•
(WP)EPIIlCPIEPI/OO2-A Report series number: RS/94IGEI4O CCHN) English only
REPORT
&iiNiCAL ADVISORY GROUP ON THE EXPANDED PROGRAMME ON IMMUNIZATION AND POLiOMYELmS ERADICATION
~RTM MEETING OF THE
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Beijing, China 31 October - 2 November 1994
13 JUl 1995 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines April 1995
, NOTE
The views expressed in this report are those of the participants of the interim Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization.
"
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for the participants in the interim meeting of the Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication in the Western Pacific Region, which was held in Beijing, China, from 31 October to 2 November 1994.
CONTENTS
SUMMARY
1. 2.
INTRODUcnON................................ ................................................... PROCEEDINGS .....................................................................................
2 2
2.1 Summary of conclusions and recommendations of laboratory meeting ............. 2.2 AFP case definitions summary.............................................................. 2.3 Surveillance requirements summary ....................................................... 3. 4. MEETING OF THE REGIONAL INTERAGENCY COORDINATING COMMflTEE ............................................................... SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS ....................... ANNEXES:
2 4 5 6 9
ANNEX 1 - TIMETABLE ..................................................................... 15 ANNEX 2 - LIST OF PARTICIPANTS .................................................... 17 ANNEX 3 ANNEX 4 1994 VIRUS ISOLATION RESULTS, SUMMARY OF PRESENTATION BY DR ZHANG LIBI. ............ 23 1994 POLIO SURVEILLANCE SITUATION, SUMMARY OF PRESENTATION BY DR WANG KE-AN ........... 25
ANNEX 5 - COMPONENTS OF AFP SURVEILLANCE.............................. 27 ANNEX 6 - SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS OF PROVINCIAL VISITS .................... 31
Kcy words: Immuni7Jltion I Poliomyelitis - prevention and control I Poliovirusca I Poliovirus vaccinc, oral I Paralysis I China
SUMMARY
The interim meeting of the Technical Advisory Group (fAG) on the Expanded Programme on Immunization and poliomyelitis eradication initiative in the Western Pacific Region was held in Beijing, People's Republic of China, from 31 October to 2 November 1994. The meeting was attended by 54 participants and observers, including four TAG members, EPI personnel from the Ministry of Health, China, representatives from national and regional poliovirus laboratories, and representatives from multilateral, bilateral and nongovernmental organizations. The purpose of the meeting was to review progress in poliomyelitis eradication in China in view of a marked decline in the circulation of wild poliOViruS, and to make recommendations for surveillance in China for 1995 and subsequent years. Surveillance for acute flaccid paralysis (AFP) has improved considerably in China during 1994, to the extent that 70% of the expected non-polio AFP cases were reported through the AFP reporting system, all reported cases of AFP were investigated within 48 hours of report, and over 80% of reporting sites provided zero reports on time. Completeness of specimen collection, with two adequate stool specimens collected for each case, was leSs than 50% however, and requires improvement. Because of the decline in poliomyelitiS cases, to avoid misclassificalion of AFP cases that are not true poliomyelitis, it has become necessary to change the case classification criteria from a clinical to a virological basis. The meeting recommended that China could adopt the new case classification criteria effective immediately, but until adequate levels of surveillance and laboratory performance have been achieved, figures derived from both the old and new classifications should be displayed in reports. The Regional Interagency Coordinating Committee (ICC) met for the fifth time during the interim TAG meeting, and presentations were made by representatives from the major donor organizations. The priority for the ICC has now moved from vaccine supply to support for surveillance. Pledges were made for support for surveillance, together with continued provision of funding for vaccine for supplementary immunization.
- 21. INTRODUCTION
The fifth meeting of the Technical Advisory Group (TAG) on the Expanded Programme on Immunization and poliomyelitis eradication held in Manila from 25 to 29 April 1994 reviewed progress in the implementation of the programme in the Western Pacific Region. The TAG considered that good progress had been made, and that this was in large part a result of the added political commitment of all countries, of international donor participation and consequent increased technical input. However, since there were now less than two years until the programmed target date for poliomyelitis eradication, much more remained to be done. In view of this, one of the recommendations made at the fifth TAG meeting was that an interim TAG meeting should be held before the sixth TAG meeting, scheduled from 3 to 7 July 1995 in Phnom Penh, Cambodia. This meeting would address the remaining issues of poliomyelitis eradication, particularly with regard to China, where poliomyelitis cases are still reported, though at a lower rate than 1993. Twenty-nine countries and areas of the Region are presumed poliomyelitis-free. The six remaining poliomyelitis-endemic countries are approaching that status. As we move towards the 1995 target date for eradication, increased attention must be given to clearly defining and meeting the criteria for certification of eradication. The currently used case definition for poliomyelitis may not be sufficient for purposes of certification of poliomyelitis-free status. This is because its continued use may result in the confirmation of many cases that are not caused by infection by the wild poliovirus. The current case definition, therefore, should be reviewed and amended accordingly.
2.
PROCEEDINGS
2.1
Summary of conclusions and recommendations of laboratory meeting
The meeting was opened by Dr Sima Huilan (WHO Regional Office, Manila). Dr T. Miyamura (National Institute of Health, Tokyo, Japan) was nominated and elected meeting chairman. Dr R. Sanders (WHO Regional Office, Manila) was nominated and elected rapporteur for the meeting. Mrs M. Kennett (Fairfield, Australia) described progress in the regional laboratory quality control system. Dr Miyamura provided an account of the intratypic differentiation methods used in the regional reference laboratory, the current status of the L alpha cell evaluation and the proposed changes to the structure of the laboratory training courses held at NIH Japan. Dr W. Dowdle (WHO, HQ) discussed aspects of laboratory procedure and management. Dr Zhang Li-Bi (National Laboratory for Poliomyelitis, Beijing, China) presented the current laboratory results in China and described some of the programmatic restrictions currently faced. Dr Wang Ke-An (Chinese Academy of Preventive Medicine, Beijing, China) described the current epidemiological surveillance situation in China and outlined the main areas of concern. Dr O. Kew (CDC Atlanta, USA) presented an overview of the experience of the laboratory network in PAHO, compared the situation in PAHO with the current situation in China, and the applicability of the PAHO experience to the China surveillance network.
