Ninth Meeting on the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region, Manila, Philippines, 12-13 November 2003 : report

(WP)/ICP/EPII5 .2/00 I-A RS/2003/GE/47(PHL) English only

REPORT NINTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION

Convened by: WORLD HEALTH ORGANIZA nON REGIONAL OFFICE FOR THE WESTERN PACIFIC

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines May 2004

WflOIWPRO .ulllRNRt' M""ILA, rlllLlPPINES 'J .)l.,~·ll.

~ MeY ')GO~

NOTE The views expressed in this report are those of the participants of the Ninth Meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization.

Keywords: !Immunization I Poliomyelitis - prevention and control I Certification This report has been printed by the Regional Office for the Western Pacific of the World Health Organization for the participants of the Ninth Meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region, which was held in Manila, Philippines, from 12 to 13 November 2003.

TABLE OF CONTENTS

1. 1.1

INTRODUCTION ................................. , .................................. """ ............................. I o BJ ECTI VES ............................................................... '" ..... " ..................................... 1 ORGANIZA TI ON .................................................................. , ..................................... 1 OPENING CEREMONy ................................................................................................ I

. 2.

1.2 1.3

PROCEEDING S .......................................................................................................... 1

2.1 2.2

GLOBAL OVERVIEW OF POLIOMYELITIS ERADICATION ........................................... I REGIONAL OVERVIEW OF HIE SITUATION AFTER POLIOMYELITIS-FREE CERTIFICATION ........................................................................................................ 7

2.2.1 Certification process..................................................................... ....... ......... 7 2.2.2 Surveillance quality in 2002 ............................................................................. 7 2.2.3 Surveillance quality in 2003 ............................................................................. 8 2.2.4 Surveillance for vaccine derived polioviruses ....................... ........................... 8 2.2.5 Immunization activities ..................................................................................... 9 2.2.6 Laboratory containment ofwild poliovirus infoctious and .............................. .. potentially infectious materials ...................................................................... 10 2.2.7 Discussion .................................................................................................... 10 2.3 PROGRESS REPORTS FROM EACH COUNTRY AND AREA ON MAINTAINING POLIOMYELITIS-FREE STATUS AFTER CERTIFICATION ........................................... 11

2.3.1 2.3.2 2.3.3 2.3.4 2.3.5 2.3.6 2.3. 7 2.3.8 2.3.9 2.3.10 2.3.11 2.3. J2 2.3. 13 2.3. J4 2.3.15 2.3.16 2.3.17 3· 4.

Australia .................................................................................................. 11 Brunei Darussalam .......... .......................................................................... 12 Cambodia .................................................................................................... 13 China........ ................................................................................................... 14 Hong Kong SAR (China) ................................................................................ 16 Japan ........ ..................................................................................................... 16 Lao People's Democratic Republic ................................................................ 18 Macao SAR (China) ................................................................................. 19 Malaysia .......... ............................................................................................. 19 Mongolia ................................................................................................... 20 New Zealand . ............................................................................................... 22 Pacific island countries and areas .. .............................................................. 23 Papua New Guinea ......................................................................................... 23 Philippines .. .................................................................................................... 25 Republic of Korea ..... ................................................................................... 26 Singapore ....................................................................................................... 27 Viet Nam ..................................................................................................... 28

CONCLU SI ON S ...................................................................................................... ,29 FUTURE MEETING OF THE REGIONAL CERTIFICATION COMMISSION ... 37

ANNEXES: ANNEX I ANNEX 2 TENTATIVE TIMETABLE ............................................ 39 LIST Of REGIONAL CERTIFICATION COMMISSION (RCC) MEMBERS, EPI TECHNICAL ADVISORY GROUP (TAG) AND SECRETARIAT ................................................... 41

I.

INTRODUCTION

The ninth meeting of the Regional Commission for the Certification (RCC) of Poliomyelitis Eradication in the Western Pacific Region (WPR) was held in Manila, Philippines, from 12 to 13 November 2003. 1.1 Objectives The objectives of the RCC at its ninth meeting were: (I) to review progress reports from all countries and areas on maintaining the poliomyefitisfree status; to review progress of completion of Phase I of laboratory containment of wild poliovirus infectious/potentially infectious materials; and to make recommendations for maintaining the Region's poliomyelitis-free status and for global certification requirements.

(2)

(3)

1.2

Organ ization

The meeting was attended by all seven commission members, the chairperson and vice-chairperson of the WPR Technical Advisory Group (TAG) on the Expanded Programme 011 Immunization (EPI) and Poliomyelitis Eradication, and a secretariat. Annex I includes the timetable of the meeting, and Annex 2 contains the list of participants. 1.3 Qgening ceremony

Dr A. Adams and Dr S. Yamazaki were requested to continue to serve as Chairperson and Vice-Chairperson respectively, and Dr A. Salonga was requested to serve as Rapporteur.

2.

PROCEEDINGS

2.1

Global overview of poliomyelitis eradication

Seven countries in the world remained poliomyelitis-endemic, the lowest ever number. They were Nigeria, India, Pakistan, Egypt, Afghanistan, Niger and Somalia (Somalia's last wild poliovirus case was rerorted on 6 October 2002). As of 12 November 2003, 95% of all new poliomyelitis cases in 2003 were found in three countries: Nigeria, India and Pakistan. Seventy-five percent of poliomyelitis cases globally could be linked to just five states or provinces within these countries - Kano (Nigeria), Uttar Pradesh and Bihar (India), North West Frontier Province, and Sindh (Pakistan). The goal of the Global Poliomyelitis Eradication Initiative is to have interrupted transmission of wild poliovirus by end-2004 and be in the process of global certification by 2005. The global funding gap of US$ 210 million for activities through 2005 remains the single greatest risk to poliomyelitis eradication.

-2-

A recent poliomyelitis outbreak, spreading from Nigeria to n:ighbouring countriesand putting 15 million children at risk, required a massive immunization campaign across five countries 111 west and central Africa. Beginning 22 October 2003, hundreds of thousands of volunteers and health workers in Benin, Burkina Faso, Ghana, Niger, and Togo aimed to reach every child in those countries with oral poliovirus vaccine (OrY) in just three days. The campaign was organized, at a cost of more than US$ 10 million, in response to a number of children being paralyzed in Burkina Faso, Ghana, Niger, and Togo by poliovirus genetically traced to northern Nigeria. Of particular concern is that monitoring data indicate the response mop-up campaigns held in West Africa may not have reached sufficient children to interrupt transmission of the imported viruses. A further case recently reported in Chad has led to similar campaigns being planned in that country and in Cameroon for mid-November. Two cases of paralytic poliomyelitis due to type I poliovirus, with onset of paralysis on 2 and 27 August 2003, have been confirmed in the Mayo-Kebbi and Logone Orientale provinces, in the southern part of the coulltry, near the borders with Cameroon, Central African Republic and Nigeria. Chad has 1I0t reported poliomyelitis cases since June 2000. The viruses detected in Chad are genetically close to viruses circulating in northeastern Nigeria in 2002 and 2003. WIIO is currently working with ministries of health in Camerooll and Chad to plan for and implement the synchronized sub-national immunization campaigns targeting children aged <5 years with Ory. It is critical that every child is reached during these activities to ensure that population immunity coverage is sufficiently high to prevent spread of imported virus and to protect against further importations. The poliomyelitis-infected states in Nigeria, centred around Kano state, have re-infected other areas of the country, most IVorryingly the city of Lagos with its 10 mil/ion inhabitants. Senior epidemiologists from the (Jlobal Poliomyelitis Eradication Initiative convened a high-level meeting with the Nigerian Minister of Health at the end of September 2003, at which the Minister provided his commitment to eradicating poliomyel itis in Nigeria by the end of 2004. To achieve this goal, strong political support must be established or strengthened at the sub-national level. Political and community leaders mllst be engaged to facilitate the logistics of immunization campaigns and ensure that all children are reached. Nigeria now has the highest number of poliomyelitis cases in the world, and the disease continues to spread, both to areas of the country that were poliomyelitis-free and to neighbouring countries. The tremendous progress made in 2002 resulted in the focus of poliomyelitis eradication tactics and resources being shifted in 2003 to the few countries that remain endemic. Now, the situation in Nigeria is forcing eradication efforts back to countries that had already eliminated poliomyelitis. These massive immunization campaigns are thus critical, to prevent these isolated viruses from again paralyzing children in areas that had previously been poliomyelitis-free. Epidemiologists attribute the marked increase in cases in Nigeria, around the state of Kano, to insufficient coverage by both poliomyelitis immunization campaigns and routine services. Monitoring data have highlighted at least one state in which as few as 16% of children have been adequately immunized. A difficult environment has severely compromised the quality of immunization campaigns and helped to propagate rulllOurS about the safety ofOry.

Angola and the Democmtic Republic of the Congo (DRC) In Angola, the reported national rollti ne imlllull izatioll coverage of infants aged < 12 months with three doses of oral poliovirus vaccine (OrY3) for the years 2000 to 2002 was respectively 33%, 44%, and 42%. In DRC, the corresponding ligures were 42%, 33%, and 45%.

-3-

Supplementary immunization activities (SIAs) targeting children aged <5 years for OPY have been conducted annually in Angola and ORC since 1996. Between January 2002 and May 2003, Angola implemented three rounds of National Immunization Days (NIOs) and one sub-national immunization days (SNIOs) using the house-to-house strategy. The May 2002 SNIOs targeted 40 municipalities with high-risk areas, including 28 camps for internally displaced persons (lOPs) and five quartering areas for former combatants and their families; approximately 2.8 million children <5 years were reached. Three NIOS were conducted in June, ./uly and August 2002 - synchronized with those in Congo, ORC, Gabon, Namibia, Sao Tome and Principe, and Zambia - and reached approximately 4.5 million Angolan children aged <5 years. In 2003, Angola conducted two rounds of NlOs in July and August. In June, July, and August 2002, ORC implemented three rounds ofNIOs, reaching approximately 12.5 million children aged <5 years during each round. Two rounds of SNlOs targeting high-risk areas were conducted in ORC in July and August 2003. High-risk areas were identified from neute flaccid paralysis (AFP) surveillance indicators, such as clustering of polio-compatible cases, low vaccination coverage during the 2002 NIOs, and wild poliovirus detection in 2000. In 2002, the non-polio AFP rate in Angola was 3.0 per 100000 under age 15. All 18 provinces achieved non-polio AFP rates> 1.0. Although the geographical distribution of AFP cases detected in 2002 was proportional to population density in western Angola, there were gaps in case detection in the central and eastern provinces. AFP cases were reported primarily from municipal centres, while several sub-provincial areas reported no cases, particularly those bordering ORC and Zambia, because of access and security issues. The proportion of cases frolll which two adequate stool specimens were collected was 85% in 2002. During January-June 2003, the annualized non-polio AFP rate was 1.4, with 13 (72%) of 18 provinces reporting at least one AFP case; adequate stool specimens were collected from 84% of Af'P cases. The non-polio AFP rate in ORC in 2002 was 5.0, with all II provinces achieving non-polio AFr rates> 1.0. At the end of July 2003, the annualized non-polio AFP rate was 3.3, with all I 1 provinces reporting at least one AFP case. The proportion of Af'P cases from which two adequate specimens were collected was 84% in 2002 and 92% during January-June 2003.

Ethiopia, Somalia, Sudan Ethiopia, Somalia and Sudan, which form an important epidemiological block in eastern Africa, have passed one year without evidence of wild poliovirus transmission. In 2002, coverage of infants with OPV3 was reported as 51 % in Ethiopia and as 64% in Sudan; WHO and the United Nations Children's Fund (UNICEF) estimated national OPV3 coverage in Sudan at 47% for 2001, while the OrY3 coverage estimate was only 20% in conflict-affected southern Sudan. Imillunization services in Somalia are delivered by internationainon-governlllental organizations (NGOs) supported by WHO, UNICEF, and other United Nations agencies. Estimated OrY3 coverage in Somalia increased from 33% in 2001 to 40% in 2002. During 2002 and 2003, all three countries implemented Ory SIAs, using house-to-house vaccine delivery, with each country conducting at least two rounds ofNIDs. Additional SNIDs targeted high-risk areas and popUlations.

-4-

[n 2002, Ethiopia conducted SNlDs reaching 3.25 million children <5 years old in March and April, and full NlDs (> 14 million children reached) in October and December; the 2003 SNlDs targeted 2.5 million children aged <5 years in high-risk areas. In Somalia, SIA implementation continued despite ongoing conflict. although with limited access to children in the Mogadishu area. SIA rounds in Somalia were conducted on a flexible timeline to access children in conflict zones during cessation of hostilities. Since the beginning of2002, five SNID rounds (four rounds reaching between 600 000 and one million children, finh round in May 2003 reaching >98000 children) and four NID rounds (each round reaching> 1.3 million children) were conducted in Somalia. In Sudan, S[As during 2003 reached more children than ever before, particularly in the conflict-affected south, where an additional 500000 children were vaccinated in 2003 compared with 2002. [n southern Sudan, five rounds ofNlOs (reaching between 1.2 and 1.7 million children), and two rounds ofSNlDs (reaching >700000 children) were conducted from 2002 to mid-2003. In government-controlled areas of Sudan, six rounds of SN [Os targeting between one and 5.8 mi Ilion children were conducted from 2002 to mid-2003. During 2002 and 2003, AFP reporting in all three countries continued to exceed the WHO-established target for surveillance sensitivity: an annual rate of non-polio AFP > I per 100000 population aged <15 years. The decrease in the non-polio AFP rate in Ethiopia from 2002 to 2003 mainly reflects the declining of reported cases not qualifying as AFP. In 2002, only Sudan met the second main AFP surveillance quality indicator - collection of two adequate stool specimens from >80% of all AFP. For 2003 (as of end-August) both Ethiopia and Sudan had met the stool adequacy indicator. Somalia was further able to improve stool adequacy, from 67% in 2002 to 77%, just below the threshold for quality surveillance cel1ification. No wild poliovirus cases have been reported frolll Ethiopia, Somalia, or Sudan in 2003. The last reported wild poliovirus-positive cases in Ethiopia and Sudan occurred in January and April of 2001, respectively; both cases were associated with wild poliovirus type I (wild PI). During 2002, three virologically confirmed wild P3 cases were identified in the Mogadishu area of Somalia, with the last case reported in October 2002.

