• , l J , I ; 1
(WP)EPUICPNID/OO I-A Report series number: RS/98/GEIl O(PHL) English only
REPORT
)
NINTH MEETING OF THE TECHNICAL ADVISORY GROUP ON THE/EXPANDED PROGRAMME ON IMMUNIZATION AND POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION
~
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 3-6 November 1998
Not for sale Printed and distributed by World Health Organization Regional Office for the Western Pacific Manila, Philippines November 1999 WHOIWPRO LIBRARY !\l \ '\'Tf .\. p:~n ~nrr7'rp$
1 6 ,IlJL 2007
NOTE
~I
'.
11 The views expressed in this report are those of the participants of the ninth meeting of the Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization.
1-1 f ~,
" I
I
J
I
, , )
~, f
~
•I ~
•,
,
This report has been printed by the Regional Office for the Western Pacitic of the World Health Organization for the participants in the ninth meeting of the Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication in the Western Pacific Region, which was held in Manila, Philippines, from 3 to 6 November 1998,
- II -
MAPs: MAP I DISTRIBUTION OF POLIOMYELITIS CASES IN THE WESTERN PACIFIC REGION, 1997 DISTRIBUTION OF POLIOMYELITIS CASES IN THE WESTERN PACIFIC REGION, 1990.... POTENTIAL CROSS-BORDER TRANSMISSION OF WILD POLIOVIRUS, WESTERN PACIFIC REGION.. 5
MAP 2 MAP 3
6
. ..... 46
TABLES: TABLE I EPI ANTIGEN COVERAGE AMONG INFANTS AND PREGNANT WOMEN IN SELECTED COUNTRIES OF WESTERN PACIFIC REGION, 1995-1997 (AS AT 10 JULY 1998) ...... TOTALAFP CASES REPORTED, CONFIRMED POLIOMYELITIS CASES AND WILD POLIOVIRUS-ASSOCIATED CASES. WESTERN PACIFIC REGION, J993- J997.. -
4
TABLE 2
6
TABLE 3
NATIONAL IMMUNIZATION DAYS AND HIGH-RISK RESPONSE IMMUNIZATION, WESTERN PACIFIC REGION. 1992-1998.. 9 AFP SURVEILLANCE INDICATORS, WESTERN PACIFIC REGION, 1994-1997 - CASE INVESTIGATION COMPLETENESS AND TIMELINESS IN PER CENT OF REPORTED AFP CASES BY COUNTRy.... ......... ..... 12
TABLE 4
TABLE 5
-
AFP SURVEILLANCE INDICATORS. WESTERN PACIFIC REGION, 1994-1997 - LABORATORY SPECIMEN COMPLETENESS AND TIMELINESS IN PER CENT OF REPORTED AFP CASES BY COUNTRy............. ........ 12 REPORTED CASES OF MEASLES AND NEONAT AL TETANUS, WESTERN PACIFIC REGION. 1994-1997... ... . . 16
TABLE 6
TABLE 7 TABLE 8 TABLE 9
-
NATIONAL LABORATORY RESULTS 1 9 9 7 . . . ..... INTRATYPIC DIFFERENTIATION RESULTS 1997 ...
. '" 18 . ..... 19
NATIONAL LABORATORY RESULTS 1998 TO I OCTOBER ....... 19 INTRATYPIC DIFFERENTIATION RESULTS 1998 TO I OCTOBER.. . ................. . ACCREDITATION STATUS OF NATIONAL POLIOMYELITIS LABORATORIES .. ACCREDITATION STATUS OF REGIONAL REFERENCE LABORATORIES.. ................
TABLE 10 TABLE II TABLE 12 TABLE 13
20
21 21
ACCREDITATION STATUS OF PROVINCIAL POLIOMYELITIS LABORATORIES IN CHINA.. . .... 22
- 111 -
TABLE 14 TABLE 15 -
AFP RATES PER 100 000 POPULATION <15 YEARS, SOUTIl-EAST ASIA REGION, 1997-1998 ",,''',' ,
..... ",,"" 45
PERCENTAGE OF AFP CASES WITH TWO SPECIMENS WITHIN TWO WEEKS, SOUTIl-EAST ASIA REGION, ...... " ... " .. 45 1997-1998."""" .... "" ..... """""",,.,,"" """'''''",,'''' SUMMARY OF IMMUNIZATION ON RESPONSE TO IMPORTED WILD POLIOVIRUS .. " ... """.' SUMMARY OF SURVEILLANCE RESPONSE TO IMPORTED WILD POLIOVIRUS ""."."" ..... . MEASLES OUTBREAKS AND MASS CAMPAIGNS IN EIGHT PACIFIC ISLAND COUNTRIES AND AREAS, .. " ' . ' " 1997-1998"" ...... " .... " . 48
TABLE 16 TABLE 17 TABLE 18 -
..49
.............. 53
TABLE 19 FIGURES: FIGURE I -
MEASLES MASS IMMUNIZATION CAMPAIGNS, PACIFIC ISLAND COUNTRIES AND AREAS, 1997-1998.. .
. ... 54
IMMUNIZATION COVERAGE IN WESTERN PACIFIC REGION FOR CHILDREN < I YEAR AND PREGNANT WOMEN FOR TT2+, 1984-1997 REPORTED POLIOMYELITIS CASES AND OPV3 COVERAGE, WESTERN PACIFIC REGION, 1974-1998 "...........
3
FIGURE 2 FIGURE 3 -
7
SUPPLEMENTARY IMMUNIZATION IN THE WESTERN PACIFIC REGION INTENSIFIES DURING THE LAST STAGES OF POLIOMYELITIS ERADICATION, 1990-1998.. " ...... "",, .. 8 NON-POLIO AFP RATES PER 100 000 POPULATION <15 YEARS, WESTERN PACIFIC REGION, 1994-1998....... ..... \0
FIGURE 4 FIGURE 5 FIGURE 6 -
PERCENTAGE OF AFP CASES WITH TWO SPECIMENS WITHIN TWO WEEKS, WESTERN PACIFIC REGION. 1994-1998 . \0 REPORTED AFP, CLINICAL POLIOMYELITIS AND WILD POLIOVIRUS CASES, WESTERN PACIFIC REGION. 1993-1997 .. DETAILED FLOW CHART OF AFP SURVEILLANCE. WESTERN PACIFIC REGION BY COUNTRY, 1997 .. PARTNER SUPPORT FOR OPV REQUIREMENT FOR POLIOMYELITIS ERADICATION, WESTERN PACIFIC REGION, 1992-1998 ... ""."""""",, ... ,,""
. II
FIGURE 7 FIGURE 8
............. 13
.... ,," "" 14
FIGURE 9 -
PARTNER SUPPORT FOR OPERATIONAL REQUIREMENTS (NON-OPV) FOR POLIOMYELITIS ERADICATION, WESTERN PACIFIC REGION, 1992-1998..
..15
- IV-
ANNEXES: ANNEX I ANNEX 2 TIMETABLE.................................................... . PROVISIONAL LIST OF TAG MEMBERS, EPI NATIONAL MANAGERS, NATIONAL AND REGIONAL REFERENCE LABORATORY STAFF, OBSERVERSIREPRESENTATIVES AND SECRETARIAT .................................................. ........... 65
.. 67
ANNEX 3 ANNEX 4
MEASLES OUTBREAKS, PACIFIC ISLAND COUNTRIES AND AREAS, AS REPORTED TO WHO, 1974-0CTOBER 1998 .... 79 CRITERIA USED FOR ACCREDITATION OF NATIONAL POLIOMYELITIS LABORATORIES ............................... .............. 81
CONTENTS
I.
INTRODUCTION 1.1
...... I
Objectives ... 1.2 Organization .. I. 3 Opening ceremony. 2
2.
PROCEEDINGS 2.1 Global EPI overview 2.2 Regional EPI overview......... ............ ................ ............... 2.3 Regional laboratory overview... .. ............. . 2.4 EPI issues ." ............. . ............
2 ............. . 3 ............ 18 . .. 23
2.5 2.6 2.7 2.8 2.9 2.10 2.11 3.
Regional operational overview.. .................... ........... ... 26 Country reports. ........ .... . .. ... 29 Poliomyelitis eradication: Progress in South-East-Asia Region (SEAR).. . . 44 Cross-border coordination: report of activities in 199711998.. . .................... 46 Regional poliomyelitis eradication certification issues. ... ........ . .. 47 Neonatal tetanus elimination....... . . 51 Accelerated measles control.. ... ... ....... . 52 ................... 55 . .......... 56 . . 56 ..56 .57 . ................. 59 ........... 60 ..60 ....... 61 ..61
INTERAGENCY COORDINATING COMMITTEE. 3. I Resources req uirements ...
4.
CONCLUSIONS AND RECOMMENDATION .... 4.1 4.2. 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4. \0 4.11 4.12 Progress since the last TAG meeting ........ . Poliomyelitis eradication .. Certification of poliomyelitis eradication .. Accelerated measles control activities.. ......................... . Neonatal tetanus elimination. Routine EP I activities ..... . Hepatitis B immunization .. New vaccines ... Safety of injections ................... . Vaccine Self Sufficiency Sustainability of EPI . . .......... . Requirements for continued financial cooperation.
.............................. 62 . . . . .......... 62 ..................... 63 .. 63
..64 ..64
5.
ACKNOWLEDGEMENTS .......................... . Keywords:
Immunization / Poliomyelitis - prevention and control/Western Pacific / Philippines
I. INTRODUCTION
The Western Pacific Region has been free of indigenous wild poliovirus since March 1997. The last case of poliomyelitis in the Region had onset of paralysis in Cambodia on 19 March 1997. This achievement is the result of the resolution for poliomyelitis eradication in the Region adopted by the WHO Regional Committee in September 1988. The first meeting of the Technical Advisory Group (TAG) on EPI and poliomyelItis eradication was held in Tokyo, Japan, in April 1991. A total of nine TAG meetings have since been held. The ninth meeting of the TAG focused on maintaining the poliomyelitis-free status in the Region by sustaining high quality acute flaccid paralysis (AFP) and virologIcal surveillance, the response to the possible importation of wild poliovirus, and the conduct of subnational immunization days (SNIDs) in high-risk areas.
l.l
Objectives
The TAG held its ninth meeting at the WHO Regional Office for the Western Pacific in Manila, the Philippines, from 3 to 6 November 1998, with the following objectives: (l) to review the EPI and poliomyelitis eradication situation in the Western Pacific Region; (2) to make further recommendations for action on EPI and other disease initiatives based upon a review of progress made since the 8th TAG meeting, particularly in the area of laboratory surveillance: (3) to disseminate information on the latest EPI developments, including neonatal tetanus elimination and measles control; to make recommendations on supplementary immunization activities for 1999 and (4) beyond; and (5) to ensure continued progress, particularly in surveillance quality, towards certification of poliomyelitis eradication.
1.2
Organization
The meeting was attended by 78 participants and observers. These included five members of the Technical Advisory Group, EPI managers from eight poliomyelitis-endemic countries within the Western Pacific Region, and representatives from the national and regional reference laboratories, international organizations, the WHO S0uth-East Asia Region. other partners in poliomyelitis eradication, and the secretariat Annex I shows the timetable ofthe meeting and Annex 2 contains the list of participants. 1.3 Opening ceremony
Dr N.V.K. Nair, on behalf of Dr S.T. Han, Regional Director, WHO Regional Office for the Western Pacific, opened the meeting and congratulated those in attendance for the achievement of interruption oftransmission of wild poliovirus. He said that the last case of poliomyelitis in the Region had had onset of paralysis in Cambodia on 19 March 1997. He also noted the progress was
-2-
being made in other areas of EPI such as neonatal tetanus elimination, measles control, ensuring safe injections, and vaccine self-sufficiency. He urged participants to be aware of the risk of the re-introduction of wild poliovirus through importation from countries in other regions, and the need to keep up the momentum that has been developed since 1991. The resources and experienced staff that had been built up over the years for poliomyelitis eradication could be used to address other challenges in the EPI. Integrating AFP surveillance with accelerated control of measles and neonatal tetanus elimination would help sustain and improve surveillance for other vaccine-preventable diseases. Dr Nair concluded by thanking all the partners for their support, including UNICEF, the Government of Australia, through AusAID; the Government of Canada; the Government of Italy; the Government of Japan, through JICA; the Government of Malaysia; the Government of the Netherlands; the Government of the Republic of Korea; the Government ofthe United States of America, through the Centers for Disease Control and Prevention, Atlanta; Rotary International· and Rotary Japan Districts 2640 and 2650. The following TAG members were appointed to serve as officers for the meeting Chairman Vice-chairman Rapporteur Dr Isao Arita Dr Kenneth Bart Dr Robert Hall
2. PROCEEDINGS
2.1
Global poliomyelitis eradication overview
The years 1997 and 1998 had seen continued acceleration towards the goal of poliomyelitis eradication. The number of reported poliomyelitis cases globally had declined to 5274 cases despite improving surveillance, representing a -90% decline since the goal had been declared 10 years previously. Progress was also evidenced by the shrinking geographic distribution of wild poliovirus as well as the decreasing heterogenecity of circulating poliovirus genotypes. In 1997, three-quarters of the world's children had been reached with oral poliovirus vaccine (OPV) during national immunization days (NIDs), reflecting the massive efforts, coordination and commitment by most endemic countries. Acute flaccid paralysis (AFP) surveillance had also improved, although continued improvements were needed to reach the standards necessary for certification, particularly in the African Region. Of note was the rapid improvement in surveillance during 1997 and 1998 in India largely due to the placement and mobilization of dedicated surveillance officers throughout the country. The major focus was now placed on interrupting transmission in the major global reservoirs which were characterized by large and highly susceptible birth cohorts, high population density, and prevailing conditions of poor sanitation. Those factors combined favoured efficient poliomyelitis transmission as evidenced by persistent wild poliovirus type 2 circulation. The global reservoirs included the Indian sub-continent, West and CentraJ Africa, and the Horn of Africa. A large proportion of the remaining endemic countries also included those effected by political turmoil, such as Afghanistan, DR Congo, Liberia, Somalia, and Nigeria. Innovative strategies were being aggressively implemented in those countries, including the implementation
, -3-
of additional NIDs/mopping up rounds, and the use of vaccine vial monitors (VVM) to take vaccine beyond the cold chain into areas with no health infrastructure. Although US$150 million had been contributed during 1998 through the generosIty of major international partners, a shortfall of US$65 million remained to cover the costs of surveillance (including laboratory support), and to accelerate efforts in the remaining global reservoirs and countries in conflict. In summary, the goal of poliomyelitis eradication was in sight and could be achieved if adequate resources were mobilized and efforts were accelerated in the remaining poliomyelitis-endemic countries. 2.2 2.2.1 Regional EPI overview Immunization coverage
In 1997, the regional coverage for EPI antigens had been 95% for BeG, 95% for DPTJ, 95% for OPV3, and 94% for measles (see Figures 1 and 2). Most countries had sllstained a high level of coverage for EPI antigens, or had consolidated the gains in coverage made in previous years (see Table I) while simultaneously carrying out poliomyelitis eradication.
Figure 1. Inununization coverage of infants < I and pregnant women for TI2+, Western Pacific Region, 1984-1997
• Exduding China from 1995. Dale from WHOfWPRO eElS sy&tem.. as of J October 1998.
-4-
Table I: EPI antigen coverage among infants and pregnant women in selected countries of the Western Pacific Region, 1995-1997 (as at 10 July 1998)
t--------
Cambodia
95 92 ----
90 97 61 9, 79 90
82 96 58 96 -----
79 ----
75 95 58
70 96 60 92
80 94 64 86 67
76 96 ..
70 9? 69 .-
75 93
72 97 73 B8
68 96 67 94
36
36
31 ._-
1---------
China
92 54
r----- - 68 -
n, 35
n, 31
n, -na 32
t----
Lao POR Mongolia
'--
59 94
6S
Papua New Guinea
88 91 96
67 83
88 90 .-60 56
-
90 ~ .
92 35 83 95
85 42 86 96
na ---
n, 65 43 96
-86 94 90
45 83 95
----86 --
57 ----
45 -
1--83 98
40
-r--46 91
62
1---- -. Viet Nam
Philippines ...
90
I 95 96
~~~!,:¢~~,~~~'• ExQjCli1ii1 Chlia •• c ....
. 92 . 96 I~.~y.
96
. 94
-.
90 94
90 96
48 82
94
96
84
.
. ,S6
$a
. .
60'
96'
.~
..
,.!iI. rD." I.... 2 ..... <if ·~ully
I ••• ,d for prognOn1
w."'."
••• ON)'
U,'lI\y .... U CMdr ... • Gil. I.... allal>l~ "n" 1n.
n. "NOloppl'OCII.·
2.2.2
Impact of EPI on target diseases
The incidence of vaccine-preventable diseases in the RegIOn in general remained low. Poliomyelitis cradication was now in the certification stage, Several countries had commenced intensified measles control activities and it was expected that the incidence of measles would drop to very low levels in the southern part of the Region, including the Pacific Islands. in 1999. Improvements in tetanus toxoid immunization of women and in surveillance had reduced neonatal tetanus to much lower levels in the few remaining high-risk areas. Major diphtheria outbreaks in Mongolia and the Lao People's Democratic Republic in 1995 and 1996 had been effectively contmlled with large-scale immunization campaigns. PertussIs rates were reportcd as remaining low in most countries. 2.2.3 Poliomyelitis eradication
As no new wild-poliovirus-associated case of poliomyelitis had been detected since March 1997, under conditions of high quality surveillance, there was good reason to believe that indigenous wild poliovirus transmission in the Western Pacific Region had finallv ceased. Epidemiological situation at the end of 1997 As at I October 1998, 5963 cases of acute flaccid paralysis (AFP) with onset in 1997 had been reported in the Region, of which 83% had had two stool samples taken within 14 days of onset Nine wild-poliovirus-associated poliomyelitis cases had been reported with onset in 1997, Eight of those cases had originated from Cambodia in the same areas as cases reported in 1996, The ninth wild-poliovirus-associated case had been reported from the central region of Viet Nam.
By the end of 1997, all countries had reached the level of AFP and laboratory surveillance quality which enabled them to confirm as poliomyelitis in 1997 only those AFP cases where wild poliovirus was detected in the stool samples, Therefore the total number of poliomyelitis cases reported in the Region for 1997 had been only nine cases (see Map 2)
-5-
Thus, 1997 had been the first year for which five countries recently classified as poliomyelitis-endemic (China, the Lao People's Democratic Republic, Malaysia, the Philippines and Papua New Guinea) had reported no poliomyelitis cases. That contrasted with 6000 poliomyelitis cases that had been reported throughout the Region in 1990 (see Map I). The last poliomyelitis case that had been reported in the Region had had onset of paralysis on 19 March 1997 in Cambodia.
Map I: Distribution of poliomyelitis cases in the Western Pacific Region, 1997
.Ex.,.nd.d~~~~~ZIIlion
, . :~S:;~ P~~c
.. ./
Poliomyelitis cases J997
//,i i/' .I
Number of poliomyelitis cases:
.'
9 as of 1 October 1998
-6-
Map 2: Distribution of poliomyelitis cases in the Western Pacific Region. 1990
Western Pacific Region .~ i ,----",.
.Ie.\ ~
~....>
'" .N n ,,-C.FY I 'or I
-V~
.'
Poliomyelitis
1990 Number of cases: 5,9911
Table 2: Total AFP cases reported, confirmed poliomyelitis cases and wild-poliovirus-associated cases. Western Pacific Region, 1993-1997
-*
China wild virus imported. U No data. Latest available data trom WPRQ AFP Surveillance System as of I October 1991<.
-7-
Figure 2. Reported poliomyelitis cases and OPV3 coverage, Western Pacific Region, 1974-1998 •
Poliomyellis cases
OPV3 Coverage (%)
14,000 , - - - - - - - - - - - - - - - -
100
12,000 80
10,000 60
8,000
6,000
4,000
2,000
o Year +Data provisIonal as of I October 1998 Source: WHO/WPRO eElS and AFP survt:,Uanct: system
Epidemiological Simation in 1998 As at I October 1998, 3307 AFP cases with onset in 1998 had been reported in the Region, 86% of which had had two stool samples taken within 14 days of onset. Surveillance and supplementary immunization activities had been intensified throughout 1997 and 1998. As a result, even though over 8000 AFP cases had been investigated throughout the Region since the onset of the last poliomyelitis case on 19 March 1997, no new cases of poliomyelitis had been detected. Therefore the regional total for poliomyelitis was zero cases for 1998, under conditions of high quality surveillance. It had been the experience in the Western Pacific Region that the efforts to eradicate the last few remaining wild polioviruses were far more intense than at the beginning of the poliomyelitis eradication initiative (see Figure 3).
-8-
Figure 3. Supplementary immunization in the Western Pacific Region intensifies during the last stages of poliomyelitis eradication, 1990-1998 *
7 6 Number of Countries Conducting:
!4 ! 3 , ~
is
-
--
-
-
-
6
...... ... -+
NIDs SNlDs HRRls
i
2 1 -------
-------
0
90
91
92
93
94
95
96
97"
98"
"'Data irom WHOIWPRO CEIS system,
115
of 1 October 1998
Supplementary PPV immunization A total of26 national immunization days (NIDs) had been conducted in the Region from 1992 to 1998 (see Table 3). Supplementary immunization in the 1997-1998 low transmission season had been carefully planned with the aim of making certain that wild poliovirus transmission had ceased by the end of 1997. Cambodia, the Lao People's Democratic Repubhc and Papua New Guinea had conducted national immunization days (NIDs), while China, Mongolia and the Philippines had held subnational immunization days (SNIDs). In addition, in early 1998, Cambodia and Viet Nam had carried out two rounds of high-risk response immunization (HRRI) for over I million children under five years of age in each country. From November 1997 to April 1998, Cambodia and Viet Nam had each carried out a total offour rounds of supplementary immunization in high-risk areas. During those activities mobile teams had made visits from house to house or boat to boat on the waterways of the Mekong River to ensure that no child aged under five years of age would be missed. The numbers of children reached by mobile teams in these areas had increased, and therc has been a marked decrease in the proportion of incompletely immunized children.
