22–24 May 2018 Manila, Philippines
Meeting Report
SECOND CONSULTATION ON ACCELERATED CONTROL OF JAPANESE ENCEPHALITIS IN
THE WESTERN PACIFIC REGION
Second Consultation on Accelerated Contr ol of Japanese Encephalitis in the W ester n Pacific Region 22–24 May 2018 Manila, Philippines
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC
RS/2018/GE/30(PHL) English only
MEETING REPORT
SECOND CONSULTATION ON ACCELERATED CONTROL OF JAPANESE ENCEPHALITIS
IN THE WESTERN PACIFIC REGION
Convened by:
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC
Manila, Philippines 22–24 May 2018
Not for sale
Printed and distributed by:
World Health Organization Regional Office for the Western Pacific
Manila, Philippines
July 2019
NOTE
The views expressed in this report are those of the participants of the Second Consultation on Accelerated Control of Japanese Encephalitis in the Western Pacific Region and do not necessarily reflect the policies of the conveners.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the Second Consultation on
Accelerated Control of Japanese Encephalitis in the Western Pacific Region in Manila, Philippines from 22 to 24 May 2018.
CONTENTS
SUMMARY ... 1
1. INTRODUCTION ... 3
1.1 Meeting organization... 3
1.2 Meeting objectives ... 3
2. PROCEEDINGS ... 3
2.1 Opening session... 3
2.2 Overview of meeting and expected outcomes... 3
2.3 Regional overview of Japanese encephalitis ... 4
2.4 Japanese encephalitis surveillance in the Western Pacific Region ... 4
2.5 Japanese encephalitis laboratory network ... 4
2.6 PATH update on JE vaccine support in the Western Pacific Region... 5
2.7 Accelerated control of JE: summary of Regional Framework and First Expert Consultation on Accelerated Control of JE in the Western Pacific Region ... 5
2.8 Experiences from countries with long-standing, effective JE control programmes .... 6
2.8.1 Japan ...6
2.8.2 Republic of Korea ...6
2.8.3 Malaysia...7
2.9 Experiences from countries that have recently introduced JE vaccine or are striving to control JE ... 7
2.9.1 China ...7
2.9.2 Viet Nam...7
2.9.3 Lao People’s Democratic Republic ...8
2.9.4 Cambodia ...8
2.10 Experiences from countries that have not introduced JE vaccine ... 9
2.10.1 Brunei Darussalam ...9
2.10.2 Philippines ...9
2.10.3 Papua New Guinea ...10
2.11 Country situation analysis ... 10
2.12 Regional strategy development ... 12
2.13 Review of draft technical guidance ... 13
2.14 Closing session ... 13
3. CONCLUSIONS AND RECOMMENDATIONS ... 14
3.1 Conclusions ... 14
3.2 Recommendations ... 14
3.2.1 Recommendations for Member States ...14
3.2.2 Recommendations for WHO Secretariat ...14
ANNEXES ... 17
Annex 1. Agenda ... 17
Annex 2. Timetable ... 19
Annex 3. List of participants, temporary advisers, observers and Secretariat ... 21
Keywords:
Encephalitis, Japanese – epidemiology, prevention and control/ Japanese encephalitis vaccine/
Regional health planning
ABBREVIATIONS AEFI adverse event following immunization
AES acute encephalitis syndrome
AMES acute meningoencephalitis syndrome
CD-JEV live attenuated Japanese encephalitis SA 14-14-2 vaccine
CSF cerebrospinal fluid
FDA Food and Drug Administration
Gavi Gavi, The Vaccine Alliance
GVAP Global Vaccine Action Plan
IgM Immunoglobulin M
JE Japanese encephalitis
MMR measles-mumps-rubella
NIP National Immunization Programme
NITAG National Immunization Technical Advisory Group PATH Formerly, Program for Appropriate Technology in Health
PMGH Port Moresby General Hospital
TA technical assistance
TAG Technical Advisory Group on Immunization and
Vaccine-Preventable Diseases in the Western Pacific Region
VPD vaccine-preventable disease
WHO World Health Organization
1 SUMMARY
The Second Consultation on Accelerated Control of Japanese Encephalitis in the Western Pacific Region was held on 22–24 May 2018 in Manila, Philippines. The consultation was attended by 19 participants from 10 countries, four temporary advisers, three representatives from partner organizations, and nine World Health Organization (WHO) staff members.
The participants discussed Japanese encephalitis (JE) in the Western Pacific Region, covering topics such as JE surveillance and the laboratory network, support from partner organizations, and regional strategies and targets for JE control. Eight of the 12 countries with JE transmission in the Western Pacific Region have introduced vaccination into some or all JE risk areas. Representatives from each country in attendance described their efforts to control JE, including surveillance and immunization programmes, and shared lessons learnt, challenges faced and successful experiences. Participants discussed in detail the timeline and proposed targets for accelerated JE control in the Western Pacific Region and reviewed and provided input into the draft Guide for Achieving Accelerated Control of Japanese Encephalitis in the Western Pacific Region.
The participants concluded that accelerated JE control in the Western Pacific Region is imperative and that it should be accomplished through maintenance of JE vaccination in several countries as well as new efforts in other countries in the Region.
The participants agreed with previous regional strategies and targets set for JE control in the Region and proposed that targets should be achieved by 2030, corresponding to the time set for achieving the Sustainable Development Goals. The participants reviewed and contributed to the draft Guide for
Achieving Accelerated Control of Japanese Encephalitis in the Western Pacific Region and recommended strategies that will be captured in the document and presented to the Technical Advisory Group on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region (TAG) in June 2018.
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1. INTRODUCTION 1.1 Meeting organization
The Second Consultation on Accelerated Control of Japanese Encephalitis in the Western Pacific Region was held on 22–24 May 2019 in Manila, Philippines. The consultation was attended by 19 participants from 10 countries, four temporary advisers, three representatives from two partner organizations,
and nine World Health Organization (WHO) staff members. The agenda, timetable and list of participants are included in Annexes 1, 2 and 3, respectively.
