WHO-EMlPOL122 1/E/L Distribution: Limited
Report on the
Seventh meeting on coordination of Operation MECACAR Plus
Cairo, Egypt 19-21 March 2001
World Health Organization Regional Office for the Eastern Mediterranean Cairo 2003
O World Health Organization 2003
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Document WHO-EM/POL/22 l/E/L/O8.03/102
CONTENTS INTRODUCTION ............................................................................................................. 1 THE FINAL STAGE OF POLIO ERADICATION: SITUATION ANALYSIS AND PRIORITIES ..................................................................................................................... 2 2.1 Global overview ................................................................................................. 2 2.2 Eastern Mediterranean Region overview ................................................................. 2 2.3 European Region overview ...................................................................................... 3 3 OPERATION MECACAR: IMPACT AND LESSONS LEARNED ................................
SITUATION IN PRIORITY AREAS FOR ACTION IN 2001 ......................................... 4 4.1 Pakistan .................................................................................................................. 4 4.2 Afghanistan ............................................................................................................ 4 .. 3.3 Taj~kistan ............................................................................................................... 4 4.4 Turkmenistan ....................................................................................................... 5 4.5 Uzbekistan ............................................................................................................ 5 4.6 Iraq ...................................................................................................................... 5 4.7 Syrian Arab Republic .............................................................................................6 4.8 Turkey ...................................................................................................................... 6 4.9 Islamic Republic of Iran .......................................................................................... 6 4.10 Egypt ........................................................................................................................ 7 SURVEILLANCE............................................................................................................. 7 ................................................................................. 5.1 Eastern Mediterranean Region 7 5.2 European Region ...................................................................................................... 8 PLANS FOR CONTAINMENT OF POLIOVIRUS ......................................................... 9 6.1 Eastern Mediterranean Region ................................................................................. 9 6.2 European Region ...................................................................................................... 9 OPERATION MECACAR MID-TERM PLANNING ................................................... 10 7.1 Coordination Plan for 2001-2002 .......................................................................... 10 7.2 Eastern Mediterranean Region ...............................................................................10 7.3 European Region .................................................................................................... 11 OPERATION MECACAR Dl THE NEW MILLENNIUM ...........................................11 .. 8.1 Country vislon ........................................................................................................ II 8.2 Regional vision (EMR) .......................................................................................... 12 8.3 Regional vision (EUR) ........................................................................................... 12 8.4 Partner vision ......................................................................................................... 12 CONCLUSIONS ............................................................................................................. 13 RECOMMENDATIONS................................................................................................. 14
1. 2. 3.
Annexes PROGRAMME ........................................................................................................... 18 LIST OF PARTICIPANTS .......................................................................................... 20 PLANS FOR NIDSISNIDSIMOPPING UP I N MECACAR COUNTRIES. 2001-2002 ....................................................................................................................... I
1.
INTRODUCTION
The Seventh Meeting on Coordination of Operation MECACAR Plus was held in the WHO Regional Office for the Eastern Mediterranean on 19-21 March 2001. Participants included national staff responsible for poliomyelitis eradication and representatives from UNICEF, Rotary International, Centers for Disease Control and Prevention, WHO headquarters and regional offices for the Eastern Mediterranean and Europe. The objectives of the meeting were to: evaluate and discuss the results of Operation MECACAR Plus 2000; coordinate the plan of action for polio eradication in countries of the Eastern Mediterranean and European regions in 2001-2002, including dates for NIDs, sub-NIDs and mopping-up activities; assess the results achieved in improvement of surveillance including laboratory services in the participating countries and discuss future actions; discuss and coordinate certification activities of the Eastern Mediterranean and European regions in 2001-2002; evaluate and to discuss progress in containment activities in MECACAR Plus countries; discuss an expansion of objectives of Operation MECACAR Plus; and brief the main partners on the efficacy and the development of Operation MECACAR Plus. The meeting was opened by Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean, who noted with satisfaction the progress towards polio eradication since the last meeting of the group 18 months earlier and congratulated the European Region for being free of reported poliomyelitis cases and nearing certification. He highlighted the progress in the Eastern Mediterranean Region as indicated by sharp reduction in incidence of polio and number of infected areas. This progress was due in large part to the extensive efforts of polio-endemic cou~ltries working closely with international partners. IIe expressed satisfaction with the impact of intensification of eradication activities that was undertaken during the preceding two years. Improvements had been made in the quality of supplementary immunization activities and the frequency of immunization campaigns increased in endemic countries. The impact of intensification was also evident in the improvements in the quality of surveillance. Dr Gezairy reminded the participants of the difficulties of polio eradication in several countries that were affected by conflict and civil unrest and the extraordinary challenges that lay ahead for achieving the goal. Dr Gezairy praised the effectiveness of Operation MECACAR Plus and urged all partners to continue close intercountry and interregional coordination to ensure polio was eradicated. Dr Roberto Bertollini, Director, Division of Technical Support and Strategic Development, WHOIEURO extended greetings from Dr Marc Danzon, Regional Director for Europe, and noted that the European Region had been free of reported polio cases for nearly 28 months, with onset of the last case on 26 November 1998. This achievement was the result of the technical success of Operation MECACAR coordinated immunization activities and
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improved surveillance. He also noted the political success of Operation MECACAR: the strengthening of the international partnership. This partnership had allowed MECACAR countries, as well as others Member States in both regions, to improve AFP surveillance and laboratory performance. The 50th Session of the WHO Regional Committee for Europe was held in September 2000 and included a review of progress towards poliomyelitis eradication. The Regional Committee had issued a resolution confirming the goal of achieving certification of the Region as polio-free by the year 2003, with emphasis on high immunization coverage, quality virological surveillance, and progress in the laboratory containment process. The coordination meeting was an important opportunity to discuss the future of Operation MECACAR, he noted, and the intent that the 'MECECAR spirit' could be applied successfully to other issues in public health. The lesson of Operation MECACAR was that a shared framework and shared objectives, implemented in coordination, improved intercountry and interregiona! effectiveness. Drs S. Cochi, R. Hafiz and M. Grassi served as Chair on a rotating basis. Drs H. Jaffari and S. Deshevoi served as Rapporteurs. The meeting programme and list of participants are attached as Annexes 1 and 2. Annex 3 lists plans of action for poliomyelitis eradication in MECACAR countries. 2.