-9-
Table 3. National immunization days, and high-risk response immunization, Western Pacific Region, 1992- 1998*
60%
600,000
5 Vbftlll'lA Tet ..... Toxoid .
' .Smlllio"
• Dall fi'M1 WHOWPRO CEISu('r1 0tI1:'ber
1m
NNe 94,7";. orthe (Nil PI'PUlatK'1I ofWPR Iwe UI !h~e endemIC CNllltnes
Poliomyelitis surveillance indicalOrs By the end of 1997, all eight recently-endemic countries of the Region had attained the quality of surveillance required to adopt the virological classification of AFP cases. thereby confirming as poliomyelitis only those cases for which wild poliovirus had been detected in their stools. All eight countries were reporting non-poliomyelitis AFP rates exceeding one per 100000 population under 15 years of age. Three countries had adequate stool sampling rates slightly lower than 60%, but were able to augment the quality of survei llance with other information, including active search data, that provided additional evidence consistent with the absence of wild poliovirus. Improvements in completeness and timeliness of AFP surveillance in each country since 1994 were illustrated (see Figures 4 and 5). More complete data was also made available (see Tables 4 and 5).
- 10 -
Figure 4. Non-polio AFP rates per lOa 000 population < 15 years. Western Pacific Regio!l, 1994-1 998*
4 , -- - - -- -- - - - - - -- - - - --
Non-Polkl AFP Rate
-
3
2
1
o CHN LAO
MAA
MOO
PIC
PNG
PHL
VTN
- Data from WHOJ \\'PRQ CEIS. as of I October 1998
Figure 5. Percentage of AFP cases with two specimens within two weeks. Western Pacific Region, 1994-1998 *
--
----,
LJ() - Data from WHOIWPRO e ElS, IL$ of I October 1998
VTN
- II -
The decline in reported poliomyelitis and wild poliovirus against a background of high level AFP reporting was outli ned (see Figure 6).
Figure 6.
Reported AFP, clinical poliomyelitis, and wild poliovirus cases, Western Pacific Region, 1993- 1997
- Wild Virus
6 ,000
• Confirmed Polio Cl AFP reported
4,000
2,000
1993
1994
1995
1996
1997
· Data from WHOJWPRO eElS Sy5tem, as of 1 October 1998
TI6b1 e 4 : AFP Surveillance lndicator3, Westcrn Pacific Regio n, 1994 - 1997" Cue Investigation Completeness and Timeliness in Percenl r.-')of Report ed AFPCues , By Co untry
Performance Indicator 1994
C antbodi a 1995 1996 1997
ChUla
I.• .,. 1997 1994 1995 1996 1997 1994
P:-IG 1995 1996 1997 1994
P hlllppln u 1995
199.
199.5
1996
I.,. 8 So.. 97·"
Vle.N.... 1997 1994 1995 1996
1997
1. Case inves tigat io n Compi ece ll tss I.J AFP inves t igated 1 2 Fo U olAcd up afier 60 d ays 2. Cllse Inv es llgatio n Tim eli ness 21 WithUl 48houn: 22 Wit hin 7 days
38~
,.. " .. ".. " . ., .. . .... "" 10092% 87-.
,."
9....
100% 100% 100% 100% 100% 100%
83"
1140 0 9 ... 99'"
» ..
.... ....
Ss o..
59',
9S"b 8Soo
97% 119·...
0%
3 8"
9 1''0
.,%
KII ~"
.2% '2'
IOO ~
100 %
76% 8 0~
"% 79° •
92%
14'
"" 3."
m. '2"
0', 0" 0..
n" n ..
41 ....
3.'>
32'> 72~.
."-
94°"
96".
100-.. 100..
SS ...
,."
,,,. " . 90°", 95"
» ..
.. " .. " ,,"640...
'6" "" .0096%
83% 8S' Hi..
'0"
.... 78°.
".. 63"0
..,."'" 86% 92C!i1 IV
6... 75°.
Table 5: AFP SUIVfe illan ce Ind ieatotl, Western PaculC Region, 1994· 1997 • Laboratory Specimen Comp leteneSll and Timelineu III Percent (0_ . ) of Reported Arp Caus, By Country
Performance Indicl6lor 1994
C..n bodh, 1995 1996 1997 J994
Chl llll
l AOS
I. Laboratory Compld en eu
1.1 1.2 2 I
:>-
I $1001s pecimen
17'. 12"" 0
48'_ 46~.
110' 80"•
:>" 2 s t oo l ~ p eci m e n s
2. Lab ora tory Ti melin ess '>-
.." .,.. "" . .,.. . .... ... ."'" .... 1995 1996
1997
1994
l"~
''''
199'
,,,. 0..
P' G 1995
'''' 73".. S9~1I
199' 72 ...
,,,. '0,,60·..
P h llippitl c:~
Vlc:t Nam 1997
1995
1996
199' HII\
1995
I.,.
97°"
77..
,"-
66'0
118°6
I s tool within 14 da ys
11
2.2 2stools wi1hin 14da ys
",
"
32"0 30'"
SS"i>
76 0 • 7 10"
.00. '00. SO"o 7S""
n"",
".. 86"-
.... 87°..
.6"
118"_
9',,-
HI"'"
90" •
0',
31°. 3Soo
""
'2" 41 ..
.,. 760 • oil"" 32".
Xo o• 10'. 47·, 41"0
9 1'" 8S~"
0'. (1 41 0
SO"
.,"S6·.
72 0 0 70"0
3S'"
0'. 0',
41-" 27 11..
20' .. 29°0
61°1J 56""
] I'.
36'.
.,.. 74'. .." ,... 6'" S9' O 87"•
,,"-
'0"
.,.
1997
.
9, ..
,"
IS".
49°.
80°0
-I)nu 110m WHOIWPRO eElS syst,'m.
A5
011 (>dob.:r 191)1'1
- 13 -
Figure 7. Detail ed fl ow chart of AFP surveillance, Westen! Pacific Region by country, 1997*
CHN LAO MAA
4,883
.9
M OG PIC PNG PHL VTN
293 4'3
" " "
12
CHN LAO M AA M OG PIC PNG PHL VTN
0 0 1. 1 12 2 1 27
CHN LAO MAA MOG PIC PNG PH L VTN
4,883
79 73 17 0 39 292
43.
CHN LAO MAA
.4 787
M OG PIC PNG PHL VTN
18 12 39 293 4.3
.. 77
CHN LAO MAA M OG PIC PNG PHL VTN OTH
116
2 3 0 0 2 0 0 0
1
CHN LAO M AA M OG PIC PNG PHL VTN
0 0 0 0 0 0 0
CHN LAO M AA M OG PIC PNG PHL VTN
45 17 0 2 0 8 20 12
CHN LAO M AA M OG PIC PNO
4,559
60 3. 15
PHL VTN
20 273 422
•
CHN LAO MAA MOG PIC PNG PHL VTN
,.3 0 SO 4 11
0 28
• Data as of I October 1998,
- 14 -
Partner support for poliomyelitis eradication The rapid progress in poliomyelitis eradication would never have been poss ible without the support of many international partners . They included UNICEF; the Governments of Australia, through AusAlD; the Government of Japan, through JlCA; the Government of the Republi c of Korea; the Government of the United States of America, through the Centers for Disease Control and Prevention in Atlanta; the Agency for Cooperation in International Health (ACIH) ; Rotary International; and Rotary Japan Districts 2640 and 2650. While the costs of providing vaccine for supplementary immunization were decreasing, the costs of sustaining surveillance during the certification period would rema in the same, even though wild poliovirus was no longer circulating in the Region. (1) Vaccine
From 1992 to 1998, US$47 .9 million had been provided by international partners for the purchase ofOPV for supplementary immunization (see Figure 8). Figure 8. Partner support for OPV requirement for poliomyelitis eradication, Western Pacifi c Region, 1992-1 998 * .
Total: US$ 47.9 million Rotary Irterretiorel Zl%
United states 13%
UNICEF 13%
ahe 4
Jallln _ _ __ 37%
Australia 6%
Data as of 1 October 1998; indudes corrrnitted as IM311 as received funds.
(2)
Operational Support
From 1992 to 1998, US$20.92 million had been provided by international partners for staff, supplies and equipment, and operational costs for surveillance and supplementary immunization activities (see Figure 9).
- 15 -
Figure 9. Partner support for operational requirements (non-OPV) for poliomyelitis eradication, Westem Pacific Region, 1992-1 998 •
Total:
US$ 20.92 million 27%
20% 'As of 1 October 1998: includes committed as weY as received funds, QIflriE' 16$0 Japan
"!uri" BouKY
2.2.4
Neonatal tetanus elimination
The six countries in the Region where neonatal tetanus (NT) remained a problem were: Cambodia, China, the Lao People's Democratic Republic, Papua New Guinea. the Philippines, and Viet Nam. Routine immunization with tetanus toxoid was steadily increasing in coverage ill al l of those countries (except China where routine doses were not being given but campaigns were being conducted in high-risk areas) . Surveillance for NT was still inadequate and fell far behind AFP surveillance in quality. In order to meet d,C goal of < I NT case per thousand li ve births per district by 2000, the approach for most countries would be to integrate NT , ith active surveillance fo r AFP, followed by a tetanus toxoid (TT) immunization response in the local area of new NT cases: In the longer term, boosters ofTT for school children would provide adequate protection from NT. China had conducted an evaluation of NT elimination activities in five provinces . Cambodia, the Lao People's Democratic Republ ic and Vict Nam were using the protection at birth methodology to measure tetanus toxoid coverage. Viet Nam had carried out an analys is of 474 neonatal tetanus eases that had been reported from 1994 to 1997. As a res ult of d,at study it had been concluded that d,e criteria set for 'protection at birth' (defined as two doses of tetanus toxoid for the mother during the last pregnancy, or at least three doses of tetanus toxoid at any time in the past) were valid and reliable enough for use by healdl workers to monitor the neonatal tetanus (NT) elimination prograrnme, and assess rapidly the eligibility of women for furd,er tetanus toxoid doses. 2.2.5 Mcasles control
Measles had declined substantially in the Western Pacific Region over d,C previous 25 years, but remained a significant cause of morbidity and mortality (see Table 6). Although there was considerable variation in measles vaccine coverage rates in different countries, overall coverage for the Region had been reported to be 94% in 1997. Outbreaks of measles usually began in pockets of low immunization coverage and soon spread to affect the whole community, where susceptibles had accumulated over time. Analysis of outbreak data usually showed that the cause was failure to immunize rather than vaccine failure .
- 16 -
Mongolia had conducted a mass immunization campaign against measl es in May 1996, targeting children aged 9 months to II years, resulting in reduction of measles cases in the second half of 1996 to 15% of the number of cases that had been reported in the same period in 1995 . During 1997, with weekly active surveillance, no confirmed cases of measles had been reported in Mongolia. in 1998 (data as at 22 August) only nine cases had been reported . Out of the 20 Pacific island countries and areas, 15 had a lready conducted nationwide measles campaigns in 1997 and 1998. New Zealand had conducted a measles campaign in 1997 and had successfully averted a major outbreak. Australia had launched a national measles campaign in August 1998 . The Plulipplnes was carrying out a national measles campaign for children from 9 months to 15 years from September to October 1998, targeting 27 million children. Other large countries had not yet embarked upon measles campaigns, but surveillance for measles was being improved in Cambodia, China, the Lao People's Democratic Republic and Viet am by integration with AFP surveillance wherever possible. Table 6. Reported cases of measles and neonatal tetanus, Western Pacific Region, 1994-1 997 • Country 94 96 0 1,196 NR 2,038 53,Zl2
Measles 96 0 496 0 97 12 853 13 3,826
Neonatal Tetanus
American Sarma Australia Bnrei ~ia
NR NR 946 76.204 0 !W 39
NR 2,81 4 68,404 0 3IY 39 3IY 0 110 1,640 13 917
94 0 NR NR 147 4,228 0 0 0 0 0
95 0 0
98 0 0
97 0 0 34 4,314 0 0 0 0 0 0
NR 8
9 3,7!i8 0 0 0 0
01,... Cook,s. Fed st. of Mcronesia F,i ~PoIynesja Horg Kong .Japon
82687 194 0 828
3,391 0 0 0 0 1 0
95 228 210
7 0 414 7 0 -
33
NR 292 964 52 3<16 0 177
NR 4 3,174 3
518 0 318 1,640
NR NR 0 10 0 9
NR 0 6 0 12
NR 0 17 9 0
NR 0 12 0 15
Kiribati
25 671 3 5ffi 0 4 58
Laos Macao MaI<l)Sa
654
_,lsIards MongoIja
NR 5Ii5 0 2 NR
4al 0 128
0 0
NR 0 0 0 0
0 0
0
NallU NewGaledoria
NR 6
NR 0 0
0 2,041
NewZealand
33 2 29
0 0 0
Niue Northern Weriars Is. Papua New runes PHlippires Rep. d I<i:Jrea
0 0 0 3,731 4,061 71 0 186 0 0 0 1
0 0 2.313 12,356 71 67 0
0 1 0 2,717 36,4ffi 2 0 1,413
0 0 0 159 336
0 0 0 134
0 0
Palau
0 6,821 3,006 7,B83 0 159 -~
0 0 0 61 338
2B8
65 364
NR 0
Sanoa Slrgapore
NR NR 0 3 0 0 0
0 1
Sdorron'....... ToI<eIau
NR 0
0 0 0 1
640
0 287 1,CB1 14 113 6.9:>7 0 142,956
Torga
NR NR 0 27 11.853
0 0 51 4 5.156
NR NR 0 0
0 0
r-rNom w,lIis ard F\.tIJ1a · 01111
~
-~-
0 2 '25l 4,492
NR 6,171 13 75,543
NR 3D 0 4,173
9 110,971
,
422 5,311
0 0 0 '25l 0 5,112
\l\est.em Paclftc Region
95,636
from Wl10IWPRQ eElS system. lIS of 19 N(wcm~r 1998
- 17 -
2.2.6
Safe injection practices for immunization
There had been some useful achievements towards ensuring safe injection practices by the year 2000. Several countries had used auto-destruct syringes and safety boxes during measles immunization campaigns, and were planning to introduce them for the routine EPL though auto-destruct syringes were more expensive than ordinary disposables. Many countries now had plans of action for improving the safety of injections, but there had been some delay in implementing them fully. There had been trials of auto-combustion incinerators in Cambodia. the Philippines and Viet Nam. These trials had so far proved successful in the collection of used syringes and needles for destruction, but less so in the destruction process. Trials were continuing. 2.2.7 Logistics and cold chain
New cold chain equipment was being provided by partner agencies to replace existing units in many countries. Vaccine vial monitors (VVMs) had been distributed widely on OPV vials throughout the Region. After some initial problems, they had been proving useful, particularly with outreach immunization. Field workers were able to keep open vials of OPV in their vaccine carriers and continue to use them as long as the VVM showed that the vacCllle was still viable. However, there remained a need to train health workers on the usc of this new technology. 2.2.8 Introduction of other antigens
All except two (Cambodia and the Lao People's Democratic Republic) of the countries and areas of the Region had incorporated hepatitis B immunization into national immunization programmes, although for some countries full national integration had not been achieved. The Pacific island countries continued to achieve high coverage leve/s, particularly as the continuity of supply of vaccine had been assured by international partners. At the end of 1997, 13 of the 20 Pacific island countries and areas had reported hepatitis B coverage of over HO% for infants. TIle cost of the vaccine and limitations in local production had affected the availability of vaccine, particularly in the larger countries. Where vaccine supplies were adequate, integration of hepatitis B into national immunization programmes had been highly successfu I. 2.2.9 Vaccine quality and self-sufficiency
Several countries had been supported in developing good estimates of vaccine reqlllTements for the medium term. The situation of self sufficiency for routine vaccincs (excluding hepatitis B) was improving for most countries and only three countries (Cambodia, the Lao People's Democratic Republic and Mongolia) remained totally dependent on partner agencies for vaccine supplies. The Regional Office was actively collaborating with centres of excellence for vaccine production and quality control. Technical support was being provided to several countries, in particular China, the Philippines and Viet Nam, on vaccine quality issues. The major focus continued to be on the strengthening of national control authorities. 2.2.10 Conclusions
The EPI continued to be a highly successful programme throughout the Region. There was a welcome trend towards greater self-sufficiency in vaccine supply. However. most countries had concerns about sustaining the EPI in the face of financial changes. Many oftbese problems could be solved by improving simple management procedures, including the better management of resources. Wild poliovirus had not been reported in the Region since 19 March 1997. the date of onset of the last poliomyelitis case. Given the sustained high quality of AFP and virological surveillance in recently-endemic countries there was growing confidence that the circulation of wild poliovirus had been interrupted in the Region. Even so, supplementary immunization would continue in
- 18 -
high-risk areas, particularly in the waterways of Cambodia and Viet Nam where the last wild polioviruses had been detected. There had been much progress in accelerating the control of measles. The mass immunization campaigns against measles that had been conducted in Pacific Islands and other countries were expected to minimize future outbreaks of measles and their consequences. In addition, new efforts were bcing made to improve measles surveillance. Surveillance for neonatal tetanus was steadily improving, as was immunization coverage with tetanus toxoid. A greater emphasis was being placed on responding to reported cases of neonatal tetanus, and the protection at birth method for measuring tetanus toxoid coverage was gaining wider use. 2.3 2.3.1 Regionallaboratorv overview Laboratory results
More than 11 000 stool specimens from almost 6000 AFP cases had been processed by national and subnational po\Jomyelitis laboratories in the Region in 1997. As of 1 September 1998, more than 6500 specimens from almost 3500 AFP cases had been reported as received in 1998. A total of nine wild poliovirus-confirmed cases had been reported for 1997, eight of those cases occurring in Cambodia and one in the central region of Viet Nal11. All of those cases were associated with wild poliovirus type 1. The date of onset of paralvsis of the last wild poliovirus-associated case had been 19 March 1997. No wild-poliovirus-ass~ciated cases had been detected in the Region since that date. Laboratory results for 1997 and 1998 to I September were presented (see Tables 7 to 10). Table 7. National laboratory results 1997 National Polio Laboratories
Cowttry
-"IID,Tokyo Prov. Lah~
CAM
AFPwith specimens submitted in 1997 JR3
PI 10 36
1'2
P3
Polio mix
CHN LAO r.,·IAA
NIIO,Tokyo
4bOO 74 68
2 97 ()
, 42 ()
Polio fNPEV 2
% At.P cases positive for :\,PEV
"'/0 of results reported
within 28 days 52%.
.'
21<° ... 17° 1,1
I 0 0 0 2 0 0 0
'" 1 3 0 0
27 0 0 0 0
89C!·o
]4% 60,'0
22% 78% 43 0/1,1 79% 3R% 29 0.0
I'll<, KL lilaanbaatar VIDRL, Aus PNG IMR
MOG PIC
14 9 29
1 0 0
0
0 0
7"" 44~'~
PNG PHI.
0 0
I 0 0
0 I
0
:qoo 41 0.0 22"·-0 22 oJ " I XO o 19%
RITM, Manila HoChi Minh Hanni
VTN VTN Oth.
2"" 197 241 33 5736
2 0 0 0
I I 0
4 0 0 60
53% 80% 88% 77%
2 0
0 49
ToW
102
48
31
- 19 -
Table 8. intratypic differentiation results 1997 AFP with polio Regional Reference Laboratory
Intra ypic differentiation results ID resutts
Country
AFPwith wild virus In 1996
NIIDTokyo CAPM Beijing
CAM CRN LAO MAA MOG PIC
15
3 I 0
isolates submitted to Reference laboratories In 1997 20 250 2 4 0 0 3 3 8 0 290
Polio I Total 13 85 I 0 0 0 2 2 5 0 108 WUd
Polio 2
Polio 3 Total G
Total 5 158 0 0 0
WiJd
Wild 0 0
within 90 days ofonsd 741):,
8 0 0 0 0 0 0 0 1 0 9
0 0 0 [)
71 0
63% 0%
NIID Tokyo VIDRL, Aus.
0 0 0 I)
3 (j
0%
NIlDTokyo VlDRL, Aus. NIID Tokyo VIDRL, Aus,
0 0 0 0 2 0 21
0 0 0 0 0 0 0
0 0 2 (,
0 I 2 7
PNG PHL VTN Others
0 I)
OOli)
0% 40~,o
0 [)
0 171
0 911
Total
0
60%
Table 9. National laboratory results 1998 to I October National Polio Laboratories AFPwith specimens submitted in 1998 109
Country
PI
P2
P3
Polio mix
Polio INPEV
NHD,Tokyo Prov_ Labs NIID,Tokyo
CAM eRN LAO MAA MOO PNG PHL VTN
[)
[)
2 19 0 0 0 [)
0 31 0 1 0 0 1 0 0 0 0 0 0
0 20 0 0 0 0 I 0 I 0 0 0 0 0 0 22
% of results reported laboratory positive for within result NPEV 28 daYli 49% 12 97%
AFP cases pending
%AFP I.:ascs
3047 39
24 0 0 0 0
83 I 0 0 0 0 0 I 0 0 0 0 0 0 85
297 0 0 3 4
15% 36"/0 2'70
96%
95% 100 1%,
IMR. KL
48 25 21 246 245 252 7 21 0 4 3
UJaanbaatar PNGIMR RITM, Manila
5% 35% 22<;-0
65% 65'% 60% t(8%
0 0 [)
0 0 0 0 0 0
48 28 6 2 2 0 0 0 0 402
Hanoi Hoehi Minh VIDRL, Aus Hong Kong
24°'a :B~'o
\'TN AUS HOK KOR NEZ PIC SIN
0 0 0 0 0 0 24
20% 5%
;;<9% 100 % 100°'0
Seoul Wellington Fairfield, Aus Singapore
1 0 0 22
00;(,
75% lOO~Q
0 0 33
67% 40°'0 18%
5 4072
100%
Total
91%
- 20 -
Table 10. Intratypic differentiation results 1998 to I October AFP Regional Reference
Country
Laboratory NIID Tokyo CAPM Beijing NIID Tokyo
with wild virus in 1997 8
CAM
AFP with polio isolates submitted to Reference laboratories in 1998 2 177 I I
lntraty. ic differentiation results
m results Polio 1
Polio 2
Polio 3
Total 0
Wild 0 0
Total 0 77 1 I
WUd 0
Total
Wild
within Results 90 days of pending onset 0 100%
2
0 0 0 0 0
CHN LAO MA.~
0
47 0 0
0 0
37 0 1
26 0
77% 100%
0 0 0
0
VIDRL, Aus. NIID Tokyo VIDRL. Aus. NIID Tokyo VIDRL, Aus. NIID Tokyo VIDRL Aus.
