WHO pre-qualified vaccines at

<t

-27-

competitive prices and supporting a Vaccine Security Supply Strategy. The need and additional timelines for countries to undertake their own tendering activity is eliminated and variations in demand and supply can be reallocated across countries. Benefits to manufacturers include reduced transaction costs, assurance of timely payment of invoices and a calming effect on demand variance.

2.16. 3

UNICEF procurement process and vaccine security

UNICEF vaccine procurement objectives are to ensure an uninterrupted, sustainable supply of affordable, quality vaccines. Supply arrangements have been established to achieve vaccine security and sustainable markets rather than the short-term gains of lowest pricing and are in compliance with UNICEF Vaccine Procurement Principles, UNICEF Financial Rules and Regulations (FRR) which are non negotiable and public procurement principles. The procurement process starts with UNICEF issuing a formal tender and evaluation of offers received. This leads to establishment oflong-term arrangements identifying the forecast quantity, price, terms and conditions it will contract under for supply of vaccines for three years. Once these are in place a purchase order will be submitted, the manufacturer will ship the order and once the country has inspected and approved the shipment, the invoice is paid. The process is reliant on couptry forecasts to identify demand requirements and is the foundation of vaccine security. Forecasting is the basis of tender quantities and therefore the basis of manufacturers' production plans. With the current regional forecasting process, individual country forecasts are submitted to UNICEF Pacific Regional Office where they are reviewed and sent to Supply Division usually with a September deadline. In the follow up to the forecast exercise, provisional plans for the following year involving approximately 40 products are issued to 90-100 countries and include planned vaccine shipments, provisional vaccine budgets and funding requirements. He described forecasting as an ongoing process because forecasts are expedited on a monthly basis and adjusted according to changes in demand with information received from countries, manufacturers and Global Initiatives/Partnerships. Forecast accuracy is important in terms of both quantities and timing and must consider target populations, wastage and coverage rates, buffer stocks, current stocks, routine and campaign activities and quantities already on order. Forecast accuracy determines the goodwill of manufacturers to offer and produce the vaccines because under the supply agreements, manufacturers carry the risk until orders are actually placed. At country level, inaccurate forecasts risk stock-outs or short shelf life of delivered vaccine. Funding to enable procurement must back a forecast and the importance of budgeting and funds management in immunization programmes is often underestimated. A delay or lack of funding is the principal cause of stock-outs at country level. Under UNICEF FRR, UNICEF may not incur a fmancialliability without having the funds allocated in Supply Division. In addition, UNICEF can only issue a purchase order when it has received funding from the country or donor and approval to spend the funding. Under VII, the guarantee fund provides this fmancial security to allow the order placement but for Pacific Island country VII participants, failure to pay within 60 days blocks the funding for all countries, delays order placement and risks occurrence of stock-outs. He stated that there were two Pacific Island country invoices from Supply Division overdue at that time. The Pacific Region VII has additional challenges with the complexity of splitting the invoices between the individual countries, inclusion of the on-forwarding charges from Nadi, Fiji to the individual countries and the invoicing from the UNICEF Pacific Regional Office. It was noted that in their 2008 WHO/UNICEF JRF, 11 of 13 Pacific Island countries reported the presence of a budget line item for vaccines and consumables; 11 of 13 Pacific Island countries reported that they have a cMYP all of which will expire by 2012 at the latest and four of which include costing; and in 2008, eight countries reported 100% government funding for vaccines and routine immunization.

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2.16.4

Overview of VII

VII was established in 1992 following UNICEF Board approval in 1991. The aim was to provide a mechanism to ensure a systematic, sustainable vaccine supply for countries that could afford to finance their own vaccine needs but required certain support services. The goal was to support countries to become .self-reliant in vaccine fmancing and move from donor to self-funding of routine immunization. VIT is approved for five years at a time, most recently in September 2010 for the 2011-2015 period. Key elements of the VIT mechanism include the donor-supported guarantee fund to allow a credit line facility for use by countries to enable payment after delivery of the vaccines using government funds; the opportunity to pay in local currency if required and agreed; and access to affordable vaccines of assured quality. Since its establishment, contributions have been made from the Governments of Australia, Canada, Japan, the Netherlands, New Zealand, Norway, the United Kingdom and the United States. Although the fund size (up to US$ 10 million) is modest compared to global expenditures on vaccines, it has been meaningful for the 28 countries that have used the mechanism. UNICEF Programme Division approves country participation and a VII-specific Memorandum of Understanding (MOU) is signed between UNICEF and individual recipient country governments following approval. A country-specific fmancial ceiling is assigned based on the funds required to support the programmatic needs although for Pacific Island countries, the specific fmancial ceiling is based on consolidated needs of the Region. The MOUs are time bound with an initial period of two years, renewable on exchange ofletters between the parties. VII makes use of the Procurement Services mechanism with specific clauses within the MOU to highlight the specific nature of the initiative. Key distinctive clauses of these MOUs in comparison to regular Procurement Services MOUs are the authorization for countries to pay after delivery of vaccines and injection .devices up to a defmed value (country ceiling), with 60-day payment terms from issuance of invoice. A Letter of Guarantee (LOG) is required from the Government for the value of the country ceiling and forms part of the MOU. Procurement may only occur ifthere is a current agreement in effect, funds are available within the respective country ceiling, UNICEF Headquarters has received a copy of the LOG, and there are no outstanding invoices pending for payment. VII MOUs include specific terms and conditions relating to the VII within the Pacific Region. This includes the regional pooled procurement initiative, joint forecasting and ordering, the maintenance of a regional buffer stock, on-forwarding of vaccines and devices to the individual countries and an overview of the specific responsibilities of the parties. This provides clear benefits to the Region in terms of cost saving on buying power, freight costs and rapid response capacity from the regional buffer stock. It was noted that the timely payment of invoices has proven to be challenging. UNICEF will not process any order requests ifUNICEF's invoices are pending for payment by any of the participating governments: countries are currently not adhering to the terms of the agreements · with respect to payment timelines. Additionally, securing country specific LOGs and time-limited agreements requiring renewal every two years has high transaction costs and are lengthy and resource-intensive to monitor or follow-up. It has been proposed that the operational procedures, responsibilities and guidelines be revised for the next five-year extension period (2011-2015) with tighter fund management, a greater focus on capacity-building components, clear accountabilities for all stakeholders and regular reporting on VII and by VII participants. To facilitate this revision, the existing agreements may be extended for an additional six-month period while the new framework and guidelines are being fmalized.

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2.16.5

UNICEF VII mechanism benefits for Pacific Island countries and alternative procurement options

Sarah Schmitt, Vaccine Procurement and Supply Consultant, WHO/Headquarters, outlined the significant benefits accruing to Pacific Island countries from utilizing the UNICEF Supply Division including: • • • • • • • receiving assured high-quality products (WHO pre-qualified); a wide range of products and suppliers willing to supply; competitive and predictable pricing; limited liability with sound defensible processes; reduced replication of processes and consequent workload reduction; reliable and predictable timing and delivery; the possibility of multiyear contracting price predictability, which improves planning; and countries pay after delivery using the Vll donor-funded credit facility (thus enabling government self financing of vaccines and the introduction of new vaccines).

•

Benefits of the Pacific Island-specific Vll mechanism include:

• assistance with forecasting, planning and consolidation; • reduced transport and insurance costs through consolidation;

• access to a regional buffer stock for rapid response to emergencies; and • easily-contactable local focal points . To allow the system to function at its optimum, countries must however provide accurate timely forecasting to allow orders to be placed together and payments must be made on time to ensure the fund is reimbursed and available for use for the next orders. This means that if one country is late in providing its forecast then the consolidated forecast cannot be submitted to UNICEF Supply Division and if one country has not paid its invoices then no order can be placed. Vll has been extended for five years and it is considered that this is enough time for Pacific Island countries to decide on the best arrangements for the future. A number of alternatives (and their ramifications) were suggested:

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(1)

Countries could individually use UNICEF Procurement Services and either pay in advance or use UNICEF Procurement Services backed up with a credit line for each country to allow for payment after delivery. This would be more expensive due to individual arrangements, especially for transport, and would require excellent forecasting and buffer stock management. The advantage of this option is that countries do not have to renew the MOU and LOG with UNICEF but the disadvantage is that it would require funding and management of the credit line for each country. Another approach would be development of a regional procurement mechanism most likely linked with pharmaceutical companies. However, as this is not currently available it would require significant planning, development and capacity building in addition to specific agreements and new arrangements. Independent country procurement is an option but again this would be more expensive especially for transport, would require excellent forecasting and buffer stock management, and would require considerable capacity building and training, and vaccine market knowledge. Small individual volumes would not be attractive to suppliers, transaction costs would increase and it would take significant time to establish processes and procedures. A fourth possibility is procurement through donor or larger neighbouring countries. This again would be more expensive due to the more complex products utilized in these countries (e.g. Australia and New Zealand); would require significant programme changes to utilize new vaccine presentations; would require inter-governmental agreements to delegate government procurement to another country; and would mean completely new logistics and supply arrangements requiring significant planning.

(2)

(3)

(4)

Participants were reminded that WHO and UNICEF can provide technical assistance to Pacific Island countries to build capacity and knowledge and improve current systems.

2.16.6 Results of an internal review of UNICEF VII performance in the Pacific-Islands, 2006-2009 Dr Eliab Seroney Some gave a presentation, on behalf of the UNICEF EPI team, of results from the internal review of performance of the Pacific VII covering the period 2006 to 2009. Actual performance of key procurement and supply steps was compared to expected operating standards. VII has been in operation since 1995 and was recently renewed to 2015, covering 13 Pacific Island countries and territories. The Solomon Islands was suspended from 1999 to 2007 for non-payment following civil unrest and re-admitted in 2008 after AusAID cleared outstanding invoices. VII involves the following steps: (1) countries sign a two-year VII agreement and annual LOG; (2) annual forecasting and ordering of vaccines and vaccination devices; (3) consolidation of orders by UNICEF Suva and forwarding to UNICEF Supply Division for cost estimates; (4) after countries accept cost estimates, Supply Division places purchase orders and four to five months later, manufacturers deliver vaccines directly to the regional cold storage in Nadi, Fiji Islands; (5) Supply Division invoices UNICEF Suva for vaccines and offshore freight charges; (6) vaccines are dispatched to countries according to orders; regional buffer stocks are maintained in Nadi, Fiji cold storage and only paid for after dispatch; and (7) UNICEF Suva invoices and instructs countries to pay within 60 days.