'l'HE FINAL S'I'AGE OF POLIO ERADICATION: SITUATION ANALYSIS AND PFUORITIES
2.1
Global overview
Remarkable progress towards global eradication of polio has continued as a result of acceleration of the programme in priority areas. Most notable was progress in India with rapid reduction in the number of cases and infected districts. Moreover, a number of coordinated multi-country initiatives have been launched, including implementation of synchronized NIDs in 16 countries of West Africa. All endemic regions are rapidly approaching certification quality standards of AFP surveillance. The international partnership in polio eradication continues to grow stronger. The major challenges for the global programme include maintaining political commitment, meeting the shortfall in funding and access to children in areas of conflict. The challenges for the future include managing risks associated with outbreaks of vaccine-derived polioviruses as recently seen Hispaniola as well the postcertification strategies of successful laboratory containment of poliovirus and safe cessation of vaccination with OPV.
2.2
Eastern Mediterranean Region overview
Progress towards polio eradication continued in the Region with a substantial reduction in the number of polio cases in the face of improving AFP surveillance. Compared with 914 polio cases (479 virologically confirmed) reported in 1999, a total of 454 cases (259
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virologically confirmed) were reported in 2000. The quality of AFP surveillance has also continued to improve as shown by an increase in the regional average non-polio AFP rate to 1.42 in 2000 compared with I .1 in 1999. The rate of adequate stool sample collection has remained at 67% during this period, reflecting mainly the challenges of case investigation in conflict affected countries of Afghanistan, Somalia and Sudan. As part of programme intensification, the number and quality of mass immunization campaigns has increased in endemic or recently endemic countries of the Region. All campaigns in such countries are now conducted using the house-to-house vaccination strategy. Synchronization of campaigns as well as exchange surveillance data continues between Afghanistan, Islamic Republic of Iran and Pakistan and between the Islamic Republic of Iran Iraq, Syrian Arab Republic and Turkey. The certification process with ongoing review of country reports as well as laboratory containment of polioviruses is proceeding well. The political commitment for polio eradication in Member States remains high.
2.3
European Region overview
Considerable progress has been made towards polio eradication in the European Region. The last confirmed case, in eastern Turkey, had onset on 26 November 1998. The quality of AFP surveillance has improved dramatically from 1998 through 2002: in 2002, the overall non-polio AFP rate was 1.12; the proportion with two specimens within 14 days was 80%. Completeness of weekly reporting for the year was 91% (and timeliness of reporting was 81%). AFP surveillance in particular was improved in the 17 recently endemic countries of the Region. Thirly-two of the candidate 37 national laboratories have been fully accrcditcd, and all faecal specimens have been examined in accredited laboratories since the end of 1999. Of the 4064 AFP cases investigated, more than 14 772 specimens were tested in 2000. Supplementary immunization will continue in high risk territories of selected countries of the Region (the Russian Federation, Tajikistan, Turkey, Turkmenistan, and Uzbekistan). The Regional Certification Commission was progressing in its review of national certification documentation, with only four MECACAR countries remaining that have not yet presented their documentation, which will be reviewed in September 2001. The containment process was initiated in the Region with a designation of a national coordinator and request for submission of a national plan of action by each Member State. 3.
OPERATION MECACAR: IMPACT AND LESSONS LEARNED Dr Steve Cochi, Directoc Vaccine Preventable Disease Eradication Division, CDC
Operation MECACAR brought together a large number of countries, a range of technical expertise and a variety of international partners in public health in a manner that enabled sound technical advice, streamlined support from partners and rallied political commitment to a shared public health goal. In this environment of increasing government involvement, expert technical assistance was translated into rational strategic vision and coordinated plans of action between countries. This harmonization of plans led by a clear vision for the future was not only a sound eradication strategy but also a system that fostered efficient use of resources. Operation MECACAR provided an excellent opportunity for partners to come together, agree on priorities and make coordinated decisions for bilateral and
WHO-Eh1/POL/22 1/E/L Page 4 multilateral support. The legacy of Operation MECACAR goes beyond polio eradication and includes institution of interregional and intercountry coordination, cross-border initiatives for public health, establishment of public health laboratory networks, coordination of partner support and regional initiatives to foster political commitment. 4.
SITUATION IN PRIORITY AREAS FOR ACTION IN 2001 Pakistan
4.1
Reported OPV3 coverage anlong infants in Pakistan during 2000 was 75%. However, assessed OPV3 coverage levels varied from 40% to 60% between the four provinces. The quality of SIAs continued to improve as Pakistan conducts all campaigns using a house-tohouse vaccination strategy. Between October 2000 and April 2001, Pakistan will conduct 5 closely spaced NID rounds; four of these rounds have been completed with high coverage. The quality of AFP surveillance improved as evidenced by increase in the non-polio AFP rate from 1.2 in 1999 to 1.5 in 2000. In both years adequate stool specimens were collected from nearly 70% of all reported cases of AFP. The incidence of confirmed polio cases declined from 324 in 1999 to 175 in 2000, a 46% reduction. Following the April NID rounds, plans for 2001 include a subilational campaign targeting high-risk districts in August followed by NIDs in Septe~nber and November. 4.2
Afghanistan
During 1999 and 2000, the reported OPV3 coverage in Afghanistan has remained at an estimated level of 30%. Afghanistan conducted four NID rounds in 2000, the two rounds in spring used house-to-house vaccination strategy in urban areas only whereas the two rounds in autumn were conducted house-to-house all over the country. In 2001, one of the three NID rounds have already been completed. Nearly all SIAs in Afghanistan are synchronized with campaigns in Pakistan. The number of active surveillance and AFP reporting sites were increased in 2001, which has led to further improvements in AFP surveillance. In 2000 the non-polio AFP rate has increased to 1.1 compared with 0.66 in 1999 to meet the standard indicator for surveillance sensitivity. The rate for adequate stool specimen collection remained around 50% during 1999 and 2000. The incidence of confirmed polio cases declined from 63 cases in 1999 compared with 26 in 2000, a more than 50% reduction despite the improvements in AFP case reporting. SIA plans for 2001 include three spring NID rounds followed by a SNID in high-risk areas in August and two NID rounds in September and November. 4.3 Tajikistan
Reported routine coverage with OPV3 has improved from 74% in 1992 to 97% in 2000. There was only one district with OPV3 coverage Iess then 90% in 2000. Annual supplementary immunization activities have reportedly reached more than 95% of all target children. The country has been using virological criteria to classify AFP cases since 1998. The non-polio AFP rate increased from 0.67 in 1997 to 1.54 in 2000. The proportion of adequate