Afghanistan and Pakistan A fghanistan and Pakistan are among the remaining seven endemic countries, but progress has been substantial. Both countries are considered as one epidemiological block because of their geographical proximity, frequent inter-country population movement and the presence of genetically similar wild poliovirus lineages. .In 2002, reported national routine OPV3 coverage of infants was 48% in Afghanistan and 71 % . In Pakistan. Reported OPV3 coverage in Afghanistan ranged from 6% in Urozgan province to 84% in Nangarhar province. Since 2000, Afghanistan and Pakistan have accelerated the frequency of SIAs, using house-to-house vaccine delivery, with both countries conducting at least four rounds ofNIDs and three rounds of SNJDs annually. Areas targeted for SNlDs are those identified as being at high risk for ~ont.inuing ~iru.s transmission based on surveillance results, genetic sequencing, supplementary or rout~ne ImnlunlzatlOn coverage and population parameters, including the presence of high-risk groups and IIlcreased nllgratory movements, particularly across the border between the two countries.

- 5-

During 2002, Pakistan conducted four NID and four SNID rounds, closely coordinated with five NID and three SNID rounds in Afghanistan. The 2003 immunization schedule for Pakistan includes four NIDs (March, April, September and October) and four SNlDs (January, June, July and December); Afghanistan is conducting fOllr NlDs (April, May, September, and October) and three SNlDs (March, July and December). The quality of SIAs is closely monitored in both countries using process monitoring during immunization rounds as well as immediate post-SIA coverage assessments through independent groups (commercial survey companies and university teams in Pakistan; university students and teachers in Afghanistan). The results of monitoring are used to target areas of weak performance with special support activities. In both countries, the OPV immunization status (routine and supplementary) of non-polio AFP cases reported through the AFP surveillance system is used as a proxy for overall levels of imlJlunity in the SIA target population, with special focus on the immunity profile of AFP cases aged <2 years. Children aged <2 years account for the majority of confirmed poliolJlyelitis cases and are more likely to be missed by vaccinators than older children. Between 2000 and 2002, the proportion of non-polio AFP cases aged <2 years with less than three OPV doses decreased from 46% to 28% in Pakistan and from 72% to 18% in Afghanistan. In 2002, areas where the immunization status of AFP cases <2 years was considerably below the average included northern Sindh, southern Punjab, Baluchistan and southern North-West Frontier Province (NWFP) in Pakistan, and the western, northern and southern regions in Afghanistan. In Pakistan during 2002, the non-polio AFP rate was 2.8 at the nationallevcl, with all provinces reaching non-polio AFP rates above 2; adequate stool specimens were collected from 87% of all AFP cases in Pakistan in 2002. From January to the end of May 2003, the projected non-polio AFP rate increased to 3.0 and adequate stool collection increased to 89%. In Afghanistan during 2002, the non-polio AFP rate was 3.3 and adequate stool specimens were collected from 81 % of all AFP cases. From January to the end of May 2003, the non-polio AFP rate and adequate stool collection rate in Afghanistan increased to 3.8 and 85% respectively. Recent genetic sequencing data indicate that the biodiversity of wild poliovirus circulating in the Pakistan-Afghanistan epidemiological block continues to decrease. The number of virus lineage clusters for PI decreased from ten in 2000 to six in 2002 and forP3 from six clusters in 2000 to three in 2002. Of 100 cases confirmed in 2002 in both countries, 90 (90%) belonged to only five clusters (four PI, one P3).

India In 2002 India accounted for more than 80% of all cases reported globally, primarily because of the large epidemic due to type I poliovirus. This epidemic spread from Uttar Pradesh to several other states, 1II0st of which had been largely poliomyelitis-free in 200 I. In addition to over 100 cases in Bihar. considerable numbers of cases were reported from West Bengal, Rajasthan, Haryana, Madhya Pradesh, and Gujurat. Type 3 poliovirus transmission was limited and was largely restricted to Uttar Pradesh. In 2003 to date transmission of both type I and type 3 continues in Uttar Pradesh, with extensive type 1 transmission also in Bihar and West Bengal. Together these states account for 70% of reported cases nationa lIy. Following the meetings of the Technical Consultative Group for Global Poliomyelitis Eradication (TCG) in November 2002 and the India Expert Advisory Group in February 2003, the Government of India has planned for six large-scale SIA rounds in 2003 (two NID rounds and four SNID rounds covering 60% of the national population). The Government ofUtlar Pradesh has identified staff to take responsibility for poliomyelitis eradication at sub-state level, has shown increased engagement in the management of poliomyelitis eradication activities, and has made efforts

-6-

to improve the effectiveness of immunization teams (e.g. increasing the proportion of female vaccinators and local community members). Monitoring data from the NID rounds in January and February 2003 indicates improved quality in the highest risk areas in Uttar Pradesh, although quality in several districts has not yet reached the level necessary to stop transmission. In other states where transmission was re-established in 2002, NID quality was not uniform. West Bengal is of particular concern as NID quality was not adequate to stop transmission.

Updates on Global laboratory containment of wi hi poliovirus infectious/potentially infectious 111 a te I'ia Is The laboratory containment requirements for global certification of poliomyelitis eradication nd are outlined in the WHO Global Action Plall/or laboratOf), containment a/Wild polioviruses, 2 edition. In Phase I of containment, each country is expected to establish a task force for containment that will conduct a national survey of biomedical laboratories and create an inventory of those found to be holding wild poliovirus infectious or potentially infectious materials. After one year without isolation of wild polioviruses anywhere in the world, Phase 2 laboratory containment activities will begin. Countries will be requested to destroy all unneeded stocks of wild poliovirus and ensure the containment of all retained wild poliovirus stocks under appropriate bio-safety conditions. Documentation demonstrating the completion of both containment phases from all countries will be required for global certification. Ensuring effective laboratory containment is critical to maintaining the achievements of poliomyelitis eradication. WHO is currently working to establish mechanisms for evaluating the activities of each phase of containment. A tool for evaluating the laboratory survey and inventory process is already being used in a number of countries that have completed this activity. Additional tools and mechanisms to evaluate subsequent containment actions are currently being developed to prepare for the global certification process. Mechanisms will be required in the future to independently verify the absence of circulating vaccine-derived polioviruses (VDPV). CUrl'ent status in cel,tified Regions

The Americas On 20 August 1994, the Americas were certified as poliomyelitis-free. At the time of certification in the Americas, laboratory containment was not yet a component of certification activities. To meet the containment requirements for global certification, countries of the Americas have now begun to implement containment activities. By August 2003, all countries of the region had appointed national containment task forces. Laboratory surveys are being conducted in 47 of 48 countries of the Region, with 99 630 of I 10254 (90%) identified laboratories surveyed. All cOlmtries ofthe Region will be requested to submit a report to a regional body that will be established in early 2004. The terms of reference of both regional and national containment groups have been extended to also review and provide oversight for maintaining sensitive APP surveillance systems in all countries.

European Region (EUR) On21 hme 2002, the RCCfEUR certified the Region as free of indigenous wild poliovirus. At the time of certification, laboratory surveys were completed in 41 of 51 countries. Completion of Phase I activities ill all countries of the Region is expected in 2004.

-7-

Current status ill endemic Regions While the first priority for poliomyelitis eradication in endemic Regions is to interrupt wild poliovirus transillission, an increasing nU1l1ber of countries have not reported a poliomyelitis case in several years. In those countries, considerable progress has been made in establishing the certification and containment process.

Eastem Mediterraneal1 Region (EMR) Laboratory surveys have been started in 16 and completed in five of23 countries of the Region. The largest challenge for containment in the EMR is to obtain information from the numerous unregistered biomedical laboratories that operate in many oUhe countries.

South-East Asian Regiun (SEAR) Laboratory containment activities have begun in all countries of the SEAR, and two countries have completed the process; 3427 of 6650 (52%) laboratories have been surveyed. 2.2 Regional overview of the situation after poliomyelitis-free certification

2.2. J

Certification process

National certification cOll1mittees (NeC) remain in place and active as well as expert review groups resulting, together with good adequate stool specimen collection for reliable virological information, in timely AFP case classification with only 6% of cases pending after 90 days of onset. Most expert panels continue to arrive at a presumptive diagnosis for all AFP cases under their review.

2.2.2

Surveillance quality ill 2002

In 2002, a total of6835 AFP cases were reported resulting in a Regional non-polio AFP rate of 1.47 per 100000 children aged under 15 years. Eighty-eight percent of these AFP cases had two stool specimens taken within two weeks of onset of paralysis. Ninety-seven percent of cases with inadequate stool samples had follow-up examinations conducted and 95% of cases had a final classification within 90 days of onset of paralysis. Only 17 cases were classified as polio-compatible. In 2002, all regional reference laboratories (RRLs) and national poliovirus laboratories (NPLs) were visited and performance levels reviewed. For two laboratories with temporarily pending accreditation, detailed workplans were developed, technical support organized from the RRL in Australia as well as parallel testing of all stool specimens from AfP cases to improve performance towards full accreditation. Except one national (Papua New Guinea) and one sub-national laboratory (Tibet) all poliovirus laboratories within the Regional network are currently accredited under WHO standards. In order to increase capacity for intratypic differentiation (ITO) testing in the Region the laboratories in Hong Kong, New Zealand and Singapore were given supplemental accreditation for ITO functions. The performance of the polio laboratory network remained at good quality levels; in 2002, 92% of laboratory results were available with in 28 days of specimen receipt at the laboratory. A II poliovirus isolates from AfP cases (over 600) as well as non-AfP sources (over 150; e.g. enterovirus and aseptic meningitis surveillance, clinical diagnostic and environmental studies) were subjected to two ITO methods to reliably determine the nature of the viruses. Preliminary ITO results were available for 98% of AfP case isolates within 28 days after receipt; availability of both final ITO

- 8-

results at 74% still required improvement. This and continued problems with timely shipn.lent of stool samples from the point of collection to NPLs and poliovirus isolates to the RRLs re~ulted III less than 80% of final ITO results available within the required 60 days after onset of paralysIs.

2.2.3

Surveillance quality in 2003

From January to 10 November 2003, a total of 4566 AFP cases were reported resulting in an annual ized non-polio AFP rate of I .12 per 100 000 under age 15. Lower case reporting than in previous years was noted in China, Malaysia and Viet Nam. Regional data suggest that the international epidemic of severe acute respiratory syndrome (SARS), its management in areas affected and development of national preparedness llIay have impacted on AFP case reporting and possibly other public health activities. Delays in reporting appear to be temporary though and other quality indicators (e.g. adequate stool specimen collection rates) were not affected. Laboratory results in 2003 (dataset as of 10 November) were available within 28 days of receipt for 95% of all AFP cases and all but one provincial laboratory in China exceeded the target of at least 80%. The non-polio enterovirus isolation (NPEV) rate declined from 9% in 2002 to 8% with several laboratories achieving rates even only under 5%. ITO results were available within 14 days of receipt for 82% of poliovirus isolates of AFP cases and for 94% within 28 days of receipt. ITO results were available for 92% of AFP cases within 90 days of onset of paralysis but although improved compared to 2002 for only 61 % within 60 days of paralysis onset for the same main reasons as in previous years. SARS related increased workload and involvement at NPL resulted in delayed distribution of the annual proficiency test (PT) but in the meantime all laboratories have completed and passed the test. All laboratories except the NPL in New Zealand and Ho Chi Minh City achieved a perfect score of 100% with the latter reaching 80%. All provincial laboratories in China passed the PT as well. Annual ITO PTs were passed by the RRL in Australia and Japan and the NPL with supplemental ITO functions (Hong Kong, New Zealand, Singapore) whereas the RRL in China still has to complete one component of the enzyme-linked immunoassay (ELISA) PT. Due to the delays in PT distribution and the recruitment ofa new Regional Laboratory Coordinator, no accreditation visits except to the NPLs in Viet Nam and some selected provincial laboratories in China had taken place at the time of the meeting. A national meeting for provincial laboratories in China was conducted in March 2003 to introduce the new accreditation criteria, followed by a joint visit of staff from WHO, the Japan International Cooperation Agency (JlCA) and the National Institute of Infectious Diseases (NJlD) in Tokyo to China to establish future accreditation procedures and cell culture training for provincial laboratories in China, supported by .lICA and the Centers for Disease Control (CDC) in Atlanta.

2.2."

Surveil/ance for vaccine derived po/iOl'irllses

Twenty-six polioviruses from AFP cases and non-AFP sources with discordant ITO results were subjected to sequencing and one VDPV was isolated from a healthy child in Mongolia. Retrospective analysis detected two VDPVs in China; the first was isolated from an AFP case from Anhui Province with onset of paralysis on 6 April 2002, a history of three doses OPV (last on 5 January 2002) and no residual paralysis upon follow-up. The VDPV was poliovirus type 3 with a drift in polymerase chain reaction-restriction fi'aglllent morphism (PCR-RFLP) whereas the ELISA lTD result was Sabin-like (SL). Sequence analysis of the complete VPI region revealed 9/900 basepair divergence compared to Sabinvirus. The second VDPV was isolated frolll an AFP case from

-9-

Sichuan Province with onset of paralysis on 27 January 2002, a history of four doses OPV (last on 5 December 200 I) and no residual paralysis upon follow-up. The VDPV was poliovirus type I with the ELISA lTD result double-reactive (DR). Sequence analysis of the complete VPI region revealed 10/906 basepair divergence. The NPL in Mongolia has routinely conducted supplementary stool surveys for poliovirus surveillance among healthy children up to five years old in several provinces and districts of Ulaanbaatar city. From November 2002 to March 2003 a total of 313 stool samples were collected, and tested at the NPL. Two SL polioviruses and 23 NPEVs have been isolated. Virological investigation had been done in 30 stool samples from Songinokhairkhan district in Ulaanbaatar City. On 13 February 2003 one stool specimen was collected from a healthy six-month old child. NPL results were positive for poliovirus type PI +P3. Virus isolates were sent to the RRL in Australia and NPL results were confirmed. peR results were SL for both isolates, ELISA was SL for the poliovirus type 3 but non Sabin-like (NSL) for the poliovirus type I. Sequencing results at the Global Specialized Laboratory (GSL) at NIID in Tokyo revealed 12/906 basepairs difference with Sabin type I (1.3%) and thus this virus under the current definition had to be classified as VDPV. Sequence of the 3D region was 99.7% identical to Sabin type I ( I /3 10 base pairs difference). Review of surveillance and coverage data as well as epidemiological investigation of and in the area of the child did not reveal any current virus circulation. In an additional supplementary virology survey among healthy children up to five years of age all stool specimens collected tested negative for poliovirus as well as follow-up stool samples taken from the healthy child. Immunological study conducted in the child and family members found cellular immunity of all family members within reference range. The child from which VDPV was isolated and his young cousin had though decreased values for immunoglobulin A (IgA), immunoglobulin G (IgG) and immunoglobulin M (IgM) while humoral immunity of all other family members was within reference range. Potency testing of OPV samples revealed a slight decrease ill titer of virus components. Detailed results of the investigation are available in the country progress report.