-3Current experience in China has important implicatio.ns for the g~obal eradication. . programme. China should be congratulated on the impressl.ve accomplishment of ~tabl~shlng a laboratory network. However, significant improvements In performance are requIred In many areas. Laboratory meeting recommendations: (1) Virus surveillance is now of national, regional and global importance and should be given the highest priority by the public health community. (2) Adequate and timely transpon of specimens and isolates within the country is one of the most significant challenges currently facing the surveillance network in China. An effective mechanism for specimen and isolate transpon is urgently required and every effon should be made to develop one. (3) A significant level of funding is required to improve the efficiency of the current laboratory network. Funds are required to improve laboratory facilities, for laboratory staff training, for laboratory reagents and for the transpon of specimens. These funds should be sought as a matter of urgency. (4) Given the importance of information and specimen movement within the network in China, it is recommended that a full-time position of national network data manager/coordinator be created and a suitable manager be appointed. (5) Uniform laboratory performance indicators should be applied to the assessment of provincial laboratories in China. Regular and routine evaluation of the performance of the laboratories should be made and steps taken to upgrade laboratory performance as required. (6) Laboratory activities should be focused on the timely and accurate isolation and identification of poliovirus in stool samples taken from AFP cases. (7) Except for special circumstances, routine collection and analysis of stool samples from contacts is not recommended. (8) All laboratories should use the national EPI identification numbering system, and all specimens should be numbered accordingly. All samples and isolates sent to the national laboratory must carry EPI identification numbers and be accompanied by a completed standard referral form. (9) Provincial laboratories should enter their laboratory data into the national database in a timely manner. All variables must be entered, panicularly the key variables which identify samples and those which allow evaluation of laboratory performance. (10) In order to avoid compromising virological surveillance, health staff should be instructed that OPV must not be given to AFP cases before collection of stool samples. (II) To allow subsequent retesting, it is recommended that laboratories retain, and store frozen, all stool samples for a period of at least three months after initial testing, and that all stool extracts be stored frozen for at least one year. (12) Evaluation of the L alpha cell line, which permits selective growth of polioviruses in cell culture, should be continued, with their distribution to selected laboratories in the network.
-4-
2.2
AFP case definitions summary
With the decline in transmission of the wild poliovirus and improvements in AFP surveillance, China is now in a position to move from current clinical confirmation criteria for poliomyelitis to laboratory confirmation criteria: CHnical confirmation criteria AFP cases are confirmed as poliomyelitis for anyone of the following: - wild virus isolated from stools - residual paralysis at 60 days after onset - death before follow up at 60 days - case lost to follow-up. All cases not fulfilling at least one of the above are discarded as non-polio. Laboratory confirmation criteria Confirmed poliomyelitiS AFP case with wild poliovirus isolation regardless of adequacy of stool specimen and regardless of whether residual paralysis is present at 60 days, or the case has died or was lost to follow-up. Discarded as non-polio AFP case with adequate stool specimens testing negative regardless of whether there is residual paralysis, or the case has died, or has been lost to follow-up. Polio-compatible AFP case with residual paralysis, who died or was lost to follow-up and for whom stool specimens were either not taken or were inadequate. Level of surveillance indicators In order to be able to change from the current clinical to the laboratory confirmation criteria, AFP surveillance must reach a minimum level of quality ("interim level"). Later, surveillance quality should improve to reach the level required for certification ("final level"), as measured by surveillance indicators. Interim level of surveillance quality Rate of non-poHo AFP: I per 100 000 children aged 0-14 years 60% of AFP cases investigated within 48 hours of report 60% of AFP cases have two adequate stool samples taken, at least 24 hours apart 80% of reporting units provide zero reports on time Achievement of the above level of surveillance will enable countries to change from clinical to laboratory criteria.
-5Final level of survejllance quality Rate of non-polio AFP: I per 100 000 children aged 0-14 years
SO" of AFP cases investigated within 48 hours of report SO" of AFP cases have two adequate stool samples taken, at least 24 hours apart SO" of reporting units provide zero reports on time Achievement of the above level of surveillance will be requited for certification of eradication. term
The surveillance indicators stipulate that "adeouate stool samples" should be taken; this can be defined as follows:
. Criteria to define 'adequate' stool samples Collected 0-14 days after onset of paralysis Arrive at laboratory with ice present Of sufficient quantity for complete laboratory analysis.
2.3
Surveillance requirements summary
A paper entitled "Activities and resources needed for adequate surveillance to achieve poliomyelitis eradication in the Western Pacific Region", was presented by Mr A. Schnur. Dramatic progress has been made in AFP surveillance in all countries in the Region, and as the target of zero poliomyelitis cases draws closer, so the surveillance system, including the laboratory network and the AFP information netwotk, becomes increasingly important. The resources needed to ensure adequate AFP survejllance in all countries in the Region have been identified under the following categories: training, personnel, equipment and supplies and operational costs. Annex 4 shows the components of AFP surveillance alongside the actions that are carried out, and the types of resources needed. Several international agenCies, in collaboration with local authorities, have been active in developing, promoting and supporting the surveillance system, including J1CA and UNICEF. At the fifth TAG meeting, Rotary International had requested a list of activities and requirements for potential funding. For the interim TAG meeting a proposal for funding for 1995 and 1996 was prepared in collaboration with the governments of Cambodia, China, Lao People's Democratic Republic, Philippines, and Viet Nam. The total amount of funds requested from Rotary International for funding of surveillance activities in 1995 is US$1 517000. The final requirements by country for 1995 are:
-6Country China Cambodia Lao P.D.R. Papua New Guinea Philippines Viet Nam TOTAL (USS)
Unmet surveillance CGSts 1995 793 SOO 325 000 115000 78000
47 SOO 158000 1517000
The secretariat was requested to collaborate with the ministries of the respective countries to prepare work plans and budgets for each country. The budgets would take account of unmet costs incurred in improving and maintaining AFP surveillance through providing training workshops and meetings, supporting costs of national staff when travelling for AFP case investigation, providing vehicles for surveillance travel and items of laboratory and office equipment. All countries also required funding support for stool sample transport, which was a major item of expenditure in China where distances can be very great.
