Report on the
26th Intercountry Meeting of National Managers of the Expanded Programme on
Immunization and
26th VPI Regional Technical Advisory Group Meeting
Cairo, Egypt 4–7 July 2010
Report on the
26th Intercountry Meeting of National Managers of the Expanded Programme on
Immunization and
26th VPI Regional Technical Advisory Group Meeting
Cairo, Egypt 4–7 July 2010
status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
Publications of the World Health Organization can be obtained from Distribution and Sales, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: PAM@emro.who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address: email: WAP@emro.who.int .
Document WHO-EM/EPI/298/E/YY.ZZ/PPP
CONTENTS
1. INTRODUCTION ... 1
Table of Contents SESSION 1: OPENING ... 1
Celebration of the first vaccination week in EMRO Error! Bookmark not defined. SESSION 2: GLOBAL AND REGIONAL BRIEFINGS ... 2
EPI Global Overview ... 2
EPI Regional Overview ... 3
Follow-up on implementation of the recommendations of the 25th EPI Managers’ Meeting ... Error! Bookmark not defined. Briefing on SAGE sessions of 2009 – 2010 ... 6
Global Burden of Disease Estimates for Hib, pneumococcal and rotavirus ... 6
SESSION 3: ... 8
PROTECTING MORE PEOPLE IN A CHANGING WORLD: REACHING THE UNREACHED ... 8
Introduction to the session ... Error! Bookmark not defined. Innovative approaches to improve routine vaccination coverage in low coverage countries ... 8
1. IMMUNIZATION MONTH IN PAKISTAN ... 8
Community involvement in Lebanon ... 12
Integrated interventions ... 13
2. GLOBAL ACTION PLAN FOR PNEUMONIA (GAPP) AND ENHANCED DIARRHEAL DISEASE CONTROL ... 13
3. INTEGRATED CHILD HEALTH INTERVENTION IN YEMENERROR! BOOKMARK NOT DEFINED. 4. CHILD HEALTH DAYS IN SOMALIA: ACHIEVEMENTS AND CHALLENGES 14 Expanding immunization activities beyond infancy ... 15
5. H1N1 VACCINATION: SUCCESSES AND CHALLENGES ... 15
6. GLOBAL STUDY ON SCHOOL-BASED IMMUNIZATION ... 17
Poliomyelitis Eradication ... 18
7. GLOBAL OVERVIEW ... 18
8. REGIONAL OVERVIEW ... 19
9. MONITORING ERADICATION ACTIVITIES AND PROGRESS ... 22
10.MONITORING IMMUNIZATION ACTIVITIES ... 22
11.MONITORING SURVEILLANCE QUALITY ... 22
12.MONITORING RISK ... 25
13.MONITORING RISK OF OUTBREAK AFTER WILD POLIOVIRUS IMPORTATION ... 25
14.OUTBREAK PREPAREDNESS AND RESPONSE ... 26
15.GUIDELINES AND REGIONAL EXPERIENCE ... 26
16.SIMULATION OF PREPAREDNESS PLAN IN OMAN ... 27
Measles Elimination ... 27
Working groups: measles session ... 29
Hepatitis B Control ... 30
17.BRIEFING ON GLOBAL ACTIVITIES AND INITIATIVES ON HEPATITIS CONTROL AND RESOLUTION ON WHA 2010 ... 30
18.HEPATITIS B REGIONAL CONTROL TARGETS: RESOLUTION OF RC 2009 AND PROPOSED REGIONAL STRATEGY FOR ACHIEVING THE TARGET ... 30
19.HEPATITIS B MONITORING AND EVALUATION TOOL ... 34
20.WORK GROUP: HEPATITIS B ... 35
SESSION 5: INTRODUCTION TO NEW VACCINES AND TECHNOLOGY ... 36
21.UPDATE ON NEW VACCINE INTRODUCTION, GLOBAL AVAILABILITY OF THE NEW VACCINES AND THE VACCINES PIPELINE ... 36
22.STRENGTHENING DECISION MAKING PROCESS FOR NEW VACCINES ... 39
23.EXPERIENCE OF SUDAN WITH DECISION MAKING ON NEW VACCINES ... 40
24.CHALLENGING IN NEW VACCINES INITIATIVE IN LOW-INCOME COUNTRIES 42 25.COST EFFECTIVENESS ANALYSIS FOR NEW VACCINES INITIATIVE ... 43
Challenges of new vaccines introduction in middle-income countries ... 44
26.MOROCCO: DECISION TAKEN ON NEW VACCINES INITIATIVE ... 44
27.IRAN: FUNCTIONAL NATIONAL REGULATORY AUTHORITY (NRA) AND FUTURE PLAN FOR NEW VACCINES INITIATIVE ... 44
28.HOW TO OVERCOME THE PERSISTING CHALLENGES ... 45
29.ESTABLISHING POOLED VACCINE PROCUREMENT SYSTEM IN THE EMR: PROGRESS AND THE NEXT STEP ... 47
30.ROLE OF UNICEF IN ASSISTING ESTABLISHING POOLED VACCINES PROCUREMENT SYSTEM IN EMR ... 48
SESSION 6: STRENGTHENING EPI LOGISTICS SYSTEMS ... 52
Overview on: ... 52
Cold chain capacity estimation for new vaccine introduction ... 52 Vaccination Supplies Stock Management (VSSM) ... 55 31.EXPERIENCE OF EGYPT IN USING VSSM ... 56 SESSION 7: INITIATIVE FOR STRENGTHENING EPI VACCINATION WEEK IN THE
EMR ... 58 32.VACCINATION WEEK IN THE EASTERN MEDITERRANEAN REGION: AN
OPPORTUNITY TO PROTECT MORE PEOPLE ... 58 33.SUMMARY OF COUNTRY ACTIVITIES DURING VACCINATION WEEK IN 2010 IN
EMR ... 58 Role of NITAGs in strengthening EPI ... 60 RECOMMENDATIONS ... 62 34.PREAMBLE ... ERROR! BOOKMARK NOT DEFINED.
35.POLIO ERADICATION ... ERROR! BOOKMARK NOT DEFINED.
36.HEPATITIS B DISEASE REDUCTION TARGET ... ERROR! BOOKMARK NOT DEFINED.
37.NEW VACCINE INTRODUCTION ... ERROR! BOOKMARK NOT DEFINED.
38.IMPROVING ACCESS TO NEW VACCINESERROR! BOOKMARK NOT DEFINED.
39.EPI LOGISTICS SYSTEM ... ERROR! BOOKMARK NOT DEFINED.
40.VACCINATION WEEK IN THE EMR .... ERROR! BOOKMARK NOT DEFINED.
41.NATIONAL IMMUNIZATION TECHNICAL ADVISORY GROUP ... ERROR!
BOOKMARK NOT DEFINED.
ANNEX 2 ... 74 List of PARTICIPANTS ... 74
1. INTRODUCTION
SESSION 1: OPENING
Twenty sixth Inter-country Meeting of National Managers of the Expanded Programme on Immunization was held in Cairo from 4 to 7 July 2010. The meeting was inaugurated by Dr. Hussein A. Gezairy, Regional Director, Eastern Mediterranean Regional Office of the World Health Organization.