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stool specirrlerls collected of AFP cases has increased from 63% to 85% respcctivcly. Mobilc surveillance teams have been operating since April 2000 in several high-risk areas for performing supervision, sensitizing field personnel and filling personnel gaps for casefinding. By the end of 2000 AFP surveillance index (non-polio AFP rate multiplied by the percentage with 2 adequate specimens collected) increased from 0.34 and 0.26 to 0.67 and 0.75 in the relevant areas of Tajikistan. Continued attention will be paid to districts and areas with few or no reports of AFP. Wild poiiovirus was last isolated in 1994 and the last clinically confirmed case was reported in 1997. Two rounds of NiDs and two rounds of autumn SNIDs will be conducted in 2001 and 2002. 4.4
Turkmenistan
Routine OPV3 coverage has been over 99% since 1997. NIDs (all with reported coverage greater than 99%) have been conducted since 1995 and SNIDs have been conducted since 1997. The reported non-polio AFP rates wcrc over 1/100 000 children under 15 years of age since 1998 (1.4-2.1), and the proportion of AFP cases from which two adequate stool specimens were collected improved substantially from 54% in 1998 to 97% in 2000, for virological investigation to the regional reference laboratory in Moscow. Turkmenistan developed a plan for earlier warning and response to wild poliovirus importation. It includes maintaining high-quality virological surveillance for AFPIpolio and high levels of immunization coverage, and using mobile teams to cover hard-to-reach and remote or silent areas. Two rounds of NIDs and two rounds of SNIDs are planned for 2001 and 2002. 4.5
Uzbekistan
Routine immunization coverage with OPV3 is at least 95% nationally, and in virtually all districts. NIDs were introduced in 1994. Since then, the reported levels of coverage during each round of NID have exceeded 99%. SNIDs has also been conducted since 1997 every autumn. AFP surveillance was established in September 1996. Since 1999-2000 the non-polio AFP rate has been 1.19-1.25 per 100 000 children under 15 years of age and 88%90% of cases had two adequate stool samples collected within 14 days of onset. The national poliovirus laboratory functioning under the National Republican Centre of Virological Investigation was accredited in March 2001. Final characterization of isolated viruses is carried out by the WHO regional reference laboratory, Moscow. Two rounds of full-scale national immunization campaign are planned for autumn 2001 and to be synchronized with those in Tajikistan, Turkmenistan, and Afghanistan. 4.6
Iraq
Coverage level of more than 90% with OPV3 was maintained among infants in Iraq until recently. However, declining health infrastructure has led to disruption of immunization services and decline in coverage in many areas. Following the outbreak of polio in 1999, Iraq has continued to implement four rounds of NIDs during spring and autunln each year. These campaigns have been synchronized with activities in the Islamic Republic of Iran, Syrian Arab Republic and Turkey and have included the three northern governorates. The quality of AFP surveillance has continued to improve as evidenced by increase in the non-polio AFP
WHO-EMROLl22 1/E/L Page 6 rate from 1.6 in 1999 to 2.4 in 2000. During the same period, adequate stool specimen collection rate improved from 79% to 84%. The outbreak of polio was terminated as a result of a strong response from the government of Iraq and the last case of polio was detected in early 2000. Iraq plans to continue NIDs in April and May, October and November of 2001 and April and May 2002. 4.7 Syrian Arab Republic
The reported OPV3 coverage among infants in the Syrian Arab Republic has been 95% or more since 1995. In addition to annual NIDs, the Syrian Arab Republic has conducted SNIDs targeting governorates that border Iraq and Turkey during 1999 and 2000. The quality of -4FP surveillance in the Syrian Arab Republic has remained high for several years. The non-polio AFP rate improved from 1.3 in 1999 to 1.5 in 2000; in both years adequate stool specimens were collected from 80% or more of AFP cases. The last indigenous case of polio was reported in 1995. In late 1999, an imporled cast: of polio was reported from a villagc ncar Aleppo. Genetic analysis of the virus indicted a close relationship with contemporary strains of type 1 poliovirus in Bihar, India. Despite enhanced surveillance, no additional cases of polio have been detected. The Syrian Arab Republic plans to continue targeted SNIDs synchronized with Iraq and Turkey. 4.8
Turkey
The reported OPV3 coverage among infants in Turkey has been approximately 80% overall since 1995, with substantial variation by province. A total of 6 sets of NIDs (since 1995) and 4 sets of mopping-up immunization in high risk provinces (since 1997) have been conducted as part of Operation MECACARIMECACAR Plus. The overall coverage rate in NIDs has always been over 92%, although, again, with substantial variation among the provinces. Since the last quarter of 1998, the quality of supplementary immunization activities improved. due to detailed microplanning at central and provincial levels, training of provincial managers and immunization teams, and increased supervision at the provincial and district levels. In autumn 2000, 1.4 million children were vaccinated in house-to-house mopping-up in 19 high-risk provinces; the percentage of 'zero-dose' children were identified as 2% in the first round and 1% in the second. The national non-polio AFP rate was 1.13 in 2000, although there are still low-reporting provinces; the rate is higher in south-eastern Turkey. Adequate specimen collection was 83% in 2000. A total of 32 polio cases from 8 provinces were identified during 1997-1998. The last identified case due to wild poliovirus occurred on 26 November 1998, reported from Agri. Two rounds of SNIDs will be conducted in 32 provinces in April-June 2001. 4.9 Islamic Republic of Iran
The routine OPV3 coverage in the Islamic Republic of Iran has remained above 95% for a number of years. However, pockets of lower coverage have been identified in a few districts in the border province of Sistan va Baluchistan with high-risk cross-border populations. Since 2000, the country has conducted SNIDs targeting border provinces and districts with refugee populations. These campaigns have been synchronized with Pakistan and Afghanistan on the
WHO-EM/POL/221/E/L Page 7 eastern borders and Iraq and 'l'urkey on the western borders. 'lhe lslamic Republic of Iran has already conducted mopping up campaigns in these areas during January and February 2001 in response to importation and circulation of wild poliovirus from Pakistan. The non-polio AFP rate increased slightly from 1.1 in 1999 to 1.2 in 2000. The proportion of AFP cases with adequate stool specimens declined from 78% in 1999 to 68% in 2000. Between September and December 2000, three cases of polio caused by poliovirus type 1 were reported from Sistan va Baluchistan province. Epidemiological investigation and viral genetic data indicate that the strain was imported from Pakistan and circulated in the province during late 2000. No more cases have been identified following enhanced surveillance of AFP. The Islamic Republic of Iran will conduct targeted immunization campaigns synchronized with bordering countries.
4.10 Egypt Although, not part of Operation MECACAR, important lessons in polio eradication have been learned in Egypt. Egypt has maintained more than 90% reported OPV3 coverage for a number of years. Egypt has continued NIDs which only recently were conducted houseto-house in urban areas of Upper Egypt. Gaps in routine immunization and quality of campaigns have allowed sustained poliovirus transmission in pockets around some cities and towns of Upper Egypt. Although overall indicators surveillance quality are in the acceptable range, case reporting rates and gaps in quality have been noted in a few critical areas. Egypt has made strong progress towards polio eradication, but low level virus transmission has persisted in a few foci in southern governorates. In 1999, a total of 9 cases were reported and 3 cases have been reported in 2000 with the last case occurring in last May. Egypt plans to improve its AFP surveillance and implement high-quality targeted supplementary in~munization campaigns.