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There were three significant events during the review period. Firstly, establishment of a new UNICEF Pacific multicountry programme (2008-2012) with a relatively large health and sanitation programme with all 12 staff new except one, and with recruitment completed in October 2008. Secondly, from 2008-most countries introduced pentavalent and this led to an additional fmancial contribution to Vll from AusAID, thus doubling the revolving fund from US$ 1 million to US$ 2 million and creating a need to renew all Vll Agreements and LOGs. Thirdly, up to 2008, UNICEF Suva invoiced Pacific Island countries for vaccines according to Supply Division invoices, pro-rated_ offshore charges, inbound charges, storage charges and outbound charges in one invoice. From 2009, invoicing was split into one for the vaccines and pro-rated offshore and inbound charges and the other for the remainder of the charges. When compared to expected timelines, there were delays in sending orders to the Supply Division in 2009, delays in all key processes in 2008, and no delays in 2006 and 2007. While all the 13 countries were able to pay for vaccines, less than half were able to pay within the invoicing year in 2008 and 2009. Countries unable to pay within the year increased from one in 2006 to five in 2009 and those able to pay with one payment decreased from eight in 2006 to six in 2009. The number of multiple payments ranges from two to six. Eventually, all invoices were cleared, but not within the same year. Only three countries have been able to pay for vaccines within 60 days of invoicing. As a pooled procurement, outstanding payments from one member led to temporary suspension of all members according to non-negotiable UNICEF FRRs. Timeliness of invoicing and securing funding for immunization remained a challenge during the review period. As a result of the review it was recommended that UNICEF: (1) consult and include Pacific Island countries in the revision and updating of vaccine procurement work processes; (2) ensure timely invoicing; (3) make the duration of LOGs the same as for the Vll agreement; and (4) PIPS partners assist Pacific Island countries to secure funding for NIPs.

2.16. 7

Process offorecasting and ordering

Dr Ingrid Hilman, UNICEF Pacific Regional Office, described how 13 Pacific Island countries order vaccines through VII (Supply Division). The number of vaccines ordered varies from two to seven per country and target populations of children under one vary from 50 to 18 000 per country. Vaccine forecasting underestimation risks interrupted vaccine supply and over estimation risks wasting resources. Calculation of vaccine requirements follows essential principles and the wastage factor is central to these. The wastage factor varies according to the different age groups targeted, alternative vaccine presentations and rates are usually less during campaigns as opposed to routine immunization. Accuracy of forecasting also depends on the reliability of data available, such as the year of the last census, estimates of population growth rate, accuracy of stock registers and historical trends of the consumption of vaccines and injection materials. Efforts made to improve vaccine forecasting include VMA in three countries (Fiji, the Solomon Islands and Vanuatu); EVSM (Fiji); improved stock management; issuing guidelines for vaccine forecasting in June 2009; and revision of the vaccine forecast form. Good results have been achieved with additional vaccine orders decreasing from six times to twice and no major vaccine stock-outs. Challenges include timeliness, with less than 50% of countries submitting on time and two countries still not submitting their forecasts and orders for the year at the time of the meeting. While eight countries submitted vaccine forecasts and orders, three countries had submitted only vaccine orders. Concerns remain regarding accuracy of target populations, and use of correct wastage factors with for example, the wastage factor for BCG in big populations being 80%, and 90%-95% for smaller populations. Additional concerns are that many countries must cope with changes in the number of doses in their immunization schedules, stock management and distribution systems may be substandard and buffer stocks have often been used.

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2.16. 8

Country presentation: Planning and budgeting, Vanuatu

Mr Jack Loughman, Manager, Exchange Services, Ministry of Finance and Economic Management, Vanuatu, gave a detailed presentation on health budgeting processes in Vanuatu. At the beginning of each budget cycle, the Ministry of Finance and Economic Management circulates a budget timetable, which provides a schedule of tasks to be undertaken by each Government Line Agency (GLA) to enable the Government to prepare an accurate budget for the next fiscal period. Between January and March each GLA reviews and formulates an annual corporate and business plan that is then integrated into the annual budget. During the month of March, the Department of Finance and Treasury National Statistics Office and Reserve Bank of Vanuatu developed a framework for fiscal aggregates and macroeconomics by establishing anoverall expenditure ceiling and setting fiscal priorities. In April, the Department of Finance and Treasury develops and compiles a Budget Policy Statement that will be approved by the Honourable Minister of Finance and Economic Management and then submitted to the Departmental Committee of Officials for review prior to submission to the Council of Ministers for approval. The approved statement is then presented publicly via media and also to government aid donors. The Department of Strateg~c Policy, Planning and Aid Co-ordination and Department of Finance and Treasury meet with each GLA and assess policy intentions and corporate plans before the latter formulates each GLA Budget Ceiling. The Budget Ceilings are then submitted to a Ministerial Budget Committee, Departmental Committee of Officials and Council of Ministers for the screening and approval process in May to June. Once approved, a Financial Circular is issued to all GLAs for information and budget input purposes. Each GLA does the budget inputs via the Vanuatu Budget Management System, which also allows each GLA to formulate a projected cash flow plan based on its Corporate and Business Plan. During the month of July, each GLA submits a copy of its Corporate and Business Plans to the Department of Finance and Treasury to meet the July Budget input deadline. In August, budget submissions are reviewed for any anomalies prior to budget presentation to the Ministerial Budget Committee. Financial agreements with donors are secured in September and any required modifications made to budget figures. Decisions on GLA budget allocations are fmalized in October and the Department of Finance and Treasury then prepares the budget paper for screening and approval. The approved Appropriation is submitted·to the State Law Office to complete drafting of the Appropriation Bill which is distributed in November with the Budget Document to Parliament. Once ratified by Members of Parliament, the GLA-ratified budget figvres are loaded into the Vanuatu Government Financial System (Smartstream) in December for the GLAs to access funds by January.

2.16.9

Country presentation: Planning and budgeting, Fiji

Ms Litiana Volavola, National BPI Co-ordinator, Fiji, explained that in August each year the National Budget Planning Committee considers the allocation for the BPI Strategic Plan together with the budgets of other Ministry of Health priorities and these are collated and sent to the Ministry of Finance. The WHO/UNICEF formula is used for vaccine forecasting with the target population being the previous year's live births and this forecast is submitted in September. Vaccines are fully government funded and procurement is undertaken through UNICEF under the VII Agreement. Once the vaccines are received and the Vaccine Arrival Report (V AR) returned to UNICEF, an invoice is received. Payment is made in two instalments, the first within 60 days of invoice receipt and the second when funds become available, often sourced from other programmes. There is currently a deficit between the budget allocation ofFJ$ 440 000 per year and the approximate costs per year ofFJ$ 600 000. Freight, insurance, handling costs and storage are often not included in the budget and there is no budget for cold chain equipment and spare parts. It·was recommended that the budget for vaccine allocation be increased to meet the cost of new additional vaccines and that a Regional Vaccine Storage facility be built to save on costs associated with private storage.

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2.16.1 0 Small group work feedback: Improving vaccine procurement and supply Participants split into three groups and each group gave feedback on different aspects of improving vaccine procurement and supply. Participants acknowledged that securing funds is vital but challenging. Suggested improvements from Group 1 included: (1) Raising awareness ofthe benefits ofEPI, including cost effectiveness particularly with leaders, perhaps at the annual Senior Officials and Health Ministers Meetings in the Pacific, and with central agencies. · Advocating for a separate budget line item for vaccines. Ensuring effective communication, including identification and use ofEPI champions. Negotiating for a higher Ministry of Health budget ceiling by arguing for evidence-based budgeting. Ensuring that UNICEF is aware of the end-of-financial year for each country and that invoices go through the most appropriate levels at each health ministry to ensure payment or endorsement. Preparation of three-to-five-year casted EPI plans, including all sources of funds and getting governments to take control. Ensuring timely forecasting, including special projects such as SIAs, to enable adequate cash flow planning.

(2) (3)

(4)

(5)

(6)

(7)

A second group gave feedback on forecasting and ordering issues and identified major problems in the areas of stock management including inventory, administration, distribution, reporting, true identification of wastage, limited airline capacity from Nadi to Pacific Island countries and also inaccuracy of forecasting and ordering particularly with ensuring accurate birth cohort numbers and wastage factors. Solutions included training on the issues at regional and local/country levels, ensuring operational procedures were standardized and ensuring good planning. VII performance was reviewed by the last group and suggestions for improvement included: (1) better invoicing practice, e.g. ensuring there are no combined invoices and that these are received before the end of the financial year; providing original signed invoices; ensuring invoices are sent to the right people with copies to the BPI manager; consistent reminders on payment (e.g. weekly reminders); ensuring adequate advance notice for forecasts and orders, at least two weeks to one month in advance; ensuring adequate advance warning with pre-advice for shipments to enable time for customs clearance, preferably seven days in advance; providing training in forecasting; and

(2) (3)

(4)

(5)

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(6)

ensuring cold chain quality at all levels.

Dr Some brought the day to a close by summarizing that the way forward would include revised and updated procedures for the renewed VII, incorporating, where possible, group recommendations on funding, forecasting and orders and improving VII performance, and for countries to sustain efficiency and be innovative. 2.17 Maintaining poliomyelitis-free status in Pacific Island countries

2.17.1

Global polio eradication: Overview of current situation

Dr Sigrun Roesel, Medical Officer, EPII WHO Regional Office for the Western Pacific, reminded participants of the devastating impact of polio as a disease: it not only kills many sufferers but those who survive are frequently left with serious lifelong disabilities. World rates of infection have fallen precipitously in the past 20 years since the World Health Assembly Resolution to eradicate polio and in 1999 one of the three types of polio (P2) was eradicated. Problems remain with four endemic areas however and this has led to importation and re-established transmission in some countries. India has pockets of under-vaccinated, highly mobile subpopulations with a high rate of infection in core endemic areas. Mghanistan and adjacent Pakistan have poliovirus reservoirs that reflect a combination of security and operational and managerial problems. Nigeria suffered a setback when rumors about polio vaccine led to discontinuation of vaccination in 2003 and there was limited support from local and religious leaders in addition to operational and managerial problems. This led to importations and re-established transmission in adjacent countries and produced a significant West African outbreak. A Global Polio Eradication Initiative in 2009 involved independent evaluation of major barriers and led to new approaches in each endemic area. New vaccines have been used including higher-titer monovalent OPV (mOPV), bivalent OPV (bOPV), and Inactivated Polio Vaccine (IPV) although it has proven to be a challenge to balance how best to use these for maximum impact. Since December 2009, 350 million doses ofbOPV have been used and as a result of all these approaches, there has been sustained progress in Nigeria and India, and the West Mrican outbreak appears to be under control with the last recorded case onset on 1 May 2010. Progress in Mghanistan and Pakistan is mainly dependent on the security situation but Angola, Central Asia and Caucasus and the Democratic Republic of Con:go are new areas of grave concern. Dr Roesel highlighted the importance of countries in poliomyelitis-free regions maintaining vigilance and population immunity to avoid re-established transmission following poliovirus importation. Several importations have occurred around the world because of easy and rapid international travel. Worldwide poliomyelitis eradication has proven elusive and with a US$ 2.6 billion budget and a US$ 1.3 billion deficit, the funding gap remains the biggest obstacle for final success.