0 0 0 0
0 0 0
0 0 0
100%
MOG rNG PHL
0 0
0 0 1
0 0 I
0 0 1 0
0
0 1
2 2
0 0 0 0
VTN AllS HOI.:
0 0 0
0 0 0 0 0
1
0 0 0
" "
0
"
0% 100%
0 0 0
" 0 0 I
0
0 0 0 1
()
0 0 0 0
" 0 0
KOR NEZ PIC SrK
0 0
0 0
0 0 0 9
0 0 0 0
0 0 0
100%
0
0
0
0 0
0 0
0 186
0
0 0
0 81
Total
48
0
42
26
77%
2.3.2
Routine proficiency monitoring
Monitoring of routine laboratory proficiency, timeliness and non-poliomyelitis enterovirus isolation rate, had continued through the monthly laboratory results reporting systeIil. Routine proficiency monitoring results were provided (see Tables II to 13). For the Region as a whole in 1997, 77% of laboratory results had been available within 28 days of specimens receipt in the laboratory, and 87% of results had been available withm42 days. To date in 1998.91% of results had been available within 28 days of receipt in the National laboratory, and 97% within 42 days. In 1996 a new criterion for suneillancc timelines had been introduced, that 80% of all poliomyelitis isolates should have intratypic differentiation results available within 90 days of onset of paralysis. Only 34% of all cases with poliovirus isolates had had final results available within 90 days in 1996. That had risen to 60% in 1997. As of I September 1998. 77% of all poliomyelitis isolates from AFP cases had had intrat)pic differentiation results available within 90 days of onset of paralysis. For the Region as a whole in 1997, non-poliomyelitis enteroviruses had been isolated from 19% of all AFP specimens processed, above the required performance criteria minimum of 10%. The non-poliomyelitis enterovirus (NPEV) isolation rate was used as an indirect measure of laboratory sensitivity. In 1998 to the date of the meeting, the non-poliomyelitis enterovirus isolation rate was 18%. Rates varied from laboratory to laboratory, but all national laboratories in the network were now reporting NPEV isolation rates compatible with the geography, climate and social factors present in the areas they served. 2.3.3 Status of WHO laboratory accreditation
The WHO poliomyelitis laboratory accreditation scheme provided documentation that a laboratory had the capability and the capacity to detect, identify, and promptly report wild polioviruses that might be present in clinical and environmental specimens. The accreditation process further provided a learning opportunity, a mechanism for identifying resource and training needs, a measure of progress, and a link to the Global WHO Laboratory Network. Accreditation
- 21 -
was reviewed annually by WHO and was based on laboratory perfonnance during the immediately preceding 12 months with complete data. A laboratory proficiency test had been carried out in the first quarter of 1997. Four of the 10 national laboratories tested had failed to achieve the 80% score required to pass the test. In line with standard practice, the laboratory worksheets from these laboratories had been examined by Regional Reference Laboratory staff to determine the nature of their problem. and advice had been given on how to improve proficiency performance. Arrangements had been made for all specimens from AFP cases received by these laboratories to be re-tested in a Regional Reference Laboratory, and visits had been made by laboratory experts to work with laboratory staff in improving performance. Further training in Regional Reference Laboratories or Specialized Reference Laboratories had also been ananged for staff from these laboratories. All remaining laboratories, including the three Regional Reference Laboratories had been reviewed (see Tables II and 12). Table I I. Accreditation status of National Poliomyelitis Laboratories recent Cowrtry Laboratory
procedures and work practict'§ score
Date last reviewed
Current status
proficiency test s{'"ore
100 100 100
Table 12. Accreditation status of Regional Reference Laboratories Country Laboratory
Date last reviewed
(,'urrent status
China
Chinese Academy of Preventiv~
15/16-Jun-98 22/2J.Jun-98 17119-Jun-9t<
Accredited Accredited Accredited
Most recent Most rel'ent proHcienl"y proficielll'J' test score - test scoreisolation ITO 100 IOU 100 96 \UO 1O(J
Operating procedures and work practices
96 97
Medicine, Bej'inl!
Jap'" Australia
National Institute of Infectious Diseases, Tokvo Victorian Infectious Diseases Reference Lworatory, Melbourne
ON
The poliomyelitis laboratory network in China had been conducting annual proficiency tests since 1992. Proficiency standards had consistently improved since that time, with all 3 I passing the test in 1997, and only one laboratory failing in 1998. In October 1997, twenty-five of the laboratories had been reviewed and all but three had been found to reach WHO accreditation standards. As of I October 1998, only 4 out of the 31 provincial poliomyelitis laboratones in China had not been demonstrated to be operating at WHO accreditation standard.
- 22 -
Table 13. Accreditation status of provincial poliomyelitis laboratories in China, 1998 Most Province ANHUI BEIJING CHONGQING FUJIAN GANSU GL'ANGDONG r~cent
Operating procedures and work practices scon
Provincial EPS
Date last reviewed 14/15-Oct-97
Current status Accredited Accredited Not accredited Accredited
Hefei Beijing
proficiency test score 100
18-Oct-97 Not reviewed
Chongqing
Fuzhou Lanzhou Guangzhou ~anning
16/17-0ct-97 15/16-0d-97 17/1 R-Oct-97
Accredited Accredited
GUANGXI GUIZHOU HAINAN
0<..1.-96
Accredited Accredited Accredited
100 60 100 100 100 100 100
93 95 91 80 98 100 82 86 92
Guiyang H~ikou
19/20-0ct-97 19!20-0~t-97
HEBEl HEILONGJIANG HENAN HUBEI
Baoding
16-0ct-97
Accredited Accredited Accredit.:d Accredited Accredited Accredited Accredited ACLTeditc::d Act'redited Accredited Accredited
Harbin Zhengzhou \\.'uhan
20-0ct-97 20-Dct-9? 0 ... 1.-96
HUNAN JlANGSU JIANGXI JILIN LIAONING NEIMONGOL NINGXIA QINGHAI SHAANXI SHANDONG
Changsha
J8/20-0ct-97 19/20-01.1-1997
Hanjing Nanchang Chang.:hlln Shenyang IIohhot Ymchuan Xining Xian Jinan Shanghai Taiyuan Chengdu Tianjin Crumqi
ISl16·0ct-97 J5-0ct-97 16·0d-97 Oct·96 15-0d-97 17irg·Od-97 17-01.:1-97
100 100 100 100 100 100 100 100 100
Not accrl"ditl"d Accredited Accredited AI,:credited Ac.:redih:d Accredited ACLTedited
14/15-0\..1-}997 17/1~·Oct-1997
SHANGHAI SHANXI SICHUAN
26-May-9R 14i16-0d-97 20-0ct-97 1r;-Oct-97 Not reviewed
TIANJIN XINJIANG XIZANG (TIBET) YUNNAN
Not accrl"dited Not accredited A00rcditcd
100 80 100 100 100 100 100 100 100 100 SO 100
98 88 100 80 88 R8 87 90 100 "8 79 94 96 92 96 86 80 77 92
Lhasa Kunming
17ilR-Od-97 Oct·9(i
ZHF.JIANG
Hangzhou
r\...: ....Tl!dited
100 lOO
100
2.3.4
Coordination of the surveillance system
Coordination of laboratory activities was founded on the monthly laboratory reporting system established in 1994. The system was now working well, with all national and subnational laboratories reporting results and performance indicators on a regular basis. Results and performance feedback were provided to all laboratories in the network on a monthly basis, and laboratory results were reported in the Poliomyelitis Surveillance Weekly Report issued by the Regional Office. The isolation of a wild poliovirus from any AFP cases anywhere in the Region was now considered to be a public health emergency, demanding a rapid response. As such, it was essential that all reports of wild poliOVirus isolatIOn must be accurate and directed rapidly to the EPr managers of the country involved. Given the importance of wild poliovirus isolation it was necessary to report all intratypic differentiation results to the WHO Regional Office rather than to the submitting laboratory. The Regional Office would then rapidly relay those results to the countries concerned.
- 23 -
2.3.5
Conclusions
The poliomyelitis laboratory network was well established in the Region, and was being used to provide essential information for action in targeting resources to eradicate wild poliovirus from the last remaining foci. Performance levels continued to improve, and were approaching those required for certification of poliomyelitis eradication. The formal system for arumal accreditation of Network Laboratories was in place and almost all laboratories in the Regional Laboratory Network were performing at WHO accreditation standard. For those laboratories that had yet to achieve this standard, appropriate steps had been undertaken to improve their laboratory performance. Coordination and cooperation between laboratories and field and epidemiology staffhad continued to improve. Regular formal and informal contact between the laboratories and field and epidemiology staff was now taking place throughout the Region, with many countries having established regular monthly meetings between laboratory and EPI staff to discuss cases, results and problems. Laboratory contamination remained a cause for concern for the poliomyelitis eradication programme in the Region. Strict adherence to WHO policy on limiting all laboratory work on wild poliovirus isolates to Regional Reference Laboratories had reduced the potential for cross-rontamination. It was time to consider establishing a system of maximum laboratory containment for wild polioviruses and wild-poliovirus-infectious materials. To this end a regional action plan for safe handling and maximum laboratory containment of wild polioviruses and potentially infectious materials had been developed and was being implemented The majority of outstanding laboratory equipment needs had been met, mainly through the generosity of the partner agencies and governments. More funding support was rcquired, however, to ensure that the laboratory network was maintained at least until global certification. Additional support was also required to meet the continuing demand for training in basic laboratory techniques. Long-term commitment to supporting the laboratory network would put planning for further development on a much firmer footing, and would allow more efficient use of resources. 2.4 2.4.1 EPI issues Cambodia Catch-up EPI in high-risk areas
Guided by AFP surveillance information, it had been found during intensified supplementary OPY rounds conducted in the first half of 1997 that large population groups had not been reached by fixed vaccination posts. Most of the "missed" populations had been living along the waterways and National Route 4, but also in some of the country's remote areas. In many instances these populations had not only been missed by the 1995 and 1996 national immunization days, but had also never been regularly reached by routine EPI or any other health services.
In August 1998, the EPI had conducted one round of intensified routine immunization activities in the largest and most difficult squatter/slum areas in six districts of Phnom Penh Municipality. The total popUlation of target areas had been about 60 000, including an estimated 2400 children under one year and 12 000 women of child-bearing age. The primary target age group for all EPI antigens had been all children a-II months of age, who were eligible for immunization on the day of activity. In addition, vaccinations had been given to any child 12-23 months that was not yet fully immunized and any child 24-59 months that had never received measles andlor had received less than three doses of OPY. Any ehild under five years of age reporting to a vaccination team but not eligible for any vaccination had been given OPV anyway, but the dose had not been recorded. Finally, women of child-bearing age had been offered IT, according to their inununization status.
- 24-
Vaccination strategies had included fixed sites and mobile teams with boats, each post team and mobile team had included two health staff and one volunteer. Each volunteer had been a person familiar with the area whose task had been to encourage people to go to the post for vaccination. The work had been completed in eight working days during the period 18-28 August with an average of 40 teams each working day. There had been one supervisor per five teams. Injectable antigens had been administered with re-usable syringes and needles. Each team had had one steam sterilizer, sixty 0.5 ml syringes and needles, and twenty-four 0.05 ml syringes and needles. Each supervisor had also had a steam sterilizer with the same number of syringes and needles. In addition, five steam sterilizers had been operated continuously at the Central EPI office in Phnom Penh to assure a constant supply of freshly sterilized needles and syringes. Volunteers had given first priority to children under the age of one year, but it was thought that a much higher number of children in the 12-59 months age group had been eligible for vaccination than had actually been vaccinated, The results for CBA women indicated that a fairly high proportion of the women had been vaccinated, Particularly notable was the high proportion ofTI immunizations that were TTl (>80%).
An informal survey of children under one year of age had been conducted in 26 different locations of the six target areas. Of the 813 children included in the survey, 613, or 75% had been reached. The actual range for proportion of target children reached in the 26 different locations surveyed had been 57% to 93%, but in 20 of the 26 locations the proportion had been 70% or higher. Conclusions (I) Given the relatively small number of children vaccinated, it was clear that widespread use of intensified efforts would have signiticant cost implications especially in areas with poor transportation infrastructure, However. if resources were available to support those costs, it was clear that properly planned and implemented intensive activities could result in substantial immunization coverage increases, (2) Reusable syringes and needles were difticult to use in a campaign-type setting. During the immunization activities awareness about the risk of transmission of blood borne diseases through improperly sterilized equipment had increased, (3) Much supervisory time had been spent trying to assure adequate supplies of freshly sterilized injection equipment. This had resulted in inadequate supervisory attention to identifying missed popUlations and directing teams to them, (4) Screening in the target areas had been difficult. The use of registers to identify unvaccinated children had been compromised by the fact that in slum and squatter areas many persons were not included in the registers. Also, many of the children and CBA women had lost their immunization cards, (5) The coverage monitoring exercise. though informal and unscientitic, had proVided useful information, That demonstrated that formal surveys were not always necessary to obtain useful evaluation and management information, 2.4.2 Viet Nam: Findings and conclusions of EPI review
A national EPI review had been implemented in October 1998, involving cluster surveys and qualitative surveys in five review provinces. The review had found the full immunization coverage rate for children under one year of age to be 81 %. Significant improvements in full immunization coverage had been documented since the 1992 national EPI review; in Oak Lak
- 25 -
Province, 1992 cluster surveys had shown the rate of fully immunized children under one year of age to be 19%, compared witb a figure of53% in 1998. The qualitative surveys had identified tbat tbe EPI in Viet Nam was very strong with priorities for tbe future including maintenance of high quality AFP surveillance until global certification of poliomyelitis eradication. identification of training needs, improvement of sterilization and injection practices, and strengthening of measles surveillance and routine coverage. 2.4.3 Sustaining tbe EPI
Sustainability was increasingly becoming an issue for countries m tbe Region. Although national immunization programmes were achieving high programme coverage and good disease control, and self sufficiency for vaccines was increasing overall, tbere were some worrying signs regarding sustainability, particularly in some of the larger countries. Those signs included reduced commitment of national and local government funds to operational and infrastructure costs for immunization, and a lack oflonger-term programme planning. A major indication of sustainability of national EPI programmes was the presence of a three-to-five year development plan which should contain: • • • • tbe objectives oftbe national EPI for tbe stated period; the strategies identified to be followed; major activities to be undertaken; estimates of requirements for vaccines, consumables, equipment. and funds.
Availability of accurate estimates of vaccine requirements actually used in ordering, and tbe pursuit of policies and practices which maximized the use of vaccine and minimized unnecessary wastage would contribute to tbe sustainability oftbe EPI. Immunization quality was also a major issue for sustainability. Maintaining and improving tbe quality of immunization would include: • • • ensuring tbe consistent availability of trained staff; ensuring the safety of injections; monitoring adverse events.
Ensuring the safety of injections required national policies or plans of action, which specified the type of equipment to be used, tbe frequency of replacement, and the methods for disposal and destruction. Monitoring adverse events required tbe development of guidelines for reporting and investigation. and the establishment of a surveillance svstem which linked both to the national EPI and tbe natio;"al autbority for controlling tbe quality ofvaccines. With tbe Shifting of immunization programmes to disease control activities. tbe importance of good quality disease surveillance data to evaluate tbe effectiveness of programmes was increasing. Consequently, countries should progress towards active disease surveillance systems witb measurable quality indicators.
- 26 -
2.5 2.5.1
Regional operational overview Progress with vaccine self-sufficiency
Since the report made to the eighth TAG meeting, further progress had been made in regional vaccine self-sufficiency, under the Regional Plan of Action. Strengthening national vaccine procurement and supply systems Since 1995 comprehensive EPI vaccine requirement calculations had been undertaken for Cambodia, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines, and Viet Nam, in conjunction with governments and where possible with UNICEF offices in the respective countries. Work had also been done with several Pacific island countries and areas to try to rationalize vaccine orders. In nearly all of these countries these calculations had been used to identify government and partner agency funds to meet vaccine requirements. In Cambodia and Lao People's Democratic Republic the calculations had been incorporated in five-year EPI plans, to form the basis of government planning and to be used in negotiations "ith partner agencies where necessary, to ensure adequate vaccine supplies in the medium term. For several countries (especially in the Pacific Islands) the improvement in estimation and projection had coincided with increasing commitment to vaccine purchase by the national government.
While the situation with respect to vaccine estimations had improved, the following problems remained: • • • Several countries still did not have estimates of requirements based on reasonable calculations, and projected for three to five years. Where estimates did exist they were frequently not regularly reviewed. and were frequently not used in planning the ordering and delivery of vaccines The absence of, or failure to use, reasonable vaccine requirements estimates was resulting in significant overstocking and wastage of vaccine in some situations, and significant shortfalls in others.
Strengthening national control authorities A workshop for national control authority staff had been held in Manila III August 1997. Eight countries had participated. The workshop was the first step in forming a network of national control authorities (NCAs) in the Region, and had led to reviews of national control authority function by international teams in China, the Philippines and Viet Nam. Progress was being made in all three countries in reviewing how their NCAs functioned and how they could be improved. The Philippines in particular had made remarkable strides towards a comprehensive system of quality control and quality improvement. Staff from national control authorities in Viet Nam and the Philippines had been trained at institutes participating in the Global Training Network for Vaccine Quality. 2.5.2 Vaccine use: policies and practices
Vaccine use and vaccine requirements estimations The issue of estimating vaccine requirements was closely related to the situation of vaccine use. Factors affecting vaccine use and estimation included vaccine use and wastage, policy on the use of open vials, vial size and immunization strategy.
- 27-
Another major factor affecting estimation of requirements was the calculation method used. Vaccine requirements were very commonly estimated based on hIstOrIcal orders but that was the worst way of estimating requirements. EstImatIOns based on number and sIze of ImmumzatIOn sessions were more accurate but relatively complicated and dIfficult to adJust.WHOIWPRO was recommending that vaccine requirements be estimated based on target populatIon. number of doses, and wastage factor. Ensuring the use of estimates of requirement~ in actual ordering It was critical to ensure that estimates of requirements were used when vaccines were being ordered. Once the frequency of delivery to national level and an appropriate buffer stock had been decided, estimates should form the basis of vaccine orders, otherwIse hIgh levels of system wastage or chronic shortfalls, would result. Storage and distribution reducing system wastage
High system wastage would result in loss of resources, imperil the sustainability of the EPI, and negatively affect rationally estimated requirements. In order to minimize system wastage the following steps must be taken: • • National requirements projections should be broken down by province/region. A distribution schedule must be developed both for shipments to national leveL and shipments from national to province/regional level. Maximum and minimum stock levels should be decided upon for all cold stores, based on requirements calculations and expected frequency of distribution. Spreadsheets indicating maximum-minimum balances should be distributed to all cold stores to improve supervision of stock levels. Prior to vaccine distribution, provincial/regional stores should report vaccine stock balances to ensure that distribution is appropriate.
• •
•
Vaccine vial monitors and policies on the use of open vials Vaccine vial monitors (VVMs) were present on all OPV vials provided through UNICEF procurement. However, VVMs were generally underused as tools for monitoring vaccine quality and storage and transport conditions. VVMs were also underused in promoting policies on the use of opened vials of vaccine in subsequent immunization sessions. Training on VVMs had generally been inadequate. Progress in ensuring the availability ofVVMs for all vaccines had been very slow, making it difficult for national managers to fully implement appropriate changes in vaccine use such as open vial policies. Policies on the use of opened vials of vaccine in subsequent immunization sessions had been widely adopted only in Pacific island countries. However, there was little data to indicate their impact on point-of-use wastage of vaccines. Since vaccines such as hepatitis B were several times more expensive than other EPI vaccines, reducing point-of-use wastage was obviolIsly extremely important. Given the heat stability of hepatitis B vaccine, there was good justification for adopting a policy on using opened vials in subsequent immunization sessions, particularly in countries with vaccine supply problems.
/
I
- 28 -
. Monitoring use and wastage Wastage should be monitored at least on an annual basis to identify problems, to confirm multipliers used in vaccine requirements estimates, and to assess the impact of immunization strategies such as the use of opened vials in subsequent immunization sessions. 2.5.3 Hepatitis B update
,
All Pacific island countries and areas had a reliable source of hepatitis B vaccine. The collaborative project between the governments of Australia and New Zealand (with the technical support of WHO and UNICEF), and ten Pacific island countries was in its third year. The project aimed at the solid integration of hepatitis B immunization in the EPI in those ten countries. Commencing in 1999, the ten countries involved were expected to pay for 25% of the cost of hepatitis B vaccine supplies from national budgets. Viet Nam had commenced hepatitis B immunization as part of the EPI for all infants in Hanoi and Ho Chi Minh City, using locally produced hepatitis B vaccine, in 1997. All countries and areas in the Region. except Cambodia and the Lao People's Democratic Republic, were using hepatitis B vaccine to some degree in immunization programmes. Data for 1997 indicated that countries with a reliable supply of vaccine were achieving coverage with three doses of hepatitis B that was comparable to DPT 3 coverage. For 1997, 19 countries and areas had reported hepatitis B immunization coverage of infants as over 80%, compared with 17 in 1995. nine in 1994 and just three in 1992.
