.j 0 NAR 2010

REPORT

EIGHTEENTH MEETING OF THE TECHNICAL ADVISORY GROUP ON IMMUNIZATION AND VACCINE PREVENTABLE DISEASES

IN THE WESTERN PACIFIC REGION

Manila, Philippines 30 June-2 July 2009

Convened by:

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines

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Printed and distributed by:

World Health Organization Regional Office for the Western Pacific

Manila, Philippines December 2009 WHOIWPRO LmRARY MANILA. PlULIPPINES

.j 0 NAR 2010

The views expressed in this report are those of the participants and members of the Eighteenth Meeting of the Technical Advisory Group on Immunization and Vaccine Preventable Diseases in the Western Pacific Region and do not necessarily reflect the policies ofthe World Health Organization.

The Expanded Programme on Immunization, WHO Western Pacific Regional Office, would like to thank the Ministry of Health, Labour and Welfare of Japan for providing financial support for the meeting, including the production of this document.

This report has been printed by the Regional Office for the Western Pacific of the World Health Organization for the participants and members of the Eighteenth Meeting of the Technical Advisory Group on Immunization and Vaccine Preventable Diseases in the Western Pacific Region, which was held in Manila, Philippines, 30 June-2 July 2009.

ii

Preventable Diseases (VPDs) in the Western Pacific Region (WPR) was held from

30 June to 2 July 2009 in Manila, Philippines. A meeting of the Regional Interagency Coordinating Committee was convened concurrently with the TAG Meeting, as in previous years.

The objectives of this meeting were to review and update technical and programmatic recommendations on achieving and monitoring progress towards measles elimination, hepatitis B control, sustaining poliomyelitis-free status, achieving maternal and neonatal tetanus elimination, strengthening routine immunization services, introducing new and underutilized vaccines, and improving VPD surveillance.

The TAG acknowledged regional progress towards the twin goals of measles elimination and hepatitis B control and maintaining poliomyelitis-free status. Regarding measles, TAG recommended that the Western Pacific Regional Office convene a task force to define criteria and processes for validation of elimination and that countries and areas review and implement the Strategic Advisory Group of Experts on Immunization (SAGE) recommendations, enhance surveillance performance at the subnationallevel, collect more specimens for virus isolation and detection and use measles elimination activities as opportunities to accelerate rubella control. Regarding rubella, TAG recommended that the Western Pacific Regional Office fmalize the strategic plan of action for accelerated rubella control and prevention of congenital rubella syndrome (CRS) and that countries and areas plan to decrease annual rubella incidence to < 10 cases per million population and annual CRS incidence to < 10 per million live births through a combination of approaches by 2015. TAG endorsed the recommendations of the Hepatitis B Expert Working Group held in November 2008 in Seoul, the Republic of Korea, and recommended that the Expert Resource Panel hold quarterly teleconferences and annual meetings and that the Western Pacific Regional Office formulate an operational plan to put into effect TAG recommendations made in 2008 and 2009. TAG

reemphasized the need of hepatitis B vaccine for health care workers. TAG commended the Region on completion of phase 1 wild poliovirus laboratory containment. To maintain poliomyelitis-free status, TAG encouraged countries and areas to monitor and ensure high routine vaccination coverage and sensitive and timely surveillance for acute flaccid paralysis at the subnationallevel. TAG looks forward to guidance on the roles of oral and inactivated polio vaccines from the forthcoming WHO position paper on this subject expected in 2010.

The Global Immunization Vision and Strategy (GIVS) and Reaching Every District (RED) approach should be adopted by countries and areas to achieve the 2010 GIVS goals of 90%

immunization coverage nationally and 80% coverage in every district. TAG encouraged countries and areas to strengthen management of vaccine, cold chain and logistics, to ensure functional

National Regulatory Authorities that include surveillance for adverse events following immunization, and to establish National Immunization Technical Advisory Groups to facilitate evidence-based policy-making.

Reliable sentinel surveillance systems are needed to provide data for new vaccine introduction decision-making and impact evaluation. A biregional plan for control of Japanese encephalitis (JE) is needed with a 2015 goal of90% JE vaccination coverage among at-risk groups. An intersectoral expert consultation on prevention of human papilloma virus (HPV) infection and cervical cancer should be convened. Countries and areas introducing HPV vaccine should consider using school and reproductive health approaches. Countries and areas should prepare pandemic influenza (HINI) 2009 vaccine deployment plans in consultation with the Western Pacific Regional Office. The funding gap to implement expanding immunization initiatives and goals is increasing, making increased resource mobilization efforts critical.

iii

SUMMARY ... iii

LIST OF ACRONyMS ... vi

1. INTRODUCTION ... 1

~:i g~~:~~~~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~.

2. REPORT FROM PRESENTATION SESSIONS ... 2

2.1 Overview of issues ... 2

2.2 Achieving Measles Elimination by 2012 and Accelerated Rubella Control... ... 4

2.3 Controlling Hepatitis B by 2012 ... 12

2.4 Maintaining the Region Poliomyelitis-free through 2012 ... 15

2.5 Progress of Laboratory Network of Polio, Measles and Rubella ... 18

2.6 Achieving Maternal and Neonatal Tetanus Elimination (MNTE) ... 20

2.7 Strengthening Routine Immunization ... 23

2.8 New and Underutilized Vaccines ... 27

2.9 Update of Laboratory Network for JE and other Vaccine-Preventable Diseases ... 38

2.10 Presentation and Discussion of Data Management Issues ... 39

3. REPORT FROM THE INTERAGENCY COORDINATING COMMITTEE MEETING ... 41

3.1 GA VI Alliance Support for the Western Pacific Region ... .41

3.2 International Vaccine Institute (ND ... 42

3.3 Japanese Government Ministry of Health ... 43

3.4 Korean Centres for Disease Control (CDC) ... .43

3.5 Rotary International District 2650, Japan ... 44

3.6 UNICEF ... 44

3.7 United States of America Centers for Disease Control and Prevention (CDC), Global Immunization Division ... 45

3.8 Asian Development Bank (ADB) ... 45

3.9 Asian Liver Centre at Stanford University ... .46

3.10 Programme for Appropriate Technology in Health (PATH) ... 46

3.11 Western Pacific Regional Office ... 47

4. CONCLUSIONS AND RECOMMENDATIONS ... 48

4.1 Measles elimination by 2012 and Accelerated Rubella Control ... 48

4.2 Hepatitis B Control by 2012 ... 51

4.3 Maintaining the Region Poliomyelitis-free through 2012 ... 54

4.4 Progress on Laboratory Network of Polio, Measles and Rubella ... 55

4.5 Achieving Maternal and Neonatal Tetanus (MNT) Elimination ... 57

4.6 Strengthening Routine Immunization ... 57

4.7 New and Underutilized Vaccines ... 60

4.8 Update of Laboratory Network for JE and other Vaccine-Preventable Diseases ... 63

4.9 Data Management Issues ... 64

4.10 Interagency Coordinating Committee and Resource Mobilization ... 65 iv

ANNEX 2 - LIST OF ATTENDEES

v

ADB Asian Develo~ment Bank

AEFI adverse events following immunization AFP acute flaccid paralysis

ALC Asian Liver Centre

ATAGI Australian Technical Advisory Group on Immunization AusAID Australian Agency for International Devel<JI>ment

BCG Bacille Calmette-Guerin Vaccine CBAW child bearing age women

COl Centre for Democratic Institutions

CDNA Communicable Disease Network Australia CDS communicable disease surveillance