2.2.5

Immunization activities

With reported national routine immunization coverage remaining at similar levels as before in almost all cOlin tries and areas, SIAs with orv were conducted in 2002 in Cambodia, China, Mongolia and Viet Nam (besides the Philippines as circulating vaccine-derived poliovirus [cVDrVj response). OPV has been included in the 2002 measles SNlDs in Cambodia and in several tetanlls toxoid CIT) SIAs targeting almost 270 000 children under five years of age and achieving an overall reported coverage of 80%. China's Ministry of Health requested seven provinces to conduct two rounds of SNIDs in the winter season 2002/2003 in 62 prefectures targeting almost II million children under four years of age and recolllmended to further 20 provinces to conduct SNlDs in high-risk populations in over 80 prefectures targeting almost 17 million children. Following identification of a cluster of AFP cases and suspected transient circulation ofVDPV in Sichuan in mid-2002, two SIA rounds were implemented in eight prefectures ill Sichuan, Guizholl and YUllnan Provinces.

- 10 -

The Lao People's Democratic Republic conducted SIAs in January and February 2?03 targeting 40% orthe country's children under five years of age in27% of all villages from all provll1~es and 80% of the districts. The strategy of the SIAs was to focus on major population concentrations, populations along major transportation routes and major border crossing points. Viet Nam conducted supplementary immunization from October to December 2002 in 28 districts in 13 provinces targeting over 330 000 children IInder five years of age.

2.2.6

LaboralO/J' containment of wild poliovirus infectious alld potelltially illfeclious materials

As China and Japan have not yet submitted a final national inventory, Phase I of the laboratory containment process is still (0 be completed in the Region. 2.2. 7

Discllssion

The TAG during its thirteenth meeting in November 2002 recognized that the EPI ill the Region has entered an era of new opportunities. Building 011 previous achievements but while maintenance of poliomyelitis-free status remains a priority, Regional measles elimination and improving hepatitis B control were introduced to guide and strengthen EPI. Without doubt, the major achievements made in quality of poliomyelitis eradication, have generally been maintained. However, in a Region (where 25% of the world's population live) free of indigenous poliovirus for several years, timely and reliable detection of imported wild poliovirus or cVDPV is of utmost importance. Regular and careful analysis of surveillance and immunization activities is required to detect quality gaps and address them. Overall timeliness of availability of ITO results compared to the onset of paralysis is still below target, dcclining NPEV isolation rates may indicate reduced virological sensitivity and acceptable national surveillance indicators may mask pockets of poor surveillance quality. Reported SIA coverage is usually high but routine field investigations often discover pockets of low immunization coverage. Changes in the global strategic plan mainly due to shortage in funding have reduced preventive SIAs requiring high surveillance quality resulting in higher costs. Other challenges include slow and incomplete integration of measles (and neonatal tetanus [NT]) surveillance into active AFP surveillance. Development and integration of a Regional measles laboratory network has only commenced recently and there is no integration yet of the poliomyelitis laboratory network with other laboratory networks. As the global poliomyelitis eradication prograllime is IlOW targeting to interrupt global wild poliovirus transmission at the end of 2004 and poliomyelitis in neighbouring regions continues to pose a constant threat to achievements made in the Region, concerns need to be addressed that financial support, both frolll national governments and international partners, has not been redirected to other public health activities. To maintain certification standards and respond to enhanced surveillance quality requirements the same level of funding support for the Region needs to be ensured. These continued efforts require large financial and hUlllan resource inputs over six years after the last indigenous wild poliovirus case occurred in the Region. The maintenance ofpoliomyelitisfree status and constant work to create a barrier not only against imported wild poliovirus but also against the emergence of VDPV make a significant contribution beyond this Region towards global eradication and eventually certificMion.

- II -

2.3

Progress reports from each country and area on maintaining poliomyelitis-free status after certification

All countries, including the Pacific island countries and areas (PICs), provided a comprehensive progress report, and summary presentations were made to the RCC. A II progress reports and presentations to the RCC are available on CD-Rom.

23.1

Australia

There were 46 unique notifications of AFP in 2002, of which 13 were errors in notification. Three cases were not reviewed by the polio expert committee, as no clinical information was available. Two adequate stool specimens were received for 26% of AfP notifications. Nine percent of notifications had one stool specimen collected within fourteen days of onset of paralysis. The committee reviewed forty-one cases. This included eleven cases outside the case definition. Thirty cases were classified by the polio expert cOlllmittee as eligible non-polio AFP cases, that is, from patients resident in Australia and aged less than 15 years with onset in the reporting period. Three cases had no clinical or laboratory information available and were therefore not reviewed by the committee. There were 17 unique notifications of AFP between 1 January - 31 August 2003, of which 10 were classified by the polio expert committee as eligible non-polio AFP cases. One case was aged greater than 15 years. Six cases have not been reviewed by the polio expert committee, as no clinical information or laboratory information is yet available. Two adequate stool specimens were received for 31 % of AFP notifications. Nineteen percent of notifications had one stool specimen collected within 14 days of onset of paralysis. In June 2003 a study was undertaken by the Victorian Infectious Diseases Regional Laboratory (V1DRL) to examine differences between procedures for AFP notifications between states and territories, and to determine if differences in procedures might explain differences in notification rates. Queensland and Victoria were selected for further study due to population size and the differences between notification of cases. Queensland's notification rate for AFP cases has steadily increased achieving greater than one case per 100000 since 2000, while Victoria has never reached the expected WHO target since the introduction of AFP surveillance in Australia in 1995. Queensland classified AFP as a notifiable disease in 2001 and is the only Australian State to have done so. Clinicians and laboratories are required by law to notify AFP cases to their local public health unit or directly to the central Queensland lIealth public health unit. The local public health unit team also takes responsibility for ensuring advice about AfP surveillance and is available in the clinical setting. Posters and pamphlets relating to a range of conditions including AfP have been developed by Queensland Health to alert and advise clinicians about the need for timely notification to the public health unit. AFP is not a notifiable disease under Victorian legislation. As a consequence the Department of I [liman Services Victoria has no specific role in the promotion, monitoring and surveillance of AfP cases. No specific promotional materials related to AFP and its surveillance have been developed for distribution in Victoria. In Victoria there is a variety of providers and private contractual arrangements for the provision of health care. Unlike the Queensland system there is no unifying integrated data collection system for public sector pathology services in Victoria. The poliovirus reference laboratory at VIDRL serves as the NPL for Australia, Brunei Darussalam and the PIes. The laboratory also acts as a RRL for the WPR.

- 12 -

Between January 2002 and August 2003, the laboratory performed ITO tests on poliovirus isolates from the NPLs of Hong Kong, Malaysia, Mongolia, New Zealand, Papua New Guinea, the Philippines, Singapore, and Viet Nam (1-10 Chi Minh City). The laboratory also re-tested specimens from patients with AFP from Mongolia, Papua New Guinea, and Viet Nam (1-10 Chi Minh City) as part of an ongoing laboratory quality control. OPV coverage rates (at 30 September 2003 for age cohort calculated at 30 June 2003) were 92.8% for 12-< 15 months, 95.1 % for 24-<27 1l10nths, 75% for 60-<63 months and 85.1 % for 72-<75 months. For laboratory containment the Infection Management Section (IMS) project team conducted a re-organization of the database in Iinc with WHO suggestions. This involved breaking down the information gathered in terms of affiliation and function including public (government funded) versus private, hospital, pathology, university, research, environmental and industry. The laboratory containment of poliovirus survey process and data recorded onto the database were subject to an independent review in February 2003 by an external panel of three professionals (representing the Therapeutic Goods Administration, Australian Institute of Health and Welfare and the Public Health Laboratory Network).

2.3.2

Brunei Darussalam

During 2003, the NCC, which was established in 1996, continued its work to ensure that all aspects of the post-eradication activities are sustained and conducted accordingly. These include surveillance, immunization and laboratory containment activities. The AFP surveillance framework adopted prior to certification continued to be maintained with particular emphasis on coverage and completeness of the AFP surveillance from the various selected reporting sites. During the year 2002 and until September 2003, the AFP surveillance performance was found to be maintained at the highest possible standard. The zero report of AFP cases during this period was substantiated by the absence of AFP case detection during the six monthly (July/December 2002; January/June 2003) and annual retrospective reviews (year 2002) of the reporting sites. Three cases of AFP were reported since the last report. The NCC, which also acts as the Expert Panel, reviewed the three cases, which were initially reported as an AFP case in October 2002, February and June 2003 respectively. Subsequent investigation and discussion cOllclusively discarded all three cases as non-polio AFP. The routine El'l integrated its lOll. antigen, the Haelll()phillls illjlllenzae type B (Hib) vaccine, in April 2002. Coverage for all antigens, incluciing OPV during 2002, continued to be maintained at high levels both nationally and sub-nationally. In view of this, SIAs are nol deemed necessary at present. Laboratory facilities for viral isolation are still unavailable in the country. Previous arrangement for analysis of stool specimells from all AFP cases with VIDRL, continued to be maintained. Apart from the nine laboratories identified during the initial screening for laboratory containment purposes of which all were determined to be handling clinical specimens not potentially infectious in nature, no further laboratories had been identified during the year 2002 and to date.

- 13 -

2.3.3

Cambodia

Since 1998, Cambodia has maintained a high-quality routine, active AFP surveillance system. The only performance indicator not fully met is the one for adequate stool rates. Cambodia's adequate stool performance rate consistently exceeds 70%, but has never achieved an 80% threshold. This is primarily because in many areas of the country, there is still an inadequate health infrastructure for the rapid detection and reporting of cases. Active searching for AFP cases has been included in all measles and TT SIAs and a special active search as a supplement to routine active surveillance was conducted in six mltior provinces. AFP surveillance meetings were organized in 2002 to private practitioners in Phnom Penh, Battambang, Kompong Cham. Clustering of AFP cases is monitored on the basis of case location and date of onset. When clusters (delined as two or more cases in the same or contiguous communes within a two-month period) are identi lied, the cases in the cluster receive special re-investigations. Since more than 60% of AFP cases have been reported from only one major reporting hospital in Phnom Penh, provinces, districts, health centers, and also private sectors need to be encouraged for early detection of AFP through refresher training or periodical meeting. This effort would benefit not only for AFr surveillance but also for the integrated surveillance with measles and NT which most of the cases are reported from community. The quality of diagnosis of AFP needs to be reviewed since the substantial amount of AFP cases reported from major reporting hospitals ended up as tuberculosis (TB), meningitis, or encephalitis with spastic paralysis. Routine immunization coverage in Cambodia still does not achieve uniformly high coverage throughout the country. The Ministry of Health and National Immunization Programme (NIP) have just implemented the Coverage Improvement Plan (CIP) in 10 operational districts (ODs) supported by the Global Alliance for Vaccines and Immunization (GA VI) fund which strengthen the outreach activities, management skills, advocacy and safe il~ection, which would be extended to other ODs to improve routine immunization coverage. When supplemental immunization campaigns are implemented in areas with poor OPV coverage, Ory will be added to the scheduled antigens. Activities to provide Ory to children aged zero to 59 months have been included in the second phase of the nationwide supplementary measles immunization activities that took place in selected areas from October to May 2000-2001, 2001-2002 and 2002-2003. OPV activities have also been included in some of the TT SIAs. There are also plans to include OPV activities in the additional measles SIAs that will be held from January to March 2004. For laboratory containment of wild polioviruses a survey of laboratories with n·eezers was conducted in early 200 I and there was no increase of laboratories with freezer facilities since then. In the future, there will continue to be inspections. to identify new laboratory freezers that may potentially start to keep poliovirus-infected materials. The global concern about potential vaccine derived paralytic poliomyelitis cases has led the NIP to pay more attention to stool samples positive for SL poliovirus. NIP has changed the policy not to investigate all positive cases, but NIP would investigate only when those cases suggest real "hot case" or request of consultation for vaccine associated paralytic poliomyelitis (YAPP). To scrve vigilance for the possibility ofVDPV cases, NIP would strengthen to monitor the duration of the sample shipment as short as possible.