2.17.2

Polio Strategic Plan 2010-2012 and implications for the Western Pacific Region

Dr Roesel explained that the major objectives for the Polio Strategic Plan 2010-2012 are: interrupting wild poliovirus in Asia; interrupting wild poliovirus in Africa; enhancing surveillance and outbreak response and strengthening immunization systems. The plan identifies cross-cutting enabling factors including strong oversight of polio campaign operations by local political leaders; enhanced community mobilization; safe and secured supply of polio vaccines; expanded technical assistance; and an intensified research agenda. The plan was formulated based on a number of recent lessons that immunity gaps allow the virus to persist in smaller areas and subgroups than previously thought: this means there must be district-specific plans and capacity, special tactics for underserved populations and independent monitoring of campaigns. In addition, immunity thresholds to stop polio differ, and are higher in Asia than Mrica so a "geographic" strategy is needed with OPV and the campaign and monitoring strategy must be

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tailored to local circumstances. Optimizing the balance of polio vaccines has been much more difficult than anticipated and requires strategic use of bivalent types 1 and 3 OPV (bOPV) and a balance ofbOPV, mOPV and trivalent OPV (tOPV) SIAs. Finally, routes of poliovirus spread and outbreaks are now largely predictable and can be countered by immunization systems strengthening, new outbreak response standards and pre-planned, synchronized campaigns. The major implication for countries and areas in the Western Pacific Region is that maintenance of poliomyelitis-free status is the most important contribution to global polio eradication. Specifically, there is a need to review and strengthen AFP surveillance and SIAs in high-risk areas: subnational risk assessments may guide action. Dr Roesel emphasized that transparency is of critical importance. Early detection and reporting can lead to early response and potentially minimize consequences of outbreaks.

2.17. 3 Wild poliovirus importation in the WHO European Region: Lessons for poliomyelitisfree regions Despite the European Region being declared poliomyelitis free in 2002, Tajikistan suffered a poliomyelitis outbreak in 2010 with a total of705 AFP cases by 23 September 2010, including 458 confirmed cases of wild poliovirus type 1. This outbreak was associated with low coverage with three doses of polio vaccine despite high reporting of OPV3 coverage. It has led to likely importation and ongoing cases in nearby countries including a total of 12 confirmed wild poliovirus type 1 cases in the Russian Federation and 37 AFP cases including three laboratory-confirmed poliovirus cases in Turkmenistan by 23 September 2010. China's and Mongolia's responses to these outbreaks included alerts to all disease control units and border stations; ongoing assessments; expanded surveillance and capacity; OPV campaigns; and strengthened risk assessment and planning processes including fmalization of the Wild Poliovirus Importation Preparedness Plan. The response of WHO Regional Office for the Western Pacific to the Tajikistan outbreak has included regular situation communication with Member States and BPI Country Officers; Regional Commission for the Certification (RCC) of Poliomyelitis Eradication in the Wes.tern Pacific Region and TAG members; development of Wild Poliovirus Importation Preparedness Plans in some countries; updating the Regional Importation Response Plan; development of risk assessment guidelines; expanding the polio agenda at BPI TAG meetings; developing resource mobilization strategies to particularly support preventive SIAs and additional surveillance activities as required; and closer collaboration with other poliomyelitis-free regions.

2.17. 4

Risk assessment to remain poliomyelitis-free

Dr Roesel noted that while wild poliovirus importations cannot be prevented, detection and spread of the imported virus can be prevented through high-quality surveillance for rapid response and up-to-date national preparedness plans; maintaining high population immunity; universally high routine immunization coverage; a booster dose schedule; and supplementary immunization when needed. A simple methodology has been developed that gives an assessment of whether a country is at low, medium or high risk of a polio outbreak should importation of wild poliovirus occur based on weighted parameters within the categories of population immunity, surveillance quality, programme performance and the level of threat of importation. Cut-offs are arbitrary and while this is not a scientific methodology and has no statistical significance, it is useful to quantify and document risk. It uses available data and does not create additional data demands and importantly takes local knowledge into consideration. Assessment parameters for population immunity include: national coverage (WHO/UNICEF best estimate); trends in Polio3 coverage (whether these are increasing, decreasing, stable); percent of districts with <90% Polio3

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coverage; trends in district coverage; interval to last SIA and vaccination status of AFP cases. Parameters for surveillance quality include: non-polio AFP rate; adequate stool specimen collection rate; subnational surveillance gaps; specimen shipment times; and late follow-up of AFP cases with inadequate stool samples. Programme performance is assessed by: Polio 1-3 dropout rates (or surrogate measures such as DPT 1-3 dropout rates); polio vaccine stock-outs and whether an updated importation preparedness plan exists. Threat is assessed by the probability of importation and whether a country borders polio-affected areas. Available data suggest that most Pacific Island countries are at low risk, except for the Federated States of Micronesia and Samoa, which have a medium risk for spread of an imported wild poliovirus.

2.I7. 5 Conclusions and recommendations from the II th Meeting of the Subregional Commission for the Certification (SRCC) ofpoliomyelitis eradication in Pacific Island Countries and Areas Dr Lisi Tikoduadua, Head, Department of Paediatrics, Colonial War Memorial Hospital, Fiji, reported that discussion at the recent 11th SRCC Meeting had included concerns that although the Pacific Region had been poliomyelitis-free since October 2000, it remains vulnerable due to suboptimal OPV3 coverage in a few Pacific Island countries and potential importations due to population movement between polio-infected countries and Pacific Island countries. She reiterated that poliomyelitis-free countries such as the Pacific Island countries are encouraged under the Global Polio Eradication Initiative Strategic Plan 2010-2012 to enhance poliovirus surveillance and outbreak response and to strengthen routine immunization systems. Coverage for OPV3 remains below 90% in many Pacific Island countries, and AFP reporting and investigations remain inadequate in timeliness and completeness. The SRCC Action Plan remains valid and has been updated for continuous implementation of the rest of 2010 through 2011. Major outcomes are that strengthening routine immunization and high-quality VPD (including AFP) surveillance remain the cornerstone to maintaining poliomyelitis-free Pacific Island countries and that Emergency Action Plans for introduction of polio virus based on the generic plan developed by the SRCC need to be developed in three countries (Fiji, the Solomon Islands and Vanuatu) by the end of2010 and not later than the first quarter of January 2011. 2.18 Review of Japanese support to PIPS (J-PIPS) and next steps Ms Miyuki Harui, Project Formulation Advisor, Health, JICA Fiji Office, described the five-year J-PIPS Programme that commenced in 2005 and was successfully completed in February 2010. Under the PIPS framework, J-PIPS endeavoured to enhance the capacity of target countries in the following areas: planning and monitoring of immunization policy and programme; vaccine and cold-chain management; injection safety and waste management; and outreach activities. Working with PIPS partners, J-PIPS contributed by supporting PIPS workshops, regional training programmes, domestic training programmes in each country, and provision of cold-chain equipment. A total of 83 EPI nurses and 54 cold chain technicians from Pacific Island countries were trained. She commented that J-PIPS is fortunate to have Nagasaki University as the implementing partner. Nagasaki University is a highly regarded academic institute with a long history of international cooperation in the field of public health, and has wide experience in human resource development. Recent reports show that remarkable achievements have been made in many Pacific Island countries: to varying degrees, almost all countries now have enhanced capacity to manage their own immunization programmes. However, thousands of children remain who are not fully immunized by their first birthday and some countries still struggle to improve the child mortality rate. Pacific Island countries face difficulties in achieving high immunization coverage for many reasons including shortages of quality staff~ equipment and facilities at the service level and

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many have difficulties caused by the geographical challenges of scattered and remote islands in a vast ocean. JICA is proud of the valuable impact that has been made by J-PIPS and feels that this should be maintained in order to continue improvements in MCH, and overall health system strengthening in the Pacific Region. It was confirmed that as a PIPS partner, JICA will continue support for further improvement of the BPI programme in the Pacific Region for the next three years through J-PIPS Phase 2. This will provide capacity development for trainers and workers in areas of vaccine management, logistics and cold-chain management and maintenance. JICA will focus its activities in five countries in the Pacific Region, namely Kiribati, Samoa, the Solomon Islands, the Federated States ofMicronesia and Vanuatu. Fiji is expected to take a lead role as JICA experts for the training courses that will be conducted. During Phase 1, the regional training programme accomplished its mission and JICA believes that BPI managers in Pacific Island countries have acquired proficiency skills but there is a need for continued updating of knowledge and skills and Phase 2 will therefore, with the cooperation of PIPS members, also include a regional refresher training course. 2.19 Independent progress report of AusAIDIUNICEF multi-country programme, immunization component Dr Tilman Ruff reported the conclusions and recommendations relating to immunization from an independent progress review of AusAID's support for UN1CEF's Pacific work on child protection and immunization undertaken in September 2009. The review team noted that immunization programmes in Pacific Island countries varied considerably in their effectiveness, with varying trends in different settings. SIAs consistently achieve high coverage, even in settings with low or moderate routine coverage, and were an effective platform for multiple interventions. It was noteworthy that introduction ofHib vaccine had not yet occurred in Vanuatu and had occurred gradually over more than a decade throughout the rest of the Pacific Islands, and in fact, no new vaccine had been introduced in Pacific Island countries without at least initial donor support. The review concluded that support at a regional and country level for many aspects of immunization policy and programmes will be required for the foreseeable future in such areas as technical support, procurement, training, surveillance, coordination of disease control and eradication, and sharing of resources, and that a high degree of programme/policy alignment between countries was beneficial. Recommendations to UNICEF included that AusAID continue to provide predictable but flexible long-term partnership support for immunization and that the two agencies align their programme time frames. Both agencies should also align more strongly with Pacific Island country government priorities and plans, and assist countries to develop coordinated government-centred multi-year plans in consultation with all donor, technical and implementation partners. It was recommended that UN1CEF empower its field offices in priority countries, which should include Samoa in addition to Kiribati, the Solomon Islands and Vanuatu, and appoint an BPI officer in each priority country. Furthermore, UN1CEF should appoint a dedicated technical officer to manage vaccine and immunization equipment supply including VII. UN1CEF should encourage and assist priority country NIPs to review the most appropriate organization of immunization for hard-to-reach areas, consider using HepB vaccine for the birth dose outside the cold chain and Uniject for births not attended by a health professional with cold chain access, and undertake mini-campaigns every two months rather than routine fixed-site immunization services and small-scale outreach.