CHD child health day

CHW community health worker cMYP comprehensive multi year plan CHW community health worker

CNS central nervous system CRI congenital rubella infection CRS congenital rubella syndrome CSF cerebrospinal fluid

CSR Communicable Diseases Surveillance and Res~onse

DBS dried blood spot

DTP3 third dose of diphtheria-tetanus-pertussis vaccine ECBS Expert Committee on Biological Standardization ELISA enzyme-linked immuno-sorbance assay

EMR Eastern Mediterranean Region (of WHO) EPI EXjJanded Prop-amme on Immunization EVM effective vaccine manaAement

EB Executive Board

FIC fully immunized coverage

GACVS Global Advisory Committee on Vaccine Safety GID Global Immunization Division

GIVS Global Immunization Vision and Strategy GMP good manufacturing practices

GPLN global polio laboratory network GSL global specialized laboratory HBsAg hepatitis B surface antigen HepB BD birth dose of hepatitis B vaccine

VI

HQ Headquarters

ICA indirect colorimetric assay

ICC Interagency Coordinating Committee lOP Institutional Development Plan

IEC information education and communication IFA immuno-fluorescence assay

IgM immunoglobulin M

IPV inactivated poliovirus vaccine ITO intra-typjc differentiation

iVDPV immunodeficient vaccine-derivedl~oliovirus

IVI International Vaccine Institute IE J~anese enc~halitis

IlCA Japan International Cooperation Agency JRF WHO-UNICEF Joint Reporting Form

LB live birth

MBD mouse brain derived MCV measles containin...£ vaccine

MCV2 second dose of measles containin...s.. vaccine MDG4 millennium development goal number 4

ME meningo-encephalitis

MMR measles-m~s-rubella vaccine MNT Maternal Neonatal Tetanus

MNTE Maternal Neonatal Tetanus Elimination MPA minimum package activities

MRI first dose of measles-rubella vaccine MRZ second dose of measles-rubella vaccine

NATSIHS National Aboriginal and Torres Strait Islander Health Survt:}' NEPI National E~anded PrCJgramme on Immunization

NIID National Institute of Infectious Diseases NIP National Immunization Prqgt"am

NITAG National Immunization Technical Advis~ Grol!E..

NL national laboratory

NPL National Polio Laborat~

NRA National Regulatory Authority NT neonatal tetanus

00 operational district OPV oral poliovirus vaccine

VB

PBPA Pharmaceutical Benefits Pricin~ Authority PBS Pharmaceutical Benefits Scheme

PCR _polymerase chain reaction PCV pneumococcal conjugate vaccine PEP Polio Eradication Pr()gCamme PIC Pacific island coun!ry

PID Eima~ immune deficien~

QUIVER Quantitative Immunization and Vaccines Related Research Committee

RC Regional Committee RCV rubella-containing vaccine RED reaching every district

RI Rotary International

RI 2650 Ro~ International District 2650 RRL Regional Reference Laborat~

RT reverse transcri£tion

SAGE Strategic Advisory Grol!£. of Experts on Immunization SEAR South East Asia Region of WHO

SIA suPIJlementa~ immunization activity STOP StQg Transmission of Polio

TAG Technical Advisory Group TBA traditional birth attendant

TD tetanus and diphtheria toxoid TGA Therapeutic Goods Administration

TLAC Technology & Logistics Advis()ry_ Committee TT tetanus toxoid

TTl two doses of tetanus toxoid UNICEF United Nations Children's Fund

VAPP vaccine associated paralytic polion.!relitis VDPV vaccine-derived poliovirus

VHW village health worker

VIDRL Victoria Infectious Disease Research Lab VPD Vaccine Preventable Disease

VPl viral protein I

WHA World Health Assembly WHO World Health Organization

WPRO Western Pacific Regional Office (WHO)

Vlll

The eighteenth meeting of the Technical Advisory Group (TAG) on hnmunization and Vaccine-Preventable Diseases (VPDs) in the Western Pacific Region was held from

30 June to 2 July 2009 in Manila, Philippines.

1.1 Objectives

The objectives of the meeting were to review and update technical and programmatic recommendations on:

(1) achieving and monitoring progress towards measles elimination and hepatitis B control, sustaining poliomyelitis-free status, achieving maternal and neonatal tetanus elimination and strengthening routine immunization services;

(2) introduction of new and underutilized vaccines with particular reference to Haemophilus influenza, type b (Hib), pneumococcal conjugate (PCY), rotavirus and other vaccines; and

(3) VPD surveillance needs for disease eradication, elimination, control and introduction of new and underutilized vaccines.

1.2 Organization

Attending the meeting were five TAG members, three temporary advisers,

33 participants from 14 countries and areas, 31 representatives from 18 partner agencies, four United Nations Children's Fund (UNICEF) officials from regional and country offices and 27 WHO staff from Headquarters (HQ), the Regional Office and country offices. The timetable of the meeting is provided in Annex 1. The list of participants is included in Annex 2.

1.3 Opening ceremonies

Dr Young-soo Shin, Regional Director, WHO Western Pacific Regional Office, welcomed the TAG members, participants and partners to this eighteenth meeting of the Technical

Advisory Group on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region, noting the recent pandemic of Influenza A (HINI) 2009 and expressing confidence in the national immunization programmes (NIPs) of the Region to meet the challenges posed by the pandemic.

He acknowledged the contributions made by the TAG and the successful efforts in the Region to maintain polio-free status and progress towards the twin goals of measles elimination and hepatitis B control. He further noted that only five countries in the Region have yet to achieve maternal and neonatal tetanus elimination (MNTE) and that new and underutilized vaccines have been introduced into an increasing number of NIP schedules. He emphasized the important contributions of NIPs to strengthen health systems and infrastructure. In closing, he requested that TAG provide continuing guidance to achieve measles elimination and hepatitis B control and guidance for the accelerated control of rubella, the introduction of new and

underutilized vaccines and the potential use of influenza vaccine during the current pandemic.

2. REPORT FROM PRESENTATION SESSIONS

2.1 Overview of issues 2.1.1 Global Update

Dr Jean-Marie Okwo-Bele, Director, Immunization, Vaccines, and Biologicals, WHO HQ, provided an overview of global immunization. In May 2008, the World Health Assembly (WHA) passed resolution WHA 61.15 expressing concern that many lower income countries are not on track to achieve under-five mortality rate reduction goals and urged Member States to (1) review national strategies, improve programme performance overall and implement measles mortality reduction strategies; (2) achieve equitable coverage of at least 80% in all districts by 2010; (3) stimulate rapid introduction of new vaccines in accordance with national priorities; (4) strengthen surveillance and monitoring of vaccination programmes; and (5) promote and

strengthen long-term financial and programmatic sustainability.

Globally, immunization has the potential to reduce under-five mortality by 25% by 2015 through a multipronged approach, including scaling up current vaccine use together with the introduction of new vaccines that can help prevent pneumonia and diarrhoea.

Four countries remain polio-endemic, and each has different key challenges. For India, the main challenge is optimizing vaccine effectiveness; for Pakistan and Afghanistan, security concerns; and for Nigeria, political and societal commitments.