3. MEETING OF THE REGIONAL INTERAGENCY COORDINATING COMMmEE
The ICC meeting was called to order by the Chairman, Mr Brian Knowles of Rotary International (Australia). Dr Steve Cochi of CDC served as Rapporteur. The first order of business was to hear presentations from each of the major donor organizations (Rotary International, JICA, AIDAB, UNICEF and CDC) participating in the poliomyelitis eradication initiative (PEl) in the Western Pacific Region, summarizing each organization's present contributions to PEl in 1994, and future plans for 1995. Dr E. Trainer expressed Rotary's satisfaction with the strong multi-organizational partnership which has characterized the ICC activities in the Western Pacific Region, stating that there has been effective sharing of information and ideas, and excellent collaboration among ICC members, under WHO direction, to address problems collectively and find solutions. Similar sentiments were also expressed by the other donors in their prepared remarks. Dr Trainer reviewed the basic policies of Rotary support for the PEl, which include acting only in full coordination with its partners in the PEl, and in accordance with the WHO global plan of action. Dr Trainer outlined the four major types of Rotary support: (I) vaccine grants, either in the form of funds for OPV for supplementary immunization activities or to improve production capacity and therehy contribute to long-term vaccine self-sufficiency; (2) non-vaccine grants, in the form of funds for social mobilization, technical assistance, and research; (3) advocacy, through efforts to influence world leaders, strengthen public-private sector cooperation, and educate Rotarians in all countries about the PEl; and (4) support to strengthen national poliomyelitis surveillance systems. Since the Rotary PolioPlus Program became operational 6-7 years ago, approximately USS200 million in funds have been allocated. Henceforth, the programme will operate under an annual ceiling of USSI5 million for the next few years, with an expected additional allocation of USS125 million in Rotary funds to PEl by the year 2005.
-7The major contribution of Rotary International in the Western Pacific Region has been to the activities in China, where US$5.5 million has been provided for OPV for national immunization days (NlDs) in 1993-1994 and 1994-1995; in addition, Rotary-Japan provided US$75O 000 in 1994 for OPV for the NlDs. The main subject of discussions at the interim TAG meeting has been the need for accelerated activities and additional resources to improve the epidemiologic and laboratory surveillance in China and the other poliomyelitls-endemic countries of the Western Pacific Region to ensure both continued progress toward poliomyel itis eradication in the region and the appropriateness of a planned change to a new, more specific poliomyelitis case classification system which relies more heavily on the performance of the laboratory and the surveillance system as a whole. To address these concerns, Rotary announced a new grant to the Western Pacific Region of up to US$2.05 million to support strengthened surveillance. However, Rotary stipUlated that such a grant is contingent on: (I) their assurance that all supplementary OPV vaccine needs will be met in the Region in 1995; and (2) that the TAG and ICC endorse the surveillance project. Dr Taira of JlCA congratulated the governments of China, Lao People's Democratic Republic, Viet Nam, and Philippines for their successful NlDs, and the Government of Cambodia for its successful sub-national immunization day (SNID). JlCA vaccine grants in 1994 to these countries totalled US$2.8 million. JlCA already has commined US$2.2 million in funds for OPV in 1995, and will study the possibility of providing additional vaccine funds toward eliminating the current region-wide vaccine shortfall of US$2.45 million. JlCA also plans to donate a vaccine tilling machine to Viet Nam, and will continue its support of the Shandong surveillance project, which includes strengthening of the laboratory services, training, and strengthening of AFP surveillance in five provinces of China. The representative of AIDAB, Mr Hellier, reviewed the organization's previous and continuing support in the Region for the cold chain, staff positions based at the Regional office and in Lao People's Democratic Republic, and US$0.5 million in 1995 for vaccine for NlDs in Viet Nam. The Government of Australia has developed a new global health initiative of S million Australian dollars. Funds from this initiative will be allocated in 1994-I99S to accelerate poliomyelitis eradication activities and cover operational costs of NIDs in Cambodia (470000 Australian dollars) and Lao People's Democratic Republic (130000 Australian dollars) and to provide 1.5 million Australian dollars to the Philippines for a UNICEF-administered child health programme which includes EPI. Dr Suomi Sa1c.ai (UNICEF Beijing) presented the UNICEF report, and limited her comments to the situation in China. UNICEF support for EPI in China has focused on three areas: (I) general EPI support; (2) poliomyelitis eradication; and (3) neonatal tetanus (NNT) elimination. In 1994, US$2.3 million was provided for general EPI support (equipment, cold chain, transportation, communication); US$120 000 from UNICEF United Kingdom for general EPI "grassroots training"; US$500 000 from UNICEF Hong Kong for OPV for the NIDs; US$200 000 for NNT activities; and US$388 000 for poliomyelitis eradication activities (US$170 000 for OPV; US$I g 000 for national meeting; US$200 000 for sub-national NID training/meetings). In 1995, approximately US$2.0 million will be available for general EPI activities; USS300 000 for NNT activities; and US$300 000 from UNICEF Hong Kong for supplementary OPV in China. In addition, up to USS500 000 more may be available for OPV in 1995 if current fund raising efforts by UNICEF Hong Kong are successful. Dr S. Cochi expressed CDC's gratitude for the opportunity to participate in activities towards poliomyelitis eradication in the Western Pacific Region. CDC support to the Western Pacific Region has consisted primarily of provision of OPV for supplementary immunization and support for long-term professional staff at the Regional office and country level. CDC provided OPV funds of US$2.0 million (China - USS\.5 million; Viet Nam - USSO.5 million) in 1994, and commined to providing US$I.O million in 1995 for supplementary OPV activities for the Western Pacific Region as a whole, to be allocated at the discretion of Dr Omi, and with the concurrence of the other PEl partners. Current support for four long-term staff will continue at least through mid-I996.