- 38-

UNICEF needs to consider options to expedite access to under-utilized vaccines such as Hib and rubella, and also to new vaccines, and should engage PIPS partners in planning for the introduction of second generation PCV, HPV and rotavirus vaccines as soon as feasible. As a first step, it was recommended that UNICEF, in association with WHO, produce a working paper to identify the best mechanisms to facilitate early introduction and include consideration of a regional fund for introduction of new vaccines with equitable access. Introduction ofPCV in Kiribati and the Solomon Islands, preferably with GAVI support, was also recommended. Long-term 'twinning' partnerships should be established with appropriate academic institutions, such as the University of the South Pacific (USP) and relevant AusAID supported Knowledge Hubs for Health, for preferential provision of technical assistance. Wider and more frequent use of immunization coverage surveys should be used to evaluate routine immunization coverage data, and specifically, coverage surveys should be undertaken in the Solomon Islands and Vanuatu. The report recommended that UNICEF should explore new immunization tools including: establishing a web-based collection of Pacific immunization resources accessible to NIP staff in all Pacific Island countrie;;; assist NIPs to explore use of mobile phones for immunization information and reminders in areas where phone ownership is high; and develop and promote a model lifetime immunization and health record. Finally, it was recommended that the PIPS mechanism should be utilized to coordinate regional immunization support work among technical and donor partners, including the development of an annual coordinated immunization support work plan between UNICEF and WHO; and that future AusAID support should require coordination with all relevant partners, including civil society organizations, and where appropriate, their inclusion in implementation. 2.20 Closing session An informal closing ceremony was conducted with Dr Revite Kirition thanking the organizations and the donors for their generous support for child health and commenting on the consensus that more funding is needed. He observed that improvement in child health programmes was slow and that there needs to be a change in how "we do business". Much can be achieved and everyone knows what to do but not enough of what is required is happening. Dr Sniadack spoke on behalf of WHO and the other partners and reiterated that BPI is one of the most effective programmes for preventing death, disability and disease among children and shows the way for other programmes to reach the most difficult-to-reach children with life-saving interventions. Recalling the proverb told by Dr Orner Pasi at the beginning of the workshop, Dr Sniadack expressed the hope that EPI would travel both "fast" and "far" to minimize any further preventable disease and death from VPD. The PIPS partners are committed to supporting Pacific Region EPI activities and this will be documented in the upcoming Joint Strategic Plan for the Pacific Region. He thanked all present, making special note of the hard work of the support staff and wished everyone safe journeys and success in protecting children.

-39-

3. ACTION POINTS

3.1

Vaccine procurement and VII (1) All countries participating in VII are encouraged to improve accuracy of annual forecasting to minimize the need to place supplemental orders and rely on the regional buffer stock. All countries participating in VII should advocate with national decision makers to ensure appropriate annual budget allocations for vaccine procurement, timely budget release to ensure availability of funds, and ensure payment within 60 days of receipt of each individual invoice. Furthermore, VII participating countries should sign and return new/updated MOUs and new LOGs to UNICEF within a month of receipt to ensure continued access to UNICEF vaccine procurement. UNICEF will improve the invoicing process to ensure timely issuance to countries, taking into consideration, wherever possible, the individual country's annual fiscal calendar, and develop a monitoring tool to report to countries and partners on invoicing and payment response times.

(2)

(3)

3.2

Cold chain/vaccine/logistics management

All countries/areas in the Pacific Region should have trained personnel for vaccine, cold chain and logistics management. Countries should regularly update their cold chain inventory and conduct proper maintenance/replacement of cold chain equipment and conduct WHO-UNICEF EVM assessment where needed to identify strengths and weaknesses of their current immunization supply chain management system. 3.3 Service delivery

All countries should strive to implement all five components of the RED strategy to reach every child: re-establish outreach; conduct supportive supervision; develop community linkages; monitor and use data for action; and improve planning and management. For United States jurisdictions, the equivalent US CDC policy should apply. 3.4 Coverage monitoring (1) The national EPI team should work closely with subnational EPI focal points (if applicable) to actively monitor reporting status ofEPI data and ensure timely follow up of all missing reports. A simple report monitoring form is recommended. The national EPI team should train and require staff at health facilities (where EPI services are provided) to utilize coverage-monitoring charts and take rapid action when needed.

(2)

(3) · Countries should conduct provincial/national EPI reviews to identify areas of concern and provide feedback to local programme managers.

-40-

3.5

VPD surveillance (1) Countries should improve sensitivity and timeliness of AFP, AFR and MNT case reporting through: L

VPD surveillance training, use of standard case investigation forms and dissemination ofiEC materials in all health facilities.

ii. Monitoring of surveillance using recommended indicators and feedback to all health facilities and staff through various means including print and electronic media, meetings, etc. iii. Designating administrative assistants at sentinel surveillance sites to assist hospital coordinators. (2) National notifiable disease surveillance systems should be used to identify and respond to reported AFR and MNT cases in addition to HBAS, and merged when possible. Radio-telecommunication or cell phone may be used for case notification from remote areas, with proper registration of contents of verbal messages or SMS. Community-based key informants should be used to increase case notification.

(3)

(4) 3.6

Polio eradication (1)

The SRCC urges Pacific Island countries, particularly those with relatively large populations and frequent international population movements, to develop or update national plans of action to quickly detect and respond to importation of wild poliovirus. Countries should maintain coverage with three doses of polio vaccine at 90% or more. Supplemental doses may be added when SIAs targeting other diseases are being conducted. Countries should improve their HBAS and case investigation through training of hospital coordinators and physicians. Countries should increase community awareness of the signs of AFP (as well as measles and MNT) through development and distribution of IEC materials.

(2)

(3)

(4)

3. 7

Measles elimination

Countries and areas should review the 2009 WHO Position Paper on Measles (Weekly Epidemiologic Record, 2009; 84: 349-360) and consider applying its guidelines with specific reference to: (i) optimal age of administration ofMCVl and MCV2; (ii) criteria for introduction ofMCV2 (for the Solomon Islands and Vanuatu only); (iii) use of school entry immunization requirements to ensure high population immunity by the time of school entry; and (iv) appropriate intervals between SIAs (before accumulation of susceptible children reaches the size of one birth cohort).

-41 -

3. 8

HepB control (1) If not recently done, consider an immunization coverage survey to assess the reliability of routine immunization coverage reports. Consider whether a HepB serosurvey (as stand alone or as part of a possible Pacific Island multicountry survey) is appropriate to be undertaken in 2011 to establish the current level of HepB control. Identify and implement options to improve coverage and timeliness ofHepB vaccine birth dose and subsequent doses. Train and regularly supervise maternity staff for delivery of birth dose and ensure that timely birth dose coverage is at least equal to that of births delivered in institutions. Health workers should be protected against HepB virus infection through immunization programmes.

(2)

(3)

(4)

(5)

3.9

New vaccines (1) Local data on pneumococcal, rotavirus and HPV disease burden should be collected and analyzed to assess the potential impact of vaccines against S. pneumoniae, rotavirus and HPV. Data sources may include hospital admissions or outpatient consultations for pneumonia, meningitis and diarrhoea (among children under five years old) and admissions for cervical cancer. These data may serve to help prioritize vaccine introduction and to mobilize additional resources. Factors that countries should consider before introducing new or underutilized vaccines include programmatic capacity (staff, cold chain capacity, etc.), cost of introduction, future fmancing and timing of administration in consideration of the existing BPI schedule. All countries and areas should make efforts to mobilize resources for introduction of PCV and rotavirus vaccines in accordance with WHO recommendatio ns for universal introduction of these vaccines. Efforts should be made with donors to set up a subregional fund or project to support the Pacific Island countries in introduction of high-priority new vaccines (PCV, rotavirus and HPV vaccines) in selected Pacific Island countries based on a model similar to the Pacific Hepatitis B Project in 1996.

(2)

(3)

3.10 Injection safety and waste management All countries/areas in the Pacific Region should ensure safe injection practices and waste management, including procurement of appropriate equipment as part of their national waste management plan. 3.11 Immunization safety

All Pacific Island countries should ensure access to and use of an NRA with capacity in licensing and post-marketing surveillance, including high-quality AEFI surveillance complete with guidelines.

-42-

3.12 Training and capacity building ( 1) All countries should review training needs at national and subnationallevels and develop a training strategy to further develop skills in delivery, monitoring and maintenance of high-quality EPI services. PIPS partners should consolidate technical, training and other needs for Pacific Island countries/areas and harmonize partner support through a Joint Pacific Islands Strategic Plan.

(2)

3.13 Linkage to other health interventions and programmes All countries should link and/or integrate EPI activities to MCH programme activities where appropriate and sustainable with support from all partners, including civil society. 3.14 Communication and advocacy (1) Countries should participate in the first Regional Vaccination Week in the Western Pacific (24-30 April2011) and use this initiative as a way to gain visibility and political support for immunization at all levels. Countries should explore bilateral opportunities with traditional and non-traditional donors (private sector) in support ofEPI activities.

(2)

3.15 Pandemic (H1Nl) 2009 (1) In accordance with WHO recommendations, during the post-pandemic period, countries should vaccinate high-risk individuals with monovalent Pandemic (H1N1) 2009 vaccine or a trivalent seasonal influenza vaccine (that includes the H1N1 2009 strain) contingent on supply availability.

(2)

Countries should document lessons learnt from the Pandemic (H1Nl) 2009 vaccine deployment and vaccination implementation and prepare accordingly for the next pandemic. This may include incorporating pandemic vaccine deployment plans into national pandemic preparedness plans.