Dr. Gezairy welcomed EPI managers, members of Regional Technical Advisory Group (RTAG), chairpersons of the National Immunization Technical Advisory Groups (NITAG), participants from United Nations Children’s Fund (UNICEF), representatives from Center for Disease Control and Prevention (CDC Atlanta), Global Alliance for Vaccine and Immunization (GAVI), Network for Education and Support in Immunization (NESI), Supporting Independent Immunization and Vaccines Advisory Committee (SIVAC), Canadian International Immunization Initiative (CIII) and staff from the WHO headquarters and country offices..
Dr. Gezairy commended EPI managers for their achievements during the recent years.
He expressed his worries on the fact that poliomyelitis is still not eradicated in the Region.
Dr. Gezairy reiterated that EPI is the backbone of polio eradication. The Regional Director repeated his personal and the Regional Office commitment to eradication of polio and he promised to do all possible to help Pakistan and Afghanistan to wipe out wild polio virus from the Region and to remove the last obstacles.
The Regional Director mentioned that Eastern Mediterranean Region was first to introduce hepatitis B vaccine into the routine immunization services and the result of this wise decision is manifesting. He spoke in details about the importance of the first Vaccination Week initiative that was organized during 24-30 April 2010 and he expressed hope that organizing this event will continue in the future, sustaining our achievements, increasing coverage and reaching the unreached. Dr Gezairy ended his remark by saying that “Think about every child to be your child. Keep this in your mind and you can make miracles.”
Participants adopted the provisional agenda (Annex 1). The list of participants is provided in Annex 2.
Celebration of the first vaccination week in EMRO
In this session a film produced by EMRO was shown in which the Regional Director emphasized the importance of immunization and Vaccination Week initiative. For more details on the importance of vaccination week and issues related to this activity see Session 7:
Initiative for strengthening EPI Vaccination Week in the EMR.
.
SESSION 2: GLOBAL AND REGIONAL BRIEFINGS
Global Overview
Dr. Thomas Cherian, Coordinator of EPI, IVB, WHO HQ
Close to a quarter of child deaths globally are caused by diseases for which vaccines exist. By scaling up coverage of vaccines to 90% globally and by introducing selected new vaccines, over 2/3 of these vaccine preventable deaths can be averted making a big contribution to reducing child mortality. This is the basis of the global immunization vision and strategies (GIVS).
While improvements have occurred in immunization coverage at global level, there are still many countries and communities that lack access to immunization services and more needs to be done to reach them. Improving data quality is a key to better performance through targeting the efforts. The WHO-UNICEF coverage estimates aims to adjust for limitations on administrative data by using data from other sources, such as surveys, vaccine stock management data and expert opinion etc .Countries are encouraged to improve the quality of empiric data particularly paying attentions to numerators and denominators.
WHO-EM/EPI/298/E Page 3
10.4 million deaths under 5 years of age
2.45 million or 24% deaths under 5 from vaccine preventable diseases
•1.16 million deaths under 5 years of age from diseases targeted by conventional EPI vaccines
•1.29 million form diseases where licensed vaccine is available
While all regions, except SEAR, have achieved the 90% measles mortality reduction goal set for 2010, these gains may prove fragile if adequate follow up activities are not undertaken. Poor routine immunization performance, delayed implementation of follow up campaigns and poor data quality have contributed to recent large measles outbreaks in southern Africa. This risk needs to be clearly recognized and prompt action taken to correct the situation. It also further emphasizes the importance of strong routine performance as a key milestone for achieving measles elimination/eradication.
There has been impressive progress with the introduction of Hib vaccine which has been introduced in 157 countries. Pneumococcal vaccine has been introduced in 35 countries while more are in the pipeline for introduction through GAVI support. the demand from developing countries for new vaccines has been steadily increasing. It is expected that with the new SAGE recommendations, which now recommend global use of Rotavirus vaccine, increasing number of countries will uptake this vaccine.
While exciting new technologies, offering enormous benefits, are now available, many challenges need to be met and overcome if all communities are to benefit from them.
Regional Overview
Dr. Nadia Teleb, Regional Advisor/VPI, WHO, EMRO
The Eastern Mediterranean Region witnessed substantial progress towards achieving the regional targets of immunization programmes during the past few years. In terms of routine vaccination, the regional coverage of DPT3-containing vaccine reached 87%
in 2009. The number of un-immunized children in region dropped from 2.7 million in 2008 to 1.9 million in 2009. 16 countries have achieved the targeted DPT3 coverage of 90% or more.
Improvement of routine vaccination coverage was observed in most of the 7 priority countries in EMR (Afghanistan, Djibouti, Iraq, Pakistan, Somalia, Sudan and Yemen). North Sudan reported 91% DPT3 coverage and Djibouti, Pakistan, Iraq and Yemen are close to achieving the target. Despite the continued concern about vaccination coverage in Somalia and southern Sudan, recognizable progress was observed in these countries/areas where reported DPT3 coverage in Somalia increased from 31% in 2008 to 51% in 2009 and the coverage of southern Sudan was 26% in 2008 and 43% in 2009. Strong partnership and implementation of the effective life saving interventions such as acceleration campaigns in Southern Sudan, Child Health Days (CHDs) in Somalia and integrated child health intervention in Yemen, in addition to expanding implementation of Reaching Every District (RED) approach, helped
achieving better coverage in 2009. Despite this achievement, within countries disparities in vaccination coverage is still observed in several countries, specially the priority ones, with variable proportions of the districts still reporting a coverage less than 80% and even less than 50% in some districts. still Neonatal tetanus elimination target wasn’t achieved in six countries iun the region
The global measles mortality reduction (90% reduction in 2010 compared to 2000 level) was achieved in the EMR 3 years before the target date. This reduction reached 93% in 2008. However, there is low probability that the regional measles elimination target by 2010 will be achieved considering the main constraints and challenges which include deteriorating security situation, funding gaps, presence of pockets of susceptible populations in presumably well performing countries. Stronger national and partners’ commitment and more stringent implementation of the measles elimination strategy are needed for sustaining the mortality reduction gains and achieving the elimination target. A new elimination target for the immunization programmes in the EMR was resolved by the Regional Committee of the EMR in 2009, that is, reduction of chronic hepatitis B viral infection to less than 1% among children less than 5 years of age by 2015. The regional coverage of hepatitis B vaccine (HepB3) is 85% and 14 countries are providing the first dose of HepB vaccine at birth. The vaccine has not yet been introduced in Somalia and Southern Sudan as they don’t qualify for GAVI support according to the criteria set by GAVI. The other high burden countries (Afghanistan, Pakistan, Sudan and Yemen) haven’t introduced the at birth dose. The main expected challenges are introduction of the birth dose in the remaining countries and achieving high coverage with birth dose implemented within 24 hours of life of the child.
New vaccines introduction gained momentum during the past 2 years with introduction of pentavalent vaccine in Sudan and Pakistan in 2008 and Afghanistan in 2009.