An evaluation of the impact of hepatitis B immunization in four Pacific island countries had recently been conducted, as part of the Australian and New Zealand Government funded Hepatitis B Control Project. The serosurveys had demonstrated a significant reduction in the risk of immunized children becoming chronic carriers, compared with older wlimmunized controls (2.6% HBsAg positive compared to 13.2%. RR O. 19). The evaluation had also shown high levels of protection (80-86%) against transmission from infectious carrier mothers to their children. One aspect of the evaluation that indicated a need for improvement had been the proportion of children receiving the first dose of vaccine within 24 hours of birth. A critical issue for hepatitis B control remained the availability of vaccine for all infants in the larger countries (China. Philippines and Viet Nam). China had been using hepatitis B vaccine for nearly a decade, but availability in rural areas had been limited. Due to its cost. in urban areas parents were paying for the vaccine, but coverage in those areas was still estimated to be low. In Viet Nam there was still an overall lack of vaccine, although production was increasing. It was likely to be several years before hepatitis B vaccine was available for all infants. In the Philippines, the Department of Health was purchasing sufficient vaccine for approximately 75% of infants, and there were plans to expand to 100% over the next two years. Cambodia and Lao People's Democratic Republic both planned to introduce hepatitis B vaccine in a limited way in 2000. Those two countries had no source ofvaccmc supply, and their routine EPI programmes were achieving less than optimal coverage. Limited introduction in 2000 was an appropriate goal. 2.5.4 Improving injection practices, safe disposal and incinerationldestmction
The objective ofWPRO for safe injection practices in the EPI by 2000 was to assure (I) enough appropriate equipment, (2) the appropriate disposal and destruction of used injection equipment, and (3) the appropriate knowledge of health workers on injection safety.
- 29 -
During 1997 and 1998 progress had been made in the following areas:
• • •
Auto-destruct syringes and safety boxes had both been used in measles campaigns in Papua New Guinea and in 13 PacifIc island countries (PICs). Safety boxes alone had been used in measles campaigns in the Philippmes Several PICs were considering the use of auto-destruct syringes and safety boxes in their routine EPIs. Incinerator trials had been held in two countries (Viet Nam and Philippines).
During the first field trials incinerator performance had not been satisfactory as the . incinerator type tested had not been effective when only used syringes were burned. A further tnal of the same incinerator model would be conducted in Cambodia. The protocol for that trIal would involve the use of different mixes of waste to see if a mix could be found which would lead to a higber burning temperature and a more complete combustion of the used materiaL 2.6 2.6.1 Country reports Malaysia
Routine EPI activities Immunization coverage for all EPI antigens had remained at satisfactory levels in 1997. Only a few districts had reported coverage rates below 80%. Coverage for BCG had been 100% for DPT3 91.2%, for OPV3 90.0%, and for measles vaccine 83.5%. Coverage for tetanus toxoid for pregnant women (TT2+) was maintained at over 81 %. There had been no indigenous ca~e of poliomyelitis due to wild poliovirus since 1984. Two cases of diphtheria had been reported in 1997. The reported incidence rate of measles had increased from 2. 17 in 1996 to 2.61 in 1997. The pertussIs incidence rate had declined from 0.03 population to 0.0 I population last year. The number of neonatal tetanus cases had decreased from 0.04/1 000 live births to 0.03/1 000 live births. Disease reduction initiatives (I)
Poliomyelitis eradication
In 1997, a total of 87 AFP cases had been reported, resulting in a non-poliomyelitis AFP rate of 1.04 per 100000 population below IS years of age. Twenty-cight per cent (28%) of these AFP cases had had two adequate stool specimens collected. The good level of reporting had been maintained in 1998. As at 30 September 1998, a total of 70 AFP cases with onset in 1998 had been reported, resulting in an annualised non-poliomyelitis AFP rate of 1.09 per 100000 population below 15 years of age. Fifty-one per cent (51 %) of these cases had had two adequate stool specimens collected. Out of 14 states and territories that expected to see at least one AFP case per year 12 had reported AFP cases. Nine states had achieved a non-poliomyelitis AFP rate above I per 100000. Stool specimen collection had generally improved, especially in states with previously weak performance, but was still below expected target levels. Seven states had conducted retrospective record searches for AFP cases at main hospitals. Unreported AFP cases detected in those searched were under further investigation.
/
.'1
- 30 -
. No supplementary immunization had been carried out in 1997. Only three out ofa total of 115 districts in the country had OPV3 coverage of less than 90%. (2) Neonatal tetanus elimination
,
The revised neonatal tetanus plan of action had been successfully implemented. Improved tetanus toxoid immunization coverage, promotion and use of sterile techniques and training of traditional birth attendants and mothers had managed to almost totally eliminate the disease. (3) Measles control
Measles still occurred throughout the country, especially in crowded environments, and most cases were clinically diagnosed and confirmed. Reporting still remained incomplete. A single dose of measles vaccine was given at nine months to one year of age, however, a two-dose regime was being recommended and would be implemented in the ncar future together with the review of the national EPr immunization schedule. Problems and constraints in disease reduction initiatives (a) Despite the increasing availability and accessibility of public health services provided through a network of health facilities there was still a small group of population who did not benefit. (b) Problems still existed in preventing cases of neonatal tetanus from occurring in the newborn infants of illegal immigrant families who only reluctantly made use of adequate antenatal care and immunization services. 2.6.2 Mongolia
Immunization coverage Generally the immunization coverage for all EPI antigens was satisfactory. For 1997, BeG coverage had been 96.4%, DPT3 92%, OPV3 92.5%, measles 90.6% and hepatitis B 88.4%. Reported cases of EPI diseases During 1997. there had been no cases of poliomyelitis or neonatal tetanus. The reported incidence of measles had declined from 5.411 00 000 in 1996 to 0.17/100 000 in 1997. Similarly diphtheria had decreased from 3.07/100 000 in 1996 to 1.711 00 000 in 1997. Ouality of EPI services With the cooperation of WHO and other international organizations, cold chain supplies had been distributed to many provinces and districts. A major cold chain rehabilitation programme liad been successfully implemented and 41 % of the 320 old refrigerators at the som level had been replaced with new refrigerators, in collaboration with WHO, UNICEF and lICA. A national EPI training team had been established and training faci Iities had been strengthened by the provision of equipment. Overall training had successfully covered all participating medical personnel at the national and aimag levels, and partly at the sum level. Forty per cent of all medical personnel nationwide dealing with EPI had been provided with manuals and reference books. Specialists from the National and Ulaanbaatar Institutes, aimag center EPI units, and sum vaccinators and doctors from II aimags had been trained in cold chain logistics in 1997. A national EPI review was conducted in May 1997. EPI logistics had been strengthened in vaccine stock control and distribution based on the guidelines provided by WHO and UNICEF. Insufficient infrastructure still had a serious negative impact on the cold chain system in rural areas.
- 3I -
(I)
Safe sterilization and injection practices
Safe sterilization and injection practices continued to be a programme concern. The policy of the Ministry of Health and Social Welfare was to improve the practice of safe injection at the aimag and sum hospitals by providing disposable syringes and needles. (2) Vaccine supplies
In 1997 EPI vaccines had been provided by JlCA and hepatitis B vaccine had been provided by WHO in 1997. From the Center for Infectious Diseases Control, the vaccines, with monitors, thermometers and ice packs, had been distributed to 10 aimags by aeroplane, five by car and six by train. (3) Cold chain equipment
A major cold chain rehabilitation programme had been successfully implemented. One hundred electric generators had been provided by JlCA for remote sums in 1997. Despite major improvements in cold chain equipment in aimags and sums, the lack of a consistent electricity supply in 70% of all sums was affecting the cold chain integrity, especially in summer and winter months. Disease reduction initiatives (I) Poliomyelitis eradication: surveillance
The last case of poliomyelitis had been reported in 1993 and had been clinically confirmed. An active surveillance system for AFP had commenced on I January 1996. The system required weekly visits by EPI staff at the aimag level to all aimag hospitals. It also required telephone reporting, including zero reports, on a weekly basis to EPI staff at the Infectious Diseases Center. A total of 18 cases of AFP with onset in 1997 had been investigated, resulting in a non-poliomyelitis AFP rate of 1.38 per 100000 <15 years. Collection of two stool specimens within 14 days of onset of paralysis had increased from 53% in 1996 to 78% in 1997. (2) Supplementary immunization
National immunization days (NIDs) for OPV had been conducted for three consecutive years beginning in 1994. In 1996 OPV had been given to 275 049 children up to six years of age. The coverage was 97%. Subnational immunization days (SNIDs) had been carried out in 1997 in Ulaanbaatar and Uvs aimag, targeting more than 80 000 children and achieving a coverage of 96.6%. A second SNIDs had been conducted in May and June 1998 III Tiv and Arkhangai aimags and in Ulaanbaatar city That SNIDs had targeted 8 I 809 children and had achieved a reported coverage of93.6% (3) Measles control
According to the four-year cycle of measles epidemics, a large outbreak had been expected in 199611997. As a result of successful large-scale mass immunization through NIDs in May 1996, incidence of measles had declined dramatically. In 1997, a total of four cases of measles had been reported nationwide, though none of those cases had been confirmed serologically. The expected peak of measles cases in the winter of 199611997 had been averted.
- 32 -
(4)
Diphtheria control
In 1995, Mongolia had averted a major diphtheria epidemic by conducting NIDs. A total of 40 cases had been reported in 1997. The incidence rate had decreased from 3.07/100 000 in 1996 to 1.711 00 000 in 1997. In 1997 specimens had been taken from 34 cases, 18 of which had been laboratory confirmed. (5) Elimination of neonatal tetanus
For many years Mongolia had had no reports of neonatal tetanus. Therefore there was no policy for vaccination of pregnant women for TI. Problems and constraints in J997 • • • • • lack of EPI surveillance system at the sum level; lack of cold chain equipment at the sum level; no regular monitoring system at the local level; lack of knowledge of rural medical personnel on surveIllance; lack of laboratory facilities for EPI target diseases.
Plans to overcome problems and constraints • • • • • 2.6.3 active surveillance for AFP should be implemented at the sum level; essential cold chain equipment should be supplied to sums; efforts to strengthen active surveillance should be continued: systematic monitoring and management should be implemented: IEC specialists on EPI should be trained. Papua New Guinea
Immunization coverage Reported national coverage at the end of 1997 had been about 40% and had remained relatively stable at this level. Coverage with TI2 for pregnant women had been reported to be 62%. Disease surveillance In 1997, a total of 39 AFP cases had been reported, resulting in a non-poliomyelitis AFP rate of 1.95 per IDa 000 below 15 years. Of those cases, 78% had been investigated within 48 hours of reporting, 62% had had two stool specimens collected, and 36% had had stool samples taken within 14 days of onset. In 1998, up to 15 Octoher, 23 AFP cases had been reported resulting in an annualized non-poliomyelitis AFP rate of 1.36. Of those cases, 83% had had two stool specimens collected and for 57% the specimens had been taken within 14 days of onset of paralysis.
- 33 -
No wild poliovirus had ever been isolated in the country. Details of surveillance performance indicators (as of 15 October 1998 at CEiS WPRO) were provided (see table below). Indicator
1995 17 14 0.6 57 86 43 50
1996 18 22 0.8 36 55 59 27 41
1997 20 39 1.95 56 78 62 36 36
1998 20 23 1.36 57 97 83 57 48
No of target AFP cases No of detected AFP cases Non-polio AFP rate % of cases reported wlin 14 days of onset % of cases investigated wlin 48 hours of report % of cases with 2 stool samples % of cases with 2 samples taken wlin 14 days % of cases with 60 day follow up
The country had reported 2717 measles cases in 1997 compared to 2879 in 1996. The number of reported pertussis cases had gone down from 1463 in 1996 to 305 in 1997. A total of 61 cases of neonatal tetanus had been reported in 1997. However, reporting was incomplete. No cases of diphtheria had been reported. Supplementary immunization In 1997, NIDs had been conducted in September and October, targeting almost 700 000 children 0-59 months of age. Reported coverage had been 89% for the first and 85% for the second round. In addition to OPV, measles vaccine had been given to eligible children and tetanus toxoid to pregnant women. In 1998, SNIDs had been conducted in four provinces and 19 districts and coverage for the first round had been reported to be 88% A similar figure was expected for the second round. Measles vaccine had been added during the second round.
2.6.4
The Philippines
Immunization coverage Coverage for the fully immunized child (FIC) had been maintained at 90%. The concept of the children protected at birth (PABC) indicator had been introduced in 1996 but had not been institutionalized. Reported cases of EPI diseases A total of36 465 measles cases had been reported in 1997, representing a threefold increase compared to 1996 and a fivefold increase compared to 1995. Pertussis cases had increased from 41 cases in 1996 to 813 cases in 1997. Neonatal tetanus cases had decreased from 364 in 1996 to 338 in 1997, and diphtheria from 149 cases in 1996 to 50 in 1997. For the first time ever, the Philippines had reported zero poliomyelitis cases in 1997.
- 34 -
Quality of services (1) Improvements in the quality of EPI services
EPI basic skills training had been conducted in various provinces and, during consultative workshops, the importance of training as a key component of high EPI performance had been emphasized and the need for provincial and city plans and their enforcement reiterated. The modules on EPI basic skills and cold chain management were being updated. (2) Safe immunization practices
Since 1993, all health workers had been using disposable needles and syringes. A policy of disposing of used needles and syringes through incineration or by burning and burying in the health centre vicinity had been introduced. Field trials of incinerators were being carried out in cooperation with WHO. (3) Vaccine supply, cold chain and other logistics
Vaccine requirements were being forecasted and procurements undertaken through the Vaccine Independence Initiative (VII) agreement with UNICEF. Costs for vaccines had significantly increased due to the devaluation of the Philippine peso. An inventory conducted on the cold chain system had revealed that most of the equipment was more than 10 vears old and required replacement. Disease reduction initiatives (1) Poliomyelitis eradication: AFP surveillance
Active surveillance for acute flaccid paralysis cases had been intensified in key hospitals. AFP Surveillance Officers (AFPSOs) had been assigned full-time to nine Regions, including the National Capital Region. The AFPSOs were visiting the surveillance sites weekly and conducting complete investigations of every AFP case identified. They were also conducting regular orientations to improve awareness of hospital staff and other health care providers. All hospitals with IOO-bed capacity or more had been selected as AFP reporting sites. AFP teams had been formed in each hospital to strengthen cooperation and coordination. A national coordinator was responsible for maintaining the national database, monitoring performance indicators in all regions and provinces and ensuring that case investigations were complete. Overall quality of AFP surveillance had been steadily improving since 1997. (a) The non-poliomyelitis AFP rate had reached 1.081100 000 in 1997 with 293 cases investigated and had been maintained above 1 in 1998, with 217 cases reported by 30 September. (b) The 2-stool collection rate within 14 days of onset had reached 56 % in 1997 and had risen to 80% by 30 September 1998.
(c)
A 60-day follow-up had been conducted for 86 % of cases with onset in 1997.
- 35 -
Details ofperfonnance indicators were provided (see table below). Indicator
1997 78 90 85 56 86
1998 91 89 94 80 60
% reported within 14 days of onset % investigated within 48 hours of report % with 2 stool specimens taken % with 2 stool specimens taken within 14 davs of onset 5 of cases with follow up at 60 days
Detailed analysis at provincial level had shown some silent areas However. most ofthose provinces had small population and would expect only one AFP case per year. Special strategies were being implemented in areas where there was underreportmg, mcludmg active search, strengthening of hospital surveillance teams, enhanced training of health personnel and advocacy with local government units in areas of political unrest. (2) Poliomyelitis eradication: supplementary immunization
In 1998, the Philippines had conducted subnational immunization days (SNIDs) in three regions and two cities, covering 33 provinces. Reported coverage had been 96%. (3) Neonatal tetanus elimination
Implementation of the neonatal tetanus (NT) elimination plan, which included training and supplementary doses ofTT to women of child-bearing age, was plaIll1ed in seven high-risk areas. 2.6.5 China
Immunization coverage In 1997, routine immunization coverage (by 12 months of age) had been as follows: BCG (95.5%), DPT3 (96.4%), OPV3 (96.9%), and measles (95.5%). Those reported coverage levels had been relatively stable from 1995 to 1997. In 1995, a reporting system for routine immunization coverage had been initiated. The system was still being adjusted and improved. Enhanced two-monthly surveillance reporting requirements would be in place in 1999. In 1997, four provinces had started routine tetanus toxoid (TT) immunization for women of child-bearing age in high-risk counties. The median for two or more doses ofTT had been 68.9% (ranged from 40.1% to 950%).
Reported cases of EPI diseases While disease reports had remained low in 1997, pertussis and measles incidence had increased as compared to 1996. 1997 had been the first year that TB data had been available through the routine Notifiable Disease Reporting system. (I)
Poliomyelitis
In 1997, there had been no virologically confirmed poliomyelitis cases. The non-poliomyelitis APP rate in China had been 1.57 for 100 000 children < 15 vears old. The proportion of zero dose children among APP cases had remamed stable from 4. I % in 1995 to 5. 1% in 1997 and 4.6% in 1998 (up to September).
- 36 -
(2)
Measles
Cases of measles were being reported through the Notifiable Disease Reporting system; however, only limited information was available. Several provinces were known to have conducted measles outbreak investigations, but those data were not available at the Ministry of Health. (3) Neonatal tetanus
Since 1996, NT data had been available through the national Notifiable Disease Reporting system. A total of 4394 cases of NT had been reported in 1997 as compared to 3657 cases in 1996. Routine case investigation of NT cases was not being carried out nationwide, although some provinces, such as Guangdong and Hainan were conducting case investigations using their own case investigation forms. Quality of EPI services ( I) Safe injections
Funds from a World Bank immunization project for procurement of reusable injection equipment in to provinces, and a Government of Luxembourg-funded project in Tibet were expected to improve safe injection practices in 1998 and 1999. Updated training on safe injections and steam sterilizers had been conducted in the 10 World Bank project provinces in 1998. Several provinces had extended the use of disposable syringes for EPI injections, but not always with sufficient planning for proper disposal. (2) Planning and implementing vaccines supply and logistics
With the increase in the price oflocally produced vaccines and decreasing birth cohorts it would be important to monitor vaccine logistics to ensure optimum use of vaccine. The safety and efficacy of vaccines used in the EPI had been well established. However, some vaccines might not be reaching WHO requirements for GMP. New facilities were not completed, but were expected to come on line over the following rew years. Shortfalls of OPV for subnational immunization days (SNlDs) were still projected over the following few years. It was estimated that there would be a shortfall of about 25 million does of OPV for the 1999/2000 SNlDs in selected provinces. (3) Cold chain equipment
Shortages of cold chain equipment existed at all levels. Areas affected by heavy flooding during the summer of 1998 m Hubei, Jiangxi, Hunan and Heilongjiang provinces had also lost large quantities of cold chain equipment that would need replacement Disease reduction activities (\) Poliomyelitis eradication: surveillance
In 1997, many of the national AFP surveillance indicators had reached or even surpassed certification levels. The total number of reported AFP cases in China in 1997 had been 4771. The rate of reported non-poliomyelitis AFP had been 1.57 per 100000 children <15 years of age. This rate had remained steady over the previous three years. Eighty-seven per cent of the AFP cases had been reported within 14 days from the onset of paralysis, 99% of cases had been investigated within 48 hours of the initial case report, and 87% of AFP cases had had two stool specimens collected within two weeks of the onset of paralysis. In 1997, from 9187 stool samples of AFP cases, 16.8% had had non-poliomyelitis enterovirus (NPEV) isolated.
- 37 -
In 1997, of the 4771 APP cases investigated, no cases had been confinned as poliomyelitis, 94.6% had been discarded, and 5.4% had been classified as poliomyelitis-compatible cases (due to inadequate stools and residual paralysis or death or lost to follow-up). A small proportion (\.2%) of cases had been classified as high-risk compatible AFP cases (fever at onset and less than three doses OPV). Four clusters (total nine cases) had been analyzed and the cases had finally been discarded as non-poliomyelitis AFP. (2) Poliomyelitis eradication: supplementary immunization
Two rounds of SNIDs had been performcd in China on 5-6 December 1997 and 5-6 January 1998. This effort had targeted 0-47 month old children in 2782 counties of 31 provinces (Yunnan province provided OPV for children 0-59 months to coordinate their immunization activities with the Myanmar NIDs). Approximately 57 million children had been targeted for both rounds and coverage had been reported as 97.9% for the first round and 98. 1% for the second round. SNIDs were being planned for several high-risk provinces and areas during December 1998 and January 1999. (3) Poliomyelitis eradication: special activities in high-risk areas
In August 1998, a special province visit had been made to Tibet to conduct APP surveillance training and to evaluate AFP surveillance and the poliomyelitis laboratory. Active AFP search in three prefectures comprising of one half of Tibet's population had not identified any unreported cases of AFP.
A review of EPI and poliomyelitis eradication activities had been conducted with international participation in seven provinces from 12 to 23 May 1997 and in 10 provinces from 21 to 29 May 1998. Problems with APP surveillance, routine immunization activities, and funding of EPI had been noted and recommendations made to solve the problems. (4) Neonatal tetanus elimination
The Notifiable Disease Reporting system had resulted in a good improvement in NT surveillance and provision of timely neonatal tetanus data. The first joint MCHlDepartment of Disease Control review of NT elimination activities had been carried out in five provinces from 7 to 16 September 1998 with the participation of WHO and UNICEF. The review had shown that two provinces had reported more than I NT case / I 000 livc births in 1997. According to reports up to August 1998, it appeared that all provinces would meet the elimination target in 1998. (5) Measles control
Enhanced measles surveillance was to be implemented nationwide in 1999. Surveillance activities would be stratified according to the category of province. In group A were more advanced provinces ready for a measles elimination goal; Group B included provinces with a measles outbreak prevention goal, while the least advanced areas in Group C followed a measles control goal. A three-year project, funded by CDC and coordinated by WHO, was to conduct Group A level activities from 1999 in two provinces that had good AFP surveillance. This project would establish accelerated measles surveillance and control in a limited area.