Estimated global measles deaths have decreased from 750000 in 2000 to 197000 in 2007, with a very large proportion of these currently occurring in India. WHO, in consultation with advisory bodies, including the Strategic Advisory Group of Experts on Immunization (SAGE), is preparing a feasibility analysis of global measles eradication to be delivered to the WHA

Executive Board (EB) in January 2010. The analysis includes biological feasibility, impact on health systems, economic analysis, vaccine market analysis, programmatic feasibility, risk analysis for the post-measles era and political feasibility in a global context.

The Western Pacific Region is the only Region to have a hepatitis B control goal.

However, the Regional Committee (RC) of the WHO Eastern Mediterranean Region (EMR) will consider a hepatitis B and hepatitis C control goal in its October 2009 meeting. In the South-East Asia Region (SEAR), a regional review of hepatitis B will be presented for discussion at the next RC meeting. In April 2008, SAGE recommended that "all regions and associated countries develop goals for hepatitis B control appropriate to their epidemiologic situations".

Coverage with at least two doses of tetanus toxoid (TT2+) in pregnant women and protected at birth (P AB) coverage have been increasing globally over the past decade, bringing the goal ofMNTE by 2012 closer to reality. Among 59 priority countries, 16 have been

validated as achieving MNTE, 15 have completed their activities and are awaiting validation and 30 need to conduct TT supplementary immunization activities (SlAs).

To implement the Global Immunization Vision and Strategy (GNS), the 72 poorest countries in the world will require approximately US$ 28 billion between 2009 and 2015 to support (1) traditional, underutilized and new vaccine procurement, (2) operational costs to sustain and increase routine coverage and (3) supplementary immunization activities (SlAs). In the best-case scenario, national governments may provide US$ 13.5 billion (48%), the Global

Alliance for Vaccines and Immunization (GA Vn US$ 7.4 billion (26%) and other partners US$ 2.7 billion (10%), leaving a funding gap ofUS$ 4.4 billion. In the worst-case scenario, national government contributions would total US$ 11 billion (39%), GA VI US$ 4.6 billion (16%) and other partners US$ 1 billion (4%), with a funding gap ofUS$ 11.3 billion. Increased donor support, innovative financing mechanisms and national financial commitments will be critical to realize the Expanded Programme on Immunization's (EPI's) full potential to prevent death, disability and disease and contribute to achieving Millennium Development Goal Number 4 (MDG 4).

2.1.2 Regional Update

Dr Yang Baoping, Regional Adviser, EPIfWHO Western Pacific Regional Office began his regional EPI update by listing key global and regional goals to which EPI contributes. Global outcome goals include:

(1) MDG 4: reducing under-five mortality by two thirds between 1990 and 2015;

(2) GIVS goals:

(a) reducing measles mortality by 90% between 2000 and 2010; and (b) reducing child mortality and mortality due to VPDs by two thirds

between 2000 and 2015;

(3) global polio eradication by 2000; and

(4) global MNTE by 2005 (now moved to 2012).

Regional outcome goals described in the 2005 RC resolution WPRlRC/56.R8 include measles elimination and hepatitis B control by 2012 and maintaining polio-free status. In addition to these outcome goals, immunization coverage goals also were established by GIVS and endorsed by the WHA. These include fully immunized coverage (FIC) by 12 months old

~ 90% nationally and ~ 80% in every district. The regional twin goals also specify immunization coverage goals, including two doses of measles-containing vaccine (MCV2) ~ 95%, three doses of hepatitis B vaccine (HepB3) ~ 85% and a dose of hepatitis B vaccine administered within 24 hours of birth (HepB BD) ~ 70%.

The EPI continues to increase its impact on health in the Western Pacific Region. More and more children are protected from the vaccine-preventable diseases that cause death, disability and disease by progressively increasing routine immunization coverage, as indicated by coverage with three doses of diphtheria, tetanus and pertussis vaccine (DTP3). The percentage of districts in the Region with at least 90% DTP3 coverage has increased annually from 83% to 87% to 89"/0 to 92% from 2005 to 2008.

The Region has remained polio-free for eight years since certification despite numerous importations of polio virus. Fully 24 countries and areas are believed to have eliminated or nearly eliminated measles A total of 87% of the Region's population in 26 countries is believed to have achieved < 2% hepatitis B surface antigen (HBsAg) seropositivity among 5-year-old children, but validation is required.

New and underutilized vaccines are being used more extensively in the Region. Fully 31 countries and areas will be using Hib vaccine by 2010. Pneumococcal conjugate vaccine (PCy) has been introduced in 13 countries and areas, Human Papilloma Virus (HPV) vaccine in 10 and rotavirus vaccine (RV) in eight. A strategic plan that includes increased vaccination coverage is being formulated for prevention and control of Japanese encephalitis (JE). Improved

infrastructure and experience established in the EPI have prepared it for the rapid uptake and utilization of the pandemic (HINl) 2009 vaccine.

While its successes are many, the EPI's challenges remain great. The EPI is the most equitable of health programmes. Nevertheless, reaching the most vulnerable children remains difficult and is expensive. Realizing the potential benefits of new and underutilized vaccines, which would further enable the EPI to contribute to achieving MDG 4, also will require substantial financial investments.

An estimated US$ 41 million will be required in 2010 and 2011 to maintain past gains, close the gaps to complete the current initiatives, and expand further the prevention of disease, disability and death by introducing more vaccines and achieving new initiatives. In addition, the EPI will need to better integrate with other health programmes and improve monitoring,

surveillance and increasingly complex programme management. WHO will continue to provide technical assistance in these efforts and foster close collaboration among Member States and with partner agencies.

Finally, to facilitate evidence-based decision-making in an increasingly complex and resource-challenged environment, national immunization technical advisory groups (NITAGs) increasingly will be important to guide policy-makers and programme managers to make evidence-based policy, to empower governments with a neutral, credible, comprehensive and integrated approach to NIP strategic planning and programme implementation, to monitor NIP performance and to provide input on the latest scientific advances related to vaccines and VPDs.

2.2 Achieving Measles Elimination by 2012 and Accelerated Rubella Control 2.2.1 Regional measles elimination update: change we can believe in

Dr David H. Sniadack, Medical Officer-EPIIWHO Western Pacific Regional Office, began by noting the importance of understanding and adapting to changing situations in relation to disease eradication, elimination and control programmes. In that context, he reviewed recent policy developments related to measles elimination, beginning with a proposal by the WHA EB delegate from the Bahamas during the May 2008 WHA EB meeting that WHO prepare a feasibility study on global measles eradication. The content of that feasibility study will be presented to the EB in January 2010, as described above (Section 2.1.1).

Dr Sniadack then reviewed several SAGE recommendations on measles immunization beginning with a recommendation from the November 2006 meeting that follow-up SIAs should be conducted before the estimated number of susceptible pre-school children reaches the size of one birth cohort. From the November 2008 SAGE meeting, recommendations included the need for a measles two-dose strategy for all countries, that the second dose of measles containing vaccine (MCV2) may be delivered through routine services or campaigns, that each dose should be recorded and monitored and that very high vaccination coverage remains the basis for

effective measles control. In its April 2009 meeting, SAGE provided recommendations about introduction ofMCV2 into routine immunization schedules, the optimal age for MCV2

administration and the need for school entry verification of immunization status. MCV2 may be added to routine schedules in countries that have achieved 2: 80% coverage with a first dose of measles-containing vaccine (MCVl) at the national level for three consecutive years as

determined by WHOIUNICEF estimates. For countries with continuing measles transmission that deliver MCVl at 9-11 months old, MCV2 should be administered at 15-18 months old.