Pneumococcal vaccine is in use in the 6 GCC countries and Rotavirus vaccine is in use in Bahrain and Qatar. Pneumococcal vaccine is expected to be introduced in Yemen in 2011.
Morocco plans to introduce rotavirus and pneumococcal vaccine while Iraq is planning to introduce Hib and rotavirus vaccine in 2010. Still the main challenge in enhancing new vaccine introduction lies with the affordability of the vaccine for the Low middle income countries. 76% of infants in the LMICs of the region did not have access to Hib vaccine and none of them had access to Pneumococcal or Rotavirus in 2009. With the financial constraints facing GAVI as result of the global financial crises, GAVI eligible countries are also facing delays in GAVI decision for supporting new vaccines introduction to the low income countries. On the request of the member states, WHO EMRO & HQ in close collaboration with key partners including UNICEF MENA, UNICEF SD and CDC (Atlanta) is in the process of establishing pooled vaccine procurement system in the EMR to enhance new vaccines introduction, especially in the low income countries.
The main challenges continued to face the EMR are the inadequate technical and managerial capacity of national EPI in some countries and consequently the inability to respond to the multiple priorities, the perception of decision makers to EPI in some countries as a very well performing programme that have achieved all targets and, therefore, does not require additional resources Inadequate financial allocation necessary to meet the current requirements; the financial constraints facing introduction of new vaccines and implementation of measles elimination activities, specially the follow up campaigns; the volatile security situation in several countries leading to inability to implement the planned activities.
Follow-up on implementation of the recommendations of the 25th EPI Managers’
Meeting
All recommendations of 25 Intercountry meeting were implemented except one related to injection safety due to the inadequate financial resources
Discussions:
Both presenters delineated the success and achievements and the problems facing the immunization programmes. It was noted from the presentations that there are still six countries in the Region where neonatal tetanus is not yet eliminated. WHO/EMRO and other partners should develop programmes to build the capacity of the National Immunization programme Managers to be able to respond to their ever increasing responsibilities
Participants expressed concerns about the recent negative propaganda and rumors against vaccination by some groups at both country and global levels in relation to H1N1.
Regional Advisor mentioned that apart from the propaganda that accompanied H1N1 vaccination, there has been no significant anti-vaccination propaganda in the EMR and fortunately this propaganda didn’t have negative effect on vaccination coverage in the region as indicated by the higher DPT3 coverage in 2009 compared to 2008.
In relation to global overview it was mentioned that disease surveillance would provide some indications about the situation but not a complete picture and full information about disease burden. Therefore, disease surveillance alone should not be interpreted for
estimation of diseases burden and there should be other parameters to give the full picture of the situation like burden of disease estimates.
Briefing on SAGE sessions of 2009 – 2010
The Strategic Advisory Group of Experst ( SAGE) was established in 1999 and restructured in 2005. It is principal advisory group to WHO for vaccines and immunizations providing evidence based guidance and holds two meetings per year
A summary of main recommendations from the four meetings of SAGE held in 2009 and 2010 was presented during the meeting. As of May 2006, all new position papers and updates are reviewed and endorsed by SAGE. In 2009 new WHO position paper was issued on HPV, while updated position papers were issued for Measles and Hepatitis B. A brief update to Rotavirus position paper was also issued in 2009. In 2010 a new position paper on Polio and an update on Cholera was issued. All position papers and full reports of SAGE are published in the WHO Weekly Epidemiological Record (WER) in a timely manner.Summarires of the recenent position papers were shared with the participants. Issues of specific interest to EPI Managers such as immunization schedules, the epidemiology of unvaccinated children, the impact of new vaccines introduction on immunization and health systems and strengthening of NITAGs were also summarized. National EPI managers were also informed about subjects for the next meetings.
Global Burden of Disease Estimates for Hib, pneumococcal and rotavirus
Dr. Thomas Cherian, Coordinator, Expanded Programme on Immunization Plus (EPI), IVB, WHO HQs
Burden of disease estimates are a key piece of information required for prioritizing new vaccines for introduction into national immunization programmes besides being of importance to donors and vaccine developers. While surveillance data contribute to defining the burden of disease, this data alone may not be sufficient to capture the full burden of some diseases. Furthermore, the lack of local good quality surveillance data may be an obstacle in some countries and even may be misleading.
To support its member states, WHO develops burden estimates for select diseases, including vaccine preventable diseases. The process of diseases burden estimation include systematic collection of publically available data conforming to set standards and independent expert review and country consultation
The rotavirus mortality estimates were based on the relatively simple model where the proportion of childhood diarrhoea deaths caused by rotavirus was estimated. This was based on the assumption that the proportion of diarrhoea deaths caused by rotavirus is equal to the proportion of severe hospitalized diarrhoea cases caused by rotavirus.
The models for estimating Hib and pneumococcal disease burden estimates are more complex, because these two organisms cause multiple disease syndromes. The estimation is based on three separate models for meningitis, pneumonia and other invasive diseases, respectively. The meningitis and other invasive disease estimates are based on the incidence- based approach, whereas the pneumonia mortality estimates are based on a proportional mortality approach.
The detailed methods and results of these estimates are published(1-3) and also available on the WHO website (http://www.who.int/immunization_monitoring/burden/en/).
Discussion:
This session surged a great deal of discussion particularly around the idea of immunization programmes to be integrated into the other relevant health interventions and programmes. For instance, a question came out whether EPI should be integrated to Integrated Management of Childhood Sickness (IMCS) or vice-versa. The reply was to have a synergistic rather than integration approach. It was correctly mentioned that two relevant programmes should harmonize their activities as much as possible.
The question of integration and specific vertical programmes came up several times during discussions. These two approaches may sometimes have conflicting effects and may confuse health workers at the field level. The scarcity of funds and diversity of priorities should also be taken into account when we plan for integration.
In order to increase funds, it was mentioned that integration also requires bringing other government bodies such as Ministry of Finance to planning session
SESSION 3: PROTECTING MORE PEOPLE IN A CHANGING WORLD:
REACHING THE UNREACHED
1. Innovative approaches to improve routine vaccination coverage in low coverage countries
Immunization month in Pakistan: an intervention for raising routine immunization coverage Dr. Altaf Bosan, EPI Manager Pakistan
The EPI Pakistan decided to conduct a ‘Immunization month’ in the month of October 2009 for 19 working days (excluding 8–16 October for the National Immunization Days (NID) for eradication of poliomyelitis and weekend day). National Immunization Technical Advisory Group (NITAG) endorsed the plan, strategy and the schedule for the activities.
Federal Secretary Health issued letters to all provinces requesting appropriate preparation for achieving desired objectives. Therefore, the immunization month was observed in October 2009 in the whole country except in Baluchistan.
The main objective of the immunization month was to raise routine immunization coverage by vaccinating all missed children with appropriate antigens; identifying all drop- outs and vaccinating them with the missed doses; using the opportunity to vaccinate all children with an additional dose of measles vaccine and vaccinating all pregnant women with TT vaccine as per schedule. Target groups were all children up to 2 years of age and all pregnant women. The intervention not only helped immunizing large cohort of children but also centre staged immunization as a key strategy of the government in disease control and prevention.