SIXTH ·PACIFIC IMMUNIZATION PROGRAMME STRENGTHENING (PIPS) WORKSHOP 27 SEPTEMBER-01 OCTOBER 2010, Nadi, Fiji

WPR/DCC/EPI(S)/201 0.1 24 September 201 0

08:3010:00

1. Opening Session • Opening remarks - Ministry of Health. World Health Organization, United Nations Children's Fund, Japan International Cooperation Agency • Self-Introduction • Administrative announcements • Group photograph

• Process and Verification of Measles elimination In WPRO, Regional Update & TAG Recommendations • SIAs in 2010-country Report • Matalka.Measies Reference Laboratory-Regional Laboratory Links • Discussion

11. New vaccines • Regional status of new vaccine Introductions HPV vaccination In-FIJI • Discussion 12. Immunization supply chain management • Effective Vaccine management Tools • Discussion

17. Vaccine procurl!ment and Vaccine Independence Initiative (VII) • Value of Vaccination • Overview of Global Vaccine Market (Traditional vs. new Vaccine) • Discussion • UNICEF Procurement Process and Vaccine Security • Discussion

• Global polio eradication- overview of current situation • Polio Strategic Plan 2010-2012 and . Implications for the Western Pacific Region • Wild poliovirus importation In the WHO EUR-Iessons to be learnt for other polio-free Regions • Risk Assessment for slaying polio-free (key countries) ·

7.. Pandemic Influenza A H1N1 • Global and Regional Update H1N1 Vaccine Deployment and Vaccination • Lessons learned from H1N 1 Deployment and Vaccine Implementation • Discussion 6. Outbreak response • Mumps: Guam • Typhoid: Aj

3. Regional oveiVIew of the 'Expanded Programme on Immunization (EPI) 4. Progress Review of EPI In PacUic Island countries

13.. Hepatitis 8 control • Current status of control of Hep B In PICs and future prospects • PICS seroprevalence experience • TAG Recommendations • Discussion

12:00

Vaccine procurement and Vaccine Independence Initiative (VII) (Cont.) • Overview of VII • VII Benefits to Pacific • Discussion • VII: Performance Trends In the Pacific & Invoicing and P_ ayment Issues • Discussion

19. Evaluation of Japanese support to the Pacific lmmunlzalion Programme Strengthening project and support 20. Independent Progress Report of AusAID/UNICEF multi-country programme Immunization corl)ponent 21. PacUic Immunization Programme Strengthening Partner coordination meeting

• Using communication to Increase Immunization coverage • Developing Effedlve Communication Strategies In Mass Campaign • Regional Immunization Week • Discussion

9. SeiVIce delivery • Improving vaccination delivery In outer islands In Kiribati

suJVelllance • Improving annual data process/content collection • Introduction of Mobile Health Phone system In FIJI 15.1mmunlzatlon safety • How to ens.ure the vaccine and Immunization quality • Discussion

15:00 ·• Process of forecasting and ordering • Discussion • Country Presentation: Planning and Budgeting (Vanuatu &FSM) Discussion • Small Group Brainstorms 15:20

23. Closure of the session 24. Individual meetings between Pacific Immunization Programme Strengthening partners and Paclftc island countries ·

• Improving vaccination delivery In Highly Mobile Population In Vanuatu • Coordination with key agencies and community based health committee/volunteer In Samoa • Linking EPI programming to other MNCH interventions. Perception of PICTs and other development partners

10. Country poster presentation: progress, challenges and planned activlfles

19:00

16. Polley and strategy • Strategy for the enhancement of EPlin PICS (2011-2013) • Group Discussion • Group Presentation Reception & Cultural Night

Vaccine procurement and Vaccine Independence lnifiative (VIIJ(Cont.) • Feedback from small groups

• Discussions l':lext steps and wrap up

..

ANNEX 1

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ANNEX2 WORLD HEALTH ORGANISATION MONDIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

SIXTH PACIFIC IMMUNIZATION PROG~ESTRENGTHENING

WPR/DCC/EPI(S)/20 10/IB/2 11 September 2010 ENGLISH ONLY

WORKSHOP Nadi, Fiji 27 September- 01 October 2010

INFORMATION BULLETIN NO. 2 PROVISIONAL LIST OF PARTICIPANTS, OBSERVERSntE PRESENTATfVE SANDSECRETAR IAT 1. PARTICIPANTS

AMERICAN SAMOA

Ms Yolanda Masunu-Faleafaga Immunization Program Manager American Samoa Immunization Program Pago Pago, AS 96799 Telephone: +684 699 8464 Facsimile: +684 699 8457 Email: y3masunu@yahoo.com Ms Rangi Tairi Chief Public Health Nurse Email: r.tairi@health.gov.ck Mr Glassie Matata Telephone: Facsimile: Email:

COOK ISLANDS

FIJI

Dr Josaia Samuela National Adviser Family Health Ministry ofHealth, 88 Amy Street, Toorak, Suva, Fiji Islands Telephone: (679) 322 1502 Facsimile: (679) 3306163 E-mail: josaia.samuela@health.gov.fi Ms Litiana Volavola National EPI Coordinator Suva Health Centre Divisional Medical Office C/E, Namosi House, Suva Telephone: 3314988 Ext 104

WP/DCC/EPI(S)/2010/IB/2 Page2

Facsimile: 3315568 Email: lvolavola@yahoo.com GUAM Ms Rita Q. Oliva CDC Coordinator II Department of Public Health and Social ServicesImmunization Program 123 Chalan Kareta, Mangilao Guam 96913-6304 Telephone: 671-735-7143 Facsimile: 671-734-1475 Email: rita.oliva@dphss.guam.gov Ms Tikua Tekitanga EPI Coordinator Address: Telephone: Fascimile: Email: tikutanga@gmail.com DrRevite Designation Address: Telephone: Facsimile: Email: MARSHALL ISLANDS, REPUBLIC OF Ms Mailynn Konelios-Lang . Grants Management Director Immunization Program Manager Ministry of Health, P.O. Box 1622, Majuro, Marshall Islands 96969 Telephone: +692 625 3355/99 ext. 2403 Facsimile: +692 625 3432/4543 Email: bukunkur@yahoo.com Ms Herokko Neamon Public Nurse Supervisor Ministry of Health, P.O. Box 1622, Majuro, Marshall Islands 96969 Telephone: +692 625 3399 Facsimile: Email: shots4kids@yahoo.com MICRONESIA, FEDERATED STATES OF

KIRIBATI

(Government funded)

Ms Louisa Helgenberger Program Manager Immunization & Vaccines Preventable Diseases P.O. Box PS-70, Palikir Pohnpei, Federated States of Micronesia Telephone: +691 320 2619/2872/2643 Facsimile: +691 3205263 Email: lhelgenberger@fsmhealth.fm Ms Jocelyne Charley (Government funded) Immunization Nurse P.O. Box 127, Torol, Kosrae, Federated States of Micronesia 96944

WPR/DCC/EPI(5 )/2010/IB/2 Page3

Telephone: (691) 370 4962 Fascimile: Email: jcharlev@fsmhealth.fm

Dr AnaMaria Yomai (Government funded) Public Health Child Physician, Children with special health needs Physician Department of Health and Social Mfairs Palikir, Pohnpei, Federated States ofMicronesia 96941 Telephone: (691) 330 5809 Facsimile: (691) 330 4145 Email: sakama189@yahoo.com NAURU Ms Geraldine Celestine Eoaeo Primary Health Care Supervisor Ministry of Health Government Offices, Y aren District Republic ofNauru Telephone: 487 3883 Facsimile: Email: celestine.eoaeo@nauru.gov.nr

NIUE

Ms Minemaligi Asu Hetutu Pulu Immunization Manager Email: phcnurse@mail.gov.nu Ms Colleen Misa Kulatea Assistant Health Services Manager Email: malolotino@mail.gov.nu

NORTHERN MARIANA ISLANDS

Ms Gloria Itibus Ramon Community Outreach Coordinator CNMI Department of Health, Immunization Program PO Box 500409, Saipan MP 96950 Telephone: (670) 236 8733 Facsimile: (670) 236 8700 Email: gloriaramon5@gmail.com Ms Fuapepe Lese Manuleleua BPI Coordinator Email: Fuapepel@nhs.gov.ws Ms Maatasesa Samuelu-Matthes Manager, Nursing and Integrated Community Health National Health Service Private Mail Bag, Apia Samoa Email: maatasesas@nhs.gov.ws

SAMOA

SOLOMON ISLANDS

Mr Raymond Mauriasi BPI Coordinator Email: rmauriasi@moh.gov.sb

WP/DCC/EPI(S)/2010/IB/2 Page4 Mr Christopher Becha Finance and Planning Officer Email: chrisbecha@gmail.com TOKELAU Ms Faimanifo Peseta Immunization Coordinator Ms Sela Sausini Paasi Immunization Services Coordination Email: spaasi@health.gov.to Dr Nese Conway Telephone: Facsimile: Email: spaasi@health.gov.to VANUATU MrMarkBebe Director General of the Ministry of Health Email: mbebe@vanuatu.gov.vu Mr Leonard J'abilip EPI Coordinator Email: ltabilip@vanuatu.gov.vu Mr Benjamin Shing Email: WALLIS AND FUTUNA Dr Jean Pierre Mathelin Docteur en Medecin Agence de Sante BP 4 G Mata Utu 98600 Terrotoire des lles Wallis et Futuna Telephone: 681 721036 Facsimile: Email: doc.jpmath@yahoo.fr

TONGA

TUVALU

2. TEMPORARY ADVISERS Dr Lisi Tikoduadua Acting Regional Adviser in Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Telephone: +632 528 8001 Facsimile: +632 521 1036 Email: sniadackd@wpro. who.int Dr Heath Kelly Head, Epidemiology Unit Victorian Infectious Diseases Reference Laboratory Associate Professor School of Population Health

WPR/DCC/EPI(S )/2010/IB/2 PageS

University of Melbourne 10 Wrekyn Street, North Melbourne, Vic 3053 Australia Telephone: 613 9342 2608 Facsimile: Email: Heath.Kelly@mh.org.au

Dr Tilman Ruff Designation Address Tel: Fax: Email:

3. SHORT-TERM CONSULTANT Ms Sarah Schmitt Short Term Consultant EPI I Immunization, Vaccines and Biologicals World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Telephone: +41 22 791 12 11 Facsimile: +41 22 791 31 11 Email: schmitt sl@hotmail.com

4. REPRESENTATIVES/OBSERVERS MINISTRY OF HEALTH FIJI Dr Salanieta Saketa Permanent Secretary for Health Ministry of Health Dinem House, Toorak, Suva, Fiji Telephone: +679 3321501 Facsimile: Email: Ssaketa@health. gov.fi Ms Mereseina Kamunaga Ministry of Health Dinero House, Toorak, Suva, Fiji Telephone: +679 3321501 Facsimile: Email:

FIJI HEALTH SECTOR TIMPROVEMENTPROGRAMME

Mrs Kylie Jenkins EPI Technical Advisor Fiji Health Sector Improvement Programme PO Box 14986,

WP/DCC/EPI(S)/2010/IB/2 Page6 Suva, Fiji Telephone: +679 3221462 or 9255426 Facsmilie: +679 3301536 Email: kyliemjenk:ins@gmail.com FIJI NATIONAL UNIVERSITY SCHOOL OF NURSING Sr Seini Tauri Ravea Primary Health Care Lecturer, School of Nursing College of Medicine, Nursing and Health Science, Fiji National University Telephone: +679 3321499 Facsimile: Email: stravea@fnu.ac.fi Ms Laisa Tikomaimaleya Primary Health Care Lecturer, School of Nursing College of Medicine, Nursing and Health Science, Fiji National University Telephone: +679 3321499 Facsimile: Email: Laisa.Tikomaimaleya@fnu.ac.fi