Such a schedule provides early protection, slows accumulation of susceptible children, reduces risk of outbreaks and provides an opportunity to integrate MCV2 administration with other

interventions such as a fourth dose of diphtheria-tetanus-pertussis vaccine (DTP4), vitamin A and dewonning medicines. For countries with very low measles transmission, MCV} can be administered at 12 months of age to take advantage of higher sero-conversion rates compared with administration at 9 months. In this scenario, countries should select the optimal age for MCV2 administration to achieve the highest level of population immunity. Early administration ofMCV2 at 15-18 months old would provide the same advantages as enumerated above. MCV2 administration at school entry could provide very high coverage if school enrolment is high.

Regardless of which second dose strategy is selected, a systematic effort to check the vaccination status of all children at school entry was recommended by SAGE to ensure that all children have- received at least two doses of measles vaccine as well as other needed vaccines.

As requested by the Western Pacific Regional Committee in 2005, the Western Pacific Regional Office monitors progress towards regional measles elimination. Despite the overall progress in following the recommended strategies, regional measles incidence was on the rise until recently. A total of 130811 measles cases were reported in 2007 and 145949 cases in 2008. In both years, China and Japan, which include 82% of the Region's population, reported 97% of the Region's measles cases. China alone reported 90% of the Region's cases in 2008. If cases reported from China are not included, the number of measles cases reported from the remaining 36 countries and areas of the Region from 2000 to 2008 decreased by 86%, from

106 172 to 14724.

The year 2009 may be a turning point for Regional measles elimination. Because of the large number of provinces conducting SIAs in China in 2008 and 2009 and a major decrease in reported cases from Japan as its measles elimination plan is being implemented, the number of reported measles cases in the Western Pacific Region decreased by nearly 58% between January and June 2009 compared with the same period in 2008.

Reported measles incidence is likely different from actual measles incidence, depending on the sensitivity of surveillance and the percentage of suspected cases from whom specimens are collected for comumation. Suspected measles cases without specimens that satisfY the clinical case defmition of measles are clinically confinned as measles but in fact may not be measles. Countries that report high measles incidence because of a large number of clinically confinned cases may not have as much actual measles virus circulation as reported incidence suggests. One possible way to estimate the true measles incidence would be to estimate the number of clinically confumed cases that actually have measles and add these to the number of laboratory-confumed and epidemiologically-linked cases. To do this, the percentage of

suspected cases with specimens that are laboratory-confumed (i.e., immunoglobulin M [IgM]

positivity ratio) may be multiplied by the number of clinically confinned cases. This method assumes a high positive predictive value of laboratory confinnation and that suspected cases without specimens are similar to suspected cases with specimens. Another way to estimate actual incidence could be for an expert review committee to further classifY clinically comumed cases as compatible or discarded in a manner similar to that for acute flaccid paralysis (AFP) cases without adequate stool specimens.

Decreased incidence of measles in many Member States of the Western Pacific Region is attributable to the increased number of children vaccinated against measles through routine systems and SIAs. In 2007,50% of the Region's children lived in districts with at least 90%

MCVl coverage. In 2008, that percentage increased to 66%, and MCV2 was provided by 30 of the Region's 37 countries and areas. fu addition to the rolling SIAs being conducted in China and Japan, SIAs were conducted in an additional 10 Member States from 2007 to 2009, with coverage exceeding 90% of target populations in all except Papua New Guinea.

The Western Pacific Regional Office also monitors surveillance quality among countries and areas using standard indicators. Countries and areas of the Western Pacific Region have been requested to submit standard core variable data collected through national measles surveillance systems to the Western Pacific Regional Office by the seventh of each month;

laboratory-specific data are reported by the lOth of each month. Completeness of national reporting of national case-based measles data increased from 51 % to 78% and timeliness of reporting increased from 19% to 47% from 2007 to 2008. From January to June 2009, completeness of reporting increased further to 81 % and timeliness to 58%.

The most important surveillance performance indicators for case-based measles surveillance include:

(1) number of reported suspected measles cases that are discarded as nonmeasles:

(a) ::-: 2 per 100000 population nationally; and

(b) ::-: I per 100 000 in at least 80% of second level administrative units (2) Percentage of reported suspected cases that have adequate investigation within

48 hours of report (adequate: core variable data collected on case investigation form):

Target: ::-: 80% of reported suspected cases

(3) Percentage of reported suspected cases that have adequate specimens collected (adequate: collected within 28 days of rash onset):

Target::-: 80% of reported suspected cases

However, some countries do not report from suspected cases all core variables that are required to calculate these indicators. China does not report any core variable and Australia, New Zealand and Singapore report only confirmed case data to the Western Pacific Regional Office. Japan, the second largest country in the Region, began reporting measles cases to the Western Pacific Regional Office in 2008 and does not yet report all core variable data.

Table 1: Key measles surveillance performance indicators, Western Pacific Region, 2007 to 2009'

Surveillance Indicator National reporting rate of discarded

measles cases second

units reporting at least 11100 000 discarded measles cases Percent of suspected cases with

adequate investigation Percent of suspected cases with

adequate blood specimens

Target ::-:2 per 100000

::: 80%

::: 80%

::: 80%

II I I :

1 --.~

.'11.(,':;', 27..1%

2(,.7^lYt, ~7..1%

64.7% 62.2%

2009"

~ I I ,

2.-'

.'1.1%

-Il) .-1'1..

71.9%

. .

Table 1 lists the key measles surveillance performance indicators and results for the Region. Performance for the Region was mixed. Among countries and areas that report suspected measles cases, overall sensitivity of surveillance was good, with 2.3 discarded measles

cases per 100000 population from January-June in 2009. However, reporting was not uniform within countries: only 31 % of all second level administrative units in the Region had discarded measles rates ;::-: 1 per 100 000 popUlation. Only 49% of case investigations were adequate because of failure to collect data on all core variables. The percentage of suspected cases with adequate blood specimens increased from 65% in 2007 to 72% in 2009 (through June).

The greatest challenges to achieving measles elimination by 2012 in the Western Pacific Region are ensuring high coverage and quality of routine immunization and SlAs in the most highly populated countries and in the lowest income countries of the Region. Visible and

substantive political commitments at the highest level will help ensure successful implementation of measles elimination strategies. These include (1) two-dose measles vaccination coverage should be sustained at high levels ~ 95% coverage); (2) until such high levels of vaccination coverage are achieved through routine systems, catch-up and follow-up SlAs and SlAs targeted for special high-risk populations should achieve at least 95% coverage of their target populations to ensure high levels of population immunity; (3) high quality case-based measles surveillance that is supported by an accredited laboratory network should be established and sustained throughout the country to identifY residual areas of measles virus transmission and determine whether new cases result from endemic transmission or are imported-or import-related. The estimated budget to support these activities from 2010 to 2012 is approximately US$ 53.9 million.

2.2.2 Country updates 2.2.2.1 Japan

Dr Nobuhiko Okabe, Director, Infectious Disease Surveillance, National Institute of Infectious Diseases, reviewed the history of measles in Japan beginning in the 1800s. More recent history included the measles outbreak occurring in 2007 and 2008 that led to several international importations of measles virus and the larger outbreak occurring from 2000 to 2001.