-8Rotary reported that construction of the RotaryIWorld Bank-funded new vaccine production facility is nearing completion and has a target to begin producing vaccine in 1996. Dr Arita recommended that WHO encourage the World Bank to publicize information about the status of the production facility to the world community involved in immunization (especially to those actively involved in the Children's Vaccine Initiative) so that appropriate planning can occur. UNICEF (Dr Sakai) made a plea to WHO to alert UNICEF as soon as possible regarding anticipated OPV needs for 1995 so the vaccine manufacturers can be alerted and problems with meeting the vaccine supply needs of NlDs in a timely manner can be avoided. The ICC session concluded with acknowledgment that a shift in highest priority for the Western Pacific Region has occurred from vaccine supply toward further strengthening of poliomyelitis surveillance, and with a note of optimism on two counts: (1) the new Rotary grant to strengthen poliomyelitis surveillance will go a long way toward ensuring the achievement of poliomyelitis eradication in China and the other poliomyelitis-endemic countries of the Western Pacific Region by the end of 1995; and (2) there is the prospect that further deliberations by the Government of Japan may lead to additional contributions to meet OPV needs for 1995 and the elimination of the remaining shortfall in vaccine funds by early next year. It is noteworthy that the activities of the ICC have now matured in the Western Pacific Region to the point that the ICC can focus on longer-term planning instead of on crisis intervention issues, which previously dominated ICC meetings as recently as the 1993 TAG. Major action points: (I) Rotary requested WHOIWPRO to develop surveillance work plans for each country, outlining how (including timeframe) the surveillance grant monies will be used, and offered to participate with WHO in preparing these work plans. (2) lICA will explore with the Government of Japan the need for additional contribution of funds for OPV to eliminate the remaining regional shortfall of USS2.45 million for 1995. Rotary requested that, if at all possible, a deadline of 15 January 1995 be honoured so that plans for the surveillance project can be implemented. (3) WHO is requested to encourage the World Bank to provide information about the status of the vaccine production facility in China to interested parties, particularly to donors and those involved in CVI activities. (4) WHO is requested to notify UNICEF as soon as possible about anticipated OPV needs for the NlDs in 1995, so that the manufacturers can, in turn, be notified.
-94. SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS
China has made substantial progress towards poliomyelitis eradication. For 21 months, wild poliovirus has not been found in 22 of the 30 provinces in China. In 1993, wild virus was isolated from 61 AFP cases in 7 provinces. Despite improvements in reporting of AFP cases and collection of stool specimens, only one wild virus isolate has so far been found in a patient with onset of paralysis in 1994. The only known remaining focus of wild virus transmission is in Kashgar prefecture, Xinjiang province. Although no wild virus has been detected in 1994, there may be another remaining focus in Guizhou province, which remains at high risk. There are several other provinces, where surveillance is not yet adequate, which remain at high risk. Using the current case definition, at least 300 AFP cases will have been confirmed as poliomyelitis by the end of 1994. The very successful NIDs in 1993/1994 were made possible by the combination of strong commitment by the Government of China and support from the international community, notably UNICEF, Rotary International, the Government of Japan through JlCA, the Government of the United States through CDC Atlanta, and the Government of Australia through AIDAB. Additional supplementary OPV campaigns were conducted in the autumn of 1994 in seven provinces where wild virus had been found in 1993, and Yunnan province. These campaigns were conducted before the second NIDs which will be held in December and January. One remaining difficulty is that surveillance quality still varies greatly by province; while several large provinces have already reached reliable levels of surveillance quality, there are other large areas with incomplete AFP reporting and stool collection. Poliomyelitis eradication efforts in China have moved away from crisis management to detailed forecasting and planning. However, three areas of concern remain: the sensitivity of the laboratory network, the quality of AFP surveillance, and the ability of the upcoming NIDs to reach all eligible children throughout the country. The 1994/1995 NIDs will be crucial to ensure nationwide interruption of wild virus circulation. (1) AFP surveillance - current status in China
Non-polio AFP rates for children under 15 have increased to 1/100 000 or higher in several large provinces (Shandong, Henan, Jiangsu, Anhui, Hebei). However, AFPreporting varies enormously by province and is still very incomplete, particularly in some other large provinces (Sichuan). The national under-IS AFP rate projected for 1994 has risen to 0.75/100 000. All reported cases of AFP were investigated within 48 hours of report. The completeness of specimen collection has also improved, but not at the same rate as AFP reporting. Projecting January-September data for the whole year, only 42 % of reported AFP had two specimens taken within 14 days of onset; 73 % have had one specimen taken within 14 days. Over 80% of reporting sites are providing zero reports on time.
- 10 -
(2)
Rationale for changing classification criteria
. As ~e in~id~nce of true poliomyelitis decreases to very low levels, using the current classification ~ntena~ ~re and more AFP cases in China are incorrectly classified as confirmed pohomyehtls cases. Using current classification criteria, it will not be possible to cenify the eradicat!on o~ poli~m~elitis. As in the Region of the Americas, it will be necessary to change the classlficatlon cntena so that only cases from whom wild poliovirus has been isolated will be confirmed as poliomyelitis. (3) New classification criteria The following criteria are proposed for the classification of AFP cases: • Poliomyelitis AFP case with wild poliovirus isolation. • Non-Polio AFP AFP case with adequate stool specimens testing negative, regardless of whether there is residual paralysis, or the case has died, or has been lost to follow-up. • Polio-compatible AFP case with residual paralysis, who died or was lost to follow-up and for whom stool specimens were either not taken, or were inadequate. Issues associated with adopting the new case classification criteria (a) Scrutiny of poliomyelitis-compatible cases
Cases previously confirmed as poliomyelitis on clinical grounds become "poliomyelitis-compatible" if specimens were not collected or inadequate. Where stool sampling is incomplete, many poliomyelitis-compatible cases will arise, some of which may be true paralytic poliomyelitis cases. Poliomyelitis compatible cases indicate a failure of the surveillance system. Therefore, steps should be taken to identify the surveillance problems and improve surveillance in areas where compatible cases occur. All data on poliomyelitis-compatible cases should be carefully analysed, including geographical distribution, immunization status and age distribution. To ensure that poliomyelitis-compatible cases can be scrutinized at a later date if necessary, medical records should be kept and stool specimens should be preserved, as outlined in the laboratory recommendations. If scrutiny of poliomyelitis compatible cases raises a concern of ongoing circulation of wild virus, consideration should be given to special surveillance and additional supplementary immunization activities. (b)
Scrutiny of clinically diagnosed cases with negative laboratory results
Similar consideration should be given to cases that are indistinguishable from pOliomyelitis on clinical grounds and are negative for wild poliovirus after testing of adequate stool specimens. In cases where poliomyelitis is strongly suspected on clinical grounds, additional testing of the original stool specimens may be warranted.