- 14 -

2.3.4

China

In 2002, the reported non-polio AFP rate exceeded 1.0 per 100000 under age 15 in 30 (97%) of China's 31 provinces, with the exception of Tibet Autonomous Region, where the rate was 0.87 per 100000 children under 15 years old. In 2002, there were a total of41 (12%) of 349 prefectures that reported less than the expected number of AFP cases, including II prefectures that expect less than one AFP case each year. From January through August 2003, there were a total of 75 (21 %) of 349 prefectures that reported less than the expected number of AFP cases. Most of tile prefectures reporting fewer than expected cases are in remote areas. From January 2000 through August 2003, three prefectures have not reported any AFP cases. These are Changdu Prefectures in Tibet Autonomollos Region and Jiayuguan in Gansu province and Yushu Prefectures in Qinghai province. In 2002, the percentage of AFP cases with adequate stool specimens was >80% in all but two provinces: Xinjiang Uygur Autonomous Region (76%) and Tibet (40%). From January-August 2003, the percentage of AFP cases with adequate stool >80% in all but seven provinces: Liaoning (73%), Ningxia Ilui Autonomous Region (60%), Xinjiang Uygur Autonomous Region (75%), Guizhou (79%), Hainan (75%), Yunnan (76%) and Tibet Autonomous Region (0%). In 2002 and January-August 2003, several supplementary surveillance activities were undertaken in silent areas, areas reporting fewer than expected AFP cases, and areas with low rates of adequate stool collection. In Tibet Autonomous Region, stool surveys of254 healthy children were conducted along the border in 2003 and six SL polioviruses were identified. Active household searches for AFP cases in 2002 and through August 2003 were conducted at 203991 houses in seven reported provinces (Guangdong, Henan, Liaoning, Guangxi, Tibet Autonomous Region, Sichuan, and Jilin). One unreported case was found in Sichuan province and fOllr were found in Tibet Autonomolls Region. Retrospective hospital record reviews were conducted in prefectures with weak A FP surveillance in 20 provinces. A total 0[3307 hospital records were screened and 95.5% of the AFP cases identified had been previously reported. Of the 86 unreported cases, 41 were found in 36 hospitals in Yunnan province and 17 were fOllnd in 183 hospitals in Gansu province. These results were used to stimulate hospital case detection and reporting. Stool surveys conducted in healthy children in 2002 and January-August 2003 did not reveal any wild polioviruses. Survey results in Inner Mongolia Autonomolls Region, Jiangsll, Zhejiang and Guangxi, however, have also been completely negative for NPEV, indicating a problem with either the laboratory testing or collection and shipment of the stool specimens. During 2002 and January-August 2003, a total of 927 AFP cases were reviewed by provincial expert panels. Of these, 25 AFP cases were classified as polio-compatible, and 812 AFP cases were discarded. At the end of 200 I, ELISA ITO method was added to the molecu lar PCR-RFLP ITO assay already in use at the RRL for detection of wild and VDPV strains. All poliovirus isolates are being prospectively screened using both ELISA and PCR-RFLP ITO methods. In addition, retrospective screening and sequencing of isolates to 1998 has begun. Discrepant isolates (atypical RFLP pattern or non-Sahin-like or double-reactive ELISA result) are being sequenced. A number of deficiencies with sequencing identified by the international laboratory review team in July 200 I have been corrected through purchase of new reagents, and technical assistance provided by CDC and NIID. A new

- 15 -

sequencer, supported by J1CA had been set up successfully both in hardware and software and it greatly improves the efficiency of sequencing in the RRL at the China CDC. One suspected clusters and one suspected case of paralysis due to YDPY were detected and investigated in 2002. In June 2002, two cases of AFP in Panzhihua, Sichuan Province were reported. Both cases had a history of zero-dose OPY and were clinically diagnosed as poliomyelitis. Type 2 poliovirus was isolated from both cases. The detailed information was described in last year's report. To screen the possible circulating poliovirus in this area, the provincial polio laboratory collected 59 stool specimens from contacts and healthy children and only one poliovirus (a mixture of serotype 2 and 3) was isolated. This virus was identified as SL in PCR-RFLP test by RRL, and the virus also showed a different character with those cluster viruses. A case of AFP with onset in June 2002 was identified in northern Anhui Province. The case was a nine-month old boy with documented history of three OPY doses. The child had residual paralysis and was clinically compatible with poliomyelitis on expert review. The isolate was SL by ELISA but showed some minor changes in the RFLP pattern. As the child was fully immunized and the ELISA normal, the isolate was not sequenced until September 2002. A total of nine (1 %) nucleotide changes frolll the vaccine reference strain were found. The isolate showed no relationship to the four other SL type 3 polioviruses isolated in this prefecture during January to September 2002. Based on rapid surveys, coverage in the area is >85% and no unreported AfP cases were found. There is no evidence that the child suffers from any immunodeficiency disorder. Follow-up stool specimens were collected and no YDPY was isolated. The China RRL was accredited in 200 I and 2002. The RRL is responsible for preparing and conducting annual PTs for provincial laboratories, and also conducting an on-site accreditation review in each provincial poliovirus laboratory once every two or three years up to the situation and location of the provincial polio laboratory. All provincial poliovirus laboratories, with the exception of Tibet Autonolllous Region, have been accredited. From January 2000-August 2003,1472 poliovirus isolates underwent lTD by both PCR-RFLP and ELISA at the RRL. All isolates with discordant results were sequenced but no wild polioviruses were isolated. Since 1988, reported coverage for Bacille Calmette-Guerin (BCG), OPY3, three doses of diphtheria-pertussis-tetanus (DPT3), and measles vaccine (MY) exceeded 90%. Reported coverage, however, is likely to greatly overestimate actual coverage as it is based on the number of reported children registered for EPI that are imlllunized. Unregistered and unreported children are not included. Based on measles incidence and special surveys, routine coverage appears to be markedly lower in the generally poorer western provinces of China. In one study in Guizhou province, reported OPY3 coverage is 90%, but using the estimated births from the Bureau of Statistics as the denominator, OrY3 coverage during 1996-2000 varied from 68% to 81 %. In addition, several studies have consistently shown <50% coverage in floating populations in large cities. Many floating population are migrants from poor rural areas. It is now estimated that 10% (120 million) of China's total population is noating and this is increasing. Two rounds ofSNIDs were conducted in December 2002/January 2003 in 31 provinces. Two rounds, with emphasis on reaching unimmunized children in high-risk and low coverage areas, were conducted in March/April 2003 in Xinjiang Uygur and Tibet Autonomous Regions. Following identification of the cluster of paralysis and circulation of YDPY in Sichuan province in June-July 2002, two rounds of high-risk response immunization (HRRI) were conducted in Yunnan, Guizhou and Sichuan provinces during October-November 2002.

- 16 -

SIAs will be conducted in the winter of 2003/2004 targeting approximately 6.9 million children zero to three years of age. On 9 January 2001, the regional guidelines for laboratory containment were distributed by the inter-ministerial task force to all relevant agencies, and a deadline of March 2001 was given to submit materials for completion of a national inventory of wild poliovirus infectious and potentially infectious materials. Feedback from these agencies is completed. To date, results have been reported to the task force by the Chinese Academy of Science, the Chinese Medical Academy of Science, the National Environ';tental Protection Bureau, the State Drug Administration, Ministry of Education, and the Ministry of Railways. So far, these institutions have identified 42 wild polioviruses. All isolates are being stored in four laboratories under bio-safety level (BSL)-21 polio conditions. Two steps had been conducted in confirmation oftite national inventory of wild poliovirlls infectious and potentially infectious materials. One is phone check to ensure all materials that should be contained have been listed into the national inventory. Another is to check on-site, not only the documents but all the factors which could affect the containment of materials, including the condition of freezers, supply of electric power and access managelllent. All units under the Ministry of Health had received tite phone check and nine of them received on-site checks.

2.3.5

!long Kong SAR (China)

Despite the challenges posed by the SARS outbreak in !long Kong from March to June 2003, the highly sensitive AFP surveillance system continues to function effectively. The target of detecting at least one AFP case per 100000 population aged below 15 years was achieved in 2002 (1.8 per 100000), and the rate was 0.7 in the first eight months of2003 (annualized rate of 1.14 per 100000). The targets for most of the other surveillance indicators were achieved in 2002 and the first eight montlts of2003. To further strengthen the surveillance programme, the NCC has convened its sixth meeting in June 2003 and developed several measures to enhance the sensitivity of the system. The Government Virus Unit, the designated NPL for I-\ong Kong, has remained fully accredited by WHO since 1997 and was accredited for ITO in 2003. Reported immunization coverage rates for polio vaccine have been maintained at 90% and above based on service data. An immunization survey just completed in early 2003 also supported the findings. However, threats from the importation of poliovirus remain because of the highly mobile population and the many intemational visitors travelling to Hong Kong. An action plan is in place to contain any importation of wild poliovirus. 1I0ng Kong has completed the Pliase I laboratory containment of wild poliovirus. An inventory of laboratories has been established. Two laboratories had in their archives potentially wild poliovirus infectious materials and destroyed the materials satisfactorily. Letters have been sent to research laboratories reminding them to keep the National Coordinator for Laboratory Containment informed if clinical specimens are to be imported from countries where poliomyelitis is still endemic. Through this mechanism, six vaccine strains of polioviruses were identified from one research laboratory in 200 I, and they were destroyed under official witness.

2.3.6

Japan

The NCC continues to meet on a regular basis to review and oversee strategies conducted to maintain poliomyelitis-free status and ensllle timely detection of imported wild polioviruses and vaccine associated poliomyelitis cases.

- 17 -

One of the main activities of the NCC is to provide concrete recommendations for the poliomyelitis vaccination strategy in Japan. The committee continues discussing the present status of poliomyelitis control and future problems. Global issues of the eradication programme were also extensively studied and the following conclusions drawn: ([) the adoption of injectable poliovirus vaccine (lPV) for routine immunization is essential; (2) it is necessary to oht<lin national consensus for conversion from OPV to IPV; and

(3) to maintain high vaccine coverage rate in the country, it is suggested to develop a combined vaccine with DPT. These recommendations were reported to the National Committee for Prevention oflnfectious Diseases (March 2003) and subsequently endorsed. The system of poliomyelitis surveillance is composed of multiple public health systems for infectious diseases. In October 1998 a new "Law for Control of Infectious Disease" was established and poliomyelitis was designated as a second grade infectious disease requiring immediate reporting to health authorities and strict investigation and control measures. Detailed guidelines for identification of poliomyelitis and response were also established. However, this law only deals with poliomyelitis caused by wild polioviruses. Vaccine associated cases are not covered. Thispoint has to be clarified in 2005, when this law will be revised. The virological surveillance of enteroviruses has been the key element of "Infectious Agents Surveillance" in Japan since 1970. The Laboratory of Enteroviruses, Department of Virology II, at NIID has performed as National Polio Laboratory since 1962. A nationwide laboratory network of 71 distinct public health laboratories (DPIlLs) under the coordination ofNIID continues to function well. ror annual infectious agents surveillance for healthy children, stool samples were collected two months after the routine OPV vaccinations from healthy children at the ages of zero to six, and virus isolation and identification were conducted at 14 DPHLs. Then, poliovirus isolates were fUl1her characterized at NIID by the lTD assays. In 2002, 863 samples from 14 DPHLs were examined. Among them, 188 samples (22%) had cytopathic effect (CPE) agents and one type I and one type 3 SL polioviruses were isolated. The NPEV isolation rate (22%) in 2002 was relatively high compared with those in recent years mainly due to the outbreak of echovirus 13 in 2002. In 2002, echovirus 13 was the major causative agent of aseptic meningitis throughout the country. In Japan, this was the first large outbreak of aseptic meningitis associated with echovirus 13. Simultaneous outbreaks of aseptic men ingitis associated with echovirus 13 have been reported globally in 2001-2002. rollowing two suspected V APP cases, the routine autumn vaccination in 2000 achieved an overall coverage of 81.1 %. This is the lowest rate in the recent history of poliomyelitis vaccination in Japan. However, vaccine coverage rate recovered to high levels in 2001. All these vaccine coverage rates are calculated as the numbers of vaccines divided by the Ilumbers of target population derived from the national census. An accurate survey of real vaccine coverage is now ongoing in Tokyo. All doctors in several districts of Tokyo are requested to report vaccination history of children who visit their hospitals for the one-year medical examination. Histories of measles vaccination are also included in this study. The poliolllyelitis RRL at NIID has been fully accredited for the period August 2002 to July 2003.

- 18 -

In the laboratory containment survey 3957 laboratories have been identified so far tOIlOt holding wild polioviruses. Thirty-one institutions have wild polioviruses or materials possibly containing infectious wild type polioviruses. They are seven universities, three national institutes, eight companies (vaccine and diagnosis), and 13 local health laboratories. For all of these institutions, the responsible laboratories are registered. Seven institutions may have wild polioviruses or potential materials. They are three hospitals, three local health laboratories and one commercial company. Thus it is considered that the wild poliovirus inventory is eventually completed and Phase I according to the Global Action Plan seems partially satisfied. However. the assessment and validation of the lIo-responses is needed. Inquiries to non-responders by telephone are still ongoing. Nevertheless, in fact, most of the remaining institutions are non-biological laboratories and are very unlikely to possess wild polioviruses. NIID is going to examine the presence of polioviruses in "possibly containing materials". One specialist was assigned for this duty. A new containment coordinator was assigned in September 2003 and a new special budget for this search ill the fiscal year of 2004 was applied for.

2.3.7

Lao People's Democratic Republic

Since 1996 (when the rate was 0.9) the national non-polio AFP rate nationally has been slibstnntially greater than 1.0. The final 2002 non-polio AFP rate is 3.45. As of25 September 2003, the annualized rnte for 2003 is about 2.78, assuilling none of the pending cases nre found to be poliomyelitis or polio compatible. As has been explained in previous reports, due to rather weak diagnostic capacity in the country there is n tendency to over-diagnose AFP. As of the end of September 2003 the number of AFP cases being detected is about the same as that in 2002. Special activities have contributed two 2003 cases to the total, and have thus increased the number of cases with inadequate stools. Special activities definitely improve the attention given to AFP cases by surveillance staff in the provinces visited and generally seem to encourage improved reporting. As of the end of Septemher 2003 only five provinces hnd not reported any AFP case in 2003. These provinces have a combined < 15 years population of 4 70 500. During the retrospective record reviews a total of 13 suspect cases were identified, of which it was possible to locate nine (five from 2002 and four froll1 2003). Of the located cases four were cOllnted as AFP (two each for 2002 and 2003) and entered into the datahase. Three additional cases that could not be found were classified as polio compatible. The stool collection rate for 2002 fell below 70%. Active searching in 2003 has located an additional five AFP cases from 2002. The inclusion of these cases results in a corrected stool collection rate for 2002 of only 50%. Considering the logistical dif/1culties of the country, rates above 70% can be considered acceptable. Rates below 70% clearly signal a need for improvement while rates below 60% are not acceptable. While part of the reason for lower stool collection rates in 2002 and, to a lesser extent, in 2003 relates to the success of central level special surveillance activities, the fact is that suh-standard stool collection rates do indicate surveillance system weakness. Since 1997, when the historical high ofaboul 70% was achieved, OPV3 coverage has declined. By 200 I OPV3 coverage nationally was about 55%. Coverage for 2002 seems to be about the same as for 200 I. As is the case with other immunizations, coverage is generally higher in urban areas, and less in remote areas. Historically the highest rates ofOPV3 coverage were achieved when the Lao People's Democratic Republic was conducting NIDs. The last NIDs were conducted in 1998. Since then SIAs have been of decreasing scope and frequency.

- 19 -

At present the national EPI cannot maintain high immunization coverage through routine immunization services alone. Between 85%-90% of the target population must be accessed through outreach services. Resources required for conducting three or four outreach rounds per year have not been consistently available, but this particular situation has improved during 2003. With the introduction of the new diphtheria-tetanus-pertussis (DTP)/Hepatitis 8 vaccine into the routine imlllunization schedule, and the concurrent introduction of auto-disable syringes and safety boxes, the EPI has begun implementing activities designed to improve immunization service delivery. During January and February 2003, two rounds ofOPV SIAs were conducted in the larger villages of the country (approximately any village with a population of more than 500 was targeted). Villages comprising approximately 40% of the national population were targeted. The specific target populat ion was a II ch iIdren zero to 59 months of age. The strategy was to conduct a "rolling campaign" for each round, starting in one part of the country, covering several provinces at one time, then moving to the next several provinces. It was envisioned that activities in anyone province would take no more than three to four days, and that a round could be completed within a month. The purpose of the rolling campaign approach was to maximize the use of monitors. While the OPV SIAs were not as successful as hoped, reasonable coverage was achieved. It is estimated the coverage of eligible children in targeted areas was 68% during the first round and 70% during the second. There is no further update on laboratory containment activities.