1.2 Meeting objectives
The objectives of the consultation were:
1) to review and discuss progress, current status and issues concerning accelerated control of JE in countries with JE virus transmission risk in the Western Pacific Region;
2) to discuss timelines for achieving accelerated control of JE in the Western Pacific Region that will be proposed to the regional Technical Advisory Group (TAG) at its 27th meeting in June 2018; and
3) to review and revise the draft Guide for Achieving Accelerated Control of Japanese Encephalitis in the Western Pacific Region, which will be submitted to the TAG for review at its 27th meeting in June 2018.
2. PROCEEDINGS 2.1 Opening session
In her opening remarks, Dr Vivian Lin, Director, Division of Health Systems, WHO Regional Office for the Western Pacific, welcomed participants and commended Member States for their efforts to combat JE.
Dr Lin encouraged participants to do more given the advances in vaccines and new global guidance with important tools for JE control. She also encouraged them to review and provide input into the draft Guide for Achieving Accelerated Control of Japanese Encephalitis in the Western Pacific Region, which will be reviewed by the TAG in June 2018.
Dr A’aisah Senin, Head of Sector, Vaccine Preventable/Food and Waterborne Diseases, Malaysia Ministry of Health, and Professor Huanyu Wang, Department of Viral Encephalitis, Institute for Viral Disease Control and Prevention, Beijing, China, were nominated as co-chairs.
2.2 Overview of meeting and expected outcomes
The three-day meeting opened with an overview of JE in the Region followed by discussion of JE country experiences, working sessions on country situation analysis, discussion of the regional strategies and timelines and review of the draft guide.
The expected outcomes were as follows:
Participants identify issues, challenges, strategies, innovations, facilitators and best practices.
Participants provide input into the draft technical guidance that will be submitted to the TAG in June 2018 for initial review and then to the TAG in 2019 for approval.
4 2.3 Regional overview of Japanese encephalitis
Dr James Heffelfinger, Technical Officer, Expanded Programme on Immunization, Division of Communicable Diseases, WHO Regional Office for the Western Pacific
JE is the leading cause of viral encephalitis in Asia. It is estimated that 68 000 JE cases occur annually, of which more than half (40 400) of the cases occur in the Western Pacific Region.1 The estimated overall incidence rate is 1.8 cases per 100 000 population, and the estimated incidence rate in the Western Pacific Region is 2.3 cases per 100 000 population. Approximately 75% of cases occur in children under 15 years of age. There are 24 countries with risk for JE virus transmission, with 12 in the Western Pacific Region, 10 in the South-East Asia Region, one in the Eastern Mediterranean Region and one in the European Region. As of 2016, eight of the 12 Western Pacific Region countries with endemic transmission have introduced JE vaccine into some or all JE risk areas. In October 2014, the WHO Regional Committee for the Western Pacific endorsed an accelerated JE control goal that called for strategies, targets and timelines to be established through consultation with experts and Member States. Recommendations from recent meetings that addressed the issue of accelerated control of JE in the Region were reviewed, including enhanced laboratory-based surveillance, development of national JE control plans, uniform case classifications, and guidance in defining and responding to outbreaks.
2.4 Japanese encephalitis surveillance in the Western Pacific Region
Dr Nyambat Batmunkh, Technical Officer, Expanded Programme on Immunization, Division of Communicable Diseases, WHO Regional Office for the Western Pacific
In 2008, JE surveillance was included in vaccine-preventable disease (VPD) surveillance guidance, which is being revised and will be disseminated in mid-2018. The new guidance sets out standards for both minimal and enhanced surveillance and establishes new case definitions and laboratory criteria for confirmation. JE surveillance in the Western Pacific Region has been implemented in many countries. Challenges of JE surveillance globally and regionally were discussed, including the fragmentation of JE surveillance in different systems including national notifiable disease reporting systems, sentinel JE surveillance or sentinel meningoencephalitis surveillance. Updated JE surveillance guidelines will be available soon and continued improvement in surveillance with laboratory
confirmation is needed, including a strong sustainable network with strong country support and financing.
2.5 Japanese encephalitis laboratory network
Ms Analisa Bautista, Technical Officer, Expanded Programme on Immunization, Division of Communicable Diseases, WHO Regional Office for the Western Pacific
The JE laboratory network in the Western Pacific Region was established in 2008 following the recommendation of the 17th TAG. The JE network consists of one global specialized laboratory, two regional reference laboratories and seven national laboratories throughout the Region and uses their capacity to improve and standardize JE diagnosis in countries with risk of JE virus transmission.
1Campbell GL, Hills SL, Fischer M, Jacobson JA, Hoke CH, Hombach JM, et al. Estimated global incidence of Japanese encephalitis: a systematic review. Bull World Health Organ. 2011;89(10);766–74.
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The JE testing algorithm was presented. A JE laboratory accreditation programme is in place, established by WHO, which includes proficiency testing, confirmatory testing and other measures to ensure high-quality laboratory procedures. Completeness and timeliness of reporting to the Western Pacific Region has improved. The JE laboratory network has met the objectives for completeness, but timeliness of reporting targets has not been met. There are plans to continue participating in proficiency testing, sending samples for confirmatory testing, doing laboratory accreditation and assisting with procurement of kits, reagents and equipment. However, several challenges remain, including that the laboratory manual needs updating, cerebrospinal fluid (CSF) specimens are not regularly obtained, there are logistical issues with transportation and receiving CSF specimens, and there are issues with monitoring laboratory performance and reporting. The way forward includes collaborating with surveillance sites in the collection of virus isolates and encouraging laboratories to share specimens with regional and global specialized laboratories for advanced virus characterization.