5. 5.1
SURVEILLANCE Eastern Mediterranean Region
AFP surveillance As noted in the regional overview, the regional surveillance quality indicators have improved and most Member States have met or exceeded the minimum standards of surveillance performance. The remaining challenges for surveillance in the region include delayed stool specimen collection in countries affected by conflict, sub-national gaps in surveillance quality, problems in flagging and follow up of 'hot' AFP cases, and improving and maintaining surveillance in high-risk border populations. Moreover, maintaining surveillance quality in polio-free countries remains a regional priority. The number of staff, infrastructure and reporting sites are being expanded in critical areas to improve timely case investigation. Active surveillance is now being monitored systematically. Regular data analyses and system reviews are being encouraged to detect and correct subnational deficiencies. Flagging and follow up of 'hot' AFP cases needs to be incorporated in routine
WHO-EMlPOLl221/E/L Page 8 sulveillance. Lessuns learned fro111 recent iriipvrlatior~s irllo Syria arid Iran are being used to address problems of late case detection in cross-border populations.
Laboratory surveillancefor poliovirus The three regional reference and nine national poliovirus laboratories that make up the regional laboratory network continue to be fully or provisionally accredited. More than 5000 specimens were tested in the regional network during 2000, whereas specimens from AFP cases in Somalia and southern Sudan were tested in the laboratory network of the African Region. Results were reported on more than 80% specimens within 28 days of specimen receipt. More than 95% of specimens arrived in 'good condition' with a non-polio enterovirus isolation rate of more than 10%. The laboratory network continues to provide timely and critical virological information to the program. Delays in sending isolates for intratypic differentiation from national to regional reference laboratories was noted as a problem. As the number of poliovirus isolates in the region declines and progress towards eradication continues, the timely availability of genetic sequence information is becoming increasingly critical.
5.2
European Region
AFP surveillance Regional surveillance quality indicators have improved in 2000 and most Member States have met or exceeded the minimum standards of surveillance performance. Among the 17 recently endemic countries (including all 10 MECACAR countries of the Region), 71% meet expected the non-polio AFP rate indicating sensitivity of surveillance, and 94% have two faecal specimens collected within 14 days of onset; 9 of the 10 European MECACAR countries meet both criteria. The remaining challenges for surveillance in the Region include quality in a delayed specimen shipment in many countries, sub-national gaps in su~veillance few key countries, and problems in identifying high priority AFP cases for urgent laboratory testing. The lessons learned from the polio eradication programme regarding surveillance are that: 1) standardi~ationallows appropriate data analysis and comparison; 2) a quality laboratory network is essential; 3) timely data analysis provides the opportunity to respond rapidly; 4) performance indicators can be monitored and acted upon to improve subsequent performance, meaning that monitoring and supervision are key; and 5) timely sharing of data at regional and global levels allows coordination of responses, with good partnerships essential to those responses.
Laboratory surveillance for poliovirus Six regional reference laboratories (one is not a national laboratory) and additional 32 national poliovirus laboratories make up the regional laboratory network. The 37 national laboratories have improved in overall proficiency; 32 are fully accredited, 3 provisionally accredited. All national laboratories are expected to be fully accredited in 2001, but in the interim, all faecal specimens from AFP cases have been tested in accredited laboratories since the end of 1999. More than 7000 specimens were tested in the regional network during 2000
WHO-EM/POL/22 1/E/L Page 9 from AFP cases, contacts or other human sources; 168 of these were positive for poliovirus, all of which were Sabin-like on intratypic differentiation. Results were reported on 80% specimens within 28 days of specimen receipt overall for the Region, with 3 of the MECACAR national laboratories failing to report results on 80% specimens within 28 days of specimen receipt. The laboratory network is providing complete and accurate virological data on interruption of wild poliovirus transmission for the preparation of countries' certification documentation. The goal of the network for the future is to have the ability to promptly detect and to identify wild polioviruses in case of importation and define the origin of the poliovirus.
6. 6.1
PLANS FOR CONTAINMENT OF POLIOVIRUS Eastern Mediterranean Region
The regional plan for containment of wild poliovirus and potentially infectious material in laboratories has been completed. The first phase of the plan requires Merriber Slates for the purpose of certification to form a national task force for containment, appoint a national focal point for containment activities, develop a national containment plan and initiate surveys of all biomedical laboratories. Several countries have created task forces and appointed focal points. The survey of laboratories is being piloted. Oman has completed a national survey and is completing an inventory of materials stored within laboratories. The Regional Committee for the Eastern Mediterranean has also endorsed a resolution urging Member States to implement the regional plan for containment.
6.2
European Region
The European Region has several challenges to successful progress in containment. Within its Member States, there are a large number of virology and other laboratories with specimens potentially collected from various endemic areas, and from various times, including when indigenous wild poliovirus was circulating in countries free from reported polio for many years. Nonetheless, the containment process is well under way in the Region; 48 of 51 Member States have nominated responsible coordinators or committees, national plans of action have been submitted to EURO for 27 countries, and lists of laboratories have been prepared for surveys in 28 countries. In many locations, special legislation may be need for further progress in preventing laboratories not operating under BSL-2 (polio) conditions from retaining wild poliovirus. The Region has several recent examples of laboratory contamination with wild poliovirus in Member States that already reported elimination of the poliovirus in their Health Sector Laboratories (Russian Federation, Ukraine, Uzbekistan). Therefore, further assessments are needed of implementation of recommendations. EURO will closely monitor progress through progress reports and country visits. Russian Federation
The process of polioviruses containment was initiated in 1996, when, according to a special order of the Ministry of Public Health, all strains of wild poliovirus were to be destroyed. A national plan of action for laboratory containment of wild polioviruses has since
WHO-EMIPOLR21IEIL Page 10 been developed. A national coordinator on containment was nominated in 2000 and an interdisciplinary commission on containment will be organized in 2001. A special inventory was conducted among 31 000 laboratories and laboratory units belonging to 33 different ministries to identify laboratories that have infectious or potentially infectious specimens and materials. At present only 96 of 302 virological laboratories belonging to 10 ministries continue to work with poliovirus strains. Work continues to identify the presence of infectious or potentially infectious specimens at virological laboratories, as well as to verify the destruction of all wild poliovirus strains. 7.