- II -
(c)
Increased reliance on laboratory
Since only cases associated with wild virus isolation are confirmed, the emphasis has shifted from clinical to virological confirmation criteria, requiring a high level of performance at provincial and national laboratories. To allow subsequent retesting, it is recommended that laboratories retain and slnre frozen all stool samples for a period of at least three months after initial testing, and that all stool extracts be stor~ frozen for at least one year. (d) Contact stools
A review of laboratory specimen results from contacts of AFP cases in the Western Pacific Region and the Region of the Americas failed to identify new geographical areas of wild poliovirus circulation. Therefore, contact stools should not routinely be taken. (4)
Implementing the new case defmition
China should adopt the new case classification criteria effective immediately. In view of possible deficiencies of AFP reporting and laboratory performance, additional tables with data using the old case definition should continue to be included in surveillance reports until the following levels of surveillance quality are reached: 1. Non-polio AFP rate of 1 per 100 000 children aged under 15 years. 2. 60% of AFP cases investigated within 48 hours of report. 3. 60% of AFP cases with two adequate stools specimens collected, at least 24 hours
apart. 4. 80% of reporting units providing zero reports on time. The following criteria are used to define "adequate stool specimens·: - Collected 0-14 days after onset of paralysis - Arrive at laboratory with ice present - Sufficient quantity for complete laboratory analysis. Surveillance data for national and provincial levels should be tabulated in two ways, using the old and the new classification criteria. The country report to WHO should contain both tabulations. Tabulation should be done at the national level and shared with the provinces, where data collection should proceed as usual. Feedback to provinces should also include a comparison of surveillance quality indicators with the other provinces. Once all four surveillance indicator levels have been reached nationally, a switch should be made In only reporting results using the new case classification criteria.
Consensus was reached that ultimately this virological case definition will need to be adopted by all countries in the Westenr Pacific Region; a decision will be made on a country-by-country basis after review of the quality of AFP surveillance, the performance of the laboratory and the existing epidemiological situation.
- 12 Recommendations (I) China should adopt the new case classification criteria, effective immediately. Until adequate levels of surveillance and laboratory performance have been reached, tables using the current classification criteria should be included as annexes in national reports. This should continue until the following levels of surveillance quality are reached at the national level : (a) (b)
Non-polio AFP rate of I per 100 000 children aged under 15 years.
60% of AFP cases investigated within 48 hours of report. 60% of AFP cases have two adequate stools specimens collected. 80% of reporting units should provide zero reports on time.
(c) (d)
It is expected that China can achieve these levels of the surveillance indicators by the . end of 1995.
(2) Active surveillance should be a routine part of surveillance activities in each county, using national guidelines and based upon the comprehensive Regional Plan of Action which concerns China and other countries in the Region. (3) Special measures should be carried out immediately by allocating additional resources to high risk: and low surveillance performance provinces. These activities should include the following: (a) Surveillance promotion visits to the 17 provinces with low AFP and stool collection rates, in the spring of 1995. (b) Improving AFP surveillance, especially in Guizhou province, through routine visits of national and international staff to conduct active searches for AFP cases and train staff on active surveillance.
(c) Special attention and close supervision of NID activities in Kashgar prefecture, Xinjiang, and Guizhou province. If complete AFP surveillance in Kashgar province from October 1994 to February (d) 1995 cannot be assured, consideration should be given to conducting active virological surveillance as well as house-to-house immunization in the spring of 1995. Special attention to low-performing provinces should not detract from maintaining poliomyelitis eradication activities throughout the country. (4) Efforts should be made to reduce the number of poliomyelitis-compatible cases since they represent a failure of the surveillance system. These cases should be scrutinized through review of medical records and if necessary retesting of specimens. If scrutiny of poliomyelitis compatible cases raises a concern of ongoing circulation of wild virus, consideration should be given to special surveillance and additional supplementary immunization activities. (5) Improving the laboratory capacity and specimen transport in China should be considered a national priority and supported by national and international agencies. All laboratories should meet the uniform performance indicators, as specified for virological surveillance.
- 13 (6) Indicators for eventual certification of poliomyelitis eradication should be determined at the sixth TAG meeting. Criteria to establish the extent of future supplementary immunization activities should be decided at the sixth TAG meeting after careful analysis of the epidemiological situation during the first half of 1995. (7)
(8) Support from the international community for poliovirus vaccine will continue to be required, even after zero cases are achieved in 1995. After 1995, additional OPV will be required to control any importations of wild virus and to ensure that OPV coverage can be sustained at adequate levels in all areas. (9) Recognizing the critical role of the 199411995 NIOs to completely interrupt wild virus circulation, the immediate priority of the programme should be to ensure its success through mechanisms such as provincial visits, particularly to high risk areas. Political support at the highest level should be given for National Immunization Days to ensure that all el igible children are reached and given OPV during the two rounds. (10) The sixth TAG should give consideration to the extension of the AFP surveillance system to other diseases of public health priority, and, if appropriate, to the mechanism by whicb this might be acbieved. (11) All suspected poliomyelitis cases in China should be considered as public health emergencies and immediately investigated with collection of two adequate stool specimens, and, if appropriate, supplementary immunization activities.
INTERIM MEETING OF THE TECHNICAL ADVISORY GROUP ON THE EXPANDED PROGRAMME ON IMMUNIZATION AND POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION (INCLUDING LABORATORY MEETING AND PROMOTIONAL VISITS) Beiji1lll. China 30 Oc:tot- - , No.....t- 1994
WPRIEPI/EPlIll94.I-A 14 Octot- 1994
ENGLISH ONLY TENTATIVE TIMETABLE
6. I. Opening ceremony
meeting Regional reference laboratory issues a) Proficiency tests b) Inll3lypic differentiation
2. Introduction and objectives
Presentations from: Rotary
ofmeeling 3. Presenlation of conclusions of laboralory meeting 4.
J1CA AIDAB UNICEF
9. Presenlation of draft summary report of conclusions and recommendations 10. Briefing for provincial visits
Promotional visits to selected provinces Ten groups, one for each
province: (I) Heilongjiang
CDC 7. Comprehensive plan of action for polio surveillance and laboratory network and vaccine requirements after 1995 Discussion
<.II
10:30
I China issues a) Chinese polio isolation results 1994 b) Constrainls on polio surveillance
AFP case definition
10. Briefing for provincial visits (continued) II. Finalizalion of summary report of conclusions and recommendations
(2) Jilin (3) Fujian
(4) Guangdong (5) Hubei
. 13:30 13: 30
I
L : 4.
u
N C
Currenl SIaIUS and goals of surveillance in China lessons from PAHO
It
B
R
(6) Hunan China presenlation (1) Hainan
Discussion (8) Guizhou
> (9) Yunnan (10) Shunxi
Z Z
)(
ttl
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ANNEX 2
LIST OF PARTICIPANTS
1.