5. SECRETARIAT WHO WESTERN PACIFIC REGIONAL OFFICE Dr David H Sniadack Acting Regional Adviser in Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Telephone: +632 528 8001 Facsimile: +632 521 1036 Email: sniadackd@wpro.who.int Dr Yoshikuni Sato Medical Officer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila· Telephone: +632 528 9750 Facsimile: +632 521 1036 Email: satoy@wpro.who.int Dr Sigrun Roesel Medical Officer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue

WPR/DCC/EPI(S )/2010/IB/2 Page7

1000 Manila Telephone: +632 528 9750 Facsimile: +632 521 1036 Email: roesels@wpro.who.int

Mr Gabriel Anaya Programme Manager Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Telephone: +632 528 9750 Facsimile: +632 521 1036 Email: anayag@wpro.who.int Dr Manju Rani Scientist Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Telephone: +632 528 9750 Facsimile: +632 521 1036 Email: ranim@wpro.who.int Dr Md. Shafiqul Hossain Technical Officer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Telephone: +632 528 9750 Facsimile: +632 521 1036 Email: hossains@wpro.who.int WHO SOUTH PACIFIC Dr Chen Ken WHO Representative WHO Representative Office in the South Pacific Level 4 Provident Plaza One Downtown Boulevard, 33 Ellery Street Suva, Fiji Telephone: +679 3 304 600 Facsimile: +679 3 304 631 Email: chenk@wpro.who.int Dr Raul Bonifacio Technical Officer WHO Representative Office in the South Pacific Level 4 Provident Plaza One Downtown Boulevard, 33 Ellery Street Suva, Fiji Telephone: +679 3 304 600

WP/DCC/EPI(S)/2010/IB/2 Page 8 Facsimile: +679 3 304 631 Email: bonifacior@wro.who.int Mrs Lynette Evans Secretary WHO Representative Office in the South Pacific Level 4 Provident Plaza One Downtown Boulevard, 33 Ellery Street Suva, Fiji Telephone: +679 3 304 600 Facsimile: +679 3 304 631 Email: evansl@wpro.who.int UNICEF PACIFIC OFFICE Dr Isiye Ndombi Representative, UNICEF Pacific Office Private Mail Bag Suva, Fiji Telephone: +679 330 0439 Facsimile: +679 330 1667 Dr Ingrid Hilman Child Survival Specialist UNICEF Pacific Office Private Mail Bag Suva, Fiji Telephone: +679 330 0439 Facsimile: +679 330 1667 Email: ihi1man@unicef.org Ms Donna Hoerder Communication Specialist UNICEF Pacific Office Private Mail Bag Suva, Fiji Telephone: +679 330 0439 Facsimile: +679 330 1667 Email: dhoerder@unicef.org Ms Reehana S. Nisha Programme Assistant Health UNICEF Pacific Office Private Mail Bag Suva, Fiji Telephone: +679 330 0439 Facsimile: +679 330 1667 Email: nreehana@unicef.org

UNICEF EAPRO (THAILAND)

Ms Diana Chang Blanc Regional Immunization Specialist UNICEF EAPRO 19 Phra Abt Chanasongkram, Phranakom 10200 Bangkok, Thailand Telephone: +66 (0) 2 356 9420 Facsimile: +66 (0) 2 280 3563 Email: dchangblanc@unicef.org

l'

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UNITCEFHEADQUARTERS

Mr Osman Mansoor Senior Advisor, EPI UNICEFNYHQ United States of America Telephone: 212 326 7410 Facsimile: Email: omansoor@unicef.org Mr Robert Matthews Contracts Manager UNICEF SUPPLY DIVISION Denmark Telephone: 45 3527 3054 Facsimile: Email: rmatthews@unicef.org

JAPAN INTERNATIONA L COOPERATION AGENCY SUVA

Mr Yutaka Fukase Deputy Resident Representative Japan International Cooperation Agency Fiji Office Level 8, Suva Central Building Renwick Road, Suva Telephone: (679) 3302522 Facsimile: (679) 3302452 email: Fukase.Yutaka@jica.go.jp Mr Kentaro Suekane Assistant Resident Representative Japan International Cooperation Agency Fiji Office Level 8, Suva Central Building Renwick Road, Suva Telephone: (679) 3302522 Facsimile: (679) 3302452 email: Suekane.Kentaro@jica.go.jp Ms Miyuki Harui Project Formulation Advisor, Health Japan International Cooperation Agency Fiji Office Level8, Suva Central Building Renwick Road, Suva Telephone: (679) 3302522 Facsimile: (679) 3302452 email: Harui.Miyuki@jica.go.jp Ms Nila Prasad Program Officer Japan International Cooperation Agency Fiji Office Level 8, Suva Central Building Renwick Road, Suva Telephone: (679) 3302522 Facsimile: (679) 3302452 email: Nilaprasad.fi@jica.go.jp

~I

WP/DCC/EPI(S)/2010/IB/2 Page 10 NEW ZEALAND INTERNATIONAL AID AND DEVELOPMENT AGENCY Ms Emma Dunlop-Bennett Regional Development Programme Manager New Zealand High Commission PO Box 1378 Suva, Fiji Telephone: Facsimile: (679) 3300040 email: Emma.Dunlop-Bennett@nzaid. govt.nz Ms Makeleta Koloi New Zealand High Commission PO Box 1378 Suva, Fiji Telephone: Facsimile: (679) 3300040 email: CENTERS FOR DISEASE CONTROL AND PREVENTION Dr Orner Gimana Pasi Med. Epidemiologist Centers for Disease Control and Prevention Atlanta, Georgia United States of America Telephone: Facsimile: email: obp3@cdc.gov

ANNEX3

MINUTES OF THE PIPS PARTNERS CO-ORDINATIO N MEETING Nadi, Fiji 1 January 2010 Present As the meeting was held at the end of the last day, many participants left part way through for transport commitments. Present at various times were: Country Representatives: Ms Yolanda Masunu-Faleafaga, Ms Rangi Taifi, Ms Ana Silatolu, Dr Josaia Samuela, Ms Litiana Volavola, Ms Rita Oliva, Dr Revite Kirition, Ms Louisa Helgenberger, Ms Jocelyne Charley, Dr Anamaria Yomai, Ms Geraldine Ceiestine Eoaeo, Ms Isabella Amwano, Ms Minemaligi Asu Hetutu Pulu, Ms Colleen Misa Kulatea, Ms Fuapepe lese Manuleleua, Ms Maataesa Sam.uelu-Matthes, Mr Raymond Mauriasi, Mr Christopher Becha, Ms Faimanifo Peseta, Ms Sela Suasini Paasi, Ms Lasini Sinam.oni, Ms Alaita Taulima, Dr Nese Conway,.Mr Mark Bebe, Mr Leonard Tabilip, Mr Jack Loughman, Dr Jean Pierre Mathelin NZ MFAT: Ms Makeleta Koloi CDC: Dr Orner Pasi TICA: Ms Miyuki Harui, Mr Kentaro Suekane, Ms Nila Prasad WHO: Dr Yoshikuni Sato, Dr Manju Rani, Dr David Sniadack, Mr Gabriel Anaya, Dr Manju Rani, Dr Raul Bonifacio Dr Md. Shafiquel Hossain UNICEF: Ms Diana Chang Blanc, Dr Eliab Seroney Some, Dr Ingrid Hilman, Ms Christine Calo-oy, Ms Donna Hoerder Temporary Advisers/ Consultants: Dr Lisi Tikoduadua, Dr Tilman Ruff Representatives: Sr Seini Tauri Ravea, Ms Laisa Tikomaimaleya Rapporteur: Dr Robyn Mcintyre Chair: Dr Omar Pasi The meeting started at 1345hrs. I. Update of major activities/support from partners

Rotary International District 2650: Dr Yoshikuni Sato spoke on behalf of Rotary International District 2650 which was unable to send a representative to the meeting. He explained that they had been PIPS partners since 2005 and a regional partner since 1995. In 2009 they gave $70,000 to Kiribati for BPI in response to a needs assessment by WHO/WPRO and this was spent on a new incinerator and vehicles. Future plans include continlied support through the Rotary International Polio Plus program, and for BPI co-ordination activities in the region through Government of Japan. In addition they will likely have funds available in 2011-2012 of around $50,000 for strengthening routine BPI in the Pacific. Countries can send proposals through the WHO Pacific office and these will be distributed in close consultation with WHO/WPRO expert assistance.

CDC: Dr Omar Pasi explained that at a· global level CDC provides support through a Cooperative Agreement with WHO and UNICEF and also through a Special Cooperative Agreement for vaccines with UNICEF. In the Pacific the CDC focuses on the 6 US territories or Freely Associated States and provides vaccines and also operational costs. Support was given to Chuuk state to undertake an SIA with CDC funds and TA from WHO. An SIA is plmmed in Pobnpei with operational funds coming from CDC. American Samoa receives vaccines, operational support and TA through regular conference calls and there are plans to establish BPI mobile vans with TA from CDC and WHO. In Guam a Hepatitis B serosurvey is planned with assistance from CDC and WHO. RMI receives additional operational support for follow up measles SIAs every April. Future plans include ongoing capacity building in the field through TA, improving surveillance and programme management. In addition CDC offers support for other Pacific countries through the CDC STOP progra.J.n and Vanuatu availed themselves of this for their 2009 measles SIA. WHO: Dr Raul Bonifacio outlined that WHO has a focus on provision ofTA for planning of routine and supplementary immunization and VPD surveillance activities throughout the Pacific. The planning is both macro (national) level atid micro (provincial and district) level. WHO also supports development of combined multi year plan (c-MYPs). Specific technical support during the past year addressed revision ofEPI policies and guidelines in Vanuatu and Samoa and provision of consultants for the measles SIA in Chuuk State, FSM. Training was undertaken with UNICEF for mid-level managers (MLM) from 6 countries and on communicable diseases with the Communicable Surveillance and Response team, such as the VPD surveillance in Fiji. Starting in late 2009 the global pandemic H1N1 activities have been extensively supported by WHO in collaboration with NZAID and AusAID. Regional training was provided for 16 countries to develop deployment plans and in country follow up support provided for fmalization of deployment plans in 5 of the 11 WHO Pandemic Influenza Vaccine Donation Initiative countries. In addition to the provision of vaccines, WHO has also contributed fmancially to operational activities and participated in monitoring activities. WHO continues to support VPD surveillance through monitoring HBAS data collection and response in all 20 Pacific countries, working with the Communicable Surveillance and Response team. Laboratory support is extended to Mataika House for AFR and Victorian Infectious Diseases Reference Laboratory in Melbourne for AFP specimens, and the Colonial War Memorial Hospital in Suva ..WHO is also supporting sentinel surveillance for Rotavirus diarrhea in Fiji. WHO also supported introduction of a mobile phone network in Fiji to promote faster HBAS reporting and wider access in areas with logistical and communication constraints. WHO in collaboration with UNICEF is responsible for data monitoring of the annual joint reporting form on coverage and other BPI related activities and guidelines. Joint country visits have been undertaken by WHO and UNICEF to monitor activities, conduct BPI reviews and support training. WHO also provides wider support to Child Health through the IMCI as well ICATT (Integrated Childhood Illness Computerized Training) conducted in the 3rd quarter of 2009 in the Pacific. Future plans include assisting development of micro-planning at provincial and/or at district level, supplying WPRO training materials for monitoring coverage charts in Sa.J.noa, strengthening VPD surveillance through training of staff, ensuring improved cold chain management, and continued assistance with BPI progra.J.n development in association with UNICEF and partners by developing an BPI Regional Strategic Fra.J.nework.