On 28 December 2007, the Ministry of Health, Labour and Welfare published its Special Guidance for Measles that included plans for measles elimination by 2012 and maintaining elimination afterwards. The plan includes establishing (1) a National Measles Elimination Committee that includes a Measles Response and Technical Support Team and (2) Measles Elimination Committees in each of 47 prefectures. Each prefecture committee conducts social mobilization and formulates plans with three components to be implemented in cities, towns and villages:

(1) Immunization: achieve 95% population immunity in each age cohort through (a)

(b)

(c)

routine systems that provide a first dose of measles-rubella vaccine (MRl) for l-year-old children and a second dose (MR2) for children one year before entry into primary school;

supplementary immunization that provides MR for children in the first grade of middle school (13 years old) and third grade of high school (18 years old) for five consecutive years; and

immunization of other populations including health care workers, school teachers and co-workers, staff at welfare institutions, students of

medicine, education, and welfare, and any student planning travel abroad.

(2) Case-based surveillance beginning I January 2008 in which (a)

(b)

Physicians report case-based data (including laboratory results) to health centres which report to prefecture health departments which report to the National Institute of Infectious Diseases (NIID) weekly; data are shared

with the Ministry of Health.

Prefecture public health laboratory and commercial laboratories report data directly to NIID.

(3) Rapid response to measles outbreaks.

Each prefecture committee is responsible for monitoring and evaluating the implementation of its plans. From I April to 31 December 2008, national routine MCV2 coverage was reported to be 66.4%, ranging from 57.5% in Miyazaki to 79.8% in Fukui Prefectures. Supplementary MCV coverage among 13 year olds was reported to be 66.1 %, nationally, ranging from 55.2% in Osaka to 87.7% in Fukui Prefectures. National supplementary MCV coverage among 18 year olds was 58.2%, ranging from 40.6% in Tokyo to 81.4% in Fukui Prefectures. In 2008, 9741 cases were reported; measles incidence decreased substantially in 2009 through week 25, with only 419 cases reported.

2.2.2.2 Viet Nam

Dr Nguyen Van Cuong, Deputy National EPI Manager, reported on the epidemiology of the measles outbreak during the period 2008-2009 and the measles elimination action plan for Viet Nam. The outbreak, the largest since Viet Nam conducted its catch-up SIAs in 2002 and 2003 targeting children 9 months to 10 years old, likely began in Ha Noi in October 2008 among unvaccinated medical and public health students and spread slowly to other northern provinces through December.

Measles virus spread dramatically during the first week of February, just after the

Tet holiday, and peaked during epidemiologic week six (between 8 and 14 February). Beginning in week seven, the number of reported cases progressively decreased in the north but increased in the south. As of June, 10 426 suspected measles cases were reported, among which 6996

submitted serologic specimens, 4617 (66%) of which had been tested for measles and 4281 (61 %) had been tested for rubella. Among those tested, 2147 (47%) were IgM positive for measles and 1016 (24%) were IgM positive for rubella. Case investigation forms were available for 5521 (53%) of all suspected cases. Age groups at highest risk for laboratory-confirmed measles included 18-26 year olds and 1-6 year olds. Those who had received two doses of MCV were protected against measles.

Viet Nam's action plan for measles elimination by 2012 includes maintaining high MCVl and MCV2 coverage, conducting SIAs for children 1-5 years old in 2010 followed by changing the current MCV2 schedule from six years to 18 months beginning in 20 II and conducting SIA targeting of adults 18-26 years old in 2010 and 2011. In addition, case-based measles

surveillance will be strengthened through training and retraining in 2010 and 2011, improving case reporting and investigation and strengthening the capacity of the national measles labs in the north and south.

2.2.2.3 China

Dr Liang Xiaofeng, National EPI Manager, China Centers for Disease Control, reviewed the history, current situation, challenges and plans for measles elimination in China. Since 1950, measles incidence in China peaked at about 1400 per 100000 popUlation in 1959 and again in

1965 at more than 1200 per 100000 population. Liquid vaccine was introduced in 1965 and the next epidemic year for measles occurred in 1972 with an incidence of about 550 per 100000.

The EPI began in 1978 with a corresponding decrease in measles incidence to about 10 per 100 000 in 1987; in 1986, liquid vaccine had been replaced by lyophilized vaccine and a 0.2 ml dose of MCV2 at 7 years old was added to the EPI schedule. By 1998, measles incidence had decreased to about 5 per 100 000, at which time an accelerated measles control strategy was implemented that included provincial-level SIAs. However, measles incidence did not decrease, and in 2006 the MCV2 schedule was shifted from seven years to 18-24 months, the dose was increased from 0.2 to 0.5 ml and a measles elimination plan was established that also included rolling SIAs conducted province by province over several years. Nevertheless, measles incidence increased to 10 per 100 000 by 2008.

China conducted SIAs in six of its 31 provinces from 2003 to 2007, usually with very high reported coverage. In 2008, SIAs were conducted in nine provinces and in 2009, 13 provinces are being targeted. As a result, the number of reported measles cases during the period I January to IS June from 2008 to 2009 decreased by 55%, from 100964 to 45893, and incidence is expected to be < 50 per 1 000 000 in 2009.

The highest incidence of measles from 2005-2008 was reported in children <12 months old, followed by 12-59 months and 5-9 years old. Increasing numbers of cases are being

reported among adults 20-29 years old, particularly in large cities. Migrant workers and children are thought to be at particularly high risk for measles and account for about 30% of reported cases overall and more than 50% of reported cases in several higher income provinces in the east.

To strengthen routine immunization coverage, China provides vaccine free, emphasizes timely vaccination and partially has established a universal computerized vaccine registry system. As noted above, SIAs were conducted in nine provinces in 2008, each with coverage

> 95%. School entry immunization requirements are continuing throughout China, but quality of implementation is variable. Outreach activities for migrant populations are being studied in a collaborative Ministry of Health-UNICEF project. National surveillance guidelines have been updated and include indicators to monitor performance; 85% of reported suspected cases were investigated and 70% had blood specimens collected in the fIrst half of 2009. The dominant measles virus genotype in China continues to be Hla, with importations ofD4 from France and D9 from Thailand identifIed in Shanxi and Sichuan, respectively.

Challenges for measles elimination in China include prevention of measles in adults and infants, reaching children in remote rural and developed urban areas, including migrants, achieving high quality SIAs with limited fInancial resources for operational costs and adequate political advocacy for measles (e.g. with the state council). Plans include:

(1) achieving and maintaining high routine immunization coverage through additional support for poor areas, training and completion of a national computerized immunization registry;

(2) strengthening of school entry requirements;

(3) ensuring high quality SIAs for l3 provinces in 2009 and a nationwide SIA in 2010;

(4) strengthening measles surveillance; and (5) establishing strong international partnerships.

2.2.3 Strategic plan for accelerated control of rubella in the Western Pacific Region

Dr David H. Sniadack reviewed the 2008 TAG Recommendation that the Western Pacific Regional Office should prepare a strategic plan for accelerated rubella control and prevention for congenital rubella syndrome (CRS) that:

(1) quickly and effectively reduces the incidence of rubella and CRS;

(2) proposes targets for accelerated rubella control and CRS prevention; and (3) includes process indicators to monitor performance and progress.

During the period 1999-2003, less than 8000 rubella cases (range: 3911 to 7854) were reported annually in the Western Pacific Region. Since 2004, the number of reported rubella cases has increased annually to 126 534 in 2008. In 2008, one country reported a rubella incidence of > 1 00 per I 000 000 population (Cambodia), five countries and areas reported an incidence of 10-99.9 per 1 000000 (China, Macao [China], Mongolia, Singapore, Malaysia), six countries reported an incidence of 1.0-9.9 per 1 000000 population, and 16 countries reported

< I per I 000 000 popUlation; eight reported no data.