TECHNICAL ADVISORY GROUP (TAG) MEMBERS Dr Hiroshi Maruyama l Deputy Director Infectious Disease Control Division Ministry of Health and Welfare Government of Japan 1-2-2, Kasumigaseki, Chiyoda-ku
Dr Isao Arita Chairman Agency for Cooperation in International Health 4-11-1 Higashi-machi, Kumamoto-shi Kumamoto City 862 Japan
!QbQ Japan
Dr Kenneth J. Bart Director National Vaccine Program Office Parklawn Building 5600 Fishers Lane Rockville, Maryland 20857 United States of America Dr Dai Zhicheng Director Department of Epidemic Prevention Ministry of Health 44 Hou Hai Bei Van Beijin, 100725 China
Dr Robert Hall National Center for Epidemiology and Population Health Australian National University Canberra. 0200 Australia
ITo attend as representative of Dr N. Sakai, Chief, Division of Health Promotion and Nutrition, Ministry of Health and Welfare, Japan.
- 18 Annex 2
2.
EPI NATIONAL MANAGERS
4. OBSERVERSfREPRESENTATIVES AUSTRALIAN INTERNATIONAL DEVELOPMENT ASSISTANCE BUREAU (AlDAB)
cmNA
De Wang Zhao Deputy Director Department of Epidemic Prevention Ministry of Health 44 Hou Hai Bei Yan BeijinK 100725 China Dr Yang Baoping .Chief of EPI Division Department of Epidemic Prevention Ministry of Public Health 44 Hou Hai Bei Yan BeiiinK 100725 China 3. REGIONAL REFERENCE LABORATORY STAFF
Me William Hellier Australian International Development Assistance Bureau Beijing China Mr Matthew Durnin Australian International Development Assistance Bureau Beijing China CENTERS FOR DISEASE CONTROL (CDC)
Ms Margery Kennett Virology Department Collaborating Centre for Virus Reference and Research Fairfield Hospital Yarra Bend Road Fairfield, Victoria Australia Dr Tatsuo Miyamura Director Department of Virology II National Institute of Health 1-23-1 Toyama Shinjuku Tokyo 167 Japan Dr Zhang Ubi Chief National Laboratory for Poliomyelitis 100 Ying Xin Jie 100052 Beiiing China
Dr Stephen Lee Cochi Chief Poliomyelitis Eradication Activity Centers for Disease Control and Prevention Atlanta, Georgia 30333 United States of America Dr Olen Kew Chief Molecular Virology Section Respiratory and Enteric Viruses Branch Division of Viral and Rickettsial Diseases National Center for Infectious Diseases Centers for Disease Control and Prevention Atlanta, Georgia 30333 United States of America CHINA
Mr Wu Guogao Deputy Director Department of International Cooperation Ministry of Health Beijing China Ms Sun Shuhua Program Officer Department of International Cooperation Ministry of Health Beijing China
- 19 Annex 2 Dr Zhou Jun Program Officer Department of Diseases Control Ministry of Health Beijing China Dr Li Huifang Deputy Chief EPI Division Department of Diseases Control Ministry of Health Beijing China Dr Wang Ke-an Vice President Chinese Academy of Preventive Medicine (CAPM) 10 Tian Tan Xi Li Beijinll China Dr Liu Xia Director Associate Professor Chinese Academy of Preventive Medicine (CAPM) 10 Tian Tan Xi Li Beijing China Dr Zhang Xinglu Assistant Professor Chinese Academy of Preventive Medicine (CAPM) 10 Tian Tan Xi Li Beijing China Dr Zhang Rongzhen Professor Chinese Academy of Preventive Medicine (CAPM) 10 Tian Tan Xi Li Beijing China DrLi Quanle Assistant Professor Chinese Academy of Preventive Medicine (CAPM) 10 Tian Tan Xi Li Dr Guan Baoying Deputy Chief Department of Epidemic Preventionl Beijing Health Bureau Ministry of Health 44 Hou Hai Bei Van Beijinll China Dr Gu Yinhua Chief EPI Section Beijing Epidemic Prevention Station Beijing China Dr Chu Jingui Consultant Hebei Epidemic Prevention Station Hehei China Dr Xu Aixiang Chief EPI Section Shandong Epidemic Prevention Station Shandong China JAPANESE GOVERNMENT Mr M. Kamohara First Secretary Japanese Embassy Beijing China JAPAN INTERNATIONAL COOPERATION AGENCY (JICA) Dr S. Taira Managing Director Medical Cooperation Department Japan International Cooperation Agency I-I Nishi-Shinjuku, 2-chome Shinjuku-ku, Tokyo 163-04 Japan Dr H. Yoshikura Director Department of Enterovirus National Institute of Health Tokvo Japan
Beijing China
- 20Annex 2 Mr M. Watanabe Assistant Resident Representative Japan International Cooperation Agency Room No. 1111, Beijing Fortune Building 5, Dong San Huan Bei-Lu Chao Yang District Beijing China Dr K. Kusumoto Chief Adviser Poliomyelitis Control Project in China Japan International Cooperation Agency Room No. 1111, Beijing Fortune Building 5, Dong San Huan Bei-Lu Chao Yang District Beijing China Dr M. Hara Japan International Cooperation Agency Room No. 1111, Beijing Fortune Building 5, Dong San Huan Bei-Lu Chao Yang District Beijing China Dr K. Hikida Japan International Cooperation Agency Room No. 1111, Beijing Fortune Building 5, Dong San Huan Bei-Lu Chao Yang District Beijing China Dr Y. Nishimura Japan International Cooperation Agency Room No. 1111, Beijing Fortune Building 5, Dong San Huan Bei-Lu Chao Yang District Beijing China Dr R. Iriyama Japan International Cooperation Agency Room No. 1111, Beijing Fortune Building 5, Dong San Huan Bei-Lu Chao Yang District Beijing China Dr Y. Chiba Medical Doctor International Cooperation Division National Medical Centre ~ Japan ROTARY INTERNATIONAL Dr E.G.P. Haran Regional Advisor (Asia) PolioPlus Program Rotary International 6251, Sector B-9, Vasant Kunj New Delhi - 110 070 India Mr Masami Hiraoka Regional Coordinator ASIA Polio Plus Task Force Rotary International 64-7-5 Ayazono, Takaishi-city Q§ill
Japan Mr Brian Knowles 43/17 Bayview Street
Runaway Bay 4216 Oueensland Australia Dr Edward Trainer Polio Plus Program Manager The Rotary Foundation of Rotary International One Rotary Center Evanston, Illinois 60201-3698 United States of America UNITED NATIONS CHILDREN FUND (UNICEF) Dr Suomi Sakai UNICEF Office for China 12 Sanlitun Lu Beijing 100600 China
- 21 Annex 2
S.