~·.

UNICEF: Dr Eliab Seroney Some emphasised that UNICEF supports BPI through its support to child survival and development. The highly successful measles SIAs supported in Samoa, Fiji, Nauru, Solomon Islands, Kiribati, Vanuatu, FSM and Tuvalu in 2009-2010 were integrated with other cost-effective health interventions such as vitamin A supplementation, deworming, malaria bed net distribution, hand washing campaigns and birth registration. In the past 2 years UNICEF has supported cold chain rehabilitation with procurement of more than 10 refrigerators, cold boxes and vaccine carriers as well as temperature monitoring devices and will continue such support. Wider support has included purchase of ambulances, boats and computers. Capacity building continues, such as the first ever MLM training conducted with WHO fat participants from 6 countries; Vaccine Management and Cold Chain Assessment in Vanuatu and Solomon Islands that gives clear directions on improving cold chain and vaccine management and reducing stock-outs; and Effective Vaccine Storage Management (EVSM) in Fiji that provided valuable inputs to Fiji which is seeking EVSM certification in the near future. UNICEF supported pentavalent introduction to Cook Xslands and Nauru in 2009 and Japan Committee for Vaccines for the World's Children (NC) has been identified as a donor for 5 years to support introduction of pentavalent to Vanuatu from 2011. UNICEF continues to support countries in vaccine forecasting and procurement through the VII and undertakes to review and improve its billing processes, including implementing recent recommendations from various sources including this meeting and likely introducing an additional dedicated staff position. Future plans include working with PIPS Secretariat and partners to develop a regional PIPS Multi-year Strategic Plan; supporting National Health Day(s) to increase routine immunization and other effective interventions such as de-worming and vitamin A distribution; .continued support for Integrated Measles SIAs and finalization ofUNICEF multi-year work plans for 20112012 to further align and harmonize with government planning and budgeting cycles. Capacity building of BPI staff at all levels will continue, with emphasis on MLM training, supportive supervision training, Immunization in Practice for nurses, National BPI Reviews, and support for communication strategies for NIPs. UNICEF will also finalise their programme of cooperation with AusAID and NZ MFAT on BPI as the AusAID 2005-2010 programme ended 30 September 2010 and the NZAID 2008-2012 agreement needs revision. Both partnerships are working towards one multi-year, multi-country and multi-donor immunization programme. TICA: Ms Miyuki Harui, Project Formulation Advisor, Health, TICA Fiji Office described the 5-year Japanese support to the Pacific Immunization Programme Strengthening (JPIPS) Programme that commenced in 2005 and was successfully completed in February 2010. Under the PIPS framework, JPIPS endeavoured to enhance the capacity of target countries in the following areas: planning and monitoring of immunization policy and programme; vaccine and cold chain management; injection safety and BPI disposal management; and outreach activities. Working with PIPS partners JPIPS contributed by supporting PIPS workshops, regional training programs, domestic training programs in each country, and provision of cold chain equipment. TICA is proud of the valuable impact that has been made by JPIPS and feels that this should be maintained in order to continue improvement of maternal and child health, and overall health system strengthening in the Pacific region. Ms Harui therefore confirmed that as a PIPS partner, TICA will continue support for further improvement of the BPI program in the Pacific region for the next three years through JPIPS phase-2. This will provide capacity development for trainers and workers in areas of vaccine management, logistics and cold chain management and maintenance. TICA will focus its activities in 5 countries in the Pacific Region, namely, Solomon Islands, Vanuatu, Kiribati, Samoa and Micronesia. AusAID: absent from the meeting.

..-i'

NZ MFAT: Ms Makeleta Koloi expressed their appreciation at being present at the meeting and noted that their priorities are guided by the ministries of health of the various PICs. Immunization has been well highlighted as a worthwhile program and in keeping with their "deeper, longer, fewer" approach to aid most support will continue through funding UNICEF programmes via the 2008-2012 $4,000,000 multi-year plan, so she suggested countries continue to present their priorities to UNICEF. They have almost finalised their 2010 contribution plus an additional $1,000,000 they are donating to boost the Vll fund. NZ MFAT remains committed to immunization and is encouraged and pleased with the efforts to achieve effective coordination. 2. Vaccine procurement and Vaccine Independent Initiative (Vll). Ms Diana Chang Blanc commented that the day spent discussing the Vll in detail had enriched the agenda and been timely and useful. She expressed appreciation for the presence and involvement of governrnent fmancial representatives in the discussion. Alternatives to the vn that had been presented were clearly unappealing so the way forward would seem to be ensuring the current system was working optimally. The VII has been renewed from 20 i 1-2015 and current funding is adequate for current levels of procurement, but more funds would be needed for introduction of new vaccines-in the future. The impact and implications of late country payments had been emphasised and the need to improve invoicing by UNICEF had been recognised. She noted that it was time to sign renewed MOUs with Letters of Guarantee, and a fast response time was ne.eded. Countries had identified that advocacy and improved communication was needed to improve understanding of the VII mechanism at senior levels. She also observed that there is clearly a need to update procedures and guidelines at a global level, there should be periodic updates regarding VII to PIPS and it was recommended that there should be a presentation ofEPI funding issues to senior Pacific Island leaders and h~alth ministers when they meet. ·3. World Health Organization Regional Committee for the Western Pacific, 11 to 15 October 2010 Dr David Sniadack discussed that the sixty-first Meeting Regional Committee (RC) for the Western Pacific will be held from 11 to 15 October 2010 in Putraj aya, Malaysia and that this would be an opportunity for renewal of immunization commitments. At the 2003 WPR meeting resolution WPRIRC54.R3 called for measles elimination and hepatitis B control. At the 2005 meeting this was strengthened with resolution WPRJRC56.R8 by establishing 2012 as the target year for measles elimination and achievement ofHbsAg seroprevalence less than 2% in five year-old children as an interim milestone towards the final regional Hepatits B control goal of less than 1% seroprevalence. The resolution also called for maintaining polio-free status. Dr. Sniadack said he expected the 2010 RC resolution on VPDs to include a reaffmri.ation of the targeted disease goals so ·that member states and partners would commit needed human and fmancial resources to achieve and sustain measles elimination and Hepatitis B goals and to maintain polio free status. He encouraged participants to advise their ministers on the importance and implications of these matters and strongly advise them to support the resolution.

4. Joint Strategic Plan fro Immunization in the Pacific Dr Some proposed a motion that one strategic plan for Pacific Immunization Strengthening be established, as per the earlier meeting discussions and this was seconded by Dr Md. Shafiquel Hossain, and passed unanimously by the group. Dr Sniadack commented that to move forward it was crucial that resources be identified and overlap be avoided, and suggested to involve all PIPS partners in the development of the Plan. The secretariat will prepare a draft by December that will be circulated to partners and countries in a participatory process with the aim of completing the process by the end of the year. 5 Discussion of 2010 sixth PIPS Meeting Key Action Points Dr Raul Bonifacio presented a proposed compilation of action points from the meeting for discussion and these will be reviewed and attached as an annex in the meeting report 6 AOB- Review of PIPS Dr Some raised the question of whether a review was needed of whether the PIPS mechanism was still relevant and effective. He suggested that issues for review were how PIPS is linking with other coordinating groups within countries, with country program mechanisms, funding and plans including c-MYPs, and with partners within the PIPS group including donors, and also wl:).ether there is still a place for the monthly PIPS Partners meetings in Suva and the annual PIPS meeting. Discussion ensued and Ms Miyuki Harui from JlCA commented that as PIPS was a JPIPS .supported mechanism and the new JPIPS cycle will start soon this was a good time for a review from their point of view. Ms Chang Blanc commented that the original Terms of Reference were for 6 years and these needed to be reviewed whilst an estimation of the value of the annual workshop would be gleaned from feedback forms. With general consensus in the room, Dr Some offered that UNICEF would explore funding an external evaluation to which other partners could perhaps contribute. The meeting closed at 1755 hours.

Annex 4: Action Point

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1. All countries to achieve vaccine forecasting within 20% of vaccine order for all antigens. 2. All countries to submit V AR to UNICEF ' 72

Government ministries on options beyond 2010 for vaccine supply in PICs and give feedback to the PIPS secretariat by July 2009 before Pacific Health Ministers Meeting in PNG .

refrigerators, cold boxes and vaccine carriers for storage and distribution of vaccines, and use appropriate temperature monitoring devices to monitor performance of the cold chain, (and/or adhere to the CDC standards if vaccines are suoolied 7. All countries should improve their vaccine handling and management by applying recommended tools and practices for vaccine arrival and receipt, stock management and vaccine distribution. Standard indicators can be used such as zero stock-outs, wastage rates less than the national average and VVMs/ ~ monitors within usable 8. All countries should have adequate and trained personnel in vaccine management to manage their cold chain and logistics systems: a) EPI Manager; b) Cold Chain manager;c) Cold chain technician and d) EPI coordinators

ss on Action Points from 5th PIPS Action Point . All countries should consider evaluating the performance of their cold chain and logistics systems by conducting either a WHO/UNICEF Vaccine Management Assessment (VMA T) or Effective Vaccine Store Management Assessment (EVSM), or the CDC equivalent and implement a plan to address weaknesses. 10. All countries should build capacity by conducting trainings with good methodology that have adequate curricula and include good vaccine management practices and appropriate supportive supervision. 11. All countries should strengthen their human resources, cold chain and logistics management systems to prepare for rapid vaccine dispatch (<7 days) in the case of a WAF FIJ

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uct supportive supervision; develop community linkages; monitor and use data for action; and improve planning and 13. All countries should develop micro-plans based on a problem analysis of the local health facility situation and identify barriers to a community's access to health services (DTPl) or utilization of services. (DTP3). Actions to address these barriers should be feasible, prioritized and funded. 14. All countries should actively use monitoring tools available to identify and follow-up with missed groups or defaulters: immunization registers, health catchment maps , coverage monitoring charts, and

defaulter 'tickler' systems.