2.3.8

Macao SAR (China)

No AFP case was detected in the past one year while the completeness of AFP reporting remained good. As population less than 15 years is only 88 357, further decreased from the level in the previous year, this may have happened by chance. A high level of oral polio immunization coverage has been sustained. In 2000, 2001 and 2003, respectively 91.8 %, 92.2%, and 91.7% of all children at their first birthday were immunized with three doses of trivalent polio vaccine. OPV immunization is part of the routine immunization provided throughout the health care system and the high coverage rate will be sustained in future years. The NCC concluded that poliomyelitis-free status was maintained and the health system in Macao has the ability to detect any importation of wild poliovirus and to prevent the spread in the population. In addition, the NCC expressed that the high immunization coverage and reliable surveillance will be sustained until the global certification of poliomyelitis-free has been achieved. A supplementary AFP surveillance method such as retrospective record review should be conducted iF the non-polio AFP rate continually remained zero.

2.3.9

Malaysia

The NCC continues to Function and did not only review the progress report presented but also major areas of concern in activities related to post-certification, to monitor and address problems in order to sllstain poliomyelitis-Free status and deliberate and support implementation of latest recolllmendations made at the 13'h TAG and the eighth RCC meetings. AFP surveillance appears to be well established with distribution of reporting sites corresponding with population density of the country. The non-polio AFP rate wa, maintained at high levels achieving 1.2 per 100000 children under age 15 in 2002 and an annualized rate of 1.0 in 2003 to the date of the report.

- 20 -

Adequate stool specimen collection is maintained at about the same level as the previous year but the required rate of 80% has still not been achieved. To supplement this sub-optimal performance, all AFP cases are being reviewed by the expert panel to ensure that clinical investigation and management results concur with a final diagnosis other than poliomyelitis. Most of the AFP cases with onset in 2002 and 2003 have a final clinical diagnosis available. Ninety-seven percent (97%) of AFP cases with onset in 2002 have a follow-up result available and the percentage of cases with follow-up result in 2003 is already 72% at time of reporting. It is anticipated that most, if not all the cases will have a follow-up result by the end of the year. The national poliovirus laboratory continues to function at high performance levels and has been fully accredited under WIIO standards since 1998. An analysis was performed for possible vaccine derived poliovirus but all poliovirus isolates from AFP cases since 1997 were reported SL. National coverage for OPV3 has been maintained at over 90% since 1996 and this rate is also achieved by all 130 districts in 2002. The national coverage has been sustained at 94.8% in 2002. Reported lower coverage in Kuala Lumpur attributed to a large proportion of immunizations given by the private sector and not included in the coverage reports has been assessed by a coverage survey conducted in 2000 and the results confirmed that 89% of children had completed their third dose of OPV and OPT before the age of one. The process of laboratory containment of wi Id poliovirus infectious and potentially infectious materials has progressed well and the first phase has been completed at the end of2002. 2.3.10 MOllgolia

As of 10 November eight AFP cases with onset in 2003 have been reported resulting in an annualized non-polio AFP rate of 1.03 per 100000 children aged under 15 years. All AFP cases except one 12-year-old child had been fully immunized. All cases were reported within 14 days of onset and investigated within 48 hours of reporting. For all cases two stool specimens were collected but as one was only taken on day 15 after paralysis onset in one case and in another samples were collected on day 15 and 16 adequate sample collection rate was slightly below target at 77.7%. Most of the stool samples (88%) reached the NPL within two weeks and 50% could be sent in less than seven days. All slool specimens except one that yielded poliovirus type 3 were negative. The poliovirus isolated was forwarded to the RRL in Australia and ITO confirmed il as SL. After provisional accreditation in 2001, the NPL was again fully accredited during the accreditation visit in September 2002. Until then all stool specimens of AFP cases had been tested in parallel at the RRL and all results confirmed. Timeliness of laboratory results of AFT' cases in 2002 was 100% and the NPEV isolation rate at 25%. Timeliness in 2003 (up to October) was also 100%. No NPEVs were isolated so far this year from AFI' cases but were found in healthy children. The NPL in Mongolia at the Public Ilealth Institute (1'111) has routinely conducted supplementary stool surveys for poliovirus surveillance among healthy children up to five years old. From November 2002 to March 2003 a total of 313 stool samples were collected, and tested at the NPL. Two polioviruses with ITO results SL and 23 NPEVs have been isolated. Stool samples taken on 13 February 2003 from a six-month old healthy child in Songino Khairkhan district in Ulaanbaatar City revealed a type I poliovirus with 1.3% difference to Sabin type I in the VPI sequence and thus this virus under the current definition had to be classified as VDPV. Sequence of the 3D region was 99.7% identical to Sabin type I.

- 21 -

All health records of the child available were reviewed and showed no unusual findings. The child had received four doses OPY according to schedule and confirmed by card. Main quality indicators of AFP surveillance in Ulaanbaatar City have been very acceptable since 1999. Son gino Khairkhan is one of the big districts of U laanbaatar City with a total population of 169 281 (population of children under 15 years, 51 459). AFP surveillance started in 1996 and five AFP cases were reported with a non-pol io AFP rate of 1.3 per 100 000 under 15 years from 1996 to date. Completeness of routine AFP reporting including zero reporting was 97% in 2002 (1060 of reports expected and 1029 reports were received). Retrospective hospital record reviews were regularly conducted in Songino Khairkhan district hospital and in 22 family doctor centers by the epidemiologist from National Center for Communicable Diseases (NCCD). As active surveillance procedure 792 in-patient history records and 2407 outpatient records were checked and no additional AFP cases were round rrom these health racilities. In response to the YDPY isolation the NCCD EPI team has conducted an active surveillance review in Songino Khairkhan district hospital and 1119 in-patient records of children up to 15 years old were reviewed. No unreported AFP cases were found. In 200 I and 2002, overall reported EPI coverage in Mongolia was very high with all districts reporting coverage over 90%. Reported routine immunization coverage in Ulaanbaatar City was 90.5% in 200 I and over 95% in 2002. As of 10 November 2003, national OPY3 coverage reached 96.6%. All 22 (100%) provinces (aimags) and cities achieved 90% coverage and 19 (86.3%) of22 sites achieved a routine coverage greater than 95%. Due to populations moving fi'olll rural to urban areas (mainly Ulaanbaatar, Erdenet and Arkhan) routine EPI coverage may be lower than reported as the denominator used is the official population not renecting unregistered population groups which may be at higher risk to miss immunizations. Songino Khairkhan district reported OPY3 coverage in 2000 at 99.6%, in 2001 at 94%, and in 2002 at 97.3%. In response to the YDPY isolation a coverage review has been done in 10 family doctor units (from three selected family doctor centers). Randomly 173 "certificates of vaccination" were selected for the investigation and 171 children were found to be fully immunized with fOlll" doses ofOry. Two children had not received the third and fourth dose of OPY. The coverage survey in these selected family doctor units of the district revealed 98.8%. A review of reported coverage data from 105 family doctor units in 2002 for three doses of routinely administered OPY by the age of one year ranged from 79.4% to 100%. The NPL team conducted additional supplementary virology surveys among heahhy children up to five years of age in Son gino Khairkhan District and sampled 50 stool specimens including that from the YDPY positive child. Children had received the same lot number OPY vaccine. All samples were negative. Repeat stool specimens were collected from the child with YDPY isolation on 12 May 2003 and 12 June 2003 and tested both negative. Immunological studies concluded that the status of cellular imlllunity for all family members was in the border ofrererence data. The YDPY positive child, II months old by then, and his seven-month old cousin have notable decreased value of the serum [gA, IgG, and JgM. These two children were classified as having juvenile hypogammaglobulinemia. The two children were found to have normal cellular immunity.

- 22 -

NPL conducted potency tests 011 the OPV vaccine samples using RDA cell line with the conclusions that OPV vaccine Lot No 8732 contained a slight decrease in the titer of virus components. All vaccine storage rooms had good temperature monitor records and all cold chain equipments were ill good condition. Based on these investigation results three main conclusions were drawn, namely that the quality of AFP surveillance performance is good and no missed cases were identified, reported OPV3 coverage is high and appears reliable and there was no indication for current or extensive circulation of the isolated VDPV. The national inventory for the laboratory containment process has been completed and all wild strains of poliovirllses were destroyed in October 200 I. Since then no new developments occurred.

2.3.11 New Zealand High coverage for all childhood vaccines is a priority for the Ministry of Health, as identified in the Ministry of Health document An llllegrated Approach to Infectious Diseases: Priorities for Action 2002-2006. A national immunization register is expected to be operational by 2004 and this will provide a more valid assessment of the vaccination coverage by 2005. IPV is administered at age six weeks, three and five months, and four years. While precise immunization coverage estimates are not available at this stage, coverage is estimated to be approximately 85%. Vaccination changed from OPV to IPV in February 2002. This was associated with a decline and disappearance of OPV circulating in the community. Paediatric inpatient and enterovirus surveillance detected OPV strains only within one month following the switch to IPV. Environmental surveillance with samples taken from sewerage plants in three major population centres reached zero in June 2002. However, OPV strains were again detected six, eight and II months after the switch from OPV to IPV. These late isolates are likely due to visitors in New Zealand from an OPV using country. Paediatricians have a high rate of returning AFP response cards monthly 10 the New Zealand Paediatric Surveillance Unit (NZPSU). During 2002 the response rate was 85%, and during 2003 (up to August) 96%. The number of AFP cases for 2002 and estimated number for 2003 is not substantially different from that for 2000 and 200 I when an audit showed NZPSU surveillance to have high sensitivity. A comparison of 2000 and 200 I AFP cases identified by the NZPSU and hospital discharge records showed NZPSU surveillance to have high sensitivity. In 2002, 55% of cases had adequate stool samples, and for the period January to August 2003 this figure was 60%. When paediatricians report a diagnosis of AFP, the NZPSU helps ensure that stool samples are received within 14 days of onset of paralysis. New Zealand's NPL (at the Institute for Environmental Science and Research, ESR) maintained full accreditation for poliovirus isolation. In addition, the NPL obtained a new supplemental accreditation for ITO of polioviruses. A II cases of AFP in persons < 15 years of age are reviewed anllually by the Nee.

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2.3.12 Pacific island cOllntries and areas The Pacific sub-region constitutes a single epidemiological entity for certifying the eradication of poliomyelitis. The five members of the Sub-regional Certification Committee (SCC) have l11et four times prior to certification of poliomyelitis-free status in 2000, and three times since, most recently on 15-16 October 2003. The Committee monitors certification activities alld serves as an Expert Review Panel for reported AFP cases. Fifty-eight reporting sites and about 200 clinicians participate in monthly, hospital-based active surveillance. This provides one reporting site for approximately every 18000 children. Reporting compliance (the proportion of the expected number of surveillance forms actually returned) fell li'om 90% in 1999 to 21%, 70% and 49% in2001, 2002 and the first six months of2003 respectively. Many forms are being held at hospital or national level and untimely and cluster signing remain COl11l11on. Between 1997 and 200 I, the Pies met or exceeded the target AFP reporting rate of one case per 100000 individuals aged less than 15 years. In 2002, the rate fell to 0.7 per 100000. In 2003, the annualized reporting rate is about one per 100000. Of the seven cases reported in 2002, only two (29%) had two adequate and timely stool specimens. For 2003, the rate of timely stool sample collection was 38% (three of eight cases); in four of the five cases with inadequate stool samples, the patients presented late and were admitted to the hospital at least 14 days after the onset of pmalysis. From 1997 to 2001, follow-up examination rates ranged from 78% to 88%. In 2002, only three of the seven cases (43%) had 60-day follow-up examinations; in 2003, 75% of cases have had follow-up exal11 i nati on. The see concluded that, despite certification and, presllmably, high levels ofOPV vaccination, the current performance of AFP surveillance may not be adequate to detect the introduction of wild poliovirus or cVDPV in the Pacific in a timely manner. The AFP reporting system is also not yet well integrated with surveillance for NT and "acute fever and rash illness", and has failed to detect or reflect recellt outbreaks of dengue, rubella, and measles in Pies. No supplementary surveillance activities were conducted in 2003. To validate data quality and to search for additional AFP cases, the see recommended that retrospective record reviews for the 2002 and 2003 calendar years be undertaken in all participating PICs. Support for testing continues at the RRL in Australia and VIDRL forwards case investigation forms received with the stool specimens to the WHO offices in Suva and Manila to support case data management and tracing. Most Pies are maintaining OPV3 coverage rates around 85% (2002 data). However, Nauru, the Solomon Islands and Vanuatu have reported recent decreases in coverage, and a survey in the Federated States of Micronesia in July 2003 found that OPV3 coverage was 65%. There were no further developments in laboratory containment in 2002-03.

2.3. J3 Papua Nell' Gllinea Following significant declines in AFP surveillance quality and very low reported routine imlllunization coverage a national EPI workshop for EPI managers, surveillance officers and key raedintricians was conducted in February 2003 to discuss strategies to improve the routine illllllunizntion programme, maintain poliomyelitis-free status, accelerate measles control and reduce mortality from measles, present plans for SIAs in 2003/2004 and develop plans for strengthening AFP and measles smveillnnce quality.