Regional data between 2007 and 2009 also indicate that about 90% of rubella cases occur among females < 20 years old, suggesting that vaccination strategies that ensure coverage of women < 20 years will substantially reduce transmission of rubella virus.

Currently, the magnitude ofCRS in the Western Pacific Region is unknown. Sixteen countries and areas have national CRS surveillance systems. Since 2004, four countries have reported a total of four CRS cases to the Western Pacific Regional Office, suggesting substantial underreporting ofCRS. A study by Felicity Cutts in 1996 estimated that 13 000 CRS cases occurred annually at that time in the Western Pacific Region.

The number of countries using rubella-containing vaccine (RCV) has increased from 11 (31 %) in 1996 to 28 (78%) in 2008. Two more (Mongolia and the Philippines) are expected to introduce RCV in 2009. Moreover, RCV has been delivered to broad age groups through SIAs in 15 countries and areas during the past 15 years. Consequently, current CRS incidence would be expected to be substantially lower than in 1996 and will continue to decrease gradually.

Data reported from the Republic of Korea, New Zealand, Mexico, the United States of America and other countries suggest that when both males and females up to 20 years old are protected against rubella by immunization, reported rubella incidence decreases to less than 10 per I 000 000 population. Moreover, as noted above, surveillance data from countries submitted to the Western Pacific Regional Office during the period January 2007-May 2009 indicate that about 90% of rubella cases were reported among people < 20 years old.

Consequently, it seems that a reasonable operational defmition of accelerated rubella control would be a reported rubella incidence of < 10 per I 000 000 popUlation. This level of rubella control should result in estimated CRS incidence < 10 per I 000000 live births. Standard measles surveillance performance indicators would validate reported rubella incidence.

Currently, 15 countries and areas have long-standing rubella control programmes in which both males and females 20 years old and older are protected against rubella. In another eight countries and areas, females 20 years and older are protected. In two more, girls over 10 years old but less than 20 years old are protected.

Countries and areas that either have recently or have not yet introduced RCV include Cambodia, China, the Lao People's Democratic Republic, Mongolia, Nauru, the Philippines,

Papua New Guinea, Solomon Islands, Vanuatu and Viet Nam. All of these countries are planning measles SlAs in the coming three years and most are at risk for not achieving the measles elimination goal by 2012. Several are reporting increasing numbers of measles cases among adolescents and young adults and may need to further expand target age groups against measles. Setting a target of accelerated rubella control by 2015 would utilize the opportunity of planned measles elimination activities to accelerate rubella control by providing MR during SlAs and to further strengthen case-based measles and rubella surveillance. Moreover, targeting adolescents and potentially young adults with MR vaccine as part of accelerated rubella control efforts would address the newly emerging risks of measles among adolescents and young adults.

Strategic objectives and approaches to achieve the proposed goal of accelerated control of rubella and prevention of CRS could include:

(1) Achieve and maintain 90% immunization coverage against rubella:

(a) incorporate RCV as either MR or measles-mumps-rubella (MMR) vaccine into the routine childhood schedule;

(b) achieve high popUlation immunity for children in accordance with the GIVS;

(c) use MR or MMR vaccine for follow-up campaigns for measles elimination;

(d) for countries that recently have introduced or will soon introduce RCV into their national programme, conduct additional wide age range campaigns or ensure vaccination of young adults through routine services; and

(e) selective immunization for women of childbearing age, as appropriate.

(2) Strengthen case-based MR surveillance that satisfies standard surveillance performance indicators:

(a) expand the regional surveillance system used for measles elimination to include integrated surveillance offever and rash illness (suspected rubella and measles cases) at the regional, national and local levels; and (b) implement CRS surveillance before or at the ^start of the introduction of

RCV to provide baseline information and document the impact of the vaccination program.

(3) Maintain an accredited regional and country measles and rubella laboratory network in the Western Pacific Region:

(a) maintain the accredited MR laboratory network that supports every country and geographic area in the Region, ensuring availability of laboratory testing of all reported cases of suspected measles and rubella andCRS.

(4) Formulate collaborative mechanisms to achieve all three strategic objectives:

(a) disseminate information at all levels of the health system; conduct advocacy, social mobilization and programme communication to improve vaccination coverage and stimulate reporting of disease; and (b) mobilize national resources and, when necessary, international resources

An Accelerated Rubella Control and CRS Prevention Task Force also could be established to:

(l) monitor progress towards the control goal and provide strategic advice;

(2) conduct advocacy to high-level national officials and partners;

(3) provide oversight for surveillance and country evaluations; and (4) validate rubella control status.

Estimated resource requirements to implement the strategic approaches and achieve accelerated rubella control by 2015 while eliminating measles are estimated at about

US$ 106.5 million. This compares to an estimated requirement ofUS$ 53.9 million to eliminate measles without addressing rubella and CRS prevention.

2.3 Controlling Hepatitis B by 2012

2.3.1 Report from International Hepatitis B Expert meeting in the Republic of Korea and progress towards the 2012 goal

The regional hepatitis B control goal aims at reduction of chronic hepatitis B infection rates in children 5 years old (as measured by hepatitis B surface antigen [HBsAg] seropositivity) to less than 1 %, with an intermediate time-bound milestone ofless than 2% by 2012 (hereafter referred to as the 2012 goal). This compares with 8%-10% chronic infection rates in the pre- vaccination era. Achieving the 2012 milestone requires achieving at least 85% coverage with three doses of hepatitis B vaccine (HepB3) and at least 70% coverage with a birth dose of hepatitis B vaccine within 24 hours of birth (HepB BD).

Dr Manju Rani, Scientist-EPIIWHO Western Pacific Regional Office, summarized the overall history of hepatitis B control since 2005 followed by a brief report on recommendations made during the International Hepatitis B Expert Working Group Meeting held in November 2008. A detailed regional review on progress then was presented based on the seven strategies articulated in the Regional Action Plan for Hepatitis B Control in 2007.

Since establishing the hepatitis B control goal in 2005, the Western Pacific Regional Office has published the following documents: Operational Guidelines to Prevent Mother to Child Transmission of Hepatitis B Infection (2006); Revised Regional Plan of Action for Hepatitis B Control (2007); Certification Guidelinesfor Validation of Achievement of the Hepatitis B Control Goal (2007), and a set of four training modules for training in delivery of a HepB BD. To provide policy guidance, the Western Pacific Regional Office convened two special international hepatitis B expert conSUltations, one in Tokyo in March 2007 and the other in the Republic of Korea in November 2008.

Establishing the regional 2012 goal triggered key policy changes in many countries, including issuing of national hepatitis B control guidelines by China in 2006, commitment of 100% domestic funding in the Philippines for hepatitis B vaccination and revision of HepB BD policies in many countries. The impact of setting the goal in the Western Pacific Region was felt in other regions as well, with the Eastern Mediterranean, European and African Regions

considering similar goals. Finally, the goal helped to maintain focus on routine inununization systems.

The International Hepatitis B Expert Consultation organized in November 2008 determined that countries reaching the required vaccination coverage levels (both HepB3 and HepB BD) in 2011 and 2012 would be deemed provisionally to have achieved the 2012 goal but

would have to demonstrate seroprevalence levels of less than 2% when these cohorts became at least 5 years old. The panel also proposed that countries with HBsAg < 2% at the national level should consider subnational2012 goals if high infection rates are demonstrated in some parts of their country.