OPERATION MECACAR MID-TERM PLANNING Coordination Plan for 2001-2002
7.1
In an open discussion moderated by WHO regional staff, countries elaborated plans for supplementary immunization activities. The timing, scope of campaigns, and OPV and resource requirements for activities in spring and autumn of 2001 and spring of 2002 were discussed. These discussions enabled synchronization of campaigns, recommendations on scope of activities depending on current epidemiology of poliovirus and risks to individual countries, and ensured adequate supply of OPV and channelling of resources (Annex 3).
7.2
Eastern Mediterranean Region
The target date for global certification remains at 2005; however, all countries of the region need to plan activities for the 2001 and 2005 phase of eradication. The key elements of the regional strategic plan include: Intensified supplementary immunization activities (SIAs) and mopping up in remaining endemic countries AFP surveillance Certification Strengthening routine EPI Containment of laboratory stocks of wild poliovirus and infectious material Stopping immunization (still in research phase). According to the plan, all countries of the Region except Afghanistan, Pakistan, Somalia, and Sudan will stop transmission by the end of 2000 and the remaining endemic countries are expected to terminate virus circulation by end of 2002. Intensified SIAs will continue at least through 2002 in currently and recently endemic and countries. The scope of SIAs will vary in polio-free countries based on risk of virus importation and quality of surveillance. All countries plan to achieve certification quality surveillance by end of 2000 and by beginning of 2001 all countries are expected to shift to virological case classification scheme. The certification process will continue and the Region is expected to be certified as polio-free by end of 2005.
WHO-EM/POL:'22 1/E/L Page I 1 7.3
European Region
With the current status, the pians for 2001-2003 focus on three areas: 1) ensuring the interruption of wild poliovirus circulation and prevent accumulation of susceptible persons by continued supplementary immunization in high-risk countries; 2) assist in enhancing the quality of surveillance and in laboratory performance in Member States; and 3) work towards implementation of regional plan of action for containment of wild poliovirus and assure the preparation of updated high-quality documentation towards certification for all countries of the Region, with final review of the status towards certification anticipated in 2002. The Commission has called for substantial progress in the containment process before regional certification can occur. In terms of supplementary immunization, continued coordination with countries of the Eastern Mediterranean Region is necessary; NIDS are planned in 2001 and 2002 in Tajikistan, Turkmenistan and Uzbekistan, and subnational immunization is planned in these countries and Turkey at least through 2004.
8. 8.1
OPERATION MECACAR IN THE NEW MILLENNIUM Country vision
Islamic Repzlblic
of Iran
Strong support for continuation of Operation MECACAR was recommended. The forum has been a source rcliable information about progress in neighbouring countries. MECACAR helped streamline technical assistance and provided opportunities for advocacy with government and political leaders. Most importantly, MECACAR was the most appropriate foruin for coordination of cross-border immunization and surveillance activities. The main reason to continue MECACAR would be to broaden its scope to include control of other diseases of public health importance.
The success of the Operation MECACAR included the exchange of information, so those inte1,aetions should continue as an opportunity to cooperate in the control of other communicable diseases of common interest to countries of both regions. Turkey Cooperation between regions should continue. In particular, cross-border issues can be discussed that would not be possible bilaterally.
Georgia Operation MECACAR should continue, as this international effort increased cooperation with countries. National partnership will be enhanced with continuation.
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Page 12 8.2 Regional vision (EMR) Operation MECACAR has become a critical forum for advocacy, rallying political support, and coordinating technical and financial assistance for a common public health objective. The main purpose and objectives of MECACAR should be gradually shaped to address other priorities for control of vaccine-preventable diseases while ensuring and maintaining successfd polio eradication. The scope and frequency of meetings should be defined by the progress towards polio eradication and consensus on other priorities.
8.3 Regional vision (EUR) Operation MECACAR was a perfect model for intercountry and interregional collaboration. EURO agrees that the first issue of continued MECACAR collaboration is to 'finish the job' of polio eradication; SIAs must remain coordinated. Quality AFP surveillance of border areas is important for focusing SIAs as well providing the necessary data for certification of both regions. Among the other options for continued collaboration is an opportunity to focus on the shared goals of regional elimination of measles. EURO proposes to build upon the polio eradication model, with first standardizing measles surveillance, investigation and laboratory confirmation, and gradually addressing other issues that are more unique about measles elimination to reach the common objective.
8.4
Partner vision
Rotary International The Chairman of the European Regional PolioPlus Committee and the Rotary Foundation highlighted the importance of Operation MECACAR in the polio eradication project. He assured the meeting that Rotary International remains fully committed to polio eradication, with increasing focus on Africa and South Asia. He also reiterated Rotary International's continued comrnitnlent to support countries included in Operation MECACAR.
Centersfor Disease Control and Prevention Dr Steve Cochi emphasized the need to focus on two issues in the future. First, the last steps in polio eradication should be taken together to ensure success. Secondly, as the final chaptcr on polio is being written, a new chapter should be written in the MECACAR collaboration. The lessons learned through Operation MECACAR should be applied to a new initiative. While several options exist, to succeed, the new initiative should be specific and measurable and capture the imagination to be a rallying point for advocacy and resource mobilization. Considering that measles is a communicable disease that also does not respect national borders and that both regions have established elimination goals and control activities that fit well with the spirit of Operation MECACAR, it fulfils all the criteria to be the next initiative that Operation MECACAR should carry forward.
WHO-EM/POL/22 1/E/L Page 13
Dr Qussay Al-Nahi, UNICEF/MENARO congratulated Operation MECACAR as a great success in polio eradication through close collaboration and synchronization of activities. He expressed support of UNICEF for Operation MECACAR and urged all to ensure its successful continuation to ensure polio eradication. He also supported continuation of Operation MECACAR to take on other public health challenges, particularly control of vaccine-preventable diseases. He recommended measles control and elimination as the next project to be included in Operation MECACAR.
United States Agency for International Development (USAID) Dr Wassilak presented views provided earlier from USAID. The benefits of Operation MECACAR include sharing of information in a transparent environment, and a useful forum for partners to coordinate their inputs. USAID recolml~endedcontinuation of Operation MECACAR to improve routine immunization services and measures to support overall health of children. These measures will also aid in the acceleration of measles control.
9.
CONCLUSIONS
Operation MECACAR has been critical to interrupting poliovims transmission in the European Region and is in large part responsible for the substantial progress toward polio eradic;ation in tile Eastern Mediterranean Region. Opcration MECACAR has led to interregional coordination, enhanced political commitment, increased coordination of countries sharing poiiovirus reservoirs, mobilization of internal and external resources and development of effective partnership for polio eradication. Despite the progress achieved to date, the quality of implementing the polio eradication strategies has not been consistently and uniformly of the level needed to interrupt poliovirus transmission in some countries of the Eastern Mediterranean Region, and may need improvements in some countries of the European Region to ensure and sustain polio-free status. Progress achieved toward polio eradication has been extraordinary in both the European and the Eastern Mediterranean Regions. Despite improving acute flaccid paralysis (AFP) surveillance, the 51-member European Region has not detected wild poliovirus since November 1998 (a two and a half year period); in addition, virus circulation has declined substantially in the 6 remaining polio-endemic countries of the Eastern Mediterranean Region, while other member countries have not isolated wild poliovirus in 2000, most of which have been polio-free for several years. Political commitment at the highest levels in each geopolitical division has been a critically important success factor for the progress achieved toward polio eradication.