- 38 -
Problems and constraints in 1997 and 1998 (1) • Poliomyelitis eradication APP Surveillance: There remained problems witb completeness and accuracy of APP reporting. As of I November 1998, all but two laboratories (Chongqing and Tibet) had achieved WHO accreditation criteria. AFP Expert Panels were not operating adequately in many provinces. Routine monitoring of APP indicators by prefecture was not routinely done in all provinces. A new APP surveillance reporting form with a reduced number of indicators would be introduced in 1999. High-risk areas for poliomyelitis: Some border areas were still at high risk of importation and circulation of wild poliovirus. SNIDs: In some provinces, targeting of floating populations during SNIDs had improved; however, tbere remained widespread difficulties in reaching children at greatest risk. Funding: There were limited resources and competing priorities for public healtb funding and support to ensure improved AFP and laboratory surveillance in all areas and to implement successful SNIDs. Neonatal tetanus elimination (NTE)
•
•
•
(2)
Major problems and constraints to achieving and sustaining NTE had been found during tbe September 1998 NTE review. Problems included a lack of priority and funding for personneL equipment costs and social mobilization. (3) Measles control
Measles continued to be a major cause of morbidity and mortality in China. A national surveillance programme based on tbe AFP model and a plan of action for accelerated measles control had been developed and both were to be implemented in 1999. 2.6.6 Cambodia
Immunization coverage There had been a slight decrease in coverage of all antigens in 1997. Coverage for BCG had been 82%, for DPT3 and OPV3 70% and for measles vaccine 68%. Coverage of pregnant women witb Tf2 had been 3 1%. Reported cases of EP[ diseases The number of measles cases had increased from 2814 in 1997 (incidence 26/100 000) to 3826 in 1998 (incidence 35/100 000). There had been 1665 pertussis cases and 34 neonatal tetanus cases reported. There had been eight laboratory-confirmed poliomyelitis cases, tbe last of which had had onset on 19 March 1997. This case had occurred in Kandal Province in a riverside community directly opposite Phnom Penh on tbe east side of the Mekong River. Disease reduction initiative (1) Surveillance for poliomyelitis eradication
By the end of 1997, Cambodia's AFP surveillance indicators had been of sufficient quality to allow shifting from the clinical case classification system to tbe virological case classification system.
- 39 -
By the end of September 1998, 138 AFP cases had been reported from 76 of 181 administrative districts located in 19 of 24 provinces (annualized non-poliomyelitis AFP rate 3.16 per 100 000 <IS years). Of those cases 80% had adequate stool specimens collected. Laboratorv results had been received for specimens taken from 134 of those cases. All the results had been' negative for wild poliovirus. During 1997, only three provinces had had a non-poliomyelitis AFP rate of less than one. Two of those three provinces had not reported any AFP in 1997, but both had such small populations that they were expected to have less than one case per year. AFP surveillance was being conducted in all except three administrative districts. Of those three, Anlong Veng, would be visited in November 1998. The other two, Veal Veng, in the west along the border with Thailand, and Samlot, an area just to the north of Veal Veng, were not accessible because of poor security. Some surveillance activity had been conducted in Veal Veng and Samlot in early 1997. At that time there had been no indication of recent cases of poliomyelitis in those areas. (2) Poliomyelitis eradication: supplementary immunization
Since the last case of poliomyelitis had occurred in Cambodia in March 1997, six rounds of supplementary immunizations had been conducted. Two of those had covered the entire country (NIDs) and had targeted almost 1.9 million children of 0-59 months of age. Reported coverage had been 95%. Four rounds of high risk response immunization (HRRJ) in 107 districts had covered the areas of the country considered to be at highest risk and had targeted almost 1.2 million children of the same age group. Reported coverage had been 97%.
In November and December 1998, two more supplementary immunization rounds were to be conducted, again covering about 60% of the national population. The districts to be included were from 21 of the country's 24 provinces. The NovemberfDecember 1998 rounds would make a total of eight rounds in high-risk areas since the last case of poliomyelitis. (3) Neonatal tetanus elimination
The major activity continued to be IT vaccination of pregnant women, and in some cases women of child-bearing age. Protection at birth (PAB) monitoring was gradually being implemented. (4) Measles control
At present, the only measles control strategy in place was improving routine immunization coverage. Efforts were being made to strengthen measles surveillance. 2.6.7 Lao People's Democratic RepUblic
Routine immunization The nationwide immunization coverage in 1997 had been sustained at the level of the previous year. The reported coverage had been 69% for OPV3, 60% for DPT3, 58% for BCG and 67% for measles. The coverage ofTT2+ had reached 32% among pregnant women and 54% among women of child-bearing age. The surveillance data had shown that the diphtheria outbreak which had started in 1996 had been effectively controlled through rapid and large-scale immunization campaigns. However. sporadic cases had continued to occur.
- 40 -
CDmputerized EPI InfDrmatiDn System (CElS) was fully DperatiDnal at central EPI tD . provide mDnthly immunizatiDn cDverage repDrt. It was cDnsldered as a very useful tODI tD mDmtDr perfDrmance DfEPI at prDvince and district levels. Mappmg prDgrammes had been mtroduced tD imprDve EPI and pDliDmyelitis eradicatiDn infDrmatIDn system. PDliDmyelitis eradicatiDn Significant progress had cDntinued tD be made in AFP surveillance system in 1997. All maJDr surveiIlance indicatDrs had been sustained at a high level .of quality. By the end .of 1997, the nDn-pDIiDmvelitis AFP rate had been 3.6 per 100000 pDpulatiDn under 15 years .of age and 71 % .of reported AFP cases had had two adequate stoDI specimens taken fDr laboratory analysis. By 1997, the Lao People's Democratic Republic had achieved the surveillance standards necessary to mDve from the clinical tD the virolDgical case classificatiDn criteria for poliomyelitis. Under conditions .of high quality surveillance, no wild poliovirus had been detected in the Lao PeDple's Democratic Republic since last wild poliovirus had been isolated .on 29 July 1996. ActIve surveillance for AFP cases with weekly hospital visits had been fully implemented In all provinces and some districts. In 1998, significant Improvement had been made in tWD southern provinces with large populations and IDW AFP repDrting rates. Intensive training and educatiDn activities on AFP surveillance had been cDnducted by the central team. Further training fDr district staff was to be cDnducted by provincial staff Supcrvision and incentives had been given tD epidemiology and hDspital staff at provincial and district levels. NatiDnal immunization days NatiDnal immunization days in 1998, the fifth NIDs, had been held in all 142 districts of 18 provinces in January and February 1998. The NIDs had reached 99% of villages across the cDuntry. The coverage ofNIDs had been 93% fDr the first round and 89% for the second round. The coverage had ranged from 66% to 100% among 18 provinces. Special efforts had been made tD reach every child in the district at risk Dfwild pDliovirus importation and with low OPV coverage from routine immunization and from previous NIDs. The adopted strategies had included setting up additional immunization teams/posts. extension of immunization session in each village and aetive searching around the village for unimmunized children. TWD rounds of high-risk response immunizatiDn (HRRJ) had been cDnducted in II districts .of five provinces in June and July 1997. Coverage had been 105% fDrthe first round and 93% fDr the second round. The National Committee for Certification of PDliDmyelitis EradicatiDn, which cDnsisted of five members, had been appDinted by the Ministry .of Health in March 1998 and a natiDnal plan .of actiDn fDr certificatiDn .of pDliDmyelitis eradicatiDn in Lao PeDple's Democratic Republic had been developed and approved by the Ministry of Health. Measles control The number .of reported measles cases had been 671 in 1997,917 in 1996 and 3174 in 1995. In 1998, measles outbreaks had .occurred in seven provinces in the nDrthern and central parts .of the CDuntry from the end .of 1997 tD May 1998. A tDtal of4238 cases, including 31 deaths, had been reported from January to September 1998 thrDugh thc national disease surveillance system AccDrding tD .outbreak investigatiDns, 209 measles cases, including seven deaths had occurred in PhoukDun district, Luangprabang province from January to February 1998. Of those cases, 98% had been children under 15 years .of age and 40% under 5 years. OfthDse, 80% had
- 41 -
never received measles immunization. The data collected from 120 cases in Phonhong and Hinherb districts, Vientiane province and data from Oudornxay province had shown a similar age distribution and immunization status. Based on analysis of the data, the major cause of the outbreak had been low immunization coverage in children under 15 years of age and accumulation of susceptibles. The Ministry of Health had approved the national plan of action for accelerated measles control developed in cooperation with WHO, in whieh measles immunization campaigns were included. Measles surveillance had been integrated to the AFP surveillance system. Safe sterilization and injection and logistics An injection and sterilization practice survey had been conducted in September 1997 in four selected provinces. The survey had shown that all provinces had received the national plan of action; supplies of sterilization and injection equipment were generally adequate at all levels, with annual replacement of syringes and steam sterilizers; the knowledge of vaccinators on safe injection and sterilization was sufficient through regular EPI training; disposable needles had begun to be widely used for EPI in urban areas and would spread to rural areas However, a system for collection and destruction of used injection equipment had not been developed in all provinces.
Planning and monitoring on vaccine procurement and distribution continued to be remarkably improved at central level. The vaccine stock was checked monthly by central staff and the results were recorded and reported to the Interagency Coordinating Comnllttee meeting. More accurate vaccine estimation had been earned out and used for vaccine procurement according to the modified formula and vaccme stock level. Neonatal tetanU5 elimination The plan of action on neonatal tetanus elimination had been developed and approved by the Ministry of Health. The goal of neonatal tetanus elimination was being pursued based on the strategies of increased coverage of pregnant women and women ofchild-beanng age with tetanus toxoid, the promotion of clean delivery practices, and improved surveillance through the national surveillance system. In 1997, immunization coverage ofTT2+ had been 32% for pregnant women and 54% for child bearing age women. The results of a coverage survey in 1997 had shown that rates of children protected at birth were 31 % in Attapeu, 3 I 'Yo in Champs sack. 36':;', in Luallgnamtha and 63% in Khammouane province. As a pilot activity, mobile teams had searched for NNT cases by using picture sheets in all districts of Vientiane and Borikharnxay provinces during the second round of I<iY8 NlDs. No eases had been found and reported. An education manual for NNT surveillance was being developed. NNT case investigation had been introduced in Vientiane and Borikhamxay provinces. The concept of "protected at birth" had been introduced during the EPI workshop and forms, which included this indicator, were being prodnced and distributed.
- 42 -
2.6.8
Viet Nam
Main achievements Routine immunization coverage of greater than 90 % nationwide had been maintained for the fourth consecutive year. Completeness and timeliness of monthly reporting and AFP case investigation, including stool specimen collection and follow-up visIts had ~ontmued to Improve and AFP cases were being classified according to the virological case classificatIon cTlteTla. Active searches for unreported AFP cases had been implemented in most provinces. National immunization days (NIDs) had been conducted for the fifth time in 1997, targeting all children under five years of age. High-risk response immunization (HRRIJ, involving fixed immunization sites and house-to-house immunization with mobile teams, and targeting 66 districts in the Southern Region, three districts in the Highland Region and fi ve districts in the Central Region had been conducted in March and April 1998. This activity had been held in coordination with Cambodia. SNIDs were planned for November and December 1998. The SN IDs had been conducted in August and September 1998 in the Central Region (to avoid the typhoon season later in the year). The entire 1997 and 1998 national requirements for OPV had been met through local production with thc cooperation of the Government of Japan. A national plan of action for safe sterilization and injection practices had been implemented to manage the distribution and use of inJection and sterilization equipment. As part orthis plan, training courses had been conducted in almost all districts during 1997 and a syringe IIlcinerator trial had been conducted in two southern provinces. The trial found that the use of IIlcineration boxes. with supervised collection and combustion at the district level. was an effective strategy for the destruction of disposable injection equipment in Viet Nam. Disease reduction initiatives (1)
Poliomyelitis
The last case of wild poliovirus had been identified from the Central Region of Viet Nam. with a date of onset of paralysis on the 29th of January 1997. No wild poliovirus cases had been identified in 1998. The non-poliomyelitis AFP rate per 100000 popUlation less than 15 vears of age in 1997 was l.53. That rate, as of 20th of October 1998. had been 1.0 case per 100 <ioo population under 15 years of age. Of 462 AFP cases in 1997.387 (84%) had had two stools collected within 14 days of onset of paralysis. Of484 AFP cases, as of20 October 1998,459 (95%) had had two stools collected within 14 days of onset of paralysis In 1997, 10.6% of AFP cases had been zero-dose for OPV. whereas only 7.4% of AFP cases had been zcro dose in 1998 (to the 20th of October). During 1997 and 1998, active searches for AFP cases had been conducted in the medical records of provinciaJ hospitaJs and selected district hospitals, and in all provinces. That activity had been effective in further raising awareness about AFP surveillance among clinicians. in improving the sensitivity of case detection and collection of stool specimens, and in identifying weaknesses in the surveillance system NIDs had been conducted in November and December 1997, with two doses ofOPV administered, four weeks apart, to all children in the country under five years of age. According to reports of doses administered, approximately ten million children had received two doses of OPV during the NIDs in 1996 and 1997. One thousand two hundred mobile immunization teams had been active in the south of Viet Nam during the 1995 NlDs and they had reached many previously unimmunized children. In the 1996 and 1997 NlDs, there had been 900 mobile tcams and the activities of these teams had been targeted to high-risk areas for unimmunized children.
- 43 -
In March and April 1997, 74 districts in the Southern, Central and Highland regions, with more one million children under the age of five years, had been successfully targeted for high-risk response immunization. Over 6000 mobile immunization teams had been active, moving from house-to-house and boat-to-boat, aiming to reach all children under the age of five. Special attention had been given to reaching children moving across the border with Cambodia and along waterways and branches of the Mekong River. (2) Measles
Measles remained a serious cause of morbidity and mortality, resulting mostly from low coverage or delayed immunization in remote areas. In 1997, 6507 measles cases had been reported and, in the first nine months of 1998, 8390 measles cases had been reported.
In 1996 and 1997, reported nationwide coverage with measles vaccine had been about 95%. Measles was particularly a problem in mountainous and remote areas, where there were weaker routine immunization services and mobile populations. Several outbreaks had been reported during 1997 and 1998 in the Highland Region and in mountainous areas of other regions. During 1998, measles outbreak investigations had shown that less than 50% of reported cases were children under five years of age and almost all of these cases were unimmunized or of unknown immunization status. Measles had been recognized as an important public health priority and new strategies, including supplementary immunization, would need to be implemented in order to achieve high level interruption of measles virus transmission. During 1998 and 1999, Viet Nam planned to not only strengthen measles surveillance, but also to develop plans for supplementary measles immunization, and to develop local production capability for measles vaccine. (3) Neonatal tetanus elimination
By the end of 1995, Viet Nam had achieved the target of less than one NT case per 1000 live births for every province in the country, under conditions of improved surveillance. That progress had been achieved by rapidly increasing routine immunization of pregnant women nationwide with tetanus toxoid (TT), usually during routine immunization sessions. In addition, campaigns for IT immunization of child-bearing age women had been conducted in high-risk districts, sometimes in conjunction with national immunization days for poliomyelitis eradication. The national rate of reported NT cases fell from 0.21 cases per 1000 live births in 1994, to 0.17 cases per 1000 live births in 1995 and 0.13 cases per 1000 live births in 1996 and 1997.
In the country as a whole, the quality of surveillance for NT had improved with the increase in immunization coverage. In 1994, 45% of the 2492 reported neonatal deaths had been investigated for NT, in 1995 this had increased to 73% of 2685 reported neonatal deaths, and by 1996 to 89% of356 I reported neonatal deaths. In 1997, 92% of3836 reported neonatal deaths had been investigated for NT. The national EPI had reported the coverage of pregnant women with at least two doses of IT as 82.1 % in 1996 and 83.5% in 1997, and the estimated coverage of women of child-bearing age in the same period had been reported as 96.7 and 91.4% respectively, in designated "high-risk" districts. At the regional level, protection at birth had been found to range from 59.3% in the Southern Region to 83.8% in the Highland Region. Every year additional districts had been added to designated high-risk districts, reaching a
total of 314 out of 610 districts by 1997, and extending to 384 districts, to cover over half of the country by 1998. When the performance of these high-risk districts had been measured against the goal ofJess than one NT case per 1000 live births, only II districts in 1996 and 19 districts in 1997 had exceeded this rate.
- 44 -
Viet Nam was now making progress towards eliminating the disease at the next administrative level (district level) in which the population was approximately 100 000 people. The protection-at-birth methodology had been successfully integrated into the surveillance system and each year a higher proportion of neonatal deaths was being investigated for NT. (4) Vaccine production and quality control
WHO had continued to provide technical cooperation to all vaccine manufacturers in Viet Nam and the National Center for the Quality Control of Biological Products. ConstructIOn of a new DTP vaccine production facility at IV AC, Nha Trang was nearing completion. A review of the National Control Authority had been conducted in 1998 and a training plan had been prepared in order to strengthen its activities. Problems and constraints in EPI activities (I) Routine EPI: In some areas, more accurate target populations could b~ d~termined with data from immunization registers at the commune level. (2) Safety of injections: Given the risk of transmission blood-borne intections, sate injections were a critical problem for the EPr in Viet Nam. AFP Surveillance: For poliomyelitis eradication, especially AFP survdllance, political (3) commitment and support would have to be continued until after the global poliomyelitis eradication target had been met. (4) Supplementary OPV immunization: Targeting of mobile and border populations continued to be a priority but there were still some difficulties in reaching children most at risk. (5) Neonatal tetanus elimination: National policy required women of Child-bearing age, (15-35 years of age) to be immunized with TT in designated high-risk districts, but this guideline was not being fully implemented in all areas. 2.7 Poliomyelitis eradication: Progress in South-East Asia Region (SEAR)
In 1997, further progress had been made in the South-East Asia Region towards poliomyelitis eradication A total of 188 million children under five years of age had been targeted during 1997-1998 NIDs/SNIDs and reported regional coverage had been >85%. Bangladesh, Bhutan, India, Myanmar, Nepal and Thailand had synchronized their NIDs in December 1997. A total of 4568 AFP cases had been reported in 1997 (as of 17 October 1998), of which 2597 had been confirmed as poliomyelitis, with 489 cases having wild poliovirus isolated. That had resulted in a non-poliomyelitis AFP rate of 0.32 per 100000 children aged under 15 years. Of the reported AFP cases, 39% had had two stool specimens collected within 14 days of onset of paralysis. Wild poliovirus had been isolated in cases from Bangladesh (6), India (481), Nepal (I) and Thailand (I ). In 1998 (as of 17 October), 8072 AFP cases had been reported and the annualized non-poliomyelitis AFP rate was 0.83 per 100 000 aged under 15 years. Of those cases 61% had had adequate stool specimens collected Wild poliovirus had been isolated from cases from Bangladesh (3) and India (367)
- 45 -
Table 14. AFP rates per 100000 population < 15 years, South-East Asia Region, 1997-1998
AFP SURVEILLANCE INDICATORS 1997-1998* 3 ~N~on~.~po~l~iO~A~F~p~ra~re~p.~r~1~OO~,O~O~O__________~~J!~~:J,
________,
2.5 2
_______________ .2..3.9. ______________ - - _ - __ - - - -
1.5 1
0.5
o
rdatd provisional 8" of 17110198
Table 15. Percentage of AFP cases with two specimens within two weeks, South-East Asia Region, 1997-1998
AFP SURVEILLANCE INDICATORS 1997-1998* % 100 100r-------------------~T---------------_,
80~--------------~~----------
•• 40
20 0 0
0
0
0
.. <$><' ~
tol
.....
'b'<'
$1>"
<)q
R-+'
i·
~
~~ ,~
~~ 0
••
~-<!'
0~
.". <'
#f"
~.<f
>
,..~
V' .. .,;,.
"..."
",,"
"I.
"data provisional as of 17 Oc:tober 1998
- 46 -
2.8
Cross-border coordination: report of activities in 1997/1998
The Western Pacific Region had borders with 12 poliomyelitis-endemic countries in three WHO Regions: the South-East Asia Region (SEAR); the Eastern Mediterranean Region (EMR) and the European Region (EUR) Map 3: Potential cross-border transmission of wild poliovirus, Western Pacific Region
Cross border coordination of poliomyelitis eradication activities had improved and matured in recent years. Between countries within the Western Pacific Region, in particular Cambodia, the Lao People's Democratic Republic and Viet Nam, there had been good coordination ofHRRl activities, NIDs and SNIDs in 1997 and 1998 as well as increased attention to AFP surveillance in the border areas. While coordination with countries in other regions had been more problematic. progress had been made over the previous two years with some notable successes. WHOIHQ was providing updates on possible poliomyelitis cases in areas not formerly reporting. However. routine sharing of maps showing the location of poliomyelitis cases and the AFP situation by province or district for EMR, SEAR and EUR was not yet occurring. Future activities would focus on improved sharing of information for the China-Pakistan, Cambodia-Thailand and Nepal-China borders. China had had successful collaboration with Myanmar and had held four meetings to review poliomyelitis eradication information and to plan joint supplementary immunization activities starting in 1996. The most recent meetings at local level in 1997 and 1998 had resulted in detailed plans for coordinated SNIDs activities, with synchronization of dates and ages of immunization. As a result of the successful collaboration, no cases of wild poliovirus confirmed poliomyelitis had been detected since April 1996 - before the second round of special coordinated HRRl immunization in China and the first NIDs in Myanmar The coordination had also resulted in improved surveillance and supervision of poliomyelitis eradication work on both sides of the border.
- 47 -
China had started collaboration with DPR Korea by providing consultants to advise on establishing AFP smveillance and organizing NlDs. Staff from the DPR Korea poliovirus laboratory were also being trained at the regional reference laboratory in Beijing. Further work was required to coordinate NlDs. 2.9 2.9.1 Regional poliomyelitis eradication certification issues Summary of progress to date
Since the last TAG meeting in June 1997 the Regional Certification Commission had met twice. During its second meeting in Manila in November 1997 national plans of action of the non-endemic countries and the Pacific islands and areas had been reviewed and approved. During the third meeting of the Commission in August 1998 in Brunei Damssalam the national plans of action of recently-endemic countries and the progress reports of non-endemic countries and the Pacific island countries and areas had been reviewed and approved. National plans of action of recently-endemic countries had contained sections on progress made in poliomyelitis eradication, supplementary immunization, performance of AFP surveillance, future immunization and surveillance activities, response to importation of wild poliovirus and national documentation. The Commission had endorsed the guidelines for investigation and response to wild poliovirus importation and the regional plan of action for the safe handling and containment of polioviruses. Finally, the Commission had endorsed the revised Manual of Operations for use by countries in submission of documentation for certification of poliomyelitIs eradIcation 10 the year 2000. 2.9.2 Response to importation
In the Western Pacific Region, the detection of any wild poliovirus was considered a national emergency. While there was general agreement about the need to mount an urgent response, the question of the nature and magnitude of the response had yet to be addressed. Response to wild poliovirus importation should be composed of: • • • Enhanced smveillance; Immunization response; Documentation of the interruption of transmission.