2.6 PATH update on JE vaccine support in the Western Pacific Region Dr George William (Bill) Letson, Scientific Advisor, PATH, Seattle, WA, USA
PATH’s support for country decision-making and vaccine introduction includes the development of a guide for decision-makers, assistance to multiple countries for monitoring JE supplemental immunization activities (SIAs) and financial support to conduct catch-up campaigns. In the Region, PATH donated JE vaccine and provided technical assistance (TA) for an application for Gavi funding in Cambodia;
donated vaccine and provided TA for an application for Gavi funding in the Lao People’s Democratic Republic; conducted a cost-effectiveness analysis of live attenuated JE vaccine and is working with the Philippines Department of Health and WHO on preparations for a JE vaccine campaign in 2019; and provided TA for an application for Gavi funding in Viet Nam. Several clinical trials were described, including study JEV06, which was conducted in the Philippines in 2016-2017 to study the safety and immunogenicity of co-administration of live attenuated JE SA 14-14-2 vaccine (CD-JEV) and measles-mumps-rubella (MMR) vaccine in children 9 to 12 months of age. Based on preliminary findings, there was no interference in co-administering JE and MMR vaccines and there were no severe adverse events. PATH is planning a JE global vaccine impact study in 16 countries that will look at historic data from 2006–2017 on acute encephalitis syndrome (AES), JE cases and vaccination data.
Data collection is scheduled to start in the second or third quarter of 2018.
2.7 Accelerated control of JE: summary of Regional Framework and First Expert Consultation on Accelerated Control of JE in the Western Pacific Region
Dr James Heffelfinger, Technical Officer, Expanded Programme on Immunization, Division of Communicable Diseases, WHO Regional Office for the Western Pacific
In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan (GVAP) 2011–2020 that detailed strategies and activities to achieve the Decade of Vaccines vision. In 2014, the Regional Framework for Implementation of the Global Vaccine Action Plan in the Western Pacific was developed to consolidate existing regional immunization goals and the new goals and objectives; one of the eight immunization goals is introduction of new vaccines. The Regional Framework recommended that a JE expert consultation be held to determine strategies, targets and timelines for accelerated control of JE.
Subsequently, an Expert Consultation on Accelerated Control of JE in the Western Pacific was held in Manila in March 2016. This consultation proposed several recommendations for Member States including the primary strategy outlined in the 2015 WHO JE vaccines position paper. In July 2016, the Technical Advisory Group on Immunization and Vaccine-Preventable Diseases in the Western Pacific
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Region (TAG) considered the targets proposed at the 2016 Expert Consultation and recommended final targets: (1) a primary target of reducing JE incidence <0.5 cases per 100 000 population in the targeted population (generally children under 15 years) in affected areas (national and subnational);
and (2) an intermediate target for Member States that do not have high-quality JE surveillance of ≥95%
coverage with primary JE vaccine series among the targeted population (generally children under 15 years) in affected areas. The TAG also recommended that JE experts propose a timeline for achieving these targets.
2.8 Experiences from countries with long-standing, effective JE control programmes 2.8.1 Japan
Dr Satoru Arai, Senior Researcher, National Institute of Infectious Diseases, Tokyo, Japan JE vaccine has been used in Japan since 1954, first in children under 12 years of age, and then later expanded to children aged 6 months to 15 years. There was JE vaccination of adults aged 55 to 64 years from 1967 to 1977, but this programme was discontinued because the case burden in adults significantly declined. Two vaccines are in use in Japan, both of which are Vero cell-derived inactivated vaccines that have demonstrated high immunogenicity. JE vaccination is supported by the national government with a four-dose schedule; coverage is 95% or greater for the first three doses administered
between 6 and 90 months, with lower coverage (60% in 2015) for the fourth dose given at 9 to 12 years of age. Forty-eight JE cases were reported between 2008 and 2017. The country is committed to maintaining high coverage for all four doses to continue control of JE disease.
2.8.2 Republic of Korea
Dr Hyungul Jung, Deputy Scientific Director, Korea Centers for Disease Control and Prevention, Chungcheongbuk-du, Republic of Korea.
The Republic of Korea introduced the JE vaccine in 1971 and achieved high vaccination coverage by the mid-1990s (current incidence is ~0.02 cases/100 000 population). JE incidence follows a seasonal pattern in the Republic of Korea, with the highest incidence from August to November each year. Funding is shared equally between the central and local governments, and 90% of JE vaccine delivery occurs in the private sector. Mouse brain–derived JE vaccine has been in use in the Republic of Korea for decades, but in 2014, the country introduced live attenuated vaccine, and in 2015, it introduced inactivated Vero cell-derived vaccine. The choice of which vaccine to use is mainly determined by providers and parents, and currently, 72% of administered vaccines are inactivated Vero cell-derived.
Coverage of three (of four) doses is 97%. In addition to children, adults with risks factors (proximity to pigs, work in rice paddies, outdoor activities/work) and travellers visiting high-risk countries) are also vaccinated. The Republic of Korea has a strong case-based JE surveillance system with laboratory confirmation. Challenges include the need to further reduce the number of booster doses for the inactive vaccine from two doses to one dose. Facilitators include the school-entry requirement for vaccinations including JE vaccine; full financial support for immunization; and the widely accepted, proper
preparedness and prompt response to adverse events following immunization (AEFI).
7 2.8.3 Malaysia
Dr Khairiah Ibrahim, Head of Unit, Vector Borne Disease Sector, Disease Control Division, Ministry of Health, Putrajaya, Malaysia
JE incidence has declined over the years in Malaysia since 1996, though there were slight increases during 2014–2016. The incidence in 2017 was 0.07 per 100 000 population. The majority of JE cases occur in two states of Malaysia: Sarawak and Sabah. JE vaccination was introduced for high-risk groups in high-risk areas in 1998 and was introduced into the routine immunization programme in Sarawak in 2002 for children aged 9 months to 15 years. Currently, JE vaccination is only part of the routine immunization schedule in Sarawak, where live recombinant vaccine (two doses) is used; 2016 coverage was 94%. There has been a 61.5% reduction in the incidence rate in Sarawak. Over the past five years, Sarawak has seen a change in the ages of confirmed cases with a higher proportion of cases occurring in those older than 15 years. There are sufficient funds for the immunization programme in Sarawak, but no additional stocks of JE vaccines for outbreak response. Shrinking resources and competing priorities are challenges, and strengthened surveillance and laboratory capacity are necessary for future programme improvement. There has been some consideration of expanding routine immunization to Sabah.