WHO-EM!POL/22 1/E!L Page 14 Another key factor responsible for the success of Operation MECACAR has been that supplemental immunization activities (i.e. National Immunization Days [NIDs] SNIDs, and mop up) have been synchronized in contiguous areas. Routine vaccination coverage levels are not optimal in many countries. Even in countries reporting high routine immunization coverage, low performing areas (OPV3 coverage of less than 90% among infants 12 months of age) can be identified readily; AFP cases that are highly suspected to be poliomyelitis (i.e. "hot cases") are not always flagged for rapid field and laboratory investigation. Reporting and mapping of polio compatible cases remains variable among countries of both regions indicating lack of uniformity in the deliberations of expert review committees. Compatible cases are not always investigated to identify reasons why they could not be confirmed or discarded. Furthermore, clusters of compatible cases are especially worrisome and deserve immediate attention and epidemiological investigation. Critical information on polio eradication, such as spot maps of cases, line lists of cases, and occurrence of "hot cases" or clusters of compatible cases is not shared
systematically between neighbouring countries and not regularly shared between WHO Regions in a timely manner. Delays in intratypic differentiation of polioviruses unnecessarily delay programmatic action. Such delays can occur if specimens are transported late to the laboratory or a national laboratory does not immediately forward poliovirus isolates to a regional network laboratory. Similarly, if the regional laboratory delays shipment of isolates to a specialized laboratory, sequencing may also be delayed. Containment activities are proceeding according to plan in both regions. It is expected that the first phase of containment (i.e. an inventory of laboratories retaining wild poliovirus or potentially infectious samples) will be completed by the end of 2001 in the European Region and by the end of 2002 in the Eastern Mediterranean Region. Preparations for the process of eventual certification of polio-free status are proceeding in both regions. Although the progress toward polio eradication achieved to date is gratifying, there is absolutely no place for complacency in the programme.
RECOMMENDATIONS Both polio-free and polio-endemic countries should ensure that the necessary polio eradication strategies are maintained. Polio-endemic countries should give the highest
WHO-EM/POL/22i / w L Page 15 priority tu iilterrupting poliovirus transmission; polio-fi-ee countries should ensw-e that poliovirus cannot re-establish circulation. 2. The political commitment toward polio eradication must be maintained, and in critical areas it should be enhanced through advocacy efforts, including visits by prominent leaders and members of the Regional Certification Commission. Where appropriate, provincial visits should be included in these activities. The quality of polio eradication strategies (i.e. routine immunization, supplemental immunization, and AFP surveillance) must be evaluated systematically and continuously, both at the national and subnational level. Sub-optimal performance at any level (or geo-political division) should be urgently addressed through enhanced training and education. Low performing areas and areas at high risk for virus importation should be closely monitored from the central level. The timing of supplemental immunization activities should continue to be synchronized in contiguous areas. The ongoing outbreak of vaccine-derived poliovirus type 1 in the Dominican Republic and Haiti (Hispaniola), attributable to low vaccination coverage, is an important reminder that polio-fiee status cannot be taken for granted. Countries that discontinue NIDs and other supplemental immunization activities, and cannot achieve or maintain high routine immunization coverage, will be at risk for circulation of imported wild poliovirus or vaccine-derived poliovirus. Thus, maintaining the highest possible population immunity against all three types of poliovirus is critical to ensure polio-free status. Population immunity can be maintained through uniformly high routine vaccination coverage (>90%). If such uniformly high levels of coverage cannot be achieved or maintained, supplemental immunization activities should continue to be conducted to ensure adequate population immunity. Highly suspicious AFP cases (i.e. "hot cases") should be identified for prompt investigation. Stool specimens collected from "hot cases" should be immediately transported to the network laboratory for priority processing. AFP cases that should be considered as "hot cases" are most likely to occur among children <5 years of age, who are unvaccinated or under vaccinated, or belong to a high risk group (i.e. minority groups, displaced or refugee populations, etc.), or have had contact with persons from polio-endemic countries, and present with symptoms typical for poliomyelitis (fever at onset, rapid progression until paralysis, asymmetric paralysis, etc.). Regional offices should be alerted about these cases and should maintain an "early warning list." The composition of national expert committees should be reviewed in each country to ensure that the necessary expertise is represented (i.e. infectious diseases, paediatrics, neurology, virology, and public health). In addition, expert committees should be properly briefed on the terms of reference, particularly on the programmatic importance of polio compatible cases. National committees should closely follow the classification
3.
4.
5.
6.
7.
WHO-EM/POL/221/E/L Page 16 sclieme for AFP cases developed by WHO. The committees should meet at least every three months. 8.
Compatible cases represent failures of surveillance. Such cases should be investigated on a frequent and regular basis by either the national level or provincial level surveillance officers. Clusters of compatible AFP cases should by investigated immediately. Areas from which these cases originate should be evaluated for inclusion in mop-up operations. Critical programmatic information should be shared between WHO regions (and headquarters) on a frequent and regular basis (at least monthly); information should include line listings of AFP cases, spot maps, "hot cases", etc. Spot maps of cases should be prepared regularly (at least quarterly) by the regional offices covering countries with overlapping poliovirus reservoirs. Information collected on AFP cases should be reviewed regularly and critically by national and subnational level epidemiologists. Such data should be analysed systematically to monitor the epidemiology of AFP, assess the quality of field investigations, monitor the geographic distribution of AFP cases, determine "silent areas" (i.e. areas from which no stool specimens had been collected during the past several months) and identify "hot cases" and compatible cases for priority follow-up. To permit rapid programmatic action, a minimal interval between stool specimen collection and final laboratory results, particularly intratypic differentiation, is crucial. Specimens should be transported to the laboratory without delay, national network laboratories should promptly forward poliovirus isolates to the I-egional network laboratories for intratypic differentiation. Regional network laboratories must promptly forward isolates to specialized laboratories rapidly to allow timely sequencing. The rcgioiral oKies should be notified whenever shipments of specimens are occurring. The MECACAR countries of the European Region should work together to facilitate prompt delivery of AFP specimens/poliovirus isolates through customs to the Moscow regional laboratory. Aithough progress towards containment is proceeding according to plan, countries should ensure that the political commitment and interagency support is secured to meet the deadline for completion of each phase of containment. Detection of wild poliovirus or a poliomyelitis case from a previously polio-free area should be considered a public health emergency. All countries should prepare a clear and detailed national plan of action to respond to importation of wild poliovirus. WHO regional offices should provide a standard format to assist countries in preparation of appropriate plans. Another joint session of the Regional Commissions for the Certification of Polio Eradication from European and Eastern Mediterranean Regions should be convened within the next 12 months; thereafter, this collaboration should continue annually.