As of2009, 26 of37 countries and areas in the Region accounting for 88% of the total regional population are believed to have achieved the 2012 goal based on vaccine coverage data.

Achievement of the 2012 goal has been certified in the Republic of Korea and Macao (China), and many other countries are planning serosurveys in 2009 and 2010. Cambodia, China and the Philippines have made the most significant progress since setting the goal, while the Lao People's Democratic Republic and Papua New Guinea have been struggling to improve vaccination coverage consistently.

Finally, strategies to prevent perinatal transmission of infection should be enhanced by strengthening links between maternal health and the EPI programmes, facilitating the

implementation of out-of-cold-chain policy and assisting countries to scale up activities from lessons learnt from various demonstration projects. The panel also recommended increasing the level of engagement of WHO and ministries of health with non-governmental organizations at the global level (e.g. World Hepatitis Alliance), the regional level (e.g. Asian Pacific Association for the Study of the Liver); and the country level (e.g., national liver and hepatitis foundations).

Uniject is an attractive alternative to single-dose vials and auto-disable (AD) syringes, and its feasibility for field use has been demonstrated in pilot projects in China, Indonesia and Viet Nam. The International Hepatitis B Expert Panel concluded that the key issue is to

vaccinate newborn infants on time, either with single-dose vials or with Uniject. Issues related to financing, supply and logistics should be considered before introducing Uniject for home births.

If pilot projects are considered essential, then they should include a component comparing the use ofUniject vis-a.-vis a single-dose hepatitis vaccine vial with an AD syringe.

Reviewing the progress made under each of the seven strategies in the Regional Action Plan, Dr Rani emphasized the priority of routine infant immunization (strategy 1) and delivery of a timely HepB BD (strategy 2). Chronically low coverage remains a concern in some countries such as the Lao People's Democratic Republic and Papua New Guinea, which reported 61 % and 56% HepB3 coverage, respectively, in the 2008 WHO-UNICEF Joint Reporting Form (JRF).

Improving routine coverage in these countries will require political commitment and

strengthening of service delivery. Similarly for HepB BD coverage, many countries (e.g. the Lao People's Democratic Republic, Papua New Guinea and the Philippines) reported coverage lower than that for institutional delivery rates, suggesting that these countries are not able to vaccinate newborn children in health facilities, a strategy that is considered to be easier than vaccinating newborn children at home.

Catch-up campaigns for older age groups are prioritized only in countries that have already sustained high coverage among infants and where additional resources are available.

China is planning a catch-up campaign for children < 15 years old from 2009 to 2011.

Campaigns targeting young children may be considered when routine coverage has been

inadequate. The Lao People's Democratic Republic organized supplementary immunization for under-five children using tetravalent DTP-HepB during recent child health days. Cambodia and the Philippines, which started nationwide Hep B vaccine introduction in 2005 and 2006, may organize a campaign for under-five children if resources allow. School entry checks for all children at different levels (primary, middle and senior) can ensure HepB3 coverage for all children who do not have proof of prior vaccination.

Non-immunization measures are also important to control hepatitis B. These include screening of all donated blood products for hepatitis B and hepatitis C, ensuring injection safety with single-use syringes, providing safe disposal of all health care waste and other measures.

2.3.2 Conducting school-based serosurvey for Hepatitis B: Malaysia experience

Dr Rohani bintis Jahis, Principal Assistant Director, Disease Control Division, Ministry of Health, reviewed hepatitis B control in Malaysia, which began in 1989 with introduction of monovalent hepatitis B vaccination for infants (including a HepB BD) in the publicly funded national immunization program. Beginning in 2002, the monovalent hepatitis B vaccine was replaced by a pentavalent vaccine (DTP-HepB-Hib) at 2 months, 3 months and 4 months old, and the timely HepB BD was continued using monovalent vaccine. In 2007, the schedule was changed again with the introduction ofDTP-IPV-Hib pentavalent vaccine and a return to monovalent hepatitis B vaccine at birth, 1 month and 6 months of age. Coverage with HepB3 has been maintained at 90% or more since 1998. Despite the introduction of hepatitis B vaccine in 1989, no formal evaluation of the impact of the HepB vaccination programme was conducted until 2009, when Malaysia implemented a nationwide hepatitis B serosurvey of HBsAg among children> 5 years old. The result of the survey will also help to certify if Malaysia has achieved the 2012 goal.

The survey was designed as a cross-sectional survey with multistage stratified systematic randomized sampling. The sampling frame included third and fourth grade classrooms in primary school in national and national-type schools. Questionnaires were administered to 8562 children in third and fourth grade (Le., 9 -10 years old) from 251 schools in all 14 states of Malaysia. Among the 7520 children who returned the questionnaire, 93.9% provided blood samples. No statistical differences were observed in refusal rates by ethnicity of the respondents.

Enzyme-linked immune sorbance assays (ELISAs) were used for HBsAg and antihepatitis B surface antibody (HBsAb) testing at the national public health laboratory.

Overall, 19 (0.3%) of children tested positive for HBsAg, which suggests that Malaysia has attained both the 2012 goal and the final hepatitis B control goal of achieving HBsAg seroprevalence of less than 1 %. The vaccination status of all of the sampled children also was assessed. Among 19 children that tested positive for HBsAg, six had completed the

recommended schedule of hepatitis B vaccination, 10 had incomplete vaccination and three had unknown vaccination status.

Lessons learnt regarding successful survey implementation included the need to ensure interministerial collaboration with the education department at all levels, adjust the survey schedule with the school schedule (holidays, examinations) and deal with school refusal to participate because of earlier participation in previous studies. Adequate numbers of medical officers need to be mobilized, sample collection from interior hard to reach areas must be insured, and follow up reporting and actions taken on test results are required.

Survey follow up actions included retesting of all HBsAg positive cases and evaluation by specialists. All of the children with incomplete vaccination and no detectable levels of anti- HBsAb will be provided with a complete series of hepatitis vaccination at zero, one month and six-month intervals. All family contracts of children found positive on follow-up repeat testing will be screened and provided adequate management (including vaccination for non-vaccinated family members).

2.3.3 Improving birth dose coverage for home births: Papua New Guinea experience Dr William Lagani, Senior Specialist Medical Officer, National Department of Health, presented the results from a pilot project undertaken in East Sepic province since May 2008. The project was designed and managed by the Burnet Institute (Australia) in partnership with the National Department of Health (Papua New Guinea) and WHOIUNICEF. East Sepic Province was selected because of its challenging and high mortality setting and well-established network of village health workers (VHWs) that work well with government and non-governmental services. Maternal mortality rates have remained high in Papua New Guinea for the past 10 years, and postnatal care interventions for mothers and newborn children remain underused. The project evaluated the feasibility of delivering early postnatal care (including vitamin A for mothers, timely HepB BD for newborns using Uniject, and education to promote mother and newborn health) using VHWs and paid government community health workers (CHWs).

HepB BD coverage remains low in Papua New Guinea. In 2008, according the national health information systems, only 28% of newborns received a timely birth dose. Almost 40% of births still take place at home unsupervised by any trained attendants, making it challenging to deliver any essential postnatal interventions, including hepatitis B vaccine.