2.9 Experiences from countries that have recently introduced JE vaccine or are striving to control JE
2.9.1 China
Ms Dan Wu, Research Assistant, National Immunization Programme, Chinese Centers for Disease Control and Prevention, Beijing, China
Although JE vaccination started since 1967, the Chinese Government has only funded all vaccines and syringes since 2008 (except in the non-endemic areas of Xinjiang, Tibet and
Qinghai provinces). The coverage for the two-dose series was 99.4% in 2015. Two kinds of vaccines are in use – the live attenuated vaccine (Expanded Programme on Immunization; two-dose schedule) and the inactivated Vero cell P-3 (private; four-dose schedule). China has an extensive JE laboratory network at the central and provincial levels (China CDC is the WHO Regional Reference Laboratory and is linked with 25 additional JE reference laboratories in China). Although the vaccination sites have a close connection with parents and use a web-based text messaging system for reminders, tracing migrant children remains a major challenge. Using a well-developed training programme, China continues to address the challenges related to surveillance, laboratory capacity and
AEFI surveillance. Remaining challenges include a need for guidance to address the question of routine and emergency vaccination of adults (70% of cases in 2017 were older than 15 years);
approaches to maintain attention to JE despite reducing number of cases; staff turnover; effectiveness of one versus two doses; and how to improve coverage in rural areas and migrant populations.
2.9.2 Viet Nam
Associate Professor Thi Hong Duong, Vice Director and Deputy Manager, Expanded Programme on Immunization, National Institute of Hygiene and Epidemiology, Hanoi, Viet Nam
JE vaccine was introduced into the childhood immunization schedule in 1997 in high-risk areas, and since 2015, JE vaccination has been implemented nationwide. The routine schedule is three doses for children 1 to 5 years of age. In addition, Viet Nam has conducted SIAs in 2017 and 2018 for children
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in areas identified as high risk based on low third-dose coverage (less than 80%), morbidity rate
(>1 deaths 100 000) or a reported fatality due to JE virus infection. Viet Nam’s JE surveillance system is based on JE sentinel surveillance in six provinces and meningitis encephalitis surveillance in
three large children’s hospitals. The number of confirmed JE cases reported in 2017 was 125, with 35 cases reported from the six provinces and 90 cases from the three hospitals. The country plans to continue JE routine childhood vaccination with supplementary campaigns in high-risk areas in children 6–15 years of age and to expand JE surveillance into more areas to better reflect population-based rates.
2.9.3 Lao People’s Democratic Republic
Dr Khammany Phommachanh, Director of Setthathilat Hospital, Maternal and Child Health Center, Vientiane, Lao People’s Democratic Republic
The Lao People’s Democratic Republic conducted JE vaccine campaigns in every province from 2013 to 2015 with support from Chengdu Institute, PATH and Gavi. A catch-up campaign reached nearly 100% coverage in all provinces. JE vaccine was introduced into the National Immunization Program in 2015, with vaccine and logistics financed by the government. JE vaccine is given at 9–11 months during the same visit with MR vaccine. Routine vaccination coverage has ranged from 20% to 45% but reached only 5% in the first three months of 2018 because of stockouts. The Lao People’s Democratic Republic has experienced stockouts of JE vaccine since 2016. Additionally, it has faced some vaccine hesitancy from parents reluctant to allow children to receive more than two injections in one visit; JE vaccine coincides with MR and Penta3 vaccines at 9 months. However, the Lao People’s Democratic Republic continues to have strong political commitment to JE vaccination and strong community engagement, particularly among minority ethnic populations in the northern provinces.
2.9.4 Cambodia
Mr Sovannara Siphan, Surveillance Officer, National Immunization Program, Ministry of Health, Phnom Penh, Cambodia
JE surveillance is conducted at six sentinel sites that identify meningoencephalitis and conduct testing to confirm JE cases. JE vaccine was introduced into the routine immunization programme in three provinces in 2009 and expanded in 2015. In 2016, a nationwide campaign was conducted targeting children aged 9 months to 15 years and approximately 4.2 million children were vaccinated.
After the campaign, JE vaccine was introduced into the routine immunization programme nationally.
Cambodia has introduced five vaccines since 2010 and initiated a human papillomavirus (HPV) vaccine demonstration project in 2017. Introduction of new vaccines has had some positive aspects (increased community involvement, decreased burden of vaccine-preventable diseases [VPDs], increased
collaboration across ministries), but it has also presented some challenges (a large amount of staff time has been devoted to introduction activities, diversion of attention from routine vaccination services including cold chain management, VPD surveillance and data management). An additional challenge has been procurement of live attenuated JE vaccine, which has led to lower-than-optimal coverage.
The Cambodia Government bears the cost of the JE vaccination programme. Key lessons learnt include: (1) coordination between all levels and vaccinators and supervisors is important for successful campaigns and introduction; (2) focused interventions are needed for hard-to-reach groups for uptake of vaccines; (3) social mobilization activities are crucial for the success of campaigns and introduction;
and (4) local initiatives and innovations indicate commitment to implementing campaigns and introduction.
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2.10 Experiences from countries that have not introduced JE vaccine 2.10.1 Brunei Darussalam
Dr Linda Lai, Senior Medical Officer, Child Health Immunisation Program Manager, Department of Health Services, Bandar Seri Begawan, Brunei Darussalam
Brunei Darussalam has four districts (Brunei-Muara, Belait, Tutong and Temburang) and each district has government-run hospitals. Brunei Darussalam has passive, national and case-based surveillance with electronic and manual notifications received by the Disease Control Division from all clinics and hospitals in the country. Notification for notifiable diseases is mandatory under the Infectious Diseases Order 2003. Surveillance for JE is integrated with AES and meningoencephalitis syndrome (AMES).