Strategy was provided to all districts such as one vaccination team will work in one union council over the 19 working days. The team would conduct outreach vaccination session in each and every village/community during this period following a detailed micro- plan. The outreach sessions would be held in already established sites in that village or in an acceptable place to the community. Fixed sites delivered vaccination services daily throughout the month.
The vaccinators would collect required vaccines and related equipment daily from the nearest supply store and would return all unused vaccines to the same supply store and reports were to be submitted to the designated supervisors. Door to door vaccination was strictly NOT allowed.
Social mobilization materials were developed. Selected firms were assigned to print messages and electronic media were involved to:
– broadcast radio spots – televise messages
– print materials were distributed – private media channels were involved
Local level community mobilization was completed through mosque announcement and social immobilizers. Leaflets/messages were distributed to the communities through polio teams during polio campaign.
Federal and provincial EPI officials, including partners, monitored the activities;
district deployed all their supervisory staff to supervise the activities and one independent monitor hired for each district through WHO for monitoring and evaluation.
The Federal EPI provided vaccines, injection equipment and printed materials and made commitment with the provinces for operational support on the basis of their performance. The indicator was that every district should reach over 85% coverage with MCV1 assessed and approved by monitors hired through WHO.
The salient feature of operational cost is given below:
• Each UC would be provided Pakistan Rupees (Rs.) 500 (US$ 6) daily as operational support. This amount was an addition to their regular support from local government for the same purpose;
• Each district would receive a lump sum amount of Rs. 40,000 (US$ 488) for supervision and monitoring
• Each province would receive a lump sum amount of Rs. 160,000 (US$ 1,951) for supervision and monitoring
a) Achievements
Number of children vaccinated during the immunization month
P
rovince Children up to 2 yrs of age Pregnant
women
B CG
O PV0
O PV&
Penta 1
O PV&
Penta 2
O PV&
Penta 3
M sl1
M sl2
T T1
T T2+
P unjab
4 22,602
2 35,583
3 59,749
2 89,492
2 95,690
3 87,344
4 39,514
2 30,500
1 80,467 Si
ndh
1 66,100
5 6,241
1 67,248
1 01,383
9 7,387
1 67,963
1 02,099
1 67,162
1 28,502 N
WFP
9 5,361
4 5,893
1 03,709
7 0,768
7 0,393
9 4,261
4 0,691
9 4,985
5 8,403 Gt
-Btan
5 ,336
1 ,505
6 ,064
4 ,426
4 ,477
5 ,240
4 ,838
6 ,771
4 ,549 T
otal
6 89,399
3 39,222
6 36,770
4 66,069
4 67,947
6 54,808
5 87,142
2 69,149
3 71,921
Proportion of annual target vaccinated during the immunization month
Pr
ovince Children up to 2 yrs of age Pregnant
women
B CG
O PV0
O PV&
Penta1
O PV&
Penta2
O PV&
Penta3
M sl1
M sl2
T T1
T T2+
Pu njab
1 4%
8
%
1 2%
9
%
9
%
1 2%
1 4%
6
%
5
%
Sin dh
1 3%
4
%
1 3%
8
%
7
%
1 3%
8
%
1 1%
8
% N
WFP
1 2%
6
%
1 3%
9
%
9
%
1 2%
5
%
1 1%
7
% Gt-
Btan
1 5%
4
%
1 7%
1 2%
1 3%
1 5%
1 4%
1 6%
1 1%
To tal
1 2%
6
%
1 1%
8
%
8
%
1 1%
1 0%
4
%
6
% Usually on average 8.33% of the annual target is reached in a month
b) Evaluation method
• One independent monitor was hired for every district by the WHO provincial PEI offices to monitor the month’s activities
• Beside monitoring the vaccination sessions, every monitor was to do at least one quick cluster survey to assess immunization coverage daily
Number of monitors
Number of cluster surveyed
Number of children surveyed
Punjab 36 681 7,243
Sindh 40 517 5,068
Assessed coverage
B CG
O
PV0 P1 P2 P3
P enta1
P enta2
P enta3
M sl1
M sl2
F IC P
unjab
9 6%
8
4% 8% 7% 5%
9 7%
9 6%
9 3%
9 1%
5 6%
8 9%
S 9 8 8 8 7 7 3 7
indh 2% 1% 8% 3% 9% 8% 2% 7% 6% 1% 0%
Number of districts in provinces achieving different benchmark for different antigens
Punjab > 85% > 80% to
<85%
>50% to
<80%
<50
%
Penta 3 32 2 2 0
Measles 1
29 4 3 0
FIC 29 2 5 0
Sindh > 85% > 80% to
<85%
>50% to
<80%
<50
%
Penta 3 13 3 4 3
Measles 1
11 3 6 3
FIC 7 3 10 3
In conclusion: It was a satisfactory exercise which has improved coverage to some extent but the programme did not succeed in transfer of funds from GAVI to WHO EMRO and promised operational funds could not be paid to 36 districts reached 85% MCV1 coverage. However, the next immunization month will be celebrated with more focused intervention to mobilize community and raise immunization coverage to reach 90% for all antigens in all districts.
Community involvement in Lebanon
Ms. Randa Hamada, EPI Manager, Lebanon
Lebanon has adopted innovative approaches in some remote areas in order to increase the vaccination coverage. Those new approaches proved to be effective and made differences.
The strategies mainly stressed on initiating an effective communication process with all potential partners starting with people in charge at lowest administrative level and at community levels, to private sector and Ministries of Education and Interior Affairs, to Media People such as actresses who became a main supportive partner.
Reported figures from districts showed improved coverage rate namely in Akkar where some 11 remote villages were targeted and vaccination coverage reached above 90%.
It should be mentioned that Lebanon has met GIVS Strategies (Area 1):
• in applying combined strategies;
• in increasing community participation through raising community awareness about the importance of vaccines
• in ensuring to reach the unreached;
• in expanding vaccination beyond traditional target group namely in vaccination against hepatitis B and neonatal
2. Integrated interventions
Global Action Plan for Pneumonia (GAPP) and Enhanced Diarrheal Disease Control
Dr. Thomas Cherian, Coordinator, Expanded Programme on Immunization Plus (EPI), IVB, WHO HQs
Synergistic approaches to prevent, protect and treat children with pneumonia and diarrhoea
Pneumonia and diarrhoea are the leading causes of death in children under 5 years of age. Failure to reduce mortality due to pneumonia and diarrhoea will result in failure to achieve MDG-4.
While simple, inexpensive and effective interventions exist to control pneumonia and diarrhoea, these have not been implemented to large scale in many developing countries, especially those not on track to achieve MDG-4. Vaccines against rotavirus, Hib and pneumococcus are likely to be important contributors to reducing diarrhoea and pneumonia mortality, respectively, but they will not address the entirety of the problem. They need to be complemented by additional strategies to address risk factors for pneumonia and diarrhoea, to provide early treatment facility at community level and to implement preventive strategies for mother to child transmission of HIV and for Pneumocystis jiroveci pneumonia in HIV infected and exposed children.