Annex 4: Pro Action Point TON

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Coverage Monitoring: 15. National EPI team should work closely with subnational EPI focal points (if applicable) to actively monitor reporting status ofEPI data and ensure timely follow up of all missing reports. A simple report monitoring form is recommended. 16. National EPI team should train and require staff at health facilities (where EPI services are provided) to utilize coverage-monitoring to monitor coverage and take rapid actions when needed. 17. Complete data should be received from subnationallevels in a timely manner. This should be analysed by the National EPI team at both national and subnational levels quarterly, allowing identification of concerning areas, feedback to local programme managers, and field visits when necessary.

18. Each country should assess performance of hospital coordinator(s) responsible hospital based active surveillance in 2007-2009, and choose the most suitable staff to take this task. 19 . Each country should conduct in-country training on AFP/AFR surveillance through multiple approaches, either through annual EPI training or combining with other programme such as communicable disease surveillance 20. Completeness and timeliness of monthly zero reporting should be improved from subnational to national level and hom each PIC to WHO SP office.

Action Point Legend: 21. Surveillance supervision may be strengthened and incorporated with supervisory visits for other purposes; checklists should be used and movement plans developed that include schedules and funded travel costs. Regular meetings with those involved wills surveillance. 22. The Sub Regional Commission for the Certification of PE urges that PICs, particularly those with relatively large populations and frequent international population movements, develop or update a national POA to quickly detect and respond to importation of wild poliovirus. Knowledge could be drawn from the process of developing influenza preparedness and requests for TA to strengthen these areas may be appropriate. 23. Countries must improve their Hospital Based Active Surveillance and case investigation through training of hospital coordinators and physicians. The main goal of AFP case investigation is to quickly come to a final classification if a case could be polio; this requires sufficient virological and clinical information; WHO can facilitate lab analysis. 24. Countries should maintain coverage of polio3 of at least 90%. During the strengthening of routine immunization for polio in countries with lower coverage, supplemental doses may be added when SIAs for other antigens are being conducted. 25. Countries should increase community awareness of AFP through techniques such as development and distribution of IEC materials

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G. Measles 26. Identification, reporting and investigations of suspected measles (AFR) cases should be improved so that a minimum of 2 AFR cases per 100,000 population are discarded as nonmeasles every year. 27. HBAS case definition for suspected measles should be changed to AFR in persons of any age or suspected measles diagnosed by a physician. 28. To improve sensitivity and timeliness of AFR case reporting: a) national notifiable disease surveillance systems should be used to identify and respond to reported AFR cases in addition to HBAS; b) radio-telecommunication or cell phone may be used for case notification from remote areas, c) VPD surveillance training, report forms and IEC materials may be provided for staff in all health facilities; d) monitoring of surveillance using recommended indicators and feedback to all health facilities and staff through various means; e) administrative assistants may be designated at sentinel surveillance sites to assist hospital coordinators; t) community based key informants may be useful for increasing case notification. 29. Countries and areas may follow SAGE guidelines for establishing or updating their MCV 1 and MCV2 schedules. Recommendations were given in several recent SAGE meetings: Nov 2006 Meeting (Weekly Epidemiologic Record 2007; 82: 1-16), Nov 2008 Meeting, and April 2009 Meeting (to be published in WER, June 4, 2009);

on Action Points from 5th PIPS Action Point 30. As recommended by SAGE, follow up SIAs should be conducted if and when the number of susceptible children reached the of one birth cohort. Countries and areas may apply this recommendation for sub-national levels, such as particular islands with low routine MCVl and MCV2 coverage. Strengthening routine MCVl and MCV2 coverage using established RED and GIVS strategies can delay or eliminate the need for NIU WAF FIJ

serosurvey in the next 1-3 years amongst 5 years or older children to determine rate of sAg positivity in line with WHO ines. Countries need to consider the scope, whether they wish to integrate other antigens, cost estimates, the timing noting especially school terms and Health Worker availability and give at least 12 months warning to PIPS partners to ensure assistance

34. Carry out at least one detailed review of timely birth dose in all the maternity hospitals. 35. Regularly supervise and train the maternity staff on the job for delivery of birth dose and ensure that timely birth dose coverage is at least equal to that of births delivered in

Annex 4: Pro Action Point 6. Assess and implement immunization for health workers by 2012 in all pacific island

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37. The technical issues about the new vaccines-such as Pneumococcal, rotavirus, HPV should be regularly discussed in national meetings and national EPI workshops to increase awareness about these new vaccines and to help make informed decision-making. bile waiting for introduction, the countries should assess issues such as programmatic capacity (staff, cold chain capacity etc), cost introduction, potential financing and timing. 38. To increase awareness on these vaccines and as an advocacy tool, EPI team should regularly collect disease burden data- hospital admissions for pneumonia, meningitis and diarrhoea (among children under 5) and admissions for cervical cancer. 39. Efforts should be made with donors to support the PICs in introduction of highpriority new vaccines (pneumococcal conjugate vaccines and HPV) based on a model similar to the Pacific Hepatitis B Proj in 1996. Safety:

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. All countries should identify one welltrained focal point person to take responsibility for and report on waste, including management

. All countries should plan and finance reti·esher training on waste management to ensure appropriate disposal of infectious wastes, including sharp wastes.

L. Training/Capacity Building: 46. All countries to review the existing Health Worker training plan, if any, and identify the 47. All countries to clarify if TOT is needed to achieve and maintain high EPI performance and ensure that the number of core trainers each have requested to conduct Health Worker training nationally is the functional minimum. Current numbers are: Cook (8), Fiji (30), Kiribati (6), Marshall (20), Micronesia (4), Nauru (2) , Niue (4), Palau (2), Samoa (10), Solomon (20), Tonga (10), Tuvalu (9) and Vanuatu (20). 48. All countries to examine institutional capacity for the implementation of future training to ensure continuous training activities

on Action Points from 5th PIPS (2009) Wo KIR MIC

M. 50. Available funds and more funds allocated efficiently and effectively utilized - "best-buys by addressing bottlenecks to high coverage, and ensuring that MDGs are scaled up and accelerated with equity. 51. Improve data collection and analysis e.g. Determine KAPB for low coverage interventions and use HMIS - health and management information systems 52. Ensure sector-wide results-based programming for all health-related MDGs 53. All countries should have a National Child Health Week as a means of focusing on integrated childcare. 54. Review the countries pandemic preparedness plans and critically review the immunization component. Identify and prioritise the population groups (e.g. population needed to keep the essential services running) in advance that must be immunized in case of shortage of vaccines. 55. Make prior plans with identification (and discussion and agreement) of alternative cold storage facilities and transportation vehicles to distribute and deploy the vaccines rapidly in the event of an epidemic. 56. As part of national pandemic preparedness plan, estimate the number of staff that may be required to administer the vaccine. Contact and keep/train additional alternative staff on standby, who could be mobilized to administer the vaccines in an event of pandemic.

Action Point Legend: 57. Assess the possibility of using seasonal influenza vaccines for priority population groups (elderly population, health workers, etc.) where affordable and where justified on disease burden.

ANNEX SA Sixth Pacific Immunization Programme Strengthening (PIPs) Workshop Nadi, Fiji 27 September- 1 October 2010 Thank you for participating in the PIPS. We would like to hear from you as to how PIPS could best serve Member States. Hence, we would appreciate it if you could complete this form to understand your needs better. Please note how useful/interesting these topic sessions were to you by circling the number in each category. (Marking "5" means it was very helpful). Thank you.

Category Communication and Advocacy MLM Training Update Measles Elimination Pandemic Influenza (A) HlNl Outbreak Response (Mumps & Typhoid) Immunization Service Delivery Country Poster Presentations New Vaccine Introduction Supply chain : Effective Vaccine Management Hepatitis B control Monitoring and VPD Surveillance Immunization Safety Strategy for Enhancing EPI in the PICs Vaccine Procurement and Vaccine Security Maintain polio-free PICS PIPs Partners Meeting Question and Answer Box Sessions

Less useful

More useful

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

2. Please list the most useful things that you heard/learned at PIPS:

3. Are there missing topics you would like to see included at the next PIPS?

4. What did you think of the programme agenda of the week? (circle one) A. There were too few items discussed B. It was just right C. There were too many items discussed

5. How comfortable do you feel raising your country issues during the PIPs? (circle one) A. Comfortable B. Neither uncomfortable nor comfortable C. Uncomfortable

6. If your answer was" uncomfortable' above, how can we make it more comfortable?

7. Are these annual PIPS Workshops useful to you and your programme? A. Yes B. No 8. If your answer above was "YES", how often should PIPs Workshop be conducted? A. More than once a year B. Every year C. Every two years 9. What would be the three key improvements you would suggest so that the PIPs can be more useful for your programme and activities?

10.

How useful is the PIPs Workshop Meeting Report to you? A. Very useful, I refer to it often B. Moderately useful, I refer to it occasionally C. Useful, I refer to it at least once a year D. Not useful, I have never used it after the meeting

11 TIME SPENT WAS TYPE OF ACTIVITY Too Short Adequate Too Long

Length of PIP.S meeting (5 days) Exchange of knowledge and experience with other participants Discussion time after presentations Small group work and feedback to the large group Interaction with other participants outside of meeting room

12.

Any additional comments?

D Country representati_ve 0

Let us know who you are (Tick the box): PIPs partner (Secretariat/Technical Advisers)

Annex 58: Synthesis of General Evaluation Results 6th Pacific Immunization Programme Strengthening (PIPS) Workshop Fiji, 27 Sept - 1 October 2010 TOTAL: 29 respondent sheets received, varying stages of completion. 20 country representatives, 4 PIPS partners and 5 no reply.

6th Pacific Immunization Programme Strengthening (PIPS} Workshop 27 September-1 October2010 Scale of whether session was considered useful 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% i:)' (0

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Q2. Please list the most useful things you heard/learned at PIPs. Q3. Are there missing topics you would like to see at the next PIPs For Q2 and Q3, see individual comments in Excel spreadsheet. Q4. What did you think .of the programme agenda of the week? (24 respondents) · Too few items Just Right Too many items

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Q7. Are these annual PIPS useful to you and your programme?

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~~~~ World. He~lth Western Pacific Region

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