CSF and blood specimens are tested for most AES/AMES cases, using a JE-specific Immunoglobulin M (IgM) antibody test. The JE incidence rate in Brunei Darussalam was estimated to be about
0.25 cases per 100 000 population in 2015 and 2016.
Although Brunei Darussalam is located very close to Sarawak, currently there are no plans to introduce JE vaccination in the National Immunization Progamme. JE vaccine (IMOJEV) is available on voluntary basis at vaccination centres in every district. JE vaccination is recommended for high-risk groups on voluntary basis (e.g. army personnel, entomology staff, border patrols, forestry staff). Vaccination is funded by the Government under the Ministry of Health budget. From October to December 2013, 18 confirmed cases of JE were reported for the first time (only one case aged 10–19 years and remaining 17 cases were adults). This outbreak was confined to one area in the country. Vaccination was done for those under 15 years using a ring vaccination strategy. Since 2014, there has been low incidence of confirmed JE cases in the country and there have been no active vaccination campaigns implemented. There are no plans for introduction of JE vaccine into the national immunization schedule.
2.10.2 Philippines
Dr Maria Wilda T. Silva, Medical Specialist II, Department of Health, Manila, Philippines The Philippines conducts acute meningoencephalitis surveillance at nine sentinel sites. There are several non-sentinel sites (mostly close to the National Capital Region) that also report cases.
In 2016, 275 laboratory-confirmed cases (14% of the reported suspected JE cases) and in 2017, 340 laboratory-confirmed cases (15% of the reported suspected JE cases) were reported.
Seventy-one per cent of cases were detected in three regions (northern/central area of country), most cases occurred in rainy season (peak in August), and 80–90% of cases occurred among persons under 15 years. In April 2016, the Philippines initiated a process to introduce JE vaccine – there is a high public demand for JE vaccination. However, the Dengvaxia issue intervened in November 2017, impacting coverage with vaccines used for routine immunization and raising concerns about introducing new vaccines. Current challenges include: (1) the country has
procured 2.4 million live attenuated JE vaccine doses through UNICEF, but these doses will expire in June 2019; (2) a local company has submitted a dossier on live attenuated JE vaccine to
the Philippines Food and Drug Administration (FDA) in an attempt to get the vaccine licensed in the country in November 2017, but the Philippines FDA rejected the application in late March 2018 because the dossier lacked several documents; and (3) the Philippines National Immunization Technical Advisory Group (NITAG) is being reconstituted and the JE vaccine introduction
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plan cannot be reviewed until this is complete. In the meantime, however, the Philippines Department of Health continues to advocate and work for introduction.
2.10.3 Papua New Guinea
Dr Mathias Bauri, Program Officer, Expanded Program on Immunization, National Department of Health, Port Moresby, Papua New Guinea
Papua New Guinea has a population of 8.8 million. In 1995, JE antibodies were detected among the inhabitants of Irian Jaya (the land border with Indonesia). JE was first reported among inhabitants of Western Province, near Australia, in 1989 and JE virus was isolated from mosquitoes in 1997.
In 2003, an outbreak of suspected JE outbreak in Milne Bay province was identified, but there was no laboratory confirmation. Laboratory-confirmed cases of JE were reported from the Port Moresby area (National Capital District) in 2004 and 2010, and a study at Port Moresby General Hospital (PMGH) confirmed JE as one of the causes of febrile encephalopathy in children.
JE sentinel surveillance started at PMGH in 2012, and testing has been done at the Central Public Health Laboratory, which is located within PMGH. In 2017, there were 79 suspected and two laboratory-confirmed JE cases. The country is balancing the need to strengthen routine
immunization, introduce other new and underutilized vaccines and consider introduction of JE vaccine.
JE vaccine might be considered for introduction in 2021.
2.11 Country situation analysis
Two working groups discussed issues and challenges with control of JE. Group 1 consisted of countries with long-standing immunization programmes and/or have controlled JE. Group 2 consisted of countries with more recent immunization programmes and those without immunization programmes.
Group 1
Group 1, consisting of Brunei Darussalam, China, Japan, Malaysia and the Republic of Korea, discussed the following issues:
The number and types of vaccines used in countries: Group 1 participants thought that there was not enough information available on each of the vaccines. There was agreement that an
overview of all of the available JE vaccines should be created, which describes their schedules, effectiveness, safety, cost and cost-effectiveness, so that countries can make more informed choices about which vaccine(s) to use. The issue of halal vaccines was also discussed;
participants agreed that religious groups should work with WHO to ensure that there is an outlined approach to address this issue.
JE vaccine schedules: Various schedules are used by the countries, and they differ for some of the vaccines. The group thought it would be important to distinguish doses used for the primary vaccination series from booster doses and that more data are needed about the lifetime immunity of vaccine schedules currently being used.
Definition of an outbreak: The group thought it would be important to have a standard definition of an outbreak. Currently, some of the countries define an outbreak as ≥2–5 cases occurring in the same geographic locality, while other countries use different definitions.
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Vaccine supply: The group agreed that their countries do not have challenges with vaccine supply, but there are issues around demand forecasting to ensure sufficient vaccine is always available.
School-entry vaccination checks: Participants from two countries reported that they have school- entry vaccination requirements that included JE vaccine whereby teachers are required to check students’ vaccination cards and students who are not up-to-date on their vaccines are required to be vaccinated before returning to school. These participants felt that the school-entry policy helped ensure high JE vaccination coverage.
Surveillance: Participants from all countries mentioned that sentinel surveillance is in place, but they thought that surveillance should be expanded to include syndromic surveillance for AES or AMES, which is done in some countries but not all because of resource constraints. Most participants thought that in addition to conducting human JE surveillance, there should be JE surveillance for amplifying hosts and vectors.