Two reports on pneumonia and diarrhoea prevention and control have been published by WHO and UNICEF in 2009. The global action plan for the prevention and control of pneumonia was discussed at the WHO Executive Board and the World Health Assembly (WHA) in 2010, leading to a WHA resolution. The next steps are to advocate for the implementation of these strategies, particularly in countries planning to introduce pneumococcal and rotavirus vaccines, to raise resources, and to assist countries in adjusting their national plans to facilitate a more coordinated implementation of the programmes that address diarrhoea and pneumonia.
Reference List
(1) Parashar UD, Burton A, Lanata C, Boschi-Pinto C, Shibuya K, Steele D et al. Global mortality associated with rotavirus disease among children in 2004. J Infect Dis 2009;
200 Suppl 1:S9-S15.
(2) Watt JP, Wolfson LJ, O'Brien KL, Henkle E, Deloria-Knoll M, McCall N et al. Burden of disease caused by Haemophilus influenzae type b in children younger than 5 years:
global estimates. Lancet 2009; 374(9693):903-911.
(3) O'Brien KL, Wolfson LJ, Watt JP, Henkle E, Deloria-Knoll M, McCall N et al. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet 2009; 374(9693):893-902.
Child Health Days in Somalia
Dr. Assejid Tessema Kebede, Medical Officer EPI, WHO Somalia
The coverage of child health services has been low in Somalia for long time. As a result, WHO/UNICEF and all partners have agreed to scale up child health services through implementation of Child Health Days (CHD) in which life-saving integrated interventions are delivered. The interventions include: measles vaccine for children 9 – 59 month of age (measles follow up campaign), routine immunization for under 1 year (except BCG), OPV together with vitamin A and de-worming tablets and nutritional screening for under 5 years of age, TT for women of child bearing age (WCBA), distribution of water purifying tablets and health promotion messages for families. CHD campaign is being conducted over 5 days in all villages of Somalia every six month.
Two rounds of CHD were conducted in 2009 all over Somalia except in 1 region and 1 district (Lower Shebelle and Kismayo), where access was denied. The third round is ongoing:
completed in North East and North West zones; and is planned in South and Central zones. In each round more than 1 million children have been reached with this approach and average coverage of more than 80% for all the interventions have been achieved except that for the coverage for TT which is still less than 60 per cent.
The CHD delivery strategy has proved to be appropriate for conflict areas like that of Somalia. Success factors include building on and utilizing existing polio program structure, delineation of roles and responsibilities of partners, integration of interventions that has increased acceptance by the community. Challenges include deterioration of security in many districts, unpredictable funding for CHD activities.
Discussion:
Somalia’s achievement in remaining polio free for the last 10 years was commended.
Somalia program always take advantage of activities related to vaccination to provide other services. The question of Somalia’s eligibility of receiving more funds from GAVI was brought up. It was also mentioned that GAVI’s eligibility for new vaccines introduction cannot be changed since the coverage of traditional vaccines is still below 70%.
3. Expanding immunization activities beyond infancy H1N1 vaccination: successes and challenges
Dr. Ezzeddine Mohsni, Coordinator, Disease Surveillance, Eradication and Elimination and coordinator, Polio Eradication Programme, WHO, EMRO
Expanding immunization beyond infancy is one of the key strategies recommended by the WHO/UNICEF Global Immunization Vision and Strategies (GIVS) 2006-2015 as well as vaccines in global epidemic preparedness plans and measures. Implementation of both above- mentioned strategies has been very variable across countries from the Regions, till recently when national immunization programmes were requested to be actively involved into the last H1N1 pandemic preparedness and response.
Well aware about the importance of this activity and the challenges that EPI programmes might have to face mainly because of the emergency context as well as the need to deal with most of them for the first time with different target groups as well as different partners, the Regional office conducted an inter-country training Workshop on Pandemic Influenza Vaccine Deployment Plan in Rabat, Morocco, from 12 to15 July 2009, attended by representatives from all countries of the Region (Communicable Diseases Control Director or his representative), National Focal Points for Pandemic Flue and National EPI Managers).
The main objectives of the Workshop were to:
– Provide country teams with a framework for permitting the deployment of a pandemic influenza vaccine and other ancillary products in seven days
– Encourage each country to conduct exercises to test its deployment and execution capacity and use the "illustrative checklists" to evaluate their existing plan
– Brief country teams on core-management activities that underpin the deployment of pandemic influenza vaccine, including the allocation of the required funds for covering the deployment of the pandemic vaccine when time arrives
– Update them on latest developments on the epidemiology and vaccine development and availability
The workshop focused on a number of key issues, including:
– National policy for the use of a pandemic influenza vaccine should be part of the pandemic preparedness plan;
– An assessment of the investment and resources required to achieve the level of surge capacity necessary to support the deployment needs to be carried out;
– Adequate funds are assigned to support the deployment of a pandemic influenza vaccine;
– Individuals and processes exist at each level of the health system or government structure with clear responsibility and roles for the rapid deployment of the pandemic influenza vaccine in the country;
– The national H1N1 vaccine deployment plan should be clear and built all available vaccine delivery systems within the country (public and private, health and extra-health)
In order to assess the degree of involvement of national EPI programmes in this activity as well as their experience (achievements and constraints), the Regional office developed a questionnaire that was sent to all countries.
The main outcomes from this survey were:
– Some countries did face problems mainly in the area of vaccine handling and regulation issues, coordination with other non-usual partners and monitoring and evaluation.
– AEFI surveillance varied across countries but in general almost all AEFI reported were minor and within the expected limit.
– Low acceptance of the different target populations in almost all countries (except for pilgrims in some countries for which H1N1 vaccination was mandatory)
The main lessons learned according to country reports were the importance of a strong and pro-active communication and social mobilization plan, as well as a perfect and dynamic inter-sectoral collaboration, in addition to the crucial need for a regional mechanism that will secure EMR countries a rapid access to good quality and affordable vaccines on time (pooled vaccine procurement, vaccine production, etc).
In general, the exercise was beneficial to almost all EPI programmes in the Region.
The exercise brought to the programmes an excellent opportunity to:
– Assess, and in most countries, upgrade their capacities in terms of vaccine procurement and regulation and vaccine management;
– Go beyond the “classic” EPI duties and tasks and be involved in wider and crucial health issues (country pandemic preparedness plans, national H1N1 committees, etc);
– Show the crucial role of EPI and capacities and gain more trust, confidence and support.
Global Study on School-based immunization
Dr. Rudolf Richard Eggers, Medical Officer, Expanded Programme on Immunization Plus (EPI), IVB, WHO HQs
School based immunization is a natural expansion of the traditional EPI when children of school going age are targeted, to countries where school enrollment is high, school based vaccination can be an effective, easy and relatively cheap means to reach adolescents.
The presentation reported a global email survey done by UNICEF and WHO, showing
that 61 of 143 reporting counts indicated that they had some kind of school immunization. In most cases (97%) tetanus toxoid was given, and to a lesser extent measles (52%) and polio vaccines (48%).