SECRETARIAT Mr A. Schnur Technical Officer Expanded Programme on Immunization WHO Representative's Office 9-2-151 Ta Yuan Diplomatic Compound I Xing Donglu Dongzhimen Wai 100600 Beijing China Mr M. Erkkila Technical Ofticer Expanded Programme on Immunization WHO Representative's Office 9-2-151 Ta Yuan Diplomatic Compound I Xing Donglu Dongzhimen Wai 100600 Beijing China Dr M. Otten, Jr. Medical Officer Expanded Programme on Immunization WHO Representative's Office 9-2-151 Ta Yuan Diplomatic Compound I Xing Donglu Dongzhimen Wai 100600 Beijing China Dr R. Tangermann Medical Officer Expanded Programme on Immunization WHO Representative's Office San Lazaro Compound Sta. Cruz Manila Philippines
Dr S. Omi Acting Director. Disease Prevention and Control Regional Adviser Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr J. Bilous Medical Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr J. Kool Associate Professional Officer Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr R. Sanders Short-term Consultant Expanded Programme on Immunization WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines Dr Sirna Huilan Regional Adviser Health Laboratory Technology WHO Regional Office for the Western Pacific United Nations Avenue Manila Philippines
- 22Annex 2 Dr J.W. Lee Director Global Programme for Vaccines World Health Organization Geneva Switzerland DrH. Hull Medical Officer Global Programme for Vaccines World Health Organization Geneva Switzerland Dr B. Aylward WHO Consultant Global Programme for Vaccines World Health Organization Geneva Switzerland Dr W. Dowdle WHO Consultant Global Programme for Vaccines World Health Organization Geneva Switzerland
- 23 ANNEX 3
1994 VIRUS ISOLATION RESULTS SUMMARY OF PRESENTATION BY DR ZHANG LlBI
In the period January to August, 1285 stool sample were collected from 1077 AFP patients. Poliovirus was isolated from 92 (7.2%) of these, and non-polio enteroviruses from 88 (6.8%). Of the polioviruses isolated, 24 were reported as type I, 34 as type 2, 12 as type 3, 19 as mixed polios and 2 as polio/entero mixtures. Polio type J isolates came from 9 Provinces; Fujian, Guangdong, Guangxi, Guizhou, Hainan, Hebei, Shandong, Shanghai and Xinjiang. From these only one wild type J polio was identified, from the Kashgar region of Xinjiang Province. Since the poliO laboratory network was established in 1992 there have been three annual training courses, and following each course proficiency testing exercises have been carried out by staff from the 29 Provincial laboratories. There has been a steady improvement in the proficiency scores attained by the laboratories, with 24 of the 29 laboratories receiving a perfect score for the test carried out in 1994. Outstanding problems included the shortage of funds to support the laboratory network, including funds for transport of specimens and isolates and for essential laboratory equipment and reagents. High turnover of laboratory technical staff is also a major prohlem, with many staff leaving the government laboratories after their training has been completed.
- 25-
ANNEX 4
1994 POUO SURVEILLANCE SITUATION SUMMARY OF PRESENTATION BY DR WANG KE-AN
Until the middle of 1994, the polio surveillance system used throughout much of China was based on surveillance for clinical polio, and cases of AFP which did not clinically resemble polio were not reported. This resulted in generally low rates of AFP being reported. The provinces of Shandong, Henan and Guangxi were exceptions, with higher rates of AFP being reported through 1993. Active searches carried out by the JlCA team in Shandong. however, showed that even here, only a small percentage of the GBS patients were being reported as AFP. Although the surveillance system for China as a whole has not yet reached the WHO indicators of one case of AFP per 100,000 children less than 15 years of age, and two stools collected from at least 80% of cases within 14 days of onset of paralysis, the system does appear to be adequate to detect wild poliovirus when present. No wild poliovirus has been isolated from 22 provinces in the past two years, and these provinces now appear to be wild-virus-free. Current information suggests that wild poliovirus may be circulating only in parts of Xinjiang Province, in the remote west of China, and possibly also in Guizhou Province. Fortunately, two rounds of supplemental immunizations were carried out in Kashgar Prefecture, Xinjiang Province, in September and October 1994. Due to lack of operational funds Guizhou was not able to carry out province-wide supplementary immunization activities. Problems remain with rapid and adequate stool collection, and with ensuring that all stool specimens receive a case identifier number (rIA). There are also problems with entry of details of stools receipt, culture result and other key variables into the Provincial laboratory database system. This makes it impossible for CAPM to monitor the laboratory surveillance system and identify surveillance problems. Operational funds are required for intensified supplementary immunizations in areas believed to be of high risk for wild virus circulation.
- 27 -
ANNEX 5 COMPONENTS OF AFP SURVEILLANCE
Item 1, Training COUNTRY A, Surveillance trainino worklhops (national and sub-national) 2· 4 per year (includes laboretory surveillance in Chine) 8. Worklhops on operetlonal asPects of speciman collection C. Virologist's study in over_. laboratory D. Meetings with hospital staff on AFP surveillanca PapuaNew~
YEARS
COST
LaoPDR Cambodia VietNam Philippines Chine Laos Cambodia Viet Ham Philippines Viet Ham Chine PhHippine. Laos
Cambodia Viet Ham SUB TOTAl
1995/6 1995/6 1995/6 1995/6 1995/6 199516 1995/6 1995/6 1995/6 1995 1995 1995/6 1995/6 1995/6 1995/6 1995/6
15,000 16,000 15,000 20,000 20,000 50.000 10,000 10,000 10,000 7,000 10,000 20,000 10,000 5,000 5,000 10,000 232,000
Item 2. Personnel COST A. Managers 1 Coordinators (two year funding) WHOIWPRO (Medical Officer) Cambodia (2 Medical! Technicat Officer.) China (Medical Officer) PNG (Epidemiologist) laos (Medical Officer) Viet Nam (Medical Officer) Viet Ham Republic: of Korea Philippines Viet Ham (Hanoi) (3 months) Malaysia (1 month) Singapore (1 month Papua Naw Guinea (1 month) WHOIWPRO (2 months) Cambodia China Laos PNG Viet Ham
B. Two virologist consultants per year X 2 months ($13,000 J)er month) C. CompUler expart
D. Consultants for Active Search IAFP Surveillance 2 per year x 1month each country SUB TOTAL
1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995 1995 1995 1995 1995 1995 1995 1995 1995/6 1995/6 1995/6 1995/6 1995/6
340,000 680,000 320,000 300,000 320,000 350,000 350.000 52,000 52,000 52000 39,000 13,000 13,000 13,000 52000 52,000 52.000 52,000 52,000 52,000 2,856,000
- 28AnnexS
Item 3. Equipment and Supplies COST A. Vehic:les for surveillance t ..1111 China (101 Cambodia 121 Lao 121 Viet Hem 121 Cambodia China Lao PNG Phlllppin.. Viet Hem Cambodia China 1995 1995 1995 1995 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 1995 200,000 40,000 40,000 40000 5,000 25,000 1,000 500 2,500 5000 5,000 25,000 1,000