Circulating JE virus genotypes: The group thought it was important to circulating JE virus genotypes to identify shifts and determine if shifts influence JE disease and vaccine impact.
Demand generation: The group did not think this was a very important issue because JE vaccine is included in the national immunization schedules of all of the countries except
Brunei Darussalam, which decided not to include the vaccine in their routine immunization schedule because of the low rate of disease in the country.
Advocacy: The group thought that, in general, there was sufficient support for JE vaccination, but that advocacy was needed for JE surveillance. Participants also discussed the need for increasing the awareness of physicians about JE disease, its severity and the importance of vaccination.
Group 2
Group 2, consisting of Cambodia, the Lao Peoples Democratic Republic, Papua New Guinea, the Philippines and Viet Nam, discussed the following issues:
Planning for JE vaccine introduction and immunization systems: Some of the participants thought that countries needed additional guidance for prioritizing JE vaccination in the context of other new vaccine introductions, and that although challenging, it was necessary to engage other ministries (finance, education) to ensure continued funding and long-term sustainability.
Participants from a country that uses mouse brain–derived vaccine expressed the need for additional evidence for the benefits of transitioning to a different type of JE vaccine.
Vaccine procurement: The group thought that vaccine procurement was generally manageable but that there was a need to ensure funding for demand generation when JE vaccine is introduced and when JE vaccine is used in outreach settings.
Vaccine supply, quality and logistics: Participants from several countries expressed a need for careful planning for cold-chain capacity down to the lowest level.
Immunization delivery: Participants from several countries expressed concern about the additional burden that JE vaccination would put on other health interventions and operations that are planned, and particularly how the timing of JE doses could impact routine immunizations delivered in outreach settings.
JE surveillance: The group agreed that provider awareness and training on JE disease and surveillance should be improved to ensure good participation in surveillance by providers.
In addition, the group discussed challenges with laboratory capacity (including the availability of diagnostic kits, the need for training and specimen transportation), expansion of sentinel sites and identifying JE outbreaks.
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Monitoring progress: The group thought that monitoring should be strengthened by providing guidance on the definition of denominators for calculating incidence and addressing needs to accurately track JE disease in rural areas and among ethnic and migrant populations.
The group also emphasized the need for strong systems for investigating and reporting AEFI.
Advocacy: The group thought that the primary advocacy needs were increasing the awareness of physicians and stakeholders about JE disease, its severity and the importance of vaccination;
and improving communications.
Research: The group thought it would be important to collect data on breakthrough JE cases following vaccine introduction and to evaluate the impact of vaccination in countries with new JE vaccination programmes.
Each group reported on the results of their sessions in a plenary session. Discussion was led by the session chair.
The chair suggested that vaccine stockouts and strategies to prevent them should be included in the guidance.
The group discussed the benefits of school-entry vaccination checks and/or requirements for JE vaccine given that there is no human-to-human transmission of JE. Several participants expressed the view that school-entry vaccination checks were an opportunity to ensure that children are fully immunized with all recommended vaccines in national immunization programmes, but they acknowledged that this could also be a barrier to children’s enrolment in school. There was general agreement that in countries that have existing school-entry vaccination checks in place, the addition of checks for JE vaccination would be reasonable.
There was general agreement by participants from both groups that more support for JE surveillance and laboratory diagnosis was needed. The session chair challenged the group to discuss the benefits of establishing guidance on a minimum requirement for JE surveillance in every country, which could also include non-human surveillance (e.g. surveillance in amplifying host and vectors) for some countries.
2.12 Regional strategy development
Dr Heffelfinger led a plenary session discussion of strategies, best practices, activity plans and timelines for accelerated control of JE in the Western Pacific Region.
The group discussed the proposed strategies from the 2016 Expert Consultation and the benefits and risks of a complete catch-up campaign versus a phased campaign. Country representatives expressed the view that either approach would be possible depending on the capacity and financial situations in the country.
At the 2016 Expert Consultation, it was suggested that surveillance data on adverse events following JE vaccination be shared among countries in the Western Pacific Region. This is not done formally for other vaccines, and participants thought that it would be beneficial if done for all vaccines. However, this may be a responsibility of national regulatory agencies and difficult to implement.
Dr Heffelfinger invited discussion on new strategies. It was suggested that there be some guidance on the selection of vaccines and appropriate schedules for all vaccines used in the Region, inclusive of vaccines that have not been prequalified by WHO.
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The group discussed the targets proposed during the 2016 Expert Consultation, including incidence and coverage targets. Incidence is a difficult target because of the variability of the quality of surveillance systems in the Region and the difficulty determining the target population to be used in the denominator for calculating incidence. A coverage target may be more feasible, and participants discussed whether or not they thought that coverage targets could be reached in each country and, if so, what the time frame would be. The group concluded that any targets need to be considered in the context of when they are expected to be met.
A discussion of the timeline for achieving targets was discussed, and there was general agreement that 2030 would be most appropriate year for achieving them.
The group discussed how to measure JE vaccine impact and the importance of having high-quality surveillance data in order to estimate JE incidence and monitor changes in incidence following the introduction of JE vaccine. There was also a discussion about the need for coverage surveys and how frequently they should be conducted.
The definition of high-quality surveillance was debated, and it was suggested that this may be defined for all VPDs and not just JE.
2.13 Review of draft technical guidance
Dr Heffelfinger led the group review of the draft Guide for Achieving Accelerated Control of Japanese Encephalitis in the Western Pacific Region. Participants actively discussed, debated and contributed to the draft.
2.14 Closing session
The chair thanked WHO for organizing the meeting as countries are waiting for the guidelines to help accelerate control of JE.
Dr Heffelfinger thanked attendees for their participation in the meeting and contributions to the draft Guide for Achieving Accelerated Control of Japanese Encephalitis in the Western Pacific Region and plans to accelerate control of JE in the Western Pacific Region.