- 48 -
Table 16. Summary of immunization on response to imported wild poliovirus IMMUNIZA TlON RESPONSE TO: L A single imported case of poliomyelitis RECENTLY-ENDEMIC COUNTRIES HRRI*: TWO ROUNDS OF SUPPLEMENTARY IMMUNIZATION WITH OPV IN AN AREA EQUIVALENT TO AT LEAST ONE PROVINCE NON-ENDEMIC COUNTRIES TWO ROUNDS OF SUPPLEMENTARY IMMUNIZATION WITH OPV: • CONTACTS, • SCHOOLS • VULNERABLE GROUPS
EXTEND TO INCLUDE WHOLE CITY/AREA IF IN DOUBT 2. Wild poliovirus isolated from sewage or other environmental sample 3. Wild poliovirus isolated from the stools of an individual person with no neurological symptoms. 4. Secondary poliomyelitis
cases associated with an imported case.
SUBNATIONAL OR NATIONAL IMMUNIZATION DAYS
SUBNATIONAL OR NATIONAL IMMUNIZATION DAYS
* I-IRRI = High-risk response immunization
- 49 -
Table 17. SIl11Jl11aIY of surveillance response to imported wild poliovirus SURVEILLANCE RESPONSE TO: J. A single imported case of poliomyelitis 2 Wild poliovirus isolated from sewage or other environmental sample Wild poliovirus isolated from the 3. stools of an individual person with no neurological symptoms. 4. Secondary poliomyelitis cases associated with an imported case. RECENTLY-ENDEMIC COUNTRIES 0
NON-ENDEMIC COUNTRIES 0
0
0
0
0
Immediate notification by telephone to all provinces 100% timely and complete active surveillance reports, from every district without exception. Immediate notification of WHO and other international partners. Immediate active surveillance visits to all districts surrounding the case. Monitoring of reports at national level 0 Daily reports from districts surrounding case 0 Weekly reports from all provinces by telephone 0 Weekly national review of situation
0 0
0
0
0
0
Immediate notification to all surveillance units and major hospitals nationally Immediate notification of WHO Nationwide dissemination of information on case investigation. Inform all virological laboratories. Stool sampling of contacts of the case. Immediate active surveillance visits to all districts surrounding the case. Monitoring of reports at national level 0 Daily reports from districts surrounding case 0 Weekly reports from all provinces by telephone 0 Weekly national review of situation
2.9.3
Regional plan for safe handling and containment of wild polioviruses
Once poliomyelitis was eradicated, the laboratories of the world would be the only remaining source of the virus. Safe handling and, ultimately, maximum containment of poliovirus and potentially infectious materials in the laboratory waS crucial. In the past, poliovirus biosafety concerns had been minimal. Universal immunization WIth inactivated polio vaccine (iPV) or oral polio vaccine (OPV) had reduced the risk of disease for laboratory workers and the general public. General laboratory biosafety practices had fi.lrther reduced the risks of poliovirus contamination of the environment. The probability of a laboratory-associated poliovirus infection was small, but the consequences of an infection were growing greater with time. A chance reintroduction of wild polioviruses from the laboratory into the community after cessation of transmission presented a threat to poliomyelitis eradication. A chance reintroduction of wild poliovirus after cessation of immunization presented a threat to public health of global proportions.
The Region faced the challenge of locating the many laboratories that had wild poliovirus infectious, or potentially infectious, materials and ensuring that they were adequately contained in the laboratory, rendered non-infectious, or destroyed. A Regional Action Plan for safe handling and maximum laboratory containment of wild polioviruses and potentially infectious materials had been developed to address these responsibilities The plan and the timetable for implementing it were linked to the Global Action Plan for Safe Handling and Maximum Containment of Wild
, - 50 -
,
Polioviruses, and to the major eradication objectives. The plan consisted of three phases, outlined below.
Phase I: Pre-Eradication. Safe Handling of Wild Poliovirus Infectious or Potentially Infectious Materials (BSL-2/polio): Phase I, pre-eradication, covered the current situation, when wild poliovirus was no longer circulating in the Region. Three tasks were critical to this phase. (1) Nations must identify and develop an inventory oflaboratories that have wild poliovirus infectious materials or potentially infectious materials.
.. • I
'
(2) Laboratories must institute enhanced biosafety level-2 (BSL-2/poho) procedures for safe handling of all such infectious or potentially infectious materials. (3) Nations must begin planning for implementation of Phase II biosafcty requirements.
.
,
Phase II: Post-Eradication. Maximum Containment of Wild Poliovirus Infectious and Potentially Infectious Materials (BSL-4): Phase II. post-eradication, would begin at a time when the probability was high that all human transmission of wild poliovirus had ceased. All laboratories possessing wild poliovirus infectious materials or potentially infectious materials would have to elect one or more of the following three options: (I) Implement maximum (BSL-4) containment procedures, or
(2) transfer wild poliovirus infectious and potentially infectious materials to WHO designated repositories, or (3) render such materials non-infectious, or destroy them, under appropriate conditions.
Because BSL-4 containment facilities were expensive to build and operate. most nations and most laboratories would elect one of the lattcr two options.
Phase Ill: Post-OPV Immunization. Maximum Containment of OPV and OPV-Derived Viruses (BSL-4): To Begin When OPV Immunization Stops: Phase 1II, post-OPY immunization, would begin with the world-wide cessation ofOPV administration. Strict control ofOPY and OPY-derived viruses would be required to prevent reintroduction and theoretical circulation of those viruses in non-immunized populations. At this time, all facilities, including laboratories, clinics, immunization centres, physicians' offices, and other sites with OPY or OPY-derived viruses would have to immediately comply with one of the following options: (I)
Destroy OPY and OPV-derived viruses, under appropriate conditions, or transport them to designated maximum containment (BSL-4) facilities.
(2)
All countries in the Region were being asked to develop an inventory of laboratories that had wild poliovirus infectious materials or potentially infectious materials. This inventory should be available early in 1999.
- 51 -
2.10 Neonatal tetanus elimination 2.10.1 China: Review of neonatal tetanus elimination in five provinces
The neonatal tetanus (NT) elimination activities in China had been initiated in 1992, following the National Neonatal Tetanus Elimination Conference. The plan of action for the elimination of the disease had been updated in 1995 and 542 high-risk counties had been identified. Tetanus toxoid (TI) inununization for women had been implemented in those high-risk counties together with strategies to improve clean delivery practices. The Notifiable Disease Reporting system had resulted in a good improvement in NT surveillance and provision of timely neonatal tetanus data. The frrstjoint MCHJDepartment of Disease Control review of NT elimination activities had been carried out in five provinces in September 1998 with the participation of WHO and UNICEF. During the review, management of NT elimination activities at each level had been reviewed, health facilities had been visited to check the records and NT cases had been revisited. The review had shown that two provinces reported more than one NT case 11 000 live births in 1997. It had also indicated improvements in clean delivery practices and immunization of child-bearing age women with three doses of IT in most of the high-risk counties, resulting in reduction in the magnitude of NT problem in many areas reviewed. Low IT coverage in some areas, shortage of vaccine due to inadequate funding and underreporting of NT cases had been among the problems identified. During the review, it had been concluded that strong national and international support was required to achieve the NT elimination goal. It had been recommended that a revised plan of action focusing on high-risk areas should be prepared, adequate funding at township/village level should be assured and detailed planning should be done at local levels. IT immunization campaigns should continue to be conducted in high-risk areas. Routine IT immunization should be initiated and IT vaccine should be considered among the other EPI vaccines to be procured by the provincial level. Surveillance of NT should be strengthened and active surveillance with zero reporting should be implemented, all reported NT cases should be investigated. As a long-term strategy, clean delivery practices should be promoted. 2.10.2 Viet Nam: Implementation of protection at birth methodology
See also 2.6.8 (3) By the end of 1995, Viet Narn had achieved the target of less than one NT case per 1000 live births for every province in the country, under conditions of improved surveillance. This progress had been achieved by rapidly increasing routine immunization of pregnant women (PW) nationwide with IT, usually during routine immunization sessions. In addition, campaigns for IT immunization of child-bearing age women (CBAW) had been conducted in high-risk districts, sometimes in conjunction with national immunization days for poliomyelitis eradication. Viet Narn had been monitoring the NT elimination programme with use of protection-at-birth methodology (PAB) since 1996. The national EPI had reported PAB as 70% for 1997 with a range from 59.3% in the Southern Region to 83.8% in the Highland Region. Provincial EPI staff had been trained in the use of the methodology. Modifications had been made in the existing forms, such as inununization register books for children and reporting forms for immunization, in order to implement the PAB methodology. The constraints in implementation of the methodology identified were unclear records in the health facility registers and women often not having their IT records at DPTI contact. From 1994 to 1997, a total of almost 10 000 neonatal deaths had been investigated for NT in Viet Nam. An analysis of 474 NT cases reported during that period, for which case investigation forms completed by the surveillance staff were available, had been carried out to determine
- 52 -
whether the criteria used to define PAB methodology had been valid. Ninety-five per cent (452) of the 474 cases had not fitted the criteria set for PAB had been defined as two doses of IT during the last pregnancy, or at least three doses of IT at any time in the past. In the study, 99% of women had previously received less than three doses of IT. The percentage of cases fitting the PAB criteria had been small (5%) and it had been concluded that the simple criteria used to define protection at birth was valid and reliable enough to be used by health workers to monitor the programme, and to assess the eligibility for further doses of IT. 2.10.3 Regional guidelines for use of protection at birth methodology and response to neonatal tetanus cases
The national guidelines for NT elimination should clearly define the actions to be taken at the national, as well as the provincial level. The approach for most countries should be to integrate NT surveillance with active surveillance of AFP. Routine immunization with TT for pregnant women should continue according to the immunization schedule. Protection-at-birth (PAB) methodology should be introduced and infants should be considered to be protected if the mother had received two doses ofTT during the last pregnancy, or at least three doses ofTT at any time in the past. Countries should start to monitor immunization activities with this simple criteria. Countries should start to monitor immunization and surveillance data in order to identify high-risk areas and populations to concentrate efforts. High-risk districts should be designated according to analyses of reported NT cases, and comparative review of immunization coverage data, ranking districts and prioritizing the low performance areas. Active searches should be conducted in "silent districts" where there was no surveillance activity for NT. In designated high-risk areas, neonatal deaths should be investigated for NT. When a neonatal tetanus case was detected, it should be reported immediately and an immunization response in the local area should be carried out. The minimum immunization response to a reported neonatal tetanus case should be immunization of all CBAW in the village/local area with TT. 2. I I Accelerated measles control 2.11. I Measles campaigns in Pacific island countries
The 20 Pacific island countries and areas, with a total population of about 2.7 million, had been presumed free of poliomyelitis for at least 15 years. The situation was different, however, for measles. Despite the generally strong success of the Expanded Programme on Immunization (EPI) in reducing the magnitude and frequency of measles epidemics, Pacific island countries had averaged about four measles outbreaks annually since the early 1980s, due to the accumulation of susceptible children. An outbreak-free year had occurred only once in the Pacific - in 1995 - but that had been followed by four outbreaks in 1996 (Annex 3). At the September 1997 WHOfUNICEF intercountry EPI workshop held in Fiji preliminary plans had been set in place in all but two countries to accomplish a measles mass campaign over the subsequent six months. One country, the Solomon Islands, had already conducted such a campaign in mid-1997, following concerns over an epidemic in New Zealand which primarily affected Pacific islanders living in that country. Unfortunately, eight epidemics had occurred in the Pacific immediately before or within four months after the 1997 EPI workshop. In each case the epidemic had occurred before a mass campaign had begun (Table 18). While recognizing that a mass campaign was seldom an effective outbreak control measure, the unfortunate timing of measles virus spread in the Pacific in late 1997
- 53 -
had prompted accelerated campaigns as an emergency measure in most of these countries. Despite the constraints on careful planning caused by this urgent response, the eventual coverage of target populations in almost all cases had been good to excellent High coverage had also been obtained in the mass campaigns conducted in several other countries which had not experienced a new measles outbreak (Table 19). Overall in the Pacific, about 582 500 children (86% of those targeted) had received a supplemental mass campaign dose of measles vaccine since mid-1997. In addition, about half of the countries had incorporated a second routine dose of measles vaccine into their immunization schedules, and several of these had school entry requirements which mandated two doses of vaCCIne.
No cases of measles had been reported in the Pacific islands since March 1998. Interruption of measles virus transmission had likely been achieved, through a combination of widespread mass campaigns, wide acceptance of two-dose schedules with high coverage, and the recent further reduction in susceptible children resulting from the outbreaks themselves. Actions recommended at the recent EPI workshop in Fiji in September 1998 had addressed the goal of further sustaining that measles-free interval in the Pacific. It had been concluded that a second round of mass campaigns would be required in most Pacific island countries in 2001-2002 to maintain a low level of susceptibility in the medium tenn, by keeping the number of susceptible children below outbreak threshold. In the long tenn, the preferred strategy for measles control and elimination was to provide two routine doses of measles vaccine to all children, achieving at least 95% coverage. Because most Pacific island countries and areas had already made the transition to a two-dose schedule, the emphasis in those would be on ensuring high coverage through school entry immunization requirements and other strategies. In those countries with operational or other constraints to ensuring high two-dose coverage, a single routine dose supplemented by a periodic mass campaign remained a viable alternative strategy. Table 18. Measles outbreaks and mass campaigns in eight Pacific island countries and areas, 1997-1998
Countryl Area Tuvalu Kiribati Vanuatu Nauru American Samoa Fiii Tonl!:a Cook Islands
Campaign planned (as at September 1997) March Februarv April October 1997 F ebruarv March March 1998 1998 1998 1997 1998 1998 1998 1998
Measles outbreak started Januarv December November November October Seotember July June 1998 1997 1997 1997 1997 1997 1997 1997
Campaign started
5 March 12 Februarv 25 March 8 December
1998 1998 1998 1997
10 November 1997 II March 1998 2 March 1998
--
- 54 -
Table 19. Measles mass immunization campaigns, Pacific island countries and areas, 1997 - 1998 Target age range 1m months) 9 m - 14 9 m - 14 8 - 12 9m-14 9 m - 14 6 - 10 9 m - 15 9 m - 15 *9 m - 14 9 m - 16 1 - 14 9 m - 14 9 m - 14 Target population 6524 251,109 25,000 27,297 2,540 20,026 796 74,470 153,757 568 35.458 3,033 77,850 678428 Number immunized 5.548 204,604 19,200 23507 2,540 17,999 790 72,344 124,611 568 33,425 3,033 74,329 582,498 Per cent coverage 85 81 77 86 100 90 99 97 81 100 94 100 95 86
Country! Area
Start of campaign March 1998 November 1997 March 1998 February 1998 December 1997 November 1997 October 1997 April 1998 June 1997 June 1998 March 199& March 1998 March 1998
Cook Islands Fiji French Polynesia Kiribati Nauru New Caledonia Niue Samoa Solomon Islands Tokelau Ton~a
Tuvalu Vanuatu TOTAL
Note: "Mop-up" campaigns were conducted in at least two additional countries (Palau and the Marshall Islands) to immunize children who had missed a routine dose. Five other countries did not conduct mass campaigns in 1997-1998 (American Samoa, Guam, Federated States of Micronesia. Northern Mariana Islands, and Wallis and Futuna). * T;;trget age range 1-8 years in Guadalcanal ** To find and immunize children who had missed a routine dose 2.11.2 Philippines: Measles campaign
In 1982, measles vaccination at nine months of age had been initiated. Coverage had increased to 51 % by 1986 and had been maintained in the mid to high 80% range since 1990, but coverage varied widely in different areas. Measles vaccination had been included for children in the NIDs in 1993, 1994 and 1995, with a maximum coverage of 82% for children nine months to five years of age. Reported measles incidence had not decreased substantiallv as a result of vaccination efforts, but the time between epidemic peaks had increased. Endemic transmission levels were high and thousands of deaths occurred annually. In 1997, a total of 36 465 measles cases had been reported, representing a threefold increase compared to 1996 and a fivefold increase compared to 1995. The Philippines had decided to conduct a nationwide measles elimination campaign (PMEC) in 1998 to provide one supplementary dose of measles vaccine to all children aged 9 months to 14 years The campaign had started on 16 September 1998 and was targeting more than 27 million children as the 6rst step in efforts to eliminate measles from the Philippines by the year 2008. Others components of the PMEC would include: • • maintaining high routine immulllzation coverage at 95 %; strengthening measles surveillance;
"
, .'
,
- 55 -
•
conducting periodic mass campaigns every 2-3 years to vaccinate accumulated susceptibles (follow-up)
A national task force had been formed to plan and oversee all phases of planing and . implementation of the campaign and had prepared a plan of action. The task force had estabhshed several sub-committees on lOgiStiCS, SOCial mobilizatIOn, surveillance and evaluatIOn to effectively organize and manage the implementation of this plan. Interagency coordmatlOn had been established with various other government and nongovernment agencies and mternatlOnal partners. During the campaign, of an estimated 27.7 million children, 60% were expected to be found and vaccinated at their schools, greatly facilitating their vaccination and the reqUIred logistics. All children attending day care or nurseries were receiving their vaccination at these faCilities. School-age children not in schools and street children were being addressed by special targeted activities. Children nine months to five years were being immunized at commuruty leveL based on a master list. The last phase of the immunization campaign focused on identifying and vaccinating children that were missed during the previous activities (mopping up). In order to test the operational strategies for the national campaign, a pilot study had been conducted on the island of Leyte, comprising of two provinces and two urban centres. The target group had included all children nine months to under 15 years old (-716000 children). Vaccination had been conducted about two months ahead of the national campaign and experiences had been used to refine strategies and policies adopted for the full national activity. Overall coverage achieved during the pilot had been reported to be approaching 100%.
3. INTERAGENCY COORDINATING COMMITTEE
The Chairman, Mr Brian Knowles of Rotary International, opened the meeting by recognizing the continuing progress towards poliomyelitis eradication and the achievement of other EPI objectives, as evidenced by the proceedings of the TAG. Statements of partner agency participation and support were received from UNICEF, Rotary International, J1CA, CDC, and the Asian Development Bank. All partners reaffirmed their commitment to polio eradication and the EPL Other partner organizations invited to the meeting but not in attendance included AusAID. CIDA, USAID, and the World Bank. The Asian Development Bank (ADB) suggested that governments may wish to consider the possibility of obtaining low interest loans through ADB to assist in the final years of the poliomyelitis eradication programme and to sustain EPL The low cost of such borrowing in the short-term could be justified in light of the tremendous long-term benefits Mr Chris Maher, Technical Officer, EPIIWPRO, presented a summary of partner contributions and support for the poliomyelitis eradication initiative in the Western Pacific Region for the period 1992-1998. Such support had ranged from US$10 to 12 million per year during 1993-1997, and was currently at a somewhat lower level of -US$6 million for 1998 because it had been 19 months since the last confirmed poliomyelitis case in the Region and the level of supplementary immunization activities was decreasing. Cumulative partner support for OPV for supplementary immunization during 1992-1998 was US$47.9 million, with the major partner contributions as follows: Government of Japan (37%), Rotary International (27%), UNICEF (13%), Government of the United States (through CDC) (13%), Government of Australia (through AusAID) (6%), and others (4%)
, - 56 -
. Cumulative partner support for the programme operations requirements, including surveillance, was US$20.92 million with the following breakdown by partner organization: Government of Japan (27%), Government of Australia (through AusAID) (23%), Rotary internatIOnal (20%), Government of the Umted States (through CDC) (18%), ACIH (5%), and others (7%). 3.1 Resource requirements
,
,
Mr Maher presented preliminary information summarizing the estimated unmet requirements for: (I) poliomyelitis eradication (1999-200 I), including OPV and operational costs of supplementary immunization acti vities, maintaining and sustaining surveillance and poliomyelitis laboratory network support, and certification activities: (2) estimates for accelerated measles control activities (1999-2003) according to the new Regional Plan of Action; and (3) general estimates of other unmet needs for the EPI (1999-2000), including routine EPI vaccines, cold chain/safe injection, and vaccine self-sufficiency activities. The total shortfall in external funding for 1999 alone was estimated at US$4.86 million for poliomyelitis eradication (including US$1.56 million for surveillance, laboratory, certification); US$1.82 million for accelerated measles control; and US$7.3J million for other EPI unmet needs. The ICC discussion focused on several key issues: (1) Although requirements for poliomyelitis eradication were gradually decreasing overall, sustaining for at least the next three years (i.e., 1999-2001) the relatively constant recurrent costs of surveillance, maintaining the laboratory network, and completing the certification process was a high priority to ensure successful regional certification. (2) Now that the poliomyelitis eradication initiative was entering its final stage in the Region, it was more essential than ever to make efforts to keep the partner agencies engaged to the end, and to begin participating in new initiatives such as the accelerated measles control, as well as in sustaining the EPI. (3) Because of budget constraints, only 4 of 13 WHO/EPI staff positions within WPRO were currently funded through the regular budget of WHO, with the remainder relying on supplemental funds from external partner organizations; funding for two of these posts (by AusAID) was about to be discontinued. Those circumstances had raised serious concerns among ICC members. It was agreed that any reduction in EPI technical posts funded through extrabudgetary sources would have a negative impact on the capacity of WHO to meet the demands of the member countries and on optimal implementation of any new initiatives such as accelerated measles control, neonatal tetanus elimination, ensuring safe injections, full incorporation of hepatitis B vaccine into routine EPI, and introduction of new vaccines.
4. CONCLUSIONS AND RECOMMENDATION
4. I
Progress since the last TAG meeting
The EPI in the Western Pacific Region has entered a new phase in the activities of poliomyelitis eradication, neonatal tetanus elimination and measles control. The last case of poliomyelitis in the Western Pacific Region had an onset of paralysis in Cambodia on the 19th of March 1997. The TAG congratulates all countries in the Region, WHO, UNICEF and all the partner agencies involved in poliomyelitis eradication for this achievement. Since then, over 9000 AFP cases have been investigated in the Region, 86% of which have had two stool specimens taken within 14 days of onset, yet no wild poliovirus has been isolated from any of these cases.