9.
10.
11.
12.
13.
14.
WHO-EM/POLR21/E/L Page 17 Members of the Eastern Mediterranean commission should be invited to the European commission meetings and vice versa. Operation MECACAR should continue and should focus on polio eradication until at least 2005. Coordination meetings should be held at least every two years. Based on operational needs, smaller technical meetings may be necessary in the interim periods. The scope of Operation MECACAR should be gradually expanded based on recommendations of the European and Eastern Mediterranean secretariat, concentrating on improving routine immunization (in collaboration with GAVI), achieving EPI disease control targets (especially measles control and elimination) and strengthening EPI surveillance. The participants of the Seventh Meeting on the Coordination of Operation MECACAR gratefully acknowledge the contribution of the polio eradication partnership (especially Rotary International), which continues to ensure that much needed external resources will be available to the initiative to finish the eradication task.
WHO-EMPOL122 1IEIL Page 18
Annex 1
PROGRAMME Monday, 19 March 2001 08:30-09:OO 09:0&09:30 Registration Opening session Address by Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean Address by Dr R. Bertoilini, DTS/EURO Election of Chair Adoption of agenda The final stage of polio eradication situation analysis and priorities Global overview1HQ EMR overview/EMRO EUR overviewIEUR0 Discussion Operation MECACAR-2 1st Century Operation MECACAR: impact and lessons learned Discussion Situation in priority areas for action in 2001 : Pakistan Afghanistan Tajikistan Turkmenistan Uzbekistan Iraq Syrian Arab Republic Turkey Islamic Republic of Iran Egypt (Lessons learned in polio eradication)
09:30-11:30
11:30-12:OO
12:OO-15:30
Tuesday, 20 March 2001 8:30-11:OO Surveillance Regional situationEMR AFP surveillance Laboratory surveillance for wild poliovirus Regional situation/EUR AFP surveillance Laboratory surveillance for poliovirus
WHO-EM/POLR2 1/E/L Page 19
Comments from RCCs Discussion 11:OO-13:30
Plans for containment of poliovirus Regional situation, EMR Regional situation, EUR Situation in the Russian Federation Discussion Operation MECACAR Coordination plan for 2001-2002 Regional plans Discussion
13:3&15:00
Wednesday, 21 March 2001 9:OO-11 : O O
Operation MECACAR-future in the new millennium Country vision Regional vision Partner vision Discussion Summary: joint vision Recommendation Closing session
11300-1 2300
WHO-EMlPOLl22 1/E/L Page 20 Annex 2 LIST OF PARTICIPANTS AFGHANISTAN Dr Gula Khan Ayub National EPI Manager Ministry of Public Health Jalalabad
ALBANIA Dr Silva Bino Director Institute of Public Health Rruga 'Aleksander Moisiu' Tirana Dr Petrit Vasili Director Primary Health Care Department Ministry of Health Tirana Shqiperi
ARMENIA Dr Ara Asoyan Chief Physician Republican Paediatric Infectious Diseases Hospital Ministry of Health Yerevan Dr Artavazd Vanyan Director Department of Hygiene and Anti Epidemic Surveillance Ministry of Health Yerevan
AZERBAIJAN Dr Firudin Huseynov Director General Republican Centre for Epidemiology and Hygiene Baku
WHO-EM/POL/22 1/E/L Page 2 1
Dr Abbas Soltan Velibekov Deputy Minister Ministry of Health Baku
GEORGIA Dr Levan Baidoshvili Coordinator Immunization Programme National Centre for Disease Control Tbilisi Dr Paata Imnadze Director National Centre for Disease Control Tbilisi
ISLAMIC REPUBLIC OF IRAN Dr Parviz Vazirian Director of Polio Eradication Ministry of Health and Medical Education Teheran
IRAQ Dr Mohamed Al-Ani EPI Director Ministry of Health Baghdad
JORDAN Dr Najwa Jaarour EPI Manager Ministry of Hcalth
Amman
KAZAKHSTAN Dr A. Belonog Deputy Chairman of the Committee of Health Chief Sanitary Physician Agency of the Republic of Kazakhstan on Health Affairs Astana
WHO-EMIPOLl22 I IEIL Page 22
Dr Gulnur Kembabanova Chief Sanitarian Physician Agency of the Republic of Kazakhstan on Health Affairs EPI Unit Astana
KYRGYZSTAN Dr Joldosh Kalilov Deputy Director, Republican Centre of Immunoprophylaxis Bishkek Dr Ljudmila Steinke Consultant Ministry of Health Toktogoul Bishkek
LEBANON Dr Atika Berry First Assistant
Department of Preventive Medicine Ministry of Public Health Beirut
PAKISTAN Dr Rehan Hafiz National Programme ManagerIEPI Federal Ministry of Health Islamabad
RUSSIAN FEDERATION Dr Serguei I. Ivanov Chief State Sanitary Inspection Department Ministry of Health Moscow Dr Galina Lazikova Head, Department of State Sanitary Surveillance Ministry of Health Moscow
WHO-EM/POL/22 l/E/L
Page 23 Dr Arkady Yassinsky Deputy Director Federal Centre for State SanEpid Surveillance Ministry of Health Moscow
SYRIAN ARAB REPUBLIC Dr Mohammed Radwan Nasri Polio Eradication Programme Focal Point Ministry of Health Damascus
Dr Hind El Sayed Focal Point EPI Target Disease Surveillance System Ministry of Health Damascus
TAJIKISTAN Dr Shamsoudin S. Jobirov Director National Immunization Centre
Dushanbe Dr Makhmadali A. Rashidov Director of the Branch Repubiican Centre for Immunoprophylaxis Ministry of Health Dushanbe
TURKEY Dr Oya Afsar Deputy General Director Communicable Diseases Department General Directorate of Primary Health Care Ministry of Health Sihhiye, Ankara Dr Sefer Aycan General Director General Directorate of Primary Health Care Ministry of Health Sihhiye, Ankara
WHO-EM/POL/221/E/L Page 24 Dr Mevliit Mercan Deputy Undersecretary Ministry of Health Sihhiye, Ankara