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A total of 5000 AFP surveillance posters targeting both health workers and the general public were reproduced and distributed throughout the country. A training workshop titled "Hull' to Recognize. Report alld Respond to Epidemics" based on a Public Health Manual for nurses, doctors and public health workers has been completed in 10 provinces. The training is in two phases; phase I includes training of all provincial and district managers while phase 2 is training of all health workers including community health workers. All provinces had the manager's training while some provinces had the second phase training completed. AFP and measles are listed as "Urgently Notifiable Conditions", which once suspected must be immediately reported to the National Surveillance Unit by the quickest available communication method. It is during this training that quality AFP surveillance is emphasized and poliomyelitis vaccination continued until global certification is achieved. With partner assistance a tool is being developed to conduct a study on the impact of the training. Besides continuing the aseptic meningitis study in the Highlands, a stool survey among healthy children was conducted in Port Moresby. the nation's capital. A total of22 specimens from 14 healthy children (non-AFP cases) were collected alld sent to the NPL. No poliovirus was isolated, however, there were six NPEVs. This exercise was to continue, however, due to several factors including the SARS situation and funding shortage, the exercise did not continue to other regional centers and areas of concern, which include international border villages und high population density places as anticipated. The low routine immunization coverage, the low performance of the surveillance system and the frequent large measles outbreaks were recognized as major problems by the National Department of Health (NDOIl). Taking also the findings of the international EPI review conducted in November 200 I into consideration, NDOH proposed as main EPI strategy for 2003/2004 provision of additional doses of measles vaccine to children six months to 10 years orage and OPV to children zero to 59 months of age regardless of previous immunization status. Coverage ror both antigens higher than 90% should be achieved in all districts under conditions of immunization safety. SIAs planned this year have been delayed to some degree though progressing. A trial of the implementation process of the SIA has been done in two districts of a province and indications are that it will be successful. The approach will be to conduct SIAs region-by-region, province-byprovince and paying special attention to districts, which do not reach above 90% coverage. Analysis of performance indicators from 200 I to October 2003 shows that indicators for 2003 are slowly improving. At the end of October 2003, 14 AFP cases had been reported resulting in an annualized non-pol io A FP rate or 0.75 per 100 000 under 15 years of age. A II cases except one had two stool specimens collected. Seventy-one percent of the cases had at least one stool sample taken within 14 days rrom onset and 57% had two adequate stool specimens taken; this is still below the required target but both figures have improved compared to 2002. Timely reporting improved with 86% and investigation of the AFP cases within 48 hours after reporting improved significantly with 93%. Two AFP cases were reported within 14 days from onset ofsYlllptoms but the stool samples collected late at the health facility. The expert panel remains runctional and has reviewed all AFP cases with onset in 2002 and 2003. One case with onset in 2003 is still pending and one AfP case with onset in 2002 was classified as polio-compatible.

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As accreditation of the NPL was still pending, all stool samples of AFP cases were tested in parallel at the RRL and 91 % of test results confirmed. The NPEVisolation· rate for AFP cases was 13% and the overall NPEV isolation rate for all stool samples tested in 2002 was 7%. There were no polioviruses isolated from AFP cases but five single poliovirus isolates from aseptic meningitis cases (one poliovirus type I, one type 2, and three type 3), one mixture of type I and 3 and one mixture of type 1,2, and 3. All polioviruses were sent to the RRL for lTD and found to be SL. In 2003 until the end of October, 27 stool samples of AFP cases were tested with all samples re-tested at the RRL and all results confirmed. All results at the NPL were available within the required 28 days of receipt. There was one NPEV isolated stool of an AFP, six NPEVs were isolated in 22 stool specimens of healthy children and six NPEVs were found among 76 stool samples of aseptic meningitis cases resulting in an overall NPEV isolation rate among all stool specimens of 10%. The 2003 PT was recently passed with a score of 100% and the next accreditation visit is scheduled in November 2003. No revisions of the national inventory of wild poliovirus infectious/potentially infectious materials were required.

2.3.14 Philippines High quality AFP surveillance is being maintained in almost all regions and has improved in three regions that were previously below target. The current AFP rate is 1.5 and only one region remained below the expected rate. Significant improvement was also observed in stool collection, with a constantly increasing rate of adequate stool collection, from 85% in 2002 to 91 % as of October 2003. Sixteen regions are maintaining the rate of more than 80% in specimen collection. The AFP expert panel committee had classified a total of 445 reported AFP cases during their quarterly meeting on February, May, August and November 2003. Among these, only 26 cases are still pending, the rest are discarded accordingly after thorough review of investigation reports, laboratory results and medical records. So far, no polio-compatible case has been identified and all polioviruses isolated from the stool specimens are SL for that period. Coinciding with the expert panel meeting, capacity-building activities are being conducted for the surveillance officers. In February 2003, the EPI surveillance officers developed a national plan to improve EPI surveillance in the country. This serves as their guide in the conduct of active EPI Surveillance in the sentinel sites. They also underwent training on adverse events following immunization (AEFI), in preparation for the Philippine Measles Elimination Campaign in February 2004. In 200 I, Opy 3 and the Fully Immunized Child (FIC) Coverage are 69.8% and 81.7%, respectively. Ilowever, in 2002 OPY and FIC was 72% and 77%. A decreasing trend was noted due to delayed arrival of vaccines, which caused some Local Government Units (LGUs) to lose interest in [PI implemen(ation. MCH Survey showed that 62.9% of children 12 to 23 months of age in the Philippines were fully imillunized in 2002. This is over one percentage point higher than in 200 I (61.3%). From January to June 2003, the National OPV3 coverage is 38%, while the FIC coverage is 35% (partial report). A iming to improve national FIC coverage for 2003, the Department of Health issued a memorandulll, dated January 17,2003, to increase routine illlmunization coverage, which focus on the high-risk areas. The Memo was immediately disseminated to the Regional Health Offices and LGUs. To catch-up on those children missed during their routine immunization, the Expanded Programme on Imlllunization rode-on with the implementation of "Garantisadong Pambata" or "Pre-Schooler's llealth Week" held in October 2003.

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Laboratory containment activities were concluded in September 2003. However, the national inventory needs to be updated (re-surveyed) to include identified laboratories in the database, newly licensed laboratories and medical and paramedical colleges and universities. A significant accomplishment of the programme is the inclusion of EPI as a priority programme to serve as part of the indicators for the Department of Health One-Script Systems Improvement Program: Getting Connected 7hrollgh Process Management. Monitoring teams, headed by the Undersecretary of llealth, were assigned to ensure efficient implementation of said programme.

2.3. J5 Republic of Korea The Nee has reviewed all AFP cases detected through surveillance activities for the fillal classification and has met regularly to discuss issues related to the national documentation. In 2003, five new members of the Nee including a chairperson and four other members were appointed. There was a meeting of new Nee in February 2003 to discuss the progress of poliomyelitis eradication activity in the Republic of Korea. In 2002, 518 reports of monthly zero reporting including 20 AFP cases were reported from 70 hospitals nationwide. Th is makes 61.7% of completeness in reporting. When considering timeliness of reporting which means monthly reporting within the first week of the following month,

430 reports (83%) were done on time. Retrospective chart review was not conducted in 2003. The current Arp surveillance tnrgeting 70 reporting sites and the prospective AFP study in five hospitals in Seoul will be maintained and strengthened. It is being considered to include 41 more AFP reporting hospitals from 2004. Retrospective chart review will be conducted in Busan and Gwangju in early next year. A prospective AFP study has been continued by a public health officer involved in the control of infectious diseases in the National Institute of I Iealth (Nil I). The approach includes visits to five major hospitals in Seoul weekly, regular meetings with junior staff or chief resident in paediatric neurology at these hospitals and illlmediate investigation of any AFP case identified. A nntional poliomyelitis workshop to improve AfP surveillance including reporting from

70 hospitals was held on I October 2003. The members of the Nee, reporting paediatricians from hospitals and members of paediatrician's society such as neurology and infectious diseases pnrticipated. Several approaches to improve AFP surveillnnce were suggested including distribution of a specific lea net explaining AFP surveillance, wh ich includes the method of collecting stool samples and the conditions presenting with AfP to reporting hospitals. The Enterovirus Laboratory in the NIH, designated as the NPL, was fully accredited in 2002 under the WHO standards. In 2002, the laboratory processed a total of 1532 specimens out of which 40 were stool specimens from Afl' cases. NPEV isolation rate for 2002 wns 24%. In 2003 (as of July), 192 specimens were processed and NPEV isolation rate was 18.6%. All results were reported within time. The results of PTs from 1999 to 200 I were 100%. However, a score of 80 was obtained in 2002 since one poliovirus isolnte was mistyped. The result for the 2003 PT wns again 100%. The enterovirus laboratory network is composed of Laboratory of Enteroviruses in the Department of Virology in the NIH, and 16 sub-national public health laboratories, which cover all geographical areas of the country. Some sub-national laboratories participating in virological surveillance forward all specimens with positive ePE to NIH for typing. Some other sub-national laboratories collect samples and senu the samples to NIH. Reports from sub-national laboratories to Nil-I are case-based and show seasonal variations in frequency. However, in general, monthly repOlis are being submitted. Most cases have been from aseptic meningitis surveillance until 2000. In 2001

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hand-foot-mouth disease/herpangina surveillance was also initiated. Private laboratories do not perform the typing of enteroviruses. However, if typing is requested by the attending physician, specimens will be forwarded to NIII. This system ensures that all possible poliovirus isolates regardless of source will be submitted to NIH and subsequently forwarded to RRL for confirmation and lTD. The polio imlllunization level has been sustained at the level of90%-95% (estimated) since the 1980's. From 2002, the use oflPV is possible by the recommendation orthe Association of Paediatricians, although the NIP established by the Department of Infectious Diseases Control in NIII only recommend OPV. For several decades now, trivalent oral poliovirus vaccine (TOPV) has been recommended for EPI by the Korean Advisory Committee on Immunization Practices (AC!P) together with other vaccines including diphtheria-tetanus-acellular pertussis (DTaP), measles-lIlllmpsrubella (MMR), TB and viral hepatitis B for infants and younger children. The policy on the use of OPV/IPV in national polio iml11unization will be officially reviewed by the Korean ACIP in the near future. Phase I of laboratory containment of wild poliovirus infectious/potentially inFectious materials has been completed. Arter sending screening forms to 245 institutes, universities and hospitals, there have been replies from all places. Since one more laboratory was confirmed to contain wild poliovirus strains, four laboratories were found to have relevant samples so far. These laboratories were reviewed by NIII in 2003 and confirmed that all relevant samples are stored safely under the BSL-3/polio conditions except one laboratory. This laboratory keeps the relevant samples ill BSL-2 conditions and agreed to destroy all relevant samples by the end of2003.

2.3.16 Singapore The NCC has continued to meet anllually to review AFP cases and to monitor the various surveillance activities. The surveillance system had identified between 7 and 1.3 lion-polio AFP cases per 100000 popUlation less than IS years old, however, the targets of>80% of AfP cases with two adequate stool samples collected at least 24 hours apart within 14 days of onset of paralysis were not met in 2001, 2002, and the first halfof2003. Follow-up examination for residual paralysis at 60 days arter the onset of paralysis remains at 100%. A further reminder will be sent to the public and private sector hospitals requesting them to comply with the recommendations on stool collection set up by WHO in maintaining AfP surveillance at pre-certification levels, so as to meet the performance standards set by WHO. It is encouraging to note that in 2003, of the 13 cases that were notified to the Ministry of Health with the at risk diagnoses (of which three were AFP), eight (60%) have had two stool samples within the specified time period which suggests a moderate response by clinicians to the reminder circulated last year.

The NPL remains fully accredited. The NPL also has supplementary accreditation for lTD functions. Besides stools from AFP or suspected AFP cases, the NPL receives stool specimens from other sources for poliovirus isolation. There had been one possible case of V APP in 2000, when a three-month old infant developed flaccid paralysis after receiving oral polio immunization. The first stool specimen sent was also positive for Poliovirus I and 2 (Sabin-like). In 2001 the first AFP case was a case of upper limb paresis secondary to polio vaccination 12 days following his second vaccination with DTP and oral Sabin. However, the two stool specimens sent were all negative for enterovirus. The child's upper limb paresis recovered ai 60 days after his onset of the paralysis.

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from 2000 to 2002, the reported immunization coverage for poliomyelitis in infants has been 91 %,93%, and 92% respectively. The national inventory for wild polioviruses and potentially infectious materials was updated in 2001 and a further update initiated in October 2003. Surveys were sent out to all public and private institutions that might have laboratories containing any infectious material. 2.3. 17 Vier Nam

from October 2002 to October 2003 all levels orthe surveillance system, from COlllmune to provinces, were continually monitored regularly, including those with zero reporting. Active search for unreported AFr cases has been implemented in all district and provincial hospitals, especially for those with sub-optilllal surveillance indicators. Routine coverage for ory among children under one year of age was maintained at high level. SNIDs were conducted in November-December 2002 in 26 districts of eight provinces in the South \vhich border with the Lao People's Democratic Republic and Cambodia, and the total of 315 816 children under five years of age was covered. In 2003, SNIDs are pillned for 22 districts of six provinces in the South to take place in November and December. Training programmes for health care workers have been carried out regularly, and the report system has been maintained regularly and on time as required. In 2003 (frol11 January until 30 October), the total number of reported AFP cases was 275, with 221 cases discarded as non-polio, while the other 54 cases are pending. Non- polio AFP rate per 100 000 children under 15 years of age was 0.87, and 97% of repOlied AFP cases had two adequate stool specimen collected within 14 days of onset. A total of 29 AFP cases were found by active search at provincial and district hospitals in this period of time. The routine coverage ofOrY3 has achieved 65.0% in August of this year. from 2002 until 17 October 2003, a total of eight AFP cases with SL poliovirus isolates were reported frolll seven different provinces. All stool samples were correctly typed by the national laboratories, and all sent to the RRL at NIID for lTD. In response to the detection of these isolates, active search in the reporting provinces for potential unreported AFr cases was conducted by regional stafr. The NCC has visited these cases and reported its finding to the EPI staff as well as to the WHO Representative in Ha Noi. All, but one case, were discarded as having no residual paralysis. The case in Tien Giang province was finally diagnosed as Y APP as described in detail in the progress report. The NPL in Hanoi was fully accredited in 2002, the NPL in Ho Chi Minh City achieved accreditation status after a repeat PT was successfully achieved. All stool specimens were tested in parallel at the RRL in Australia in the interim time. RCC as well as NCC had previously recommended to strengthen its performance and its quality of isolation ofNI'EV. As a result, the NPEV rate obtained by this laboratory in 20(j3 has increased and achieved 19% indicating improvement in the qua lity 0 r sample processing and of vi rus isolation/typing procedure of the laboratory. for laboratory containment, visits to m~or laboratories to monitor the containment were performed, and no infectious or potentially infectious materials for poliovirus have been identified to date. The NPL, Pasteur Institute, flo Chi Minh City, has been planned to be a target laboratory for the NCC to conduct the assessment of the condition of stool and other infectious material maintenance and containment in November--December 2003. No other new laboratory related to the containment process has been identified up to date.

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3.