B. Stool collection klts
C. Stool specimen shipping box..
Lao PNG D. Freezers, ·20 C for laboratories E. 'Consumables' 1_ annexl x expected workload Laboratory suppli.. F. • Permanent' equipment Idetailed list to followl G. Computers and software for surveillance and laboratories IDesk tops end notebooksl SUBTOTAL Philippines Viet Nam China I x 28 Provlncesl China Ix 28 Provinceal Philippines VietNam China Ix 24 Provinc.., China, Subnetional Labs. Viet Hem Cambodia Laos Viet Hem WHOIWPRO
500 2,500 5,000 36,000 210,000 254,000 10,000 10000 240,000 50,000 10000 10,000 10,000 10,000 20,000 1,508,000
- 29Annu S
Item 4. Operational Costa COST A. Travel expen... end per diem • Surveillance _menta IActlve searchl • Promotional visits • Training assignments B. Preparation and distribution of guidelines, training materiala, forms fo, AFP surveillance Cambodia ChIna
Lao PNG PhilIppines VIet Nam . Cambodia China Lao
PNG C. Surveillance publications, communicetions - Television publicity - Posters -l..flets - Laboratory Manual for China D. Airfreight I Cou,iers for specimens Phillpplnee VlatNam Cambodia China Lao
PNG Phtllppinee Viet Nam China Australia China 26 x 6 x 200 Cambodia Lao 11) Viet Nam 14) China
1995/6 199516 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 199516 1995/6 1995/6 1995/6 1995/6 1995/6 1995/6 1995 1995 1995
E. Support for national surveillance Officer
1995/6 1995/6 1995/6 1995/6 1995/6
SUBTOTAL
70,000 30,000 30,000 30,000 20,000 30000 20,000 20,000 20.000 20,000 20,000 20,000 4.000 4,000 4.000 4,000 4,000 4,000 2,000 4,000 8,000 24,000 30,000 20,000 50,000 50,000 542,000
Item 5. Meetings COST Smell TAG meetings x 2 Cross border meetings x 2 Laboretory meetings x2 SUB TOTAL Regional CambodialLaosNiet Nam ChinalPakistan + others
1995/6 1995/6 1995/6 1995/6
50,000 40,000 50,000 50,000 190,000
- 30AMex5
SUMMARY OF RESOURCE REQUIREMENTS
ITEM 1. Training 2. Personnel 3. Equipment and supplies 4. Operational costs 5. Meetings GRAND TOTAL 232,000 2,856,000 1,508,000 542,000 190,000 5,328,000
./
- 31 ANNEX 6 SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS OF PROVINCIAL VISITS, 3-6 NOVEMBER 1994
In general all teallls were met with the greatest cooperation and enthusiasm by the provincial authorities. Above all, the opportunity to meet the provincial vice-governors was welcomed by provincial EPS and health bureau staff. Based on the visits, we have the following recommendations: (I) National level personnel should be sent to the three highest risk areas in China before the NID to make sure that the NID is conducted optimally. The three areas are: Yunnan Province and the Myanmar-Yunnan border area, Guizhou Province, especially the areas that did not receive the EORI (mopping up), and Kashgar/Hetian Prefectures in Xinjiang. It is essential that a highly effective NID is conducted in those areas. Without an effective NID in these areas, it maybe necessary to conduct additional EORIs in the future. (2) With only one month before the NID, the national level should ensure that all provinces have allocated and paid for adequate vaccine for two rounds of NlDs. (3) All isolates, including non-polio enteroviruses, should be sent to the national laboratory from all provinces. (4) The national level should raise the visibility of the provincial poliovirus laboratory with the provincial health bureau and epidemic prevention station, this should include explaining the importance of the provincial laboratory in wild poliovirus surveillance to the provincial health bureau and epidemic prevention station. (5) A national schedule for shipments of isolates from the provincial laboratory to the national laboratory should be set up. A person should be designated to monitor this schedule to ensure that isolates are not delayed at province level or lost. The monitoring can take place by examining the provincial and national laboratory computer databases. Opportunities of travellers going to Beijing should continue to be used for sending isolates to save on shipping costs. (6) Zero reports being sent on time but many AFP cases are being missed. The active surveillance system needs to be fully implemented. (7) Contacts and non-AFP cases have been found to be included as AFP and given TI A identification numbers. Provincial personnel should regularly review data entered into provincial AFP line listing, to ensure the highest data qUality. (8) In the final phases of polio eradication in China, there is a need to establish criteria for provinces to actively follow up high risk counties and AFP cases reported from these counties. This will enable focusing of limited resources on the highest risk areas. For example: (I) Stool samples have not been submitted in 1994 from counties with wild poliovirus isolated in 1993. (2) Poliovirus I was isolated by the provincial laboratory from a county in a prefecture reporting wild poliovirus for the last two years yet a follow-up visit has not yet been made 140 days after onset of paralysis.
- 32 Annex 6 (3) A poliovirus I isolate was sent to the national laboratory in Beijing only four months after onset of paralysis. (9) Poliomyelitis eradication jnformation data has already shown that there are only a few areas in a few provinces where wild poliovirus is still suspected to be circulating. These high-risk provinces need to be closely followed up from national level and staff sent to work with the provinces to urgently eliminate the remaining wild poliovirus foci. Since there are shortages of staff or funds in several provinces, consideration should be given to making use of experienced polio eradication staff from provinces which are no longer reporting polio cases to support high-risk provinces. For example, a roster of experienced polio eradication staff can be established and one or more of these staff sent for about one month to work with provincial staff in activities including active search for cases in high-risk areas, follow-up of pending cases, etc.
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