- 57 -
The TAG is particularly impressed at the enormous efforts that have been made in 1997 and so far in 1998 to ensure that wild poliovirus circulation has been interrupted. These include eight rounds of supplementary immunization in high risk areas of Cambodia and Viet Nam in the period from November 1996 to April 1998. However, the TAG believes that there is no room for complacency, since the potential for new cases and for new cases and for the importation of wild poliovirus will be present as long as wild poliovirus is circulating anywhere in the world. Therefore, all countries need to achieve and sustain very high levels of OPV3 coverage and AFP and virological surveillance at certification levels to ensure that the certification process is completed on schedule. Regional EPI coverage has remained at high levels during 1997 and 1998, and this must be sustained indefinitely. In order to sustain the EPI and ensure external support all countries should make increasing commitment to self-sufficiency. 4.2. Poliomyelitis eradication
Although the AFP surveillance performance of all recently-endemic countries is impressive, there are still areas of under-reporting. The TAG believes that the quality of surveillance is sufficiently high to conclude that, despite the presence of some silent or under-reporting areas in the region, indigenous poliovirus is no longer circulating. With adoption of the virological case classification criteria for AFP cases throughout the region, all laboratories participating in the regional AFP surveillance network have undergone a process of accreditation. 4.2.1 Surveillance for poliomyelitis eradication
The TAG has reviewed the performance of all recently-endemic countries in 1997 and 1998 to date. The TAG notes that in 1997 although some countries did not quite meet the required level of 60% of AFP cases with adequate stool samples and I per 100 000 non-poliomyelitis AFP rate in children under 15 years, these countries have provided additional evidence to conclude that AFP surveillance is of sufficient quality to adopt the virological case classification for reporting AFP cases. Recommendations:
Implementation of the virological case classification criteria (I) All recently-endemic countries should apply the virological case c1assitlcation criteria for all AFP Cases with onset since I January 1997, This means that the total number of poliomyelitis cases in the Region for 1997 is nine cases, and for 1998 zero caSe as at I October 1998, (2) Strenuous efforts should be made to thoroughly investigate all poliomyelitis compatible cases, particularly in relation to border areas and clustering of such cases, It should be ensured that expert AFP surveillance panels thoroughly review all reported poliomyelitis compatible cases. Complete data on these cases should be kept at the national level with timely reporting of poliomyelitis-compatible investigations to WPRO.
Assurance of surveillance quality (3) Given the continued risk of reintroduction of wild poliovirus through importation from other Regions, high quality AFP surveillance standards must bt: sustained until global eradication has been achievt:d,
- 58 -
(4) Strenuous efforts should be made to identify silent and low performing areas for AFP surveillance and to improve the quality of surveillance in these areas. Active searches for AFP cases should be implemented immediately in these areas and strengthening of routine and active surveillance should follow as soon as possible. (5) Active surveillance must extend to all areas of the country. All districts should provide weekly or monthly reports including zero-reports for AFP. In low-performing areas. supervisory visits should be conducted, and active searches of records should be carried out.
Sustaining AFP surveillance (6) High quality AFP surveillance. at the level required for certitlcation, will need to be sustained until the global certitlcation goal is achieved. In order to do this, sutficient tinancial support, personnel and training of personnel will need to be maintained. 4.2.2 Laboratory Network
The TAG congratulates the laboratories of the Regional network for continuing to improve laboratory perfonnance, the standards for almost all laboratories in the Region having now reached those required for certification of poliomyelitis eradication. The WHO laboratory accreditation scheme has provided a powerful stimulus to improving laboratory performance, in addition to providing essential documentation on the quality of laboratory work. To further improve the sensitivity and specificity of poliovirus isolation, the L20B cell line has been distributed to all laboratories, together with guidelines on their use and integration in the poliomyel it is eradication programme. The Regional action plan for safe handling and maximum laboratory contamment of wild polioviruses and potentially infectIOUS materials has been reviewed and endorsed by the Regional Certification Commission, and requests have been made to all countries, areas and territories in the Region, through the WHO Regional Committee, to begin implementing the plan. The Plan of Action has been distributed and nations have been requested to ensure that all laboratories working with wild poliovirus-infectious, and potentially infectious materials do so under strict BSL-2/polio conditions. They have also been requested to compile inventories of all laboratories retaining wild poliovirus-infectious, and potentially infectious materials. Recommendations: The process of formal annual review and accreditation of all poliomyelitis laboratories (1) should be continued. (2) Every effort should be made to improve performance levels of the remaining nonaccredited laboratories so that they can be accredited for 1999. (3) All laboratories should begin using the L20B cell line for poliovirus isolation. according to the recommended procedure provided by WHO. (4) Network laboratories should be encouraged to participate fully in the activities required for containment of wild poliovirus and poliovirus-infectious materials, based on the WHO Plan of Action. 4.2.3 Supplementary immunization activities: High-risk response immunization (HRRJ)
The TAG applauds the efforts made by countries to synchronize their supplementary immunization activities with their neighbours, both within and outside the Region. Given that there has been no reported poliomyelitis since 19 March 1997 under conditions of high quality surveillance, unless there is reintroduction of wild poliovirus through importation from other
- 59 -
Regions, the TAG believes that full scale NIDs are no longer recommended for any recently-endemic country. However, given that immunization coverage may still be low in certain high-risk areas, supplementary immunization, in the form of SNIDs, is still required in these areas. Recommendations:
Response to wild poliovirus cases (1) All countries should adopt the RegionaL guideLines for response to importation of wild poliovirus, with adaptation for local conditions. These guidelines call for a rapid immunization and surveillance response in the event of any wild poliovirus being detected.
SuppLementary immunization (1) The TAG reaffirms previous recommendations on the use of locally produced OPV in China and Viet Nam. While locally produced vaccines in these countries are not known to meet WHO standards, the results of surveillance have shown that they are efiective. Further, they are approved for national use by appropriate national authorities. Therefore, the TAG endorses the continued use of locally produced OPV in poliomyelitis eradication activities in China and Viet Nam. (2) Countries where there has been wild poliovirus detected in the last three years (Cambodia. China, the Lao People's Democratic Republic, Viet Nam) should conduct SNIDs in high-risk areas in the 1999/2000 winter season. The focus of these areas should be on horder areas and attention should be given to ensuring cooperation between neighbouring countries, particularly if there is evidence that routine immunization in these areas is weak. International agencies and national governments should pay particular attention to this cooperation. (3) Consideration should be given to the administration of Vitamin A during supplementary OPV immunization campaigns. 4.2.4 Cross-border coordination
The TAG commends the progress made in cross-border coordination within the Region and with neighbouring Regions. As there is now evidence that indigenous wild poliovirus transmission has ceased there should be increased vigilance against importation. Recommendations: (I) WHO/HQ should coordinate regular reports on mapping the location of wild poliovirus cases and surveillance and immunization indicators of the border areas between WPR and SEAR/EMR/EUR, to facilitate planning further cross-border activities. 4.3 Certification of poliomyelitis eradication
The TAG notes the recommendations of the third meeting of the Regional Certitication Commission and commends all recently-endemic countries in having prepared plans of action for certification of poliomyelitis eradication. Recommendations: (1) Every effort should be made to reach the complete standards of surveillance recommended by the Regional Certification Commission. (2) Full details on all poliomyelitis-compatible cases should be kept in a national database.
- 60-
4.4
Accelerated measles control activities
The TAG notes that some countries have commenced accelerated measles control activities. The TAG commends those countries, including Australia, New Zealand, the Pacific islands countries and the Philippines for commencing accelerated measles control activities. While other countries, especially those on the Asian continent, may not yet be ready to begin mass measles immunization campaigns, they should improve measles surveillance in preparation for accelerated measles control. From experience in the Western Pacific and other regions, it has been recognized that two doses for each child is essential for accelerated measles control and, ultimately, for measles elimination. These doses may be given in campaigns or as a part of the routine programme. Recommendations:
Regional guidelines (1) Strengthening of coverage of the first dose of measles vaccine given through routine immunization is critical to accelerated measles control. (2) The TAG endorses the Regional guidelines/or accelerated measles control, 1999 to 2003, which have been developed and all countries should take steps to reduce measles morbidity and mortality by taking into consideration these guidelines.
Surveillance (3) Measles surveillance should be strengthened in three stages (I) measles control, (2) measles outbreak prevention. and (3) measles elimination. The approach should be through integration with APP surveillance. on an expanding basis and improvement ofthe quality of outbreak investigation and routine reporting. according to the approach presented in the Regional guidelines. which includes establishment of a regional laboratory network.
Mass campaigns (4) To implement accelerated measles control, countries should consider introduction of a two-dose strategy. either by routine delivery or through campaigns. This decision will be made on a country-to-country basis. The over-riding concern should be the ability to achieve 95% coverage for both doses for both routine and supplementary immunization campaigns. (5) Any countries planning mass campaigns for measles should make calculations and projections well in advance to ensure an adequate vaccine supply and materials for safe injections . (6) The administration of Vitamin A should be considered in the implementation of mass campaigns for measles. 4.5 Neonatal tetanus elimination
The TAG commends the progress made in countries where NT is still a public health problem. The protection at birth methodology has been adopted in at least three countries, but only in Viet Nam has it gained widespread use. However, the TAG notes that NT is still greatly underreported and where surveillance information is available, there is often a failure to take action with TT immunization in the high-risk areas where the cases have been detected. The TAG recognizes that clean deliveries are a major component for the long-term control of NT and will be required in addition to TT immunization.
- 61 -
Recommendations: (1) The simple criteria of protection at birth against NT presented in the Rexional guidelines should be adopted for monitoring of the immunization component of the NT elimination programme. (2) Surveillance and immunization data should be used in conjunction with other information, such as the proportion of home deliveries, in the identification of high risk areas tilr neonatal tetanus. (3) All countries should aim to investigate NT cases and a database of all reported NT cases should be established with core variables, including the location of birth and immunization starus of the mother. (4) The surveillance of NT should be integrated into pre-existing AFP surveillance systems.
(5) An immediate immunization response should be conducted after a report of an NT case. The minimum immunization response to a reported NT case should be immunization of all child-bearing age women in the village/local area. (6) WHO, in conjunction with UNICEF, should explore the feasibility of making a transition to replace TT with Td for all usage, and consider implementing a school-age Td booster dose in countries, where appropriate. 4.6 RoutineEPI activities
Routine immunization delivery The TAG is impressed by the efforts made to increase and sustain cowrage in the Region. but notes that several countries are facing problems in ensuring regular routine immunization services. The TAG commends those countries which have adapted the experience of poliomyelitis supplementary immunization to strengthen routine immunization services. Recommendations: (I) Countries should adapt the experiences learnt from poliomyelitis eradication to identify high-risk populations and ensure that they receive routine immunization with all EPI antigens. (2) In countries subject to natural disasters routine immunization should be assured ttlr the displaced persons. (3) Countries of the Region should develop plans for immunization safety surveillance for the collection of data on adverse events related to immunization. (4) The administration of Vitamin A with routine EPI vaccines should be considered in high-risk areas, based on the country situation. (5) 4.7 Special strategies should be developed in order to cover hard-to-reach populations. Hepatitis B immunization
Many countries in the Region are making steady progress with hepatitis B immunization. The Pacific island countries continue to achieve high coverage levels ofhcpatitis B vaccine. particularly as international partners have assured the continuity of vaccine supply. The high cost of the vaccine continues to limit its full integration in the EPI.
- 62-
Recommendations: (1)
Member countries should continue to increase coverage of infants with hepatitis B vaccine and to further integrate hepatitis B vaccination into national EPls.
In those countries which have introduced hepatitis B vaccine, vaccine coverage data (2) should be collected and reported routinely. (3) International partners should be encouraged to collaborate in ensuring adequate supplies of high quality of hepatitis B vaccine. (4) International partners and WHO should increase advocacy for the cost-effectiveness of hepatitis B immunization as a part of the EPI. 4.8 New vaccines
The TAG notes that new vaccines and combinations of vaccines have emerged in the last decade and continue to be developed. There have been difficulties in the introduction of new vaccines into the EPI in many countries. Recommendation: The TAG requests the EPI secretariat to study the current situation with respect to newly developed and licensed vaccines and to present recommendations on these vaccines, in relation to their introduction into national EPI programmes. The TAG asks that a report be presented at the next TAG meeting. 4.9 Safety of injections
The TAG considers the safety of injections to be a critical issue for immunization programmes, and notes the serious consequences of improper use of non-sterile injection equipment. Four countries are implementing national plans of action for safe sterilization and injection practices. The safe destructIOn of used injection equipment is an important issue for further development. Recommendations: (1)
Countries, which have not done so, should prepare and implement a national plan for ensuring the safety of injections, including appropriate components for the training of field staff.
(2) All countries currently using dL~posable equipment for immunization activities should immediately adopt the use of safety boxes for the safe disposal of used equipment. (3) During mass immunization campaigns the best available immunization practices should be followed. Autodestruct syringes are the equipment of choice, but if the campaign cannot be implemented with autodestruct syringes, carefully supervised use of reusable equipment may be considered. Safety boxes should be supplied with disposable syringes. (4) The TAG requests the WHO secretariat to continue etlorts to identify safe and effective ways of destroying used equipment (including the identitlcation of appropriate incinerators). (5) The TAG further requests the secretariat to facilitate the transfer of teChnology for autodestruct syringe production
- 63 -
4.10 Vaccine self sufficiency The strengthening of national quality control authorities continues to be a major focus. The Regional Office acovely collaborated with the centres of excellence for vaccine production and quality control and technical support to several countries was provided. Recommendations: (I) All countries, in particular those producing EPI vaccines, should continue to strengthen the activities of their national control authorities in the evaluation of locally produced and imported vaccines. National control authorities should ensure good manufacturing practices, and optimal levels of quality control and quality assurance in an independent working environment. (2) Countries currently producing vaccines for national use should be encouraged to focus on improving the supply of good quality vaccines to meet national programme requirements. (3) Countries should develop appropriate projections of vaccine requirements to plan vaccine supply, ensure effective monitoring of supplies, and to identify shortfalls. 4.11 Sustainability of EPI
The EPI in the Western Pacific Region has entered a new phase in the activities of poliomyelitis eradication, measles accelerated control and neonatal tetanus elimination. The TAG considers that monitoring of a sustainable supply of vaccines is an important priority for the future of the EPI. Recommendation: The TAG recommends that the following indicators for EPI sustainability be adopted by national EPls and regularly reviewed: • • • • • • • • • Presence of a national programme plan; Funding of vaccines and operational costs in the national / subnational budgets; Calculation of vaccine requirements estimates; Implementation of reviews of vaccine use; Development of pre-service curricula for immunization; Preparation of a national policy/plan on injection safety; Presence of a system for reporting and investigating adverse events: Creation of a national expert group for immunization policy review; Development of surveillance systems for vaccine preventable diseases meeting quality indicators; Maintenance of high levels of immunization coverage; Presence of an interagency coordinating committee at national level.
• •
- 64-
4.12 Requirements for continued financial cooperation The TAG commends the national governments of the Region which have provided most of the resources required for the EPI and poliomyelitis eradication in 1997 and 1998; however, . international partner agency cooperation has been instrumental in the successful ImplementatIOn of poliomyelitis eradication activities. Recommendations: (1) Cooperation for surveillance, laboratory, and certification requirements for 1999 should be assured and continued by funding operational, equipment, and technical costs.
(2) Cooperation for OPV requirements for supplementary immunization in 1999 and 2000 should be assured. (3) Regional funds need to be assured for rapidly covering operational costs for supplementary immunization in 1999. (4) Coordination of partners at the country level should be strengthened to ensure optimal use of resources for routine EPI and especially for measles control activities.
5. ACKNOWLEDGEMENTS
The Technical Advisory Group (TAG) of the Expanded Progranune on Immunization and Poliomyelitis Eradication of the Regional Office of the Western Pacific gratefully acknowledges the Regional Director of the Western Pacific Region of the World Health Organization, Dr S.T. Han for the invitation to hold this meeting at the WHO Regional Office of the Western Pacific in Manila, Philippines.
As in all previous meetings, the TAG gratefully acknowledges the outstanding contribution and participation of all the partners in the EPI and poliomyelitis eradication, including the national governments of the WHO member countries; the Government of Australia through AusAID; the Government of Japan, through JICA; the Centers for Disease Control and Prevention, Atlanta, USA; Rotary International; Rotary Japan Districts 2650 and 2640; UNICEF; and the World Bank. In addition to funds, partner agencies have generously contributed technical, management and promotional expertise. Large amounts of additional funds have been provided for critical areas, such as vaccine supply, operational support for NIDs, high-risk response immunization and surveillance, including stool specimen collection and transport. 11,e poliomyelitis eradication initiative would not have been able to make its remarkable progress without the cooperation ofthe ICC partners and this cooperation is gratefully acknowledged.
NINTH MEETING OF THE TECHNICAL ADVISORY GROUP ON EXPANDED PROGRAMME ON IMMUNIZATION AND POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION
23 October 1998 ENGLISH ONLY
3~
Manila, Philippines November 1998
Time OBOO OB30~930
Tuesday. 3 November REGISTRAnON 1. Opening ceremony
Time OBOO~930
Wednesday. 4 November 7. Poliomyelitis eradication
TENTATIVE TIMETABLE Time OBOO~930
Thursday. 5 November 11. Neonatal tetanus elimination (a) China: Review of NT erlmination
Time OBOO~930
Friday. 6 November 14. presentations of summary of draft conclusions and
Country reports on AFP surveillance
recommendations
• Opening speech • Self-introduction
and supplementary immunization (a) Malaysia
in five provinces 0930-1000 (b) Viel Narn: Implementation of protection at birth methodology (c) Regional guidelines for use of protection at birth methodology and response to neonatal tetanus cases
• Election of officers, Chairman, Vice-Chairman and Rapporteur • Administrative announcements • Group photograph
(b) Mongolia (c) (d) (e) (f) Papua New Guinea Philippines China Cambodia
0930-1000 1000-1030
COFFEE BREAK • Address or the Chairman • Introduction 2. Global EPI overview 3 Regional EPI QVefView 4. Regional laboratory overview
0930-1000 1000·1200
COFFEE BREAK (9) Lao P.D.R.
0930-1000 1000-1200
COFFEE BREAK 12. Accelerated measles control (a) Measles campaign in Pacific Island countries (b) Philippines: Measles campaign (c) Guidelines for measles surveillance (d) Proposed plan of action for accelerated measles Control
0930-1000 1000-1100
COFFEE BREAK Continuation - discussions of draft conclusions and recommendations
(h) Viet Nom (i) Summary of AFP surveillance and supplementary Immunization
1030-1200
1100-1130
15. Closing ceremony
~
1200-1330 1330.1430
LUNCH BREAK 5, EPI issues (a) Cambodia: Catch-up EPI 'In high risk areas (b) Viet Nam: Findings and conclusions of EPI review (c) Sustaining the EPI
1200·1330 1330-1430 8
LUNCH BREAK Poliomyelitis eradication: Progress in South·East ASia Region (SEAR)
1200-1330 1330-1430
LUNCH BREAK 13. Interagency Coordinating Committee Partner agencies: AusAIO
1200-1330
LUNCH BREAK
9 Cross-border coordination: Report of actjviti~ in 1997/1998
CDC JICA
Rotary International
UNICEF World Bank
1430-1500 1500-1600
COFFEE BREAK 6. Regional operational overview (a) Progress with vaccine self-sufficiency (b) Vaccine use: policies and practices (c) Hepatitis B update RegiOnal and Pacific Islands (d) Improving injection practices. safe disposal and inclnerationfdestruction Informal get-together hosted by the Regional Director, WHOIWPRO -
1430-1500 1500-1600
COFFEE BREAK 10. Regional poliomyelitis eradication certification issues (a) Summary of progress to date (b) Response to importation (c) Regional plan for safe handling and containment of wild poIioviruses
1430-1500 1500·1600
COFFEE BREAK Continuation ~ ICC discussions
~ -.--- -_._---
1630 -
1830
Dinner hosted by the Polio Team
--
- 67ANNEX 2 PROVISIONAL LIST OF TAG MEMBERS, EPI NATIONAL MANAGERS, NATIONAL AND REGIONAL REFERENCE LABORATORY STAFF, OBSERVERS/REPRESENTATIVES AND SECRET ARIAT
1. TECHNICAL ADVISORY GROUP (TAG) MEMBERS Dr Isao Arita Chairman Agency for Cooperation in International Health 4-11-1 Higashi-machi Kumamoto 862-090 1 Japan Tel: +81-96-367-8899 Fax: +81-96-367-9001 E-mail: acih@msa.biglobe.ne.jp Dr Kenneth J. Bart Director Graduate School of Public Health San Diego State University 5500 Campanile Drive San Diego, California 92182-4162 United States of America Tel: (619) 594-1255 Fax: (619) 594-6112 E-mail: KBART@mail.sdsu.edu Dr Robert Hall Director Communicable Disease Control Branch South Australian Health Commission 162 Grenfell Street Adelaide SA 5000 Australia Tel: (61-8) 8226-7177 Fax: (61-8) 8226-7187 E-mail: cdcb@health.sa.gov.au Dr Ichiro Okubo Chief Medical Adviser of Intelligence Service Tuberculosis and Infectious Disease Control Division Health Service Bureau Ministry of Health and Welfare 1-2-2, Kasumigaseki, Chiyoda-ku Tokyo 100-8045 Japan Tel: +81-3-3595-2263 Fax: +81-3-3581-6251 E-mail: Dr Dai Zhicheng Deputy Director Chinese Association of STD and AIDS Prevention and Control Chinese Academy of Preventive Medicine 27 Nanwei Lu Beijing 100050 China Tel: 8610-6303-4521 Fax: 8610-6303-4521 E-mail: 2. EPI NATIONAL MANAGERS CAMBODIA Dr Chea Kim Ly Director Expanded Programme on Immunization National Centre for Hygiene and Epidemiology Ministry of Healtb Phnom Penh Tel: (855-23) 426841 Fax: (855-23) 366186 E-mail: Ms Ly Nareth National POliomyelitis Eradication Manager National Centre for Hygiene and Epidemiology Ministry of Health Phnom Penh Tel: (855-23) 426841 Fax: (855-23) 366186 E-mail:
- 68Annex 2 CHINA Dr Wang Ke-An President Chinese Academy of Preventive Medicine 27 Nanwei Lu Beijing 100050 Tel: 8610-6303-0799 Fax: 8610-6317-1724 E-mail: Dr Wang Zhao Director-General Department of Diseases Control Ministry of Health 44 Hou Hai Bei Yan Beijing 100725 Tel: 8610-6401-2877 Fax: 8610-6403-3122 E-mail: Dr Yu Jingjin Director EPI Division Department of Diseases Control Ministry of Health 44 Hou Hai Bei Yan Beijing 100725 Tel: 8610-6401-2877 Fax: 8610-6403-3122 E-mail: Dr Liu Shui English Editor/Interpreter People's Health Publishing House Ministry of Health 44 Hou Hai Bei Van Beijing 100725 Tel: 8610-6402-4266 Fax: 8610-6401-4332 E-mail: LAO PEOPLE'S DEMOCRATIC REPUBLIC Dr Sam thana Douangmala Deputy Director National Institute of Hygiene and Epidemiology Ministry of Health Vientiane Tel: (856) 21-312351 Fax: E-mail: Dr Phengta Vongprachanh Chief Epidemiology Division National Institute of Hygiene and Epidemiology Ministry of Health Vientiane Tel: (856) 21-312351 Fax: E-mail: MALAYSIA Dr R. Devan Principal Assistant Director of Health Communicable Disease Section Public Health Division Ministry of Health 50590 Kuala Lumpur Tel: (603) 254-0088 Fax: (603) 256-1566 E-mail: MONGOLIA
Dr D. Narangerel EPI Manager and Officer Ministry of Health and Social Welfare Government of Mongolia Ulaanbaatar Tel: (976) 1-321569 Fax: (976) 1-327872 E-mail:
.