CONCLUSIONS

Following a thorough review of all submitted country update reports, the RCC concluded that sufficiently sensitive surveillance systems for AFP and wild or VDPV are still in place in most countries, that more than six years have passed since the last isolation of indigenous wild poliovirus in the Region and that the WHO WPR has remained poliomyelitis-free. The Commission thanked the NCCs and all country teams for the timely assembly and submission orthe update reports, as well as for the informative and frank update presentations given at the ninth RCC meeting. The Commission commended countries in the Region for maintaining good quality AFP surveillance, even in view of other, often competing, health priorities and public health emergencies such as the epidemic of SARS earlier in 2003 and generally declining attention given to poliomyelitis eradication inmost poliomyelitis-free countries. While the quality of activities to sustain poliomyelitis-free status was high in most countries, not all countries were able to maintain certification level surveillance quality or previous levels of routine immunization coverage. The Commission noted the continued concern of countries in the Region to fund both surveillance and SIA necessary to maintain poliomyelitis-free status, and appreciated the recent decision of the Global Certification Commission (GCC) to call 011 all polio partners to continue to provide sufficient advocacy as well as technical and funding support to certified Regions at Regional and country level to allow to maintain surveillance quality and sustain poliomyelitis-free status. The Commission remained very concerned about the decreasing visibility of activities to sustain poliomyelitis-free status at the Regional and country level, and urged WHO, UNICEF and all other polio partners to maintain a high profile for the programme, particularly using fora such as the WHO Regional Committee, for which poliomyelitis eradication should remain on the agenda of the annual meeting as a permanent item. All polio partners and national governments in the Region should be reminded that wild virus continues to circulate in neighbouring areas. Recalling how these areas have been the source of importation of wild poliovirus into WPR countries in the past, the Commission again highlighted that high-qual ity surveillance and maintenance of sufficient population immunity against pol iomye Iitis are essential for countries to protect the enormous investment they already made into poliomyelitis eradication. The COlllmission, responsible for a Region that is home to one quarter of the world's population and reached certification at an early stage of the Global programme, strongly again urged for timely interruption of wi Id virus transmission globally. The COlllmission noted further progress made globally, resulting in only six countries remaining endemic for wild poliovirus. The three major global reservoir countries of India, Pakistan and Nigeria account for >99% of all wild polioviruses detected over the past two years, while only smallllumbers of cases are reported from Afghanistan, Egypt alld Niger. The Commission noted the significance of the WHO draft Global Strategic Plan for Poliomyelitis Eradication 2004-2008, which takes into account the now apparent additional delays in interrupting wild poliovirus transmission globally.

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The draft Global Strategic Plan focuses on closing the immunity gap in the endemic countries through increasing the frequency and quality of targeted OPY campaigns, and through rapidly detecting find approprifltely responding to wild poliovirus importations into poliomyelitis-free countries. The Commission shared the urgent concern that a funding gap of more than 200 million USD for 2003-05 remains a major threat for the Global initiative. The strategies for the period 2004-2008 as presented in the dran Global Strategic Plan aim at addressing this problem in order to make most efficient use of avai lable resources. The Commission noted that the number of SIAs carried out in recently endemic countries and areas has decreased dramatically from 266 SIAs in 93 countries in 2002 to only 51 SIAs in 13 countries in 2003. While this focllses maximum attention on remaining endemic areas, there is a risk of developing large susceptible populations in poliomyelitis-free areas with low routine OPY coverage. This places these populations, with the continuing possibility of wild poliovirus importation, at risk of sllch imported virus to spread and eventually re-establ ish ind igenous transmission, as well as of emergence and circulation ofYDPY. The Commission considered it very beneficial if further recommendations on required levels of SIA in Regions and countries certified poliomyelitis-free could be incorporated into the draft Global Strategic Plan to facilitate planning for technical as well as mid-term financial requirements. The Commission requested countries to review their national plans of action for detection and response to wild poliovirus importation for continuing appropriateness, update where required and expand to also include cYDPYs. The Commission noted that Phase I of laboratory containment of wild poliovirus infectious/potentially infectious materials still has not been completed in the Region. The Commission considered it as very important to have comprehensive information available on laboratories where such materials are being stored and the conditions of storage. Despite delays in global interruption of virus transmission, potential release of wild poliovirus from laboratory sources into populations already free of virus transmission poses significant risks. The COlllmission encouraged countries that have completed the national surveys to initiate Phase 2 and particularly consider destroying all infectious materials, replacing wild poliovirus and Sabin reference strains with authenticated Sabin strains which can be obtained from the NPLs and if infectious materials will still be retained ensuring that they are kept under BSL-2/polio. The COlllmission appreciated that the TCG discussed the RCC's request to consider modifications to the virological AFP case classification scheme to allow integration of poliomyelitis cases due to cYDPY and YAPP cases. The Commission noted that the TCG does not currently deem it necessary to modify the existing scheme for the Global initiative. Global certification of the eradication of wild poliovirus is now anticipated not before 2008. The further extension of the time frame will make it even more important for countries in WPR to slistain both high-quality surveillance and levels of population immunity appropriate (0 prevent the spread of wild poliovirus importations and to avoid the emergence and possible circulation ofYDPY. In this regard, the Commission welcomed that while building 011 poliomyelitis eradication achievements made and maintaining the initiative as priority, the WPR EPI has introduced Regional measles elimination and hepatitis B cOlitrol to guide and strengthen El'l and through this approach support maintenance of poliomyelitis-free status. The Commission offered the following country-specific conclusions and recommendations:

- 31 -

Australia The Commission noted Australia's efforts for continued implementation of activities to maintain poliomyelitis-free status. As surveillance quality remains below certification standards, the Commission encouraged the efforts of the national expert panel and its secretariat to review as many AFP cases as possible and provide a definite diagnosis of all AFP cases. The COlllmission requested the expert panel to discuss management and reporting of AFP cases, which are notified initially but for which no fmther information could be obtained. The Commission appreciated the evaluation study on variance of AFP surveillance performance at the sub-national level.

BnllIei Dan/ssalam The Commission noted with great satisfaction that Brunei Darussalam has maintained high quality immunization services and certification standard AFP surveillance and commended particularly its NCC for its continued involvement in and support of poliomyelitis eradication. Cambodill The Commission commended Cambodia on the attention paid to country specific recommendations made during its previous meeting. The Commission noted and supported the recommendations made by the NCC in the current update report on strengthening the roles and responsibilities of provincial health staff, the need to work towards integrating AFP surveillance with surveillance for other diseases, and on measures to improve the frequency and timeliness of stool specimen transport to obtain tlnallaboratory results as soon as possible. The COlllmission applauded current efforts to improve routine immunization systems at district level through the "Reach Every District" (RED) strategy. The COlllmission noted that Cambodia was able to maintain AFP surveillance quality overall at the desired level. However, considerable variation in quality remains at the sub-national level. Surveillance activities still appear too centralized at the national level and there is a need for better coordination with and involvement of provincial health staff in surveillance activities. The understanding of AFP surveillance concepts, particularly at the main children's hospital ill Phnom Penh reporting the majority of AFP cases, needs strengthening. Active surveillance visits [or AI'/' cases to priority health facilities are not yet systematically conducted and should commence as soon as possible. Efforts should be made to understand reasons why many AFP cases are still reported with delay, with subseqllent late stool specimen collection, to identify strategies to further improve the timeliness of stool sample collection. China The Com III iss ion cOlllmended Ch ina for maintaining both AFP rates and collection of adequate stool specimens at certification-quality during 2003 to date, despite the fact that the SARS epidemic fully absorbed the energies of many Chinese health workers for several months earlier this year.

- 32 -

The Commission also applauded China's efforts to maintain its quality poliovirus laboratory network (30/31 provincial laboratories were internally accredited using the main WHO accreditation criteria) and to intensify laboratory surveillance for VDPV, through which several isolates with> I % difference from Sabin strain in the VPI region of the genome were found, without evidence to date, however, for extended circulation. The Commission noted that continuing efforts will be needed to further strengthen and maintain the proficiency of the provincial poliovirus laboratory network, as a vital component of virological surveillance in China, and that all polio partners assure the continued availability of the required resources. The RCC looked forward to the report of the upcoming visit of an international laboratory accreditation review team to China and requested the WHO secretariat to provide copies of the final report to the RCC members. While China has made progress towards completing the inventory phase of laboratory containment, it is unclear if Phase I activities have yielded a comprehensive inventory of all laboratories holding wild poliovirus infectious or potentially infectious materials. Thorough and complete laboratory containment activities in China are a crucial part of the Regional and Global poliomyelitis eradication progralllme. The Commission recommended that WHO assist the government in assessing and validating ihe quality of Phase I containment activities and such exercise is expected to be helpful for finalizing all components of the national inventory as required. The Commission noted that the scope of the SIA originally planned for the coming winter seasons in China was considerably reduced. Main target areas for the planned SIA are provinces bordering poliomyelitis-endemic countries in the West, but not the densely populated provinces of southern and South-Eastern China that previously had been major wild poliovirus reservoirs. While routine OPV coverage is reported as very high from most areas, there is evidence for increasingly large imlllunity gaps, particularly alllong children of the 'floating population' in the large, densely populated urban areas of southern and South-Eastern China. The COlllmission noted that the decrease in the scope of the upcoming winter season SIA, compared to previous years, in addition to suspected low routine immunization coverage in high-risk areas, could further lower population immunity and increase the probabi lily of spread of imported wild virus or of cVDPV emergence. Resulting outbreaks could have a potentially devastating impact on the Global poliomyelitis eradication programme. Given the importance of the Chinese programme for the Global eradication effort, the potential epidemiological risks associated with declining SIAs while routine immunization coverage is not uniformly high and the magnitude of the investment already made into poliomyelitis eradication, the Comll1ission expressed its confidence that the Chinese Government will do all it possibly can to maintain what has been achieved and calls on the international polio partnership to provide as much support as possible for the national efforts.

Hong Kong, SAR, China The Commission was very impressed that despite extraordinary demands put onto the health services system by the recent SARS outbreak, Hong Kong has maintained high quality immunization services and certification standard AI'P surveillance. The Commission particularly commended Hong Kong's NCC for its continued involvement in and support for activities to sustain poliomyelitis-free status.

- 33 -

Japan The COlllmission appreciated that Japan provided detailed immunization coverage data for 200 I as requested and notes that coverage improved again significantly in both rounds. The Commission was very concerned that Phase I of laboratory containment is still not complete and requested Japan to finalize the national inventory of laboratories holding wild-virus infectious and potentially infectious material as soon as possible. The COlllmission also requested a more complete analysis and documentation of the current slatns of containment as well as advice on what further steps need to be taken towards finalizing Phase I, [or which sufficient resources and technical suppOJ1 should be made available.

Lao People's Democnltic Republic The Commission commended the Lao People's Democratic Republic on efforts made to assure sustained poliomyelitis-free status during the past year - particularly on the successful SIAs conducted in early 2003, and the supplemental surveillance activities conducted by the national surveillance unit in low-performing areas. The Commission noted, however, that progress on several recommendations previously made has been slow, including the need to improve adequate stool specimen collection rates, timeliness of 60-day follow up and the need to assure regular and timely AFP case classification through more frequent NCC meetings. The Commission re-emphasized the need for the NCC to meet at least quarterly. The Commission endorsed the NCC recommendation for supplementary surveillance activities to become a regular and routine part of annual AfP surveillance activities. The Commission noted the high performance level of provinces in terms of reporting completeness and timeliness to the national level. The Commission also noted the NCC concern about quality of reporting to the province level froll1 the periphery, and supported the NCC suggestion to begin assessing the quality of reporting within provinces in three or more provinces per year. While recognizing the special access and communication difficulties faced in the Lao People's Democratic Republic the Commission encouraged the NCC to continue efforts and support for improving adequate stool collection rates, and for improving the timeliness of 60-day follow-up investigations. The Commission was concerned about the continued decline in OrV3 coverage rates in the Lao People's Democratic Republic, and is supportive of all efforts to improve routine imlllunization coverage in the country, while considering additional OPV SIAs, as appropriate. in the future. The RCC noted that the EPI did not pass a recent data quality audit conducted by a GA VI contractor, shared the NCe's concern about the quality of immunization data, and is supportive of any efforts to improve immunization data quality. Macao, SAR, China The Commission noted with great satisfaction that Macao has maintained high quality illlllllJnization services and certification-standard AfP surveillance, and commended particularly its NCC for its continued involvement in and support of poliomyelitis eradication.

- 34 -

The Commission concurred with the conclusion of the NCC that the fact that no AFP case was reported in 2003 to date most probably represents statistical year-to-year variation and not a decline in survei IIance sensitivity.

Malaysia The Commission noted with appreciation that Malaysia has maintained quality immunization services and AFP surveillance. The Commission was concerned, though, that reporting of AFP cases in some States (e.g. Sabah, Sarawak) has declined and requests the programme to work towards certification surveillance quality at all levels expected to see AFP cases. The Commission noted with satisfaction that the expert panel and its secretariat managed to assign a final diagnosis to all AFP cases and encouraged continuation of this measure in view of sub-optimal adequate stool specimen collection. The Commission highly commended the Government of Malaysia for its support towards a resolution adopted by the Heads of States of 57 Islamic countries at the recent summit ofthe Organization of the Islamic Conference (OIC) to eradicate poliomyelitis from remaining endemic OIC countries. Mongolia The Commission noted with appreciation that Mongolia has maintained quality immunization services and AFP surveillance. The Commission was very impressed with the completeness and thoroughness of the recent investigation of a VDPV isolated from a healthy child and concurs with the conclusions made. The Commission recommended that the investigation response to the VDPV isolation be considered as a model approach.

New Zealand The Commission noted with appreciation that New Zealand has maintained quality immunization services and AFP surveillance. The Commission noted with satisfaction that the expert panel and its secretariat managed to assign a final diagnosis to all AFP cases and encouraged continuation of this measure under circulllstances of sub-optimal adequate stool specimen collection. The Commission encouraged the expert panel to conduct final classification of AFP cases more frequently than annual review. The Commission noted that supplemental accreditation for ITO was granted to the national poliovirus laboratory and noted the importance of the findings from a recently conducted study on the persistence ofOPY circulation after the transition to using IPV, which have important implications for the development of global post-certification immunization policy. The Commission noted that a national immunization register is currently being established and expected to be operational in 2004 allowing more accurate coverage figures for IPV.

Pacilic Island Countries and An'as The Commission was very impressed with the quality of the progress report and the comprehensive and detfliled action points developed by the SCc.