Dr Cevdet Yalniz Primary Health Care Gen. Dir Ministry of Health Silhiye, Ankara
TURKMENISTAN Dr Djurnaguli A4krmamedov Head of Research Anti-plague Station Ministry of Health Ashgabat
Dr Kaka A. Amangeldiev Head, Department of Epidemiological Control and Parasitology Acting Head of SanEpid Inspection Ashgabat
UKRAINE Dr Olga Bobyliova First Deputy Minister of Health Main State Sanitary Physician Ministry of Health Kiev Dr Liudmila Mukharskaya Head, Department of Infectious Diseases Control Main Department of SanEpid Surveillance Ministry of Health Kiev
UZBEKISTAN Dr Vladimir Andreanov Chief Physician SES Tashkent Region Tashkent
WHO-EMIPOLI22 1IEIL Page 25 Dr Sanat B. Shaurnarov Chief Physician Republican Sanitary and Epidemiology Station of Uzbekistan Tashkent Dr Dilorom Tursunova Senior Specialist Sanitary and Epidemiology Department Ministry of Health Tashkent
YUGOSLAVIA Dr Mila Jankovic-Vucic Serliur Epiderniulogist Vaccination Department Institute of Public Health
Dr Milan Jovanovic-Batut Belgrade
OBSERVERS
Dr Ibrahim Barakat EPI Manager Ministry of Health and Population Cairo, EGYPT Dr Abdullahi Deria Member of the Regional Certification Commission for Poliomyelitis Eradication London, UNITED KINGDOM
OTHER ORGANIZATIONS Centers for Disease Control and Prevention (CDC) Dr Stephen L. Cochi Director Vaccine Division, National Immunization Program Centers for Disease Control and Prevention Atlanta, UNITED STATES OF AMERICA Dr Howard Gary Division of Viral and Rickettsia1 Diseases Centers for Disease Control and Prevention Atlanta, UNITED STATES OF AMERICA
WHO-EM/POL/22 1/E/L Page 26 Dr Roland Sutter Chief, Technical Services Branch National Immunization Program Vaccine Preventable Disease Eradication Centers for Disease Control and Prevention Atlanta, UNITED STATES OF AMERICA
Rotary International Dr Mario P. Grassi Massagno, ITALY Mr Rudolf Horndler Chairman, European Regional PolioPlus Committee Neumarkt, GERMANY Mr Benmejdoub Mohamed Chairman, EMRO PolioPius Committee Casablanca, MOROCCO Dr Diaa Saif-El Din Chairman, PolioPlus Conxllittee of Egypt Cairo, EGYPT Dr Amr Abbassy Member, Egypt National PolioPlus Committee Alexandria, EGYPT
United Nations Children's Fund (UNICEF) Dr Anatoly Abrarnov Officer in Charge UNICEF Turkmenistan Office Turkmenistan Dr Qussay Al-Nahi Regional Immunization Officer UNICEF MENARO Dr Imran Ravji EPIIPolio Eradication UNICEF Pakistan Islamabad
WHO-EM/POL/22 l/E/L
Page 27 Dr Suleman Daud Khan UNICEF Pakistan Peshawar Dr Abdul Jarnil Khan UNICEF Pakistan Quetta
TEMPORARY ADVISERS Dr Margareta Bottiger Saltsjo-Boo SWEDEN Professor Istvaan Domok Scientific Adviser Budapest HUNGARY Dr Walter Dowdle Director of Programs The Task Force for Child Survival and Development Decatur, Georgia UNITED STATES OF AMERICA Professor Sergey G. Drozdov Director, Institute of Poliomyelitis and Virus Encephalitis Russian Academy of Medical Sciences Moscow RUSSIAN FEDERATION Dr Olga Eugenyevna Ivanova Chief, Laboratory of Environmental Virology Institute of Poliomyelitis and Viral Encephalitis Academy of Medical Sciences Moscow RUSSIAN FEDERATION Dr Harrie A.M. van der Avoort Senior Scientist, Poliomyelitis Laboratory of Infectious Diseases and Perinatal Screening National Institute of Public Health and Environmental Protection (RIVM) Bilthoven NETHERLANDS
WHO-EMIPOLI22 1IEIL Page 28 WHO SECRETARIAT
Headquarters Dr Rudolf Tangermann, Medical Officer, Vaccines and Biologicals Regional Office for the Eastern Mediterranean Dr Hussein A. Gezairy, Regional Director for the Eastern Mediterranean Dr M. Haytham A1 Khayat, Senior Policy Adviser to the Regional Director Dr Abdel Aziz Saleh, Assistant Regional Director Dr Moharned H. Wahdan, Special Adviser to the Regional Director for Poliomyelitis Dr Zuhair Hallaj, Director, Communicable Disease Control Dr Taky Gaafar, Regional Adviser, Vaccine Preventablc Discascs and Immunization Dr Faten Kamel, Medical Officer, Poliomyelitis Eradication Dr Hamid Jaffari, Medical Officer, Poliomyelitis Eradication Dr Esther de Gounrille, Scientist/Virologist, Poliomyelitis Eradication Dr Hala Safwat, Short-term Professional, Poliomyelitis Eradication Mr Fehri Fassi, Technical Officer, Poliomyelitis Eradication Dr Naveed Sadozai, Medical Officer, Polio Programme, WHOIAfghanistan Dr Omar Mekki, Medical Officer, Polio Programme, WHOJIraq Dr Anthony W. Mounts, Medical Officer, Polio Programme, WHOIPakistan Ms Nagla Dessouki, Administrative Assistant, Poliomyelitis Eradication Ms Christine Fares, Senior Secretary, Poliomyelitis Eradication Ms Fatma Moussa, Secretary, Poliomyelitis Eradication Regional Office for Europe Dr Roberto Bertollini, Director, Division of Technical Support and Strategic Development Dr Nedret Emiroglu, Acting Regional Adviser, Communicable Diseases Control Prevention and Eradication Dr Sergei Deshevoi, Medical Officer, Expanded Programme on ImmunizationPolio Dr Steven Wassilak, Medical Officer, Poliomyelitis Dr Galina Lipskaya, Scientist, Coordinator of the EUR Polio Laboratory Network Ms Johanna Kehler, Programme Assistant Dr Rafi Aslanian, Short-term Professional Dr George Oblapenko, Short-term Professional Ms Louise Gare, Short-term Professional Dr Margarita Balasanian, Technical Officer, Communicable Diseases Ms Olga Avanessova, Secretary Interpreters Mr Vladimir M. Ilyukhin Mr Georgy G. Peegnasty
WHO-EM/POL/221/EL Page 29
Annex 3 PLANS FOR NIDS/SNIDS/MOPPING UP IN MECACAR COUNTRIES, 2001-2002
WHO-EM/POL/22 l/E/L Page 30