Unable to attend.
- 69Annex 2 PAPUA NEW GUINEA Mr Barry Ropa National Surveillance Officer for Poliomyelitis Eradication Department of Health P.O. Box 807 Waigani National Capital District Tel: (675) 301-3730 Fax: (675) 325-9424 E-mail: Mr Steven Toikilik Cold Chain and Logistics Officer National Health Department P.O. Box 807 Waigani National Capital District Tel: (675) 301-3752 Fax: (675) 323-9710 E-mail: Dr James Wangi SSMO - Disease Control Division of Technical Health Services Department of Health P.O. Box 807 Waigani (675) 301-3749 Tel: Fax: (675) 301-3604 E"mail: PHILIPPINES Dr Elvira Dayrit Director Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila Tel: (632) 732-9956 Fax: (632) 732-9961 E-mail: Professor Do Si Hien National EPI Secretary National Institute of Hygiene and Epidemiology Ministry of Health I Yersin Street Hanoi 10 000 Tel: (844) 971-2989 Fax: (844) 821-3782 E-mail: Dr Van Thi Thanh Binh Pasteur Institute Ministry of Health 167, duong Pasteur, Q3 Ho Chi Minh City Tel: 84-88 230352 Fax: 84-88 202814 E-mail: Dr Camilla Hahacon Chief, EPI Division Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila Tel: (632) 732-9966 Fax: (632) 732-9961 E-mail: VIETNAM Protessor Dang Due Trach National EPI Manager National Institute of Hygiene and Epidemiology Ministry of Health I Yersin Street Hanoi 10 000 Tel: (844) 971-2989 Fax: (844) 821-3782 E-mail: trach@nihe.gov.vn Dr Nguyen Thi Thu Yen National Institute of Hygiene and Epidemiology Ministry of Health 1 Yersin Street Hanoi 10000 Tel: (844) 971-2989 Fax: (844) 821-3782 E-mail:
- 70Annex 2
3. NATIONAL LABORATORY STAFF MALAYSIA Dr Mangalam Sinniah Head Division of Virology Institute for Medical Research Jalan Pahang 50588 Kuala Lumpur Tel: (603) 440-2345 Fax: (603) 293-6323 E-mail: mangalam@irnr.gov.my MONGOUA Dr J. Mendsaikhan Head Department of Virology Public Health Institute Emkhtaiwan Street Ulaanbaatar 49 Tel: (976) 1-452677 Fax: (976) 1-452677 E-mail: PAPUA NEW GUINEA Dr Peter M. Siba VirOlogist Virology Unit Papua New Guinea Institute of Medical Research P.O. Box 60 Goroka, EHP Tel: (675) 732-2800 Fax: (675) 732-1998 E-mail: imrgka@datec.com.pg PHIUPPINES Dr Fern Julia E. Paladin Head, Virology Section Research Institute for Tropical Medicine Department of Health Compound Alabang, Muntinlupa City Tel: (632) 842-2079 Fax: (632) 842-2245 E-mail: dohritm@gaia.psdn.org.ph
VIETNAM Dr Nguyen Thi Hien Thanh Laboratory of Enteroviruses National Institute of Hygiene and Epidemiology Ministry of Health 1 Yersin Street Hanoi 10000 Tel: (844) 826-6352 Fax: (844) 821-0853 E-mail: nihe@nemam.org.vn Dr Nguyen Thanh Long Laboratory of Enteroviruses Pasteur Institute Ministry of Health 167, duong Pasteur, Q3 Ho Chi Minh City Tel: 84-88 230352 Fax: 84-88231419 E-mail:
4. REGIONAL REFERENCE LABORATORY STAFF Dr Akio Hagiwara Chief Section of Enteroviruses Department of Virology II National Institute ofinfectious Diseases Gakuen 4-7-1, Musashimuravama-shi Tokyo 208 . Japan Tel: +81-42-561-0771 Fax: +81-42-561-4729 E-mail: ahagiwar@nih.go.jp Ms Margery Kennett Regional Poliovirus Reference Laboratory Victorian Infectious Diseases Reference Laboratory 10 W reckyn Street North Melbourne 3051, Victoria Australia Tel: 6 I -3 9342-2607 Fax: 61-3 9342-2665 E-mail: margery.kennett@nwhcn.org.au
,
"
,
- 71 Annex 2 Dr Zhang Libi Director EPI Laboratory Institute of Virology Chinese Academy of Preventive Medicine 27 Nanwei Lu Beijing 100050 China Tel: 8610-6317-1710 Fax: 8610-6317-1724 E-mail: 5. OBSERVERS/REPRESENTATIVES REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION N THEWESTERN PACIFIC Professor Tony Adams National Centre for Epidemiology and Population Health Australian National University Canberra. A.C.T. 0200 Australia Tel: +61 262495616 Fax: +61 262490740 E-mail: Tony.Adams@anu.edu.au ASIAN DEVELOPMENT BANK (ADB) Dr Benjamin Loevinsohn Senior Health Specialist Education. Health and PopUlation (West) Division Asian Development Bank 6 ADB Avenue Mandaluyong City 0401 Metro Manila Philippines Tel: (632) 632-4444 Fax: (632) 636-2444 E-mail: adbhq@mail.asiandevbank.org CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC). ATLANTA Dr Steve Cochi Director Vaccine Preventable Disease Eradication Division National Immunization Program Centers for Disease Control and Prevention M ailstop E-05 1600 Clifton Road E-05 Atlanta. Georgia 30333 United States of America Tel: 404-639-8252 Fax: 404-639-8573 E-mail: slcl@cdc.gov Dr Lisa Lee Deputy Chief . . . International Child SurVival Activity National Center for Intectious Diseases Centers for Disease Control and Prevention Mailstop E-05 1600 Clifton Road E-52 Atlanta, Georgia 30333 United States of America Tel: 770-488-4921 Fax: 770-488-4203 E-mail: leI2@cdc.gov CANADIAN INTERNATIONAL DEVELOPMENT AGENCY (CIDA) Ms Mirjam Schnupf Development Officer Canadian International Development Agency Canadian Embassy II /F. Allied Bank Centre 6754 Ayala Avenue Makati City Metro Manila Philippines Tel: 867-000 I Fax: 810-5142
- 72 Annex 2 DEPARTMENT OF HEALTH, PHILIPPINES Dr A. Benegas Medical Specialist Maternal and Child Health Service Department of Health San Lazaro Compound Sta. Cruz Manila Philippines Tel: (632) 732-9966 Fax: (632) 732-9961 E-mail: Dr J. Ducusin Medical Specialist Maternal and Child Health Service Department of Health San Lazaro Compound Sta.Cruz Manila Philippines Tel: (632) 732-9966 Fax: (632) 732-9961 E-mail: INTERNATIONAL MEDICAL CENTER OF JAPAN Dr Hitoshi Murakami Bureau of International Cooperation International Medical Center of Japan 1-21-1 Toyama, Shinjuku Tokyo Japan Tel: (813) 5273-6827 Fax: (813) 3205-7860 E-mail: JAPAN INTERNATIONAL COOPERATION AGENCY (HCA) Dr Akira Hashizume Director I st Medical Cooperation Division Medical Cooperation Department Japan International Cooperation Agency 8/F, Shinjuku Maynds Tower Building I-I, Y oyogi, 2-Chome Shibuya-ku, Tokyo 151 Japan +813-5352-5217 Tel: +813-5352-5320 Fax: E-mail: Dr Yasuo Chiba Chief Advisor China Polio Control Project Japan International Cooperation Agency 27 Nanwei Road Beijing 100050 China Tel: 8610-6317-1892 Fax: 8610-6304-2355 E-mail: Dr Chushi Kuroiwa Chief Advisor Japan International Cooperation Agency Pediatric Infectious Disease Prevention Project P.O. Box 3933 Vientiane Lao People's Democratic Republic Tel: (856) 21-312120 Fax: (856) 21-312120 E-mail: ckuroiw@laonet.net Dr Harumichi Ito Chief Advisor Japan International Cooperation Agency Maternal and Child Health Project Ministry of Health and Social Welfare Karl Marx Street 4 Ulaanbaatar II Mongolia Tel: (976) 1-329548 Fax: (976) 1-329548 E-mail:
,
,
I
- 73 Annex 2 NATIONAL INSTITUTE OF INFECTIOUS DISEASES (NIID) Dr Tetsuo Yoneyama Department of Virology II National Institute of Infectious Diseases Gakuen 4-7-1, Musashimurayama-shi Tokyo 208 Japan Tel +81-42-561-0771 Fax: +81-42-561-4729 E-mail: tyoneyam@nih.gojp PACIFIC COMMUNITY Dr Tom Kiedrzynski Notifiable Disease Specialist Secretariat of the Pacific Community Post Box 05 98848 Noumea Cedex New Caledonia Tel: (687) 26-2000 Fax: (687) 26-3818 E-mail: tomk@spc.org.nc ROTARY INTERNATIONAL Mr Brian Knowles Chairman Western Pacitic PolioPlus Committee Rotary International 43/17 Bayview Street, Runaway Bay 4216 Oueensland Australia Tel: 617-5537-1666 Fax: 617-5537-1666 E-mail Mr Masami Hiraoka Regional Coordinator ASIA PolioPlus Task Force Rotary International 15-18-1 Kitabatake, Abeno-Ku Osaka 545 Japan 816-624-2451 Tel: Fax: 816-623-6350 E-mail: Mr M.R. Ophas Kanchanavijaya Rotary International Western Pacific Regional PolioPlus Committee Member 50 Ladprao 92 Bangkok 10310 Thailand Tel: 662-539-4775 Fax: 662-530-1358 E-mail: ROTARY JAPAN DISTRICT 2650 Mr Kiyoshige Konishi Rotary Japan District 2650 21F, Nihon-Seimei Kyoto Santetsu Building 608-9 Shiokoji-chyo, Shiokoji-agaru Higashi Nishinotouin-tori, Shimogyo-ku Kyoto-fu Japan Tel: 81-75-351-2778 Fax: 81-75-351-2888 E-mail: UNITED NATIONS CHILDREN'S FUND (UNICEF) Dr Suomi Sakai Senior Health Adviser Expanded Programme on Immunization United Nations Children's Fund Three United Nations Plaza New York, New York 10017 United States of America Tel: (212) 824-6313 Fax: (212) 824-6460 E-mail: Dr W. Grattan O'Connell Vice Chairman Western Pacific Regional PolioPlus Committee P.O. Box 25 589 St. Heliers Auckland 1130 New Zealand Tel: (09) 575-7730 Fax: (09) 575-7730 E-mail:
- 74Annex 2 Mr Chum Aun United Nations Children's Fund P.O. Box 176 Phnom Penh Cambodia Tel: Fax: E-mail: Mr Basil Rodrigues Programme Officer Health and Nutrition United Nations Children's Fund 12 Sanlitun Lu Beijing 100600 China Tel: 86-010-6532-3131 Fax: 86-010-6532-3107 E-mail: Dr Intong Keomoungkhoune Assistant Project Officer Health and Nutrition United Nations Children's Fund P.O. Box 1080 Vientiane Lao People's Democratic Republic Tel: (856)21-315200 Fax: (856) 21-314852 E-mail: Vientiane@unicef.org Dr Meera Shekar Chief Health and Nutrition United Nations Children's Fund P.O. Box 1076 Makati Central Post Oftice 1250 Makati City, Philippines Tel: (632) 892-0611 Fax: (632) 810-1453 E-mail: Dr Nguyen Minh Tuan Project Officer Expanded Programme on Immunization United Nations Children's Fund 72, LY Thuong Kiet Hanoi Viet Nam Tel: 844-826-1170 Fax: 844-826-2641 E-mail: hanoi@unicef.ac.vn Dr Vu Quoc Ai Medical Officer Regional EPI Secretariat Pasteur Institute Ministry of Health 167, duong Pasteur, Q3 Ho Chi Minh City Viet Nam Tel: 848-820-2878 Fax: 848-823-1419 E-mail: Dr Nguyen Van Cuong Medical Officer National EPI Secretariat National Institute of Hygiene and Epidemiology I Yersin Street Hanoi 10000 Viet Nam Tel: (844) 826-6352 Fax: (844) 821-0853 E-mail: nihe@nemam.org.vn UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT (USAID) Ms Marichi de Sagun Child Survival Specialist United States Agency for International Development Ramon Magsaysay Center Building 1680 Roxas Boulevard, Malate 1004 Manila Philippines Tel: (632) 522-441 I Fax: (632)521-4811 E-mail:
"
- 75 -
Annex 2
6. SECRETARIAT WHO WESTERN PACIFIC REGIONAL OFFICE Dr LJ. Blanc Acting Director Communicable Disease Prevention and Control World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) 528-8001 Fax: (632) 521-1036 E-mail: blanci@who.org.ph Dr J. Bilous Regional Adviser Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) 528-8001 Fax: (632) 521-1036 E-mail: bilousj@who.org.ph Dr N. Emiroglu Medical Officer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) 528-8001 Fax: (632) 521-1036 E-mail: emiroglun@who.org.ph Mr C. Maher Technical Officer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) 528-8001 Fax: (632) 521-1036 E-mail: maherc@who.oeg.ph Dr S. Roesel Medical Officer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacitlc United Nations Avenue 1000 Manila Philippines Tel: (632) 528-8001 Fax: (632) 521-1036 E-mail: roesels@who.org.ph Dr R. Sanders Scientist Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) 528-8001 Fax: (632) 521-1036 E-mail: sandersr@who.oeg.ph Dr Y. Saw Medical Ofticer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) 528-8001 Fax: (632) 521-1036 E-mail: satoy@who.org.ph
- 76Annex 2 Ms S. Takahashi JICA Volunteer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) 528-8001 Fax: (632) 521-1036 E-mail: takahashis@who.org.ph WHO/CAMBODIA Mr O. Bassett Technical Officer Expanded Programme on Immunization WHO Representative's Office House 120, Street 228 Sankat Chadomuk Khan Daun Penh Phnom Penh Cambodia Tel: (855) 23-216610 Fax: (855) 23-216211 E-mail: bassett@who.org.kh WHO/CHINA Dr E. Hoekstra Medical Officer Expanded Programme on Immunization WHO Representative's Office 9-2-151 Ta Yuan Diplomatic Compound I Xingdonglu, Dongzhimen Wai 100600 Beijing China Tel: (8610) 6532-5634 Fax: (8610) 6532-2359 E-mail: hoekstrae@who.org.cn Mr A. Schnur Technical Officer Expanded Programme on Immunization WHO Representative's Office 9-2-151 Ta Yuan Diplomatic Compound I Xingdonglu, Dongzhimen Wai 100600 Beijing China Tel: (8610) 6532-5634 Fax: (8610) 6532-2359 E-mail: schnura@who.org.cn WHO/FIJI Dr M. O'Leary Epidemiologist Expanded Programme on Immunization WH 0 Representative's Oftice 3rd Floor, YWCA Building Sukuna Park Suva Fiji Tel: (679) 30-0727 Fax: (679) 300-462 E-mail: olearym@who.org.tj Mr F. Rousar Technical Officer Expanded Programme on Immunization WH 0 Representative's Office 3rd Floor, YWCA Building Sukuna Park Suva Fiji Tel: (679) 30-0727 Fax: (679) 300-462 E-mail: RousarF@who.org.tj WHO/LAO PEOPLE'S DEMOCRATIC REPUBLIC Dr Yang Baoping Medical Officer Expanded Programme on Immunization WHO Representative's Oftice Quatier That Luang Vientiane Lao People's Democratic Republic Tel: (856) 2 I -4 13430 Fax: (856) 21-413432 E-mail: who_ybp@udon.ksc.co.th WHOIVIET NAM I
I'
Dr M. Hodge Medical Officer Expanded Programme on Immunization WHO Representative's Office 2A (Ground Floor) Van Phuc Quarters Hanoi Viet Nam Tel: (844) 845-7901 Fax: (844) 823-3301 E-mail: mhodge@hn.vnn.vn I
I
•
- 77 -
Annex 2
WHO HEADQUARTERS, GENEVA Dr Maureen Birmingham Medical Oft1cer Expanded Programme on Immunization Global Programme for Vaccines and Immunization World Health Organization CH-1211 Geneva 27 Switzerland Tel: 4122-791-4409 Fax: 4122-791-4193 E-mail: birminghamm@who.ch Dr Ana-Maria Henao-Restrepo Medical Officer Expanded Programme on Immunization Global Programme for Vaccines and Immunization World Health Organization CH-1211 Geneva 27 Switzerland Tel: 4122-791-4409 Fax: 4122-791-4193 E-mail: henaorestrepoa@who.ch WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA (SEARO) Ms Sonja Schmidt Division of Expanded Programme on Immunization Regional Oftice for South-East Asia World Health House Indraprastha Estate Mahatma Gandhi Road New Delhi 110002 India Tel: (91-11) 3317804 Fax: (91-11) 331 8607 E-mail:
Country
Measles outbreaks, by year
3:
~
'"
>0 ",c )<ltd
~
~~ 0> )<l:>'1 ....,,,, m0..., ....,> 00 ::t
:;;!:!l
0. '" ~~ ..... z 1'"0
n
.....
'"
On no ""'c Oz tIl....,
;.0_
m;.o
~~ ~>
8 ;.0
-
Year.
19-- I 74 I 75 I 76 I 77 I 78 I 79 I 80 I 81 I 82 I 83 I 84 I 85 I 86 I 87 I 88 I 89 I 90 I 91 I 92 Large outbreak (>5 reported cases I 1000 population)
94 I 95 I 96 I 97 I 98 I
> m >
'"
Source of data: WHO EPI Information System, 1996 (plus additional reports from countries)
> z
z
Small outbreak (> 1 reported case I 1000 population; or laboratory-confirmed)
~
'"
- 81 ANNEX 4 CRITERIA USED FOR ACCREDITATION OF NATIONAL POLIOMYELITIS LABORATORIES l.
Test results are reported by the laboratory on at least 80% of AFP specimens within 28 days of receipt. This criterion may be met for all virus negative specimens after 2 passages in 14 days. Viruses that appear late in passage, virus mixtures, or viruses that present typing difficulties may require longer than 28 days, but these generally represent less than 20% of specimens receivcd Tests are performed on at least 150 specimens annually. Fully active virus laboratories that maintain the appropriate cell cultures weekly and annually test 150 specimens of any origm for any viruses are deemed to meet this criterion. Laboratories anticipating less than this number may collaborate with the EPI staff to develop protocols sampling healthy children in high risk areas, routinely testing specimens from meningitis cases, or other epidemiologically sound virus surveillance activities.
2.
3. The annual non-polio enterovirus (NPEV) isolation rate from all stool specimens is at least 10%. The NPEV isolation rates in some tropical areas may exceed 30%. Rates may be <10% in some areas with cool seasons, high elevations, low population densities, or high levels of sanitation. Adjustments in anticipated rates, in consultation with the Regional Laboratory Coordinator, may be required for laboratories in these situations. 4. The accuracy of poliovirus detection and identification among all virus isolates is at least 80%. Accuracy is determined by the agreement in test results on all poliovirus isolates and all NPEV isolates (not to exceed 20) submitted to the Regional Reference Laboratory (RRI") by the National Laboratory during the 12 month review period. 5. The score on the most recent WHO approved proficiency test is at least 80%. Proficiency tcst results must be reported within 60 days of panel receipt.
6. The score from the annual on-site review of laboratory operating procedures and practices is at least 80%. For Laboratories with consistently high annual scores, the Regional Laboratory Coordinator may waive the on-site review upon satisfactory completion of the annual check list bv the laboratory. Three criteria are used for accreditation of Regional Reference Laboratories: l.
Intratypic differentiation test results are reported to the Regional Laboratory Coordinator on at least 80% of all AFP pOliovirus isolates within 28 days of receipt or completion of typing if specimens processed in that Laboratory. This criterion applies to isolates from AFP cases and contacts of AFP cases from investigations. Polioviruses isolated from routine testing of clinical materials or from special studies may be assigned lower priority according to Laboratory work load.
2. A score of at least 90% is achieved on the most recent WHO proficiency test for Regional Reference Laboratories. 3. The score from the annual on-site review oflaboratory operating procedures and practices is at least 90%. The following two additional criteria apply for those Regional Laboratories that also serve as National Laboratories: 4. Test results are reported by the Laboratory on at least 80% of AFP specimens within 28 days of receipt.
5. The non-polio enterovirus (NPEV) isolation rate from all stool specimens is at least 10%.