In depth case studies were conducted in Malaysia, Indonesia, Sri Lanka, Tunisia and Syria (not completed). In the four completed countries, the school-based immunization were part of a native programme, well integrated in district and local health services. Generally all schools were targeted and school enrollment was high. Vaccines delivered through this means differed country by country, and standard operating procedures were in place to guide health workers. This delivery strategy can become an effective delivery method if planned correctly.
Discussions;
Both presenters reemphasize on the key word of “expansion”. The role of internet and other media in acceptance of vaccines by public was significant in many countries. It was mentioned that in some countries physicians were acting on anecdotal incidences. The importance of taking the opportunity of the H1N1 pandemics to further expand EPI programmes was reemphasized during discussions. The size and the capacity of the vaccine cold chain was one of the issues of concern in relation to storage and distribution of H1N1 vaccine. In some instances the pandemic help expansion and improvement of the logistics and the vaccine cold chain.
SESSION 4: ACHIEVING REGIONAL TARGETS 1. Poliomyelitis Eradication
Global Overview
Dr. Roland Sutter, WHO, HQs
Since the 1988 resolution by the World Health Assembly to eradicate poliomyelitis globally by the year 2000, substantial progress towards this target has been achieved. The incidence of polio cases was reduced by >99%, and the number of polio-endemic countries
decreased from >125 to 4. There were two waves of polio exportation from Nigeria (and to a lesser degree from India) in 2003-2004 and 2008-2009, which affected primarily sub-Saharan countries but long-distance exportation were experienced by Indonesia in 2005 (originating from Nigeria) and Angola multiple importations originating from India.
Since 2005, there has been an unprecedented effort to strengthen the program and integrate many innovations, including the introduction of new vaccines (mOPV1, mOPV3), introduce short-interval rounds, increase the number of supplemental immunization activities (SIAs), improve the monitoring (including reporting within 15 days after completion of an SIAs round of independent monitoring data to regional / global levels), feed-back and supervision of SIAs. Because the monovalent OPVs led in some instances to alternating outbreaks of the strain that was less well targeted, a new bivalent (1+3) OPV (bOPV) was developed in 2008-2009, and licensed in Fall 2009. The enhanced efforts finally paid of by mid-2009, with polio cases dropping precipitously in two major polio-endemic countries (i.e., India and Nigeria). No type 1 polioviruses were detected in Uttar Pradesh and Bihar States in India since November 2009. Similarly, in the first 6 months of 2010, only three wild poliovirus cases were detected in Nigeria. The progress in Afghanistan and Pakistan is less striking because of conflict causing access difficulties. However, there is still polio in India (most likely restricted primarily to migrant populations) and probably in Nigeria (most likely in pockets of under-vaccinated children in Northern States). In addition, a large outbreak in Tajikistan, a country that has been polio-free for many years, highlights the risk for poliomyelitis as a result of importation, should one decrease efforts or vigilance.
Although the program has now a unique opportunity to finish the eradication job, however, further enhanced efforts will be needed that are outlined in the recently published Strategic Plan 2010-2012. A new independent monitoring committee will quarterly assess the progress and suggest, mid-course corrections, if necessary. However, the most immediate threat to the eradication effort is short-falls in funding which will curtail programmatic activities.
Regional Overview
Dr Tahir Pervaz Mir, WHO, EMRO
Presentation was focused on the progress and remaining challenges in the polio endemic countries of the region. It included an update on situation in the countries where there had been polio virus circulation re-established in the recent past and on what should be done by the polio free countries with respect to preparedness to address importation. In the
endemic countries, Pakistan and Afghanistan, poliovirus circulation is localized to thirteen district in Afghanistan and fifteen districts in Pakistan but continued circulation poses risk outside the transmission zones. Insecurity and weak campaign management are the major risks for achieving the strategic milestones. District specific planning and linking payment with performance have resulted in recent improvement in Pakistan which needs to be sustained.
The polio eradication program introduced large number of innovative approaches to address the issue of ‘access’ including SIAD, Focused District strategy and HRC approach, working through NGOs and CDCs, negotiating access and tranquility with ISAF/NATO, Letter of support from Anti Government Elements through ICRC, engaging access negotiators locally, negotiations with local and religious leaders /Jirgas, vaccinating IDPs on exit points and established transit vaccination posts in inaccessible districts.
In response to situation in Tajikistan, Afghanistan program established vaccination posts at the border crossing points, enhanced surveillance, risk prediction analysis for action by district and conducted mOPV1 vaccination round in synchronization with Tajikistan and Uzbekistan.
The outbreak in South Sudan came to an end with the last polio case in June 2009.
Program major focus is on the AFP surveillance in order to ensure not missing any circulation. Actions taken to improve case detection are increasing field visits, active case search, strengthening ‘0’ Reporting, enhancing Logistic support (7 vehicles, 13 motorbikes and 300 bicycles) and taking additional stool samples from the community children particularly from the counties not reporting AFP case and there is positive impact and reporting of AFP cases have improved.
The EMR is making good progress in the Certification process. Basic National Documentation has been accepted from nineteen countries (BAH, DJI, EGY, IRA, IRQ, JOR, KUW, LEB, LIB, MOR, OMA, PAL, QAT, SAA, SOM, SYR, TUN, UAE and YEM). Final National Documentation has been accepted from 17 countries that have been polio free for 5 years or more and have completed Phase I Laboratory Containment (BAH, DJI, EGY, IRA, IRQ, JOR, KUW, LEB, LIB, MOR, OMA, PAL, QAT, SAA, SYR, TUN and UAE). Regular (Annual and Abridged) Updates were submitted by all countries who submitted the Basic National Documentation. Lab Containment process in the region is progressing satisfactory.
Regional priorities and plans are to interrupt virus transmission in Pakistan and Afghanistan block at the earliest possible, consolidate achievements in Sudan, sustain polio- free status of other countries by avoiding large immunity gaps in polio-free countries while maintaining certification-standard surveillance, aadequate preparedness to detect and respond to importation, ooptimize PEI / EPI collaboration, maintain and further strengthen coordination activities inter-regional, continue with containment and certification activities, and avail the financial resources required to implement the regional plan for eradication.
Discussions on the Global and Regional overview:
The following points were raised:
• Regarding the outbreak of wild poliovirus type 1 (WPV) in Tajikistan it was indicated that the European RCC in their meeting labeled Tajikistan as high risk country well before outbreak, but there was no parallel response from the
authorities. In response to the SIA were conducted in Tajikistan and also in some neighboring countries. This will help to boost the immunity status of central Asian States of European region. On Afghanistan side of Tajikistan, routine and SIA activities were carried out and vaccination posts were put in place to vaccinate children entering into and going out of border areas, and at the same time AFP surveillance is enhanced. O6 cases have been reported from Russia and all these cases have history of travel to Tajikistan.
• Situation in countries with reestablished WPV infection; out of the 04 countries in this category, 02 are already polio free (DRC and Sudan). Vulnerable populations (with no immunity or partial unprotective immunity against poliovirus) are in many countries, and it poses the risk of spread following importation.