- 35 -

The Commission concurred with the SCC on the need to strengthen hospital-based active surveillance for AFP and, in particular, to re-establish effective AFP surveillance in those Pacific Island Countries and Areas and hospitals where recent performance has been poor. The Commission agreed that in order to maintain active and prospective AfP surveillance and enhance its quality where required, it is imperative that national authorities, national coordinators, hospital coordinators, key clinicians, and all public health personnel must be kept fully aware about the requirements and developments of global poliomyelitis erad.ication in order to remain vigilant and committed to maintaining the AFP surveillance system as a means of keeping the sub-region pol iomyel itis-free.

Papua New Guinea The Commission appreciated having received the requested interim report, which highlighted recent activities towards maintaining poliomyelitis-free status, including some activities to improve A FP survei lIance (e.g. national surveillance workshop, information and awareness campaign, improvements in the NPL). The Commission also welcomed the inclusion ofOPY in the national measles SIA cmrcntly being implemented in thc country. The COlllmission remained seriously concerned with the overall low routine immunization coverage for all antigens, including OPY as well as with the continued performance of AFP surveillance below certification quality. The Commission was aware of the overall difliculties faced by the health care system in the country with many beyond its control. Nevertheless, the Commission would like to remind the NCC of the urgent need to improve the immunity levels of children against poliomyelitis and to achieve more sensitive AFP surveillance quality. also in view of the overall requirements of Global poliomyelitis-free certification. The COlllmission wished to highlight the importance of partner coordination for a successful EPI in Papua New Guinea, encouraged the establishment of an Interagency Coordinating Committee (ICC) and noted that a permanent EPI manager needs to be urgently appointed. A long-term WHO Medicnl Officer would further improve the needed external technical support for the programme. Improved management of routine EPI services will be helpful to sustain activities to maintain poliomyelitis-free status, and vice versa. Philippines The Commission commended the Philippines for maintaining and further improving its AFP sur\'eillance system, particularly through the appointment of EPI surveillance officers, and recognizes that the full integration of AFP surveillance with surveillance for other diseases will add efliciency and be cost saving. The Commission was very concerned, however, about declining reported OPY routine immunization coverage rates in many parts of the country - confirmed by finding significant proportions of AFP cases without any previous OPY dose - and alerted the national programme as well as all polio partners that the current situation may be similar to the conditions leading to the poliomyelitis outbreak in 2001 caused by cYDPY. The urgent action needed to identify problems that may have resulted in low or declining imillunization coverage and improve routine imillunization will require comprehensive and rapid assessment at all administrative levels, particularly the level of Local Government Units, being at the front lines of service implementation.

- 36 -

The Commission requested to be updated after six months on routine imJllunization coverage performance for the year 2003 and the first months of 2004.

Republic of Korea The Commission noted with appreciation that the Republic of Korea has maintained quality immunization services and AFP surveillance. The Commission noted the recommendations made at the recent national AFP surveillance workshop and agreed that in order to maintain active and prospective AFP surveillance and enhance its quality where required all health personnel likely to see AFP cases must be kept fully aware about the requirements and developments of global poliomyelitis eradication in order to remain vigilant and committed to maintaining poliomyelitis-free status.

Singapore The Commission was very impressed that despite extntordinary demands put onto the health services system by the recent SARS outbreak, Singapore has maintained quality imlllunization services and AFP surveillance. The Commission noted with satisfaction that the expert panel and its secretariat managed to assign a final diagnosis to all AFP cases and encourages continuation of this measure in view of low adequate stool specimen collection.

Viet Naill The Commission commended Viet Nam for maintaining good quality AFP surveillance overall, but was concerned about a declining trend in the reporting of AFP cases. The Commission agreed with the NCC recommendation to conduct supplemental surveillance activities (e.g. AFP case searches) to validate reported data in low-performing areas. The Commission commended the Ha Noi NPL for its continuing high quality routine laboratory work and prompt compliance with WHO recommendations. The Commission acknowledged that several activities have been undertaken, with the support of poliovirus laboratory network partners, to strengthen the performance of the NPL in Ho Chi Minh City. This resulted in restoring WHO accreditation status; however, follow-up assessment of laboratory performance revealed that some problems continue to persist. The Commission requested that this situation will be urgently addressed in order for the laboratory to be able to fully meet its responsibilities as an integral component of the Viet Nam AFP surveillance system, in serving populations of particular epidemiological importance and as a member of the Global Poliovirus Laboratory Network. The COlllmission welcomed and is looking forward to the results of the upcoming EP[ review.

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4.

FUTURE MEETING OF THE REGIONAL CERTIFICATION COMMISSION

The Ree will continue to meet on an annual basis in order to fulfil its repOiting mandate to the Gee. As the Gee has requested all RCCs to meet before the next Gee meeting and provide progress reports 011 the Regional situation, the Rce is tentatively planning to schedule the 10'h meeting in mid-October 2004, a month before the next Gee meeting.

NINTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Manila, Philippines, 12-13 November 2003 TENTATIVE TIMETABLE Time 0830-0900 I. Opening ceremony

11 November 2003 ENGLISH ONLY

Wednesday, 12 November 2003

Time 0830-1000

Thursday, 13 November 2003 6. Discussion on country progress reports (cant.)

I I

•

•

• • •

Welcoming remarks by the Responsible Officer Opening remarks by the Regional Director Election of officers Remarks by RCC Chairperson Group Photo

0900-0940

2. Global poliomyelitis eradication overview including updates on laboratory containment of wild poliovirus infectious/potentially infectious materials 3. Conclusions and recorrunendations from 8th meeting of the Global Certification Commission COFFEE BREAK 4. Regional poliomyelitis eradication overview including activity plan for laboratory containment 5. Country presentations on sustaining poliomyelitis-free status (a) Cambodia (c) Lao People's Democratic Republic (b) China LUNCH BREAK' 1000-1030 COFFEE BREAK

I

0940-\000

1000-1030 1030-1100 1100-1200

w

\!)

1030-1145

7. Conclusions and recorrunendations

1145-1200

8. Future activities ofllIe Regional Certification Commission

1200-1330

1200-1330

LUNCH BREAK

1330-1500

5. Country presentations on sustaining poliomyelitis-free status (cont.) (d) Mongolia (g) Viet Nam (e) Papua New Guinea (h) issues and concerns of remaining countries (I) Philippines +COFFEE BREAK 6. Discussions on country progress reports

1330-1400

9. Closing ceremony

.

1500-1530 1530-1700

~ ~ I--'

1800

Dinner (Gloriamaris Seafood Restaurant)

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ANNEX 2

WORLD

HEALTH

ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

NINTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Manila, Philil'pines 12-13 November 2003

WP RlI CPIEP 1/5.2/00 lIEPI(2 )/2003/1 B/2 07 November 2003

ENGLISH ONLY

LIST OF REGIONAL CERTIFICATION COMMISSION (RCC) MEMBERS, EPI TECHNICAL ADVISORY GROUP (TAG) AND SECRETARIAT

l. REGIONAL CERTIFICATION COMMISSION

Dr Anthony I. Adams, (Chairman, Regional Certification Commission) No. 6/2-4 Chapman Crescent, Avoca Beach, New Soulh Wales 2251, Australia Tel: (612) 4382-6516. E-mail: aarr@netspeed.com.au Dr Shudo Yamazaki, (Vice-Chairman, Regional Certification Commission) (Director Emeritus, National Institute oflnfectious Diseases) 3-1204-3, Sayama, Higashiyamato-shi, Tokyo 207-0003, Japan, Tel: (8142) 564-3630 Fax: (8142) 564-3640, E-mail: yshudo@khaki.plala.or.jp Dr Carlyle Guerra de Macedo, Former WHO Regional Director for the Americas and I' A110 Director Emeritus, SMDB Conjunto 0 I Casa OS, SHlS, Brasilia, DF, Brazil 71680-0 iO 13razil, Tel: (614) 269595/ (55-61) 248-4245 (Res.), Fax: (5561) 321-1922 E-mail: !llal:y®_@bIJ.l.OP"§~Q!!I~Ull:g Dr Olen M. Kew, Molecular Virology Section MSG-IO, Respiratory and Enterovirus Branch National Centre for Infectious Diseases, Centers for Disease Control and Prevention 1600 Clifton Road N.E., Atlanta, GA 30333, United States of America Tel: (1404) 6391341, Fax: (1404) 639 2648, E-mail: omkl(iil.cdc.gtlY Professor Nguyen Dillh I1uong, Health Policy Adviser, Viet Naill Red Cross Society National Headquarters, 68 Ba Trieu Street, Hanoi, Viet Naill Tel: (844) 943-3874, fax: (844) 943-3874, E-mail: ttncldavhn.vnn.vll Dr Aida M. Salonga, IIead, Neurology Section, DepartmentofNeurosciences University of the Philippines-Philippine Generaillospital, Taft Avenue, Manila Philippines, Tel: (632) 52 I -8450, local 2405, Fax: 632) 525-4996 E-mail: [Ills-.lld@pacif!l=.net Ilui Zhuang, Professor, Department of Microbiology, Beijing Medical University

38 Xue-Yuan Road, Haidian District, Beijing 100083, People's Republic of China Tel: (8610) 6209-8899, Fax: (86 10) 6209-1617, E-mail: zhuanghur7iJpublica.bj.cninfo.nct

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Annex 2 2. TECHNICAL ADVISORY GROUP MEMBERS

Dr Isa6 Arita, (Chairman, EPI Technical Advisory Group), Chairman, Agency for Cooperation in International Health (ACIH), 4-11-1 Higashi-machi, Kumamoto 862-090 I, Japan Tel: (8196) 367-8899, Fax: (8196) 367-900 I, E-mail: arita@acih.com; acih@lllsa.biglobe.ne.jp Dr Robert Hall, (Vice Chairman, EPI Technical Advisory Group), Director of Public Health and Chief Health Officer, Department of Human Services, Level 18, 120 Spencer Street Melbourne, Victoria 300 I, Australia, Tel: (613) 9637-4200/4204, Mobile: (614) 1835-3069, Fax: (613) 9637-4250, E-mail: Robert.G.Hall@dhs.vic.gov.au

3. SECRETARIAT

Dr Dong II-AIm, Acting Director, Combating COllllllunicable Diseases Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila Philippines, Tel: (632) 528-8001, Fax: (632) 521-1036, E-mail: ahnd@wpro.who.int Dr Yang Baoping, Regional Adviser, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila, Philippines, Tel: (632) 528-9747 Fax: (632) 521-1036, E-mail: yangb@wpro.who.int Dr Yoshikuni Sato, Medical Officer, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific, United Nations Avenue 1000 Manila, Philippines, Tel: (632) 528-9742, Fax: (632) 521-1036 E-mail: satoy@wpro.who.int Dr Sigflln Roesel, Medical Officer, Expanded Programme on Ill1munization World Health Organization Regional Office for the Western Pacific, United Nations Avenue 1000 Manila, Philippines, Tel: (632) 528-9741, Fax: (632) 521-1036 E-mail: roesels@wpro.who.int Mr Wayne Antkowiak, Technical Officer, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila, Philippines, Tel: (632) 528-9751 Fax: (632) 521-1036, E-mail: antkowiak@wpro.who.int Dr Kazunobu Koj ima, Scientist (Laboratory Virologist), Expanded Programme on Illlll1un ization, World Health Organ ization Regional Office for the Western Pacific, United Nations Avenue 1000 Manila, Philippines, Tel: (632) 528-9750, Fax: (632) 521-1036 E-mail: koi imak(w,wjJro. who.int Ms Margaret Hercules, Technical Officer, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila, Philippines Tel: (632) 528-89740, Fax: (632) 521-1036, E-mail: herculesm@wRro.who.int Mr Hisakazu Hiraoka, Technical Officer, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila, Philippines Tel: (632) 528-9744, Fax: (632) 521-1036, E-mail: hiraokah@wpro.who.int

- 43 -

Annex 2 Dr Ernest Smith, CDC Consultant, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila, Philippines Tel: (632) 528-9746, Fax: (632) 521-1036, E-mail: smithe@wpro.who.int Mr Alan Arthur Crouch, WHO Consultant, Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue, 1000 Manila, Philippines Tel: (632) 528-9748, Fax: (632) 521-1036, E-mail: croucha@wpro.who.int Dr Kohei Toda, Medical Officer, Expanded Programme on Immunization WHO Representative's Office, No. 177-179 corner Pasteur (51) and 254 P.O. Box 1217, Sangkat Chaktomouk, Khan Daun Penh, Phnom Penh, Cambodia Tel: (855) 23 216610, Fax: (855) 23216211, E-mail: todak(a)cam.wpro.who.int Dr Lisa Lee, Medical Officer, WHO Representative's Office - China 401, Dongwai Diplomatic Office Building, Chaoyang District Beijing 100600, China, Tel: (8610) 65327189 to 92, Fax: (8610) 6532-2359 E-mail: leel@chn.wpro.who.int Dr Yoshihiro Takashima, Medical Officer, Expanded Programme on Immunization WHO Representative's Office - China, 401, Dongwai Diplomatic Office Building Chaoyang District, Beij ing 100600, China Tel: (8610) 6532 7189 to 92, Fax: (8610) 6532-2359, E-mail: takashimay@chn.wpro.who.int Mr David Bassett, Technical Officer, Expanded Programme on Immunization WHO Representative's Office, Ban Phonxay, That Luang Road, Vientiane Lao People's Democratic Republic, Tel: (856) 21 413-431, Fax: (856) 21 413 432 E-mail: bassettd@lao.wpro.who.int Dr Howard Sobel, Medical Officer, WHO Representative, Philippines National Tuberculosis Centre Building, Second Floor, Bldg. 9 Department of Health San Lazaro Hospital Compound, Rizal Avenue, Sta. Cruz, Manila Tel: (632) 338-7479, Fax: (632) 731-3914, E-mail: sobelh@phl.wpro.who.int Dr Hitoshi Murakami, Medical Officer, Expanded Programme on Immunization WHO Representative's Office, 63 Tran Hung Dao Street, Hoan Kiem District Ha Noi, Viet Nam, Tel: (844) 943-3734, Fax: (844) 943-3740 E-mail: murakamih@vtn.wpro.who.int Dr R. H. Tangermann, Medical Officer, Department ofImmunization, Vaccines and Biologicals, World Health Organization, CH-1211 Geneva 27, Switzerland Tel: (4122) 791-2111, Fax: (4122) 791-3111, E-mail: tangermannr@who.int