Dr Po-Lin Chan, Technical Officer, WHO Regional Office for the Western Pacific, closed the session on behalf of Dr Shin Young-soo, WHO Regional Office for the Western Pacific. She thanked country representatives, temporary advisers and partners. She noted that discussions had been constructive and would help the Region continue to accelerate JE control. She emphasized that to achieve accelerated control, participants must work together to pool resources and collaborate across the Region. She mentioned that WHO senior management at the Regional Office would be briefed on the meeting and the draft Guide for Achieving Accelerated Control of Japanese Encephalitis in the Western Pacific Region would be presented to the TAG in June 2018. Countries were asked to ensure that the strategies would be implemented and that the targets would be achieved in the Region.
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3. CONCLUSIONS AND RECOMMENDATIONS 3.1 Conclusions
Participants discussed JE surveillance and immunization as well as progress made and lessons learnt in efforts to control JE in the Western Pacific Region. Participants agreed that accelerated control of JE is critical for the Region and noted that Member States are in different stages. While some still need to accelerate control, others that have achieved control in the target population will need to maintain control.
During the consultation, participants agreed with operational targets recommended by the TAG and proposed a timeline and strategies and actions for achieving the operational targets.
3.2 Recommendations
3.2.1 Recommendations for Member States
(1) Member States are encouraged to make efforts to reach the primary regional target of reducing JE incidence to less than 0.5 cases per 100 000 population in the targeted population (typically children under 15 years of age) in affected areas (national and subnational) by 2030.
(2) Member States that do not have high-quality JE surveillance should reach the intermediate regional target of at least 95% coverage with primary JE vaccine series among the targeted population in affected areas by 2030.
(3) Efforts by Member States to achieve targets for accelerated control of JE should be guided by strategies included in eight strategic areas discussed at the consultation (see Recommendations for WHO Secretariat for the eight strategic areas and accompanying strategies).
3.2.2 Recommendations for WHO Secretariat
The consultation participants recommended strategies in eight strategic areas that WHO headquarters, the WHO Regional Office for the Western Pacific and Member States should use to achieve
accelerated control of JE in the Region.
A summary of the strategic areas and strategies will be included in the technical guidance on how to achieve accelerated control of JE in the Western Pacific Region and will be presented to the TAG in June 2018. The strategic areas are as follows:
(1) Overall planning and immunization system
a. Ensure that Member States’ JE immunization policies are guided by National Immunization Technical Advisory Groups (NITAGs).
b. Ensure evidence-based decisions on the type(s) of vaccines and schedules used in national immunization programmes.
c. Establish guidance on the duration of protection and need for booster dose(s) of vaccines used in national immunization programmes.
d. Provide guidance on vaccination approaches for specific risk groups and special circumstances.
15 (2) Vaccine supply, quality and logistics
a. Support countries to secure sufficient and timely supply of vaccines.
b. Work to diversify a supply base for vaccines.
(3) Immunization delivery
a. Provide additional guidance on immunization delivery for specific risk groups and special circumstances.
b. Ensure JE vaccination is fully incorporated into routine immunization programmes.
(4) Disease surveillance
a. Ensure that all Member States with JE virus transmission risk have or develop high-quality JE surveillance.
b. Develop a definition of JE outbreaks.
c. Consider confirming virus circulation in animals and/or mosquitoes where JE disease in humans is well controlled.
(5) Monitoring progress
a. Ensure that JE vaccination coverage is monitored, reported and disseminated to all levels in Member States.
b. Provide guidance on methods for determining and reporting JE incidence and JE vaccination coverage that will be used consistently across the Region.
c. Strengthen monitoring and reporting of adverse events following immunization.
(6) Advocacy and communication
a. Establish and maintain a high level of advocacy for JE control.
b. Establish and maintain a high level of awareness of JE among health-care providers.
(7) Financing
a. Support financing activities to achieve accelerated control of JE.
(8) Research questions and needs
a. Identify needs for further research.
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17 ANNEXES Annex 1. Agenda
1. Opening session
2. Overview of meeting and expected outcomes 3. Regional overview of Japanese encephalitis 4. Japanese encephalitis surveillance in the WPR 5. Japanese encephalitis Laboratory Network 6. PATH update on JE vaccine support in WPR
7. Accelerated control of JE: Summary of Regional Framework and First Expert Consultation on Accelerated Control of JE in the Western Pacific Region 8. Experiences from countries with longstanding, effective JE control programmes
– Japan
– Republic of Korea – Malaysia
9. Experiences from countries that have recently introduced JE vaccine or are striving to control JE
– China – Viet Nam
– Lao People's Democratic Republic – Cambodia
10. Experiences from countries that have not introduced JE vaccine – Brunei Darussalam
– Philippines – Papua New Guinea
11. Working Group Session: Country situation analysis, strategy development and activity planning
12. Plenary Session: Regional strategy development, activity planning and timelines
13. Review of draft technical guidance on achieving accelerated control of JE in the Western Pacific Region
14. Review of main issues, challenges, strategies and best practices identified for achieving accelerated control of JE
15. Closing session
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19 Annex 2. Timetable
SECOND CONSULTATION ON ACCELERATED CONTROL OF JAPANESE ENCEPHALITIS IN THE WESTERN PACIFIC REGION
Manila, Philippines, 22–24 May 2018
Time Tuesday, 22 May 2018
Time
Wednesday, 23 May 2018
Time
Thursday, 24 May 2018
08:00 – 08:30 08:30 – 09:00
09:00 – 09:10 09:10 – 09:35 09:35 – 09:50 09:50 – 10:05
Registration 1. Opening session
Welcome remarks by the Responsible Officer
Opening remarks of the Regional Director
Self-introduction, Election of Officers
Administrative announcements
Group photo
2. Overview of meeting and expected outcomes 3. Regional overview of Japanese encephalitis 4. Japanese encephalitis surveillance in the WPR 5. Japanese encephalitis Laboratory Network
08:30 – 08:45
08:45 – 09:10 09:10 – 09:35 09:35 – 10:00 10:00 – 10:30
Summary of Day 1
10. Experiences from countries that have not introduced JE vaccine
10.1 Brunei Darussalam 10.2 Philippines 10.3 Papua New Guinea Discussion
08:30 – 08:45 08:45 – 10:15
Day 2 summary
13. Review of draft technical guidance on achieving accelerated control of JE in the Western Pacific Region
10:05 – 10:30 COFFEE BREAK 10:30 – 11:00 COFFEE BREAK 10:15 – 11:15 COFFEE BREAK
10:30 – 10:45 10:45 – 11:00
11:00 – 11:45
6. PATH update on JE vaccine support in WPR 7. Accelerated control of JE: Summary of Regional
Framework and First Expert Consultation on Accelerated Control of JE in the Western Pacific Region
Discussion
11:00 – 12:30 11. Working Group Session: Country situation analysis, strategy development and activity planning (2 groups)
11:15 – 12:30 13. Review of draft technical guidance on achieving accelerated control of JE in the Western Pacific Region (cont.)