• The bOPV is produced by four manufacturers and it is prequalified by WHO, however, its registration should be the job of ministry of health. Polio free
countries at risk of importation and should act in advance to initiate registration of bOPV in their countries.
• The risk of importation to polio free countries remains high up till the time all countries are polio free, and this highlights that all EPI managers should take all measure to alert and response to any WPV importation.
• In Pakistan and Afghanistan three quarter of population are living in polio free areas.
Monitoring Eradication Activities and Progress Monitoring Immunization Activities
Dr A. Elkasabany, WHO,EMRO
Monitoring immunization activities involve monitoring routine immunization, monitoring SIAs and using surveillance data to monitor immunity outcome. The approaches for monitoring SIAs include administrative coverage, field visits by national supervisors or international observers and independent monitoring. Independent monitoring is the gold standard since it avoids the possible shortcomings in other methods.
The data obtained from independent monitors can be analyzed to help direct the corrective actions. Examples of this data include the reason for missing children, the source of information about the round. Another source of data that can evaluate the immunity outcome is the AFP surveillance data. It can provide information about the immunity profile of NPAFP, the distribution of zero dose children and the immunization coverage as evaluated for children who live around AFP cases. The regional office is working on regional guidelines for independent monitoring. The highlights of the guidelines were shared stressing the important areas of the different types of independent monitoring, the independence of the process, and the selection of districts and the timeliness of the reporting.
Monitoring Surveillance Quality Dr F. Kamel, WHO/EMRO
Different approaches are available to monitor and discover gaps in AFP surveillance including
• Regular analysis of surveillance data which is done at Global (weekly and monthly update), regional (Regional weekly polio-fax, RCC documentations ) and country (review meetings, weekly presentation and monthly bulletin) levels. It is mostly based on performance indicators (sensitivity, quality, process and timeliness). It represents a quick way for highlighting problems and initiating actions
• Supervisory field visits (should be regular, based on standard checklist with written report and follow-up)
• Desk reviews are done by independent evaluators. These look at all aspects of the surveillance system not only the indicators e.g. structure and guidelines, staffing and
logistics, data and communications, review central unit and files and Interview field staff at capital. These reviews can be followed by field review (sub-national) if needed and can be done jointly for a group of countries
• Field reviews: Independent evaluation through an external reviewer, it supersedes any other evaluation, can be National or international. It is done according to standard guidelines by combination of nationals and internationals in every team. It covers all aspects of the programme: structure, system, personnel , communication, coordination, feedback, supervision, AFP case management , stool specimen collection, data
analysis/data validation, active surveillance, quality of active visits, zero reporting, awareness among clinicians and hospital staff and importation preparedness.
The above approaches are complementary and provide different kinds of insight. They should be implemented properly with care to avoid their pitfalls.
Dr H. Asghar
The Global Polio Laboratory Network (GPLN) comprises of 3 tiers, each is performing its specific functions: Global Specialized Laboratory, mainly responsible for genomic sequencing, training, and development of methods; Regional Reference Laboratory (RRL), responsible for virus isolation and Intratypic Differentiation (ITD), and; National Polio Laboratory (NPL) is responsible for virus isolation.
The performance of the Polio Laboratory Network (PLN) is monitored and assessed by measuring a set of laboratory performance indicators, which are mainly addressing timeliness of results reporting for various stages of testing: virus isolation, ITD etc. The PLN are annually accredited by WHO through on-site visits and by testing of proficiency testing panel of unknown viruses for isolation and ITD methods, and cell sensitivity data is also monitored regularly. The AFP surveillance is supplemented with environmental surveillance in only two countries of Region (Egypt and Pakistan). It can help to detect wild poliovirus circulation in the absence of paralytic cases. The nucleotide sequencing of poliovirus is helping to detect epidemiologic links between polio cases, identify local reservoirs sustaining poliovirus circulation, gaps in surveillance (Orphan viruses) and importations, and detection of vaccine derived polioviruses (VDPVs).
The Phase 1 of laboratory containment of polioviruses and other potential infectious material (developing list of laboratories, surveying laboratories, collecting and collating data, identifying laboratories storing WPV material/potential infectious material, developing a National inventory of laboratories storing WPV, and instructing these laboratories to implement BSL-2/ polio) has been completed in nineteen countries of the Region (Bahrain,
Djibouti, Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Syrian Arab Republic, Sudan, Tunisia, United Arab Emirates and Yemen), remaining countries are Afghanistan, Pakistan, and Somalia. At the end of completion Phase 1 activities a comprehensive self-assessment report of containment activities including tables of relevant data is submitted. The Global Action Plan of containment activities, 3rd edition, is addressing to minimize the post eradication risk of reintroducing wild polioviruses or Sabin strains from the laboratory to the community, at a time when OPV use has stopped. It is in draft awaiting endorsement by World Health Assembly.
It is expected from the national EPI to support and assist laboratories to resolve their problems when and where required, and also make on-site visits and data verifications. It is also important to invite them to meetings related to polio eradication activities.
Discussion on Monitoring Eradication Activities:
During this discussion the following points were raised:
• The atmosphere of fear can cause multiple problems like faking data and false reporting, which will affect the quality of data and it will lead to inaccurate information and
mislead the programme.
• Concerns were shown about the situation in Pakistan and it was reiterated that solution should be sought to resolve the management issues and security/access problems. The EPI manager of Pakistan stated that they are taking all innovative measure through specific plans (Prime Minister Polio Action Plan) and progress is reviewed quarterly at federal level. They are faced with district management issues and these are mainly responsible for poor performance in these districts. Payments to vaccinators and
supervisors have been linked to their performance during SIA, and more accountability has been added by taking actions against the poor performance staff.
• The process of independent monitoring (IM) should be finalized and shared with the countries.
• Other methods of IM like cluster lot quality assurance (CLQA) method can be used in which 06 clusters of 10 children are randomly selected. It can be carried out by two persons after the campaign in one day. This has been pilot tested in Nigeria and now implement in Nigeria and in other countries of Africa Region.
• The problem of denominator and numerator should be given very special attention to seek proper figures..
• It is important to collect accurate Independent monitoring data and it should be presented and shared at WHO website.
• NGOs should be involved in the process of independent monitoring especially in conflict and inaccessible areas.
• There is advantage of using international observers that they can share their experience of other countries and they can criticize the system. They are not part of implementation, so they can correlate the process with system and come up with solution for bottle neck areas.
Monitoring Risk
Monitoring Risk of Outbreak after Wild Poliovirus Importation Dr H. Safwat, WHO, EMRO
EMRO undertook a quantitative analysis in the region based on EURO experience and tailored to EMRO situation to assess risk of transmission of wild polio virus after an importation. The assessment was based on surveillance performance indicators, population immunity, performance of health systems, and environmental factors.
Countries were classified using a cumulative score of low, medium and high risk groups. Besides determining the risk of wild polio virus outbreak after importation, this assessment will help identifying weak areas on which to focus improvement efforts by prioritizing technical assistance, immunization and surveillance activities.