As part of this pilot project, technical papers were prepared about Uniject, vitamin A and postnatal care and presented to the National EPI Committee, the Child Health Advisory

Committee and other specialist societies. Ethical approval and endorsement by the National Department of Health was obtained for service delivery, including hepatitis B birth dose by village health volunteers. A baseline survey of households and communities was undertaken in August 2008 on perinatal care and care-seeking practices. Various training and educational materials also were prepared for VHW s, CHW s and communities. Monitoring tools were created for VHW s and CHW s and included routine tally sheets, birth record forms and

out-of-cold chain calendars. Supervision checklists and an activity database were established for the project officer to record operational details.

The hepatitis B vaccine in Uniject was distributed from the provincial medical store to health centres that had refrigerators. VHW s and CHW s collected the vaccine and baby books (the parent-held immunization record) from health centres and monitored the use of vaccine through the out-of-cold-chain calendar. As of May 2009,97 (of 146) VHWs and eight CHWs had been trained in three of seven sites. Data monitoring forms from one village showed five to eight births per month since February 2009 were attended by a VHW with provision of a

postnatal care package. A supervision system is in place at three sites thus far, with emphasis on data collection, technical reinforcement and problem-solving for logistics distribution.

Major challenges included suboptimal administration and infrastructure in the province and delays in training due to several factors. The project is likely to continue until June 2010 and fmal evaluation is planned with input from national and provincial partners.

2.4 Maintaining the Region Poliomyelitis-free through 2012

2.4.1 Update on the global and regional situation and key developments on post eradication activities

Dr. Sigrun Roesel, Medical Officer, EPlIWHO Western Pacific Regional Office, provided updates on the regional strategic plan for maintaining polio-free status, laboratory containment, Regional Certification Commission (RCC) activities, AFP surveillance, immunization against polio and post eradication activities.

(I) Regional Strategic Plan

After review by NIPs and key partners, the Regional Strategic Plan was fmalized and endorsed by the RCC) at its thirteenth meeting in December 2008. Since then the plan has been distributed individually and at EPI meetings. The plan provides direction on technical

requirements and its external financial support forecasting serves as the basis for budget allocations this year and for the next biennium.

(2) Completion of Phase I wild poliovirus laboratory containment

Based on reviews of the final reports on Phase 1 wild poliovirus laboratory containment and fmdings from the external technical review panel, the RCC concluded that the Phase 1 containment activities documented by China and Japan provided a complete and accurate national inventory of laboratories with wild poliovirus infectious and potentially infectious materials. With these final reports, the RCC declared Phase 1 wild poliovirus laboratory containment, laboratory surveys and national inventories complete for the whole ofthe Western Pacific Region. A total of 77 260 laboratories were included. The number of laboratories storing relevant materials has been reduced from 107 in 2008 to 45 in 2009.

In order to protect the huge investments made in the exercise and to facilitate the

destruction of materials, a maintenance plan has been established in China and also will be set up in Japan. Similar work has been conducted in Australia, Mongolia and the Philippines and is plarmed for Cambodia.

(3) Maintaining the certification process

The ongoing work of the RCC is considered instrumental in maintaining countries' adherence to certification-level quality standards. The last RCC meeting in December 2008 was held in the Lao People's Democratic Republic for advocacy purposes and to allow RCC members to participate in ceremonial and monitoring activities of the Child Health Days (CHDs), which included OPV immunization. In a similar context, the next RCC meeting will be held in Cambodia in December 2009.

(4) AFP/polio surveillance

The majority of Western Pacific Region countries were able to maintain AFP/polio surveillance quality at the "certification standard" of sensitivity during 2008. Notable

performance improvements were observed in the Lao People's Democratic Republic. Previous gains made in Papua New Guinea could not be sustained and the performance last year declined significantly. However, while overall quality levels have been maintained, a detailed review of country performances revealed that gaps exist at a subnationallevel in several countries (e.g.

Cambodia, the Philippines) and need to be addressed to ensure timely and reliable identification of circulating polioviruses.

Important activities in 2009 included introduction of environmental surveillance in Australia and China (10 provinces), consideration for targeted AFP surveillance reviews in Cambodia and China, a visit by the RCC Chairperson to Papua New Guinea for advocacy purposes and technical discussions, and a special surveillance project in the Pacific island countries and areas.

Important issues in 2009 include the continuing need to retrain and sensitize new surveillance staff and clinicians on AFP surveillance, particularly in public health offices and

priority health facilities with high stafftumover, and the special focus placed by all countries on pandemic influenza A (HINl) 2009, often involving national and WHO EPI staifto a significant extent (e.g. surveillance, vaccine deployment plan preparation, etc.).

(5) Immunization against polio

Data on immunization activities in 2007 and 2008 indicate that, overall, countries are maintaining high levels of immunity against polio with some notable exceptions (e.g. the Lao People's Democratic Republic, Papua New Guinea and some subnational areas in the Philippines). SIAs were conducted in China and the Lao People's Democratic Republic.

China will continue to conduct its annual OPV SIAs during the winter seasons. Future planning should include carefully establishing risk criteria for areas and populations to be targeted, external monitoring and other operational issues, and innovative strategies for fund- raising. China is also planning to conduct serosurveys in six provinces. SIAs conducted in Lao People's Democratic Republic are discussed below (2.4.2). In Papua New Guinea, inclusion of OPV in the measles SIAs planned in 2010 is being discussed.

(6) Post eradication activities

Several countries and areas have introduced IPV with their own fmancial and technical resources (Australia, Hong Kong [China], Macao [China), Malaysia [partially], New Zealand, the Republic ofE ':Irea). Brunei Darussalam is considering IPV in the near future, and the Japan National Certitication Commission (J-NCC) recommended the adoption ofIPV for routine immunization to reduce the risk of vaccine-associated paralytic poliomyelitis (V APP).

Moreover, to maintain a high vaccine coverage rate, it was suggested to introduce a combined IPV-DTP vaccine. Adoption of this recommendation will require greater national consensus. In countries such as China with large populations, there is a growing need to consider various aspects to establish scientific evidence for decision-making on future polio immunization

options. Phase II clinical trials have started for Sabin-based IPV production in China and work is also going on in Japan.

China and the Philippines participated in the WHO-led multicountry study on

immunodeficient vaccine-derived poliovirus (iVDPV) detection in people with primary immune deficiency (PID). Australia is planning its own study for detection of chronic poliovirus

infection in people with PID.

2.4.2 OPV SIAs and integration with other child health interventions in the Lao People's Democratic Republic

Dr. Anonh Xeuatvongsa, National EPI Manager, reported that OPV SIAs were planned in the Lao People's Democratic Republic for January 2008 (during CHDs) and February 2009 and initially targeted 319 989 children under 5 years old in 59 priority districts in 12 provinces based on available financial. Vitamin A and mebendazole were provided in the January round. A donation from the Government ofItaly in response to floods allowed an additional 191 855 children to be targeted in February 2009 and again during a third round in March 2009. In some difficult to reach areas, additional antigens such as measles vaccine were added during the February round. In the December 2008 round, 297806 (93%) of319 989 targeted children

< 5 years old were vaccinated with OPV. In the February 2009 round, 463899 (91%) of 509839 targeted children received OPV and in March and April 2009, 174 149 (91%) of 191 855 received OPV. The remaining districts will be covered during the forthcoming tetanus toxoid (TT) SIAs, planned in November 2009 (in conjunction with the CHD) and in early 2010.