11:45 – 12:45 LUNCH BREAK 12:30 – 13:30 LUNCH BREAK 12:30 – 13:30 LUNCH BREAK
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12:45 – 13:10 13:10 – 13:35 13:35 – 14:00 14:00 – 14:30
8. Experiences from countries with longstanding, effective JE control programmes
8.1 Japan
8.2 Republic of Korea 8.3 Malaysia Discussion
13:30 – 14:30 11.1 Reports from working groups on country situation analysis, strategy development and activity planning
13:30 – 14:30
14:30 – 15:00
15:00 – 15:30
13. Review of draft technical guidance on achieving accelerated control of JE in the Western Pacific Region (cont.)
14. Review of main issues, challenges, strategies and best practices identified for achieving accelerated control of JE
Discussion
14:30 – 15:00 COFFEE BREAK 14:30 – 15:00 COFFEE BREAK 15:30 – 16:00 COFFEE BREAK
15:00 – 15:25 15:25 – 15:50 15:50 – 16:15 16:15 – 16:40 16:40 – 17:10 18:00
9. Experiences from countries that have recently introduced JE vaccine or are striving to control JE
9.1 China 9.2 Viet Nam
9.3 Lao People's Democratic Republic 9.4 Cambodia
Discussion RD's Reception
15:00 – 16:00 12. Plenary session: Regional strategy development, activity planning and timelines
16:00 – 16:30 15. Closing session
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Annex 3. List of participants, temporary advisers, observers and Secretariat
1. PARTICIPANTS
BRUNEI DARUSSALAM Dr Lena binti MAT SALLEH, Medical Officer Office of the Director of Environmental Health Services, Ministry of Health, Commonwealth Drive,
Bandar Seri Begawan BB3910
Tel. No.: +673 717 6406, Fax No.:+673 238 0316 Email: [email protected]
Dr Linda LAI, Senior Medical Officer
Child Health Immunization Manager, Ministry of Health, Commonwealth Drive, Bandar Seri Begawan BB3910 Tel. No.: +673 878 0078, Fax No.:+673 238 1165 Email: [email protected]
CAMBODIA Mr ORK Vichit, Manager, National Immunization Program Ministry of Health, Phnom Penh
Tel. No.: +855 1283 0548, Fax No.:+855 2342 6257 Email: [email protected]
Mr SIPHAN Sovannara, Surveillance Officer
National Immunization Program, Ministry of Health, Phnom Penh Tel. No.: +855 1754 5373, Fax No.:+855 2342 6257
Email: [email protected]
CHINA Dr WANG Huanyu, Professior, Department of Viral Encephalitis Institute for Viral Disease Control and Prevention, Beijing
Tel. No.: +8610 5890 0842, Email: [email protected]
Ms WU Dan, Research Assistant, National Immunization Program, China Center for Disease Control and Prevention, Beijing
Tel. No.: +8610 8315 9521, Email: [email protected]
JAPAN Dr Satoru ARAI, Senior Research, National Institute of Infectious Diseases, Tokyo, Tel. No.: +813 5285 1111, Fax No.:+813 5285 1129 Email: [email protected]
LAO PEOPLE'S Dr Bounthanom SENGKEOPRASEUTH, Deputy Chief of DEMOCRATIC Epidemiolog Unit, National Center for Laboratory and REPUBLIC Epidemiology, Ministry of Health, Vientiane
Tel. No.: +856 2131 2351, Fax No.:+856 2131 5006 Email: [email protected]
Dr Khammany PHOMMACHANH, Director of Setthathilat Hospital, Maternal and Child Health Center, Vientiane
Tel. No.: +856 020 222 19902, Fax No. : +856 021 452 519 Email: [email protected]
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MALAYSIA Dr Khairiah IBRAHIM, Head of Unit (Filariasis/JE/Chiku) Vector Borne Disease Sector, Disease Control Division Ministry of Health Malaysia, 62590 Putrajaya
Tel. No.: +603 8883 4264/ +601 2292 1098, Fax No.:+603 8888 6215 Email: [email protected]
Dr A'aisah SENIN, Head of Sector, Vaccine Preventable Food and Waterborne Diseases, Disease Control Division, Ministry of Health Malaysia, 62590 Putrajaya
Tel. No.: +601 9331 2382/8883 4411, Fax No.: +603 8889 1013 Email: [email protected]
PAPUA NEW GUINEA Dr Mathias BAURI, Program Officer
Expanded Program on Immunisation, National Department of Health P.O. Box 807, Port Moresby, Tel. No.: +675 301 3792
Email: [email protected]
Mr Willie PORAU, Laboratory Manager, Central Public Health Laboratory National Department of Health, P.O. Box 807, Port Moresby
Tel. No.: +675 324 8199, Email: [email protected]
PHILIPPINES Dr Maria Wilda T. SILVA, Medical Specialist II, Department of Health San Lazaro Compound, Sta. Cruz, Manila, Tel.No.: +632 732 9956 Fax No.:+632 732 9956, Email: [email protected]
Ms