Assessment tool identified Sudan, Djibouti, Somalia, Yemen, Iraq, Syria and Lebanon to be at high risk of outbreak after an importation. It was noted that countries of highest risk had a population immunity gap.
The assessment tool is a work in progress that is not finalized. It is re commended to undergo similar assessment at country/ sub-national levels.
Discussion on the monitoring risk:
Draft risk assessment model is in the process of development and it should be modified/revised taking into consideration variables and redefining some of those, calculation criteria, and scoring. The criteria may not be the same for countries in different stages of polio eradication or status. There is no fix cut off point for variables and it can be tailored to the needs of the country. The purpose is to know the gap and
address those. Once it is modified should be shared with countries and all concerned and their comments should be addressed, before final approval.
Risk assessment exercises have been carried out earlier in Pakistan/Afghanistan and Somalia taking into consideration more variables. This experience can be combined with risk assessment model and it can help to refine the model.
Outbreak Preparedness and Response Guidelines and Regional Experience
Dr F. Kamel, WHO, EMRO
Isolation of wild poliovirus in polio-free area is a public health emergency.
Importation of wild poliovirus cannot be prevented until global polio eradication is achieved, but its spread within the country can be controlled.
Between 2003-2009 EMR experienced 12 wild virus importation events in 6 countries including 4 outbreaks with a total of 910 cases and 2 isolates, all except two are P1.
Pillars for importation preparedness include High quality surveillance which is essential for early detection and High general population immunity, achieved by routine immunization and SIAs to guard against virus spread. Countries should monitor population immunity (coverage, vaccination status of AFP cases). In addition, special attention should be given to high risk areas/populations.
Proper response include rapid Notification and investigation, enhancing surveillance for AFP and wild poliovirus, Immediate and appropriate immunization response with at least 3 large scale house to house rounds using type specific monovalent vaccine, 1st campaign within 4 weeks of confirmation with potential target ( 2 to 5 million). In small populations entire country and bordering areas may be included. Documenting cessation of transmission should also be done. The lessons learned from regional experience were shared
Risk factors for emergence of Circulating Vaccine Derived Poliovirus (cVDPV) are
similar to factors facilitating wild virus circulation and warrant similar response.
Simulation of Preparedness Plan in Oman
Dr S. Awaidy, EPI Manager, Sultanate of Oman
The purpose of the simulation was to test the capacity of system to know the strength and weaknesses and any need for further improvement of different component of the preparedness plan. Most important components looked at, were planning, resources, organizational coordination, roles and responsibilities, and individual performance etc. In this regard, wild poliovirus importation and containment measures to control spread were simulated in Dofar, Oman. This exercise provided a good opportunity of training and understanding of the process. It helped to improve the emergency management system. Such exercises should be conducted involving the national and sub-national levels. This exercise can be monitored by the national certification and/or expert committee.
Discussion on the Outbreak Preparedness and Response:
Before simulation exercise, public, political and community leaders and media should be involved and well informed to avoid any public panic
SESSION 4: ACHIEVING REGIONAL TARGETS (CONT’D) 2. Measles Elimination
Regional Situation:
-
Dr. Boubker Naouri
Medical Officer, Vaccine Preventable Diseases and Immunization, WHO/EMRO
Remarkable progress has been made since 1997 when the Regional Committee passed the resolution of measles elimination by 2010. Regional routine coverage with the first dose of measles-containing vaccine (MCV1) reached 84% in 2009, compared to 75% in 1995 (64% increase). However, the regional MCV1 is still below the 95% coverage target. The number of reported measles cases dropped dramatically especially during last three years, with around 15,800 measles confirmed cases recorded in 2009. This was an epidemic year. In 2008-09 the reported outbreaks were small outbreak by historical standards. Comparing this epidemic year with the previous ones one can notice that the size of the epidemic decreases over time. Another great achievement is that countries in the EMR reduced the number of measles-related deaths by approximately 90% from 2000 to 2007. This is a great public health success. Goal reached three years before the year target of 2010. The largest regional percent reduction in estimated measles mortality during this period and accounting for 16%
the global reduction in measles deaths, in 2008, this reduction was around 93%. MCV1 is still provided at 9 months in 7 countries (Afghanistan, Sudan, Somalia, Iraq, Djibouti, Morocco. Nineteen countries have 2 routine measles doses. MCV1 reached a coverage over 90% in16 countries and 95% in 14 countries. MCV2 reached 90% in 13 countries over 90%
and 95% in 12 countries. Three countries reported that all districts reached more than 95%
(Bahrain, Oman, Palestine). All countries have now completed a catch-up SIA. Between 1994-2009, 154 SIA were conducted and approximately 384 million children were vaccinated.
National measles case-based surveillance is established in 19 countries. However, performance indicators need to be improved in most of the countries, even those that are close to elimination. Both epidemiology and laboratory together must provide the needed sensitivity and specificity to ensure the detection of measles virus. The performance indicators and targets should be monitored by countries with elimination goals to assess the quality of the surveillance system.
Countries within the Region are at different stages of, and have variable capacity of measles elimination. Fifteen countries are very close or are at the phase to interrupt measles virus transmission. These countries are scaling up and intensifying surveillance measles requirement monitoring indicators and programme performance, with these continued activities they may be able to validate measles elimination by the year 2012. Seven countries are making efforts to strengthen their measles routine vaccination coverage and surveillance and some of these countries still need to conduct regular supplemental Immunization Activities (SIA) and strengthen routine immunization services to sustain the gain of the high immunity reached through the catch-up and follow-up campaigns. By the end of 2013, these countries can interrupt measles transmission and be able to validate measles elimination by 2015.
During the discussion it was mentioned that the reason for the recent outbreaks of measles might have been combination of technical and financial problems. Some campaigns were postponed due to lack of funds.
Group work: reviewing situation of measles elimination in the region
Objectives
The objective of the group work was to assess the status of measles elimination in EMR countries and to propose a new elimination target date. For this purpose, indicators for monitoring achievement of measles elimination in different countries were reviewed and used during this group work session. Countries were categorized in three groups: countries at elimination phase, countries near elimination phase and countries with high burden of disease.
procedure of the group work:
After explaining the objective and the process of the group work, each country had 5- 10 minutes to go through the matrix that they filled out prior to the meeting. These matrices contain markers and criteria to monitor progress toward measles elimination. For the targets that are not reached, the country are asked to firstly provide an explanation, secondly the action needed to achieve the target and thirdly the timeline to achieve the specified target.
Outcome
The three groups agreed that they would achieve measles elimination by 2015. In addition, each group made some specific recommendations. In countries at elimination phase, main recommendations were to have measles elimination programs up to the elimination standards focusing on reaching high measles immunity, validation of administrative coverage and having a well performing measles case-based surveillance and epidemiological virologic surveillance. The Gulf Countries brought the issues of the risk of importation due to high number of foreign workers.
GAVI supported countries will need to conduct follow-up measles campaigns until reaching over 95% coverage for MCV1 and MCV2 (routine or campaign). Resources mobilization needs to be conducted at the Regional level to bridge the funding gaps supporting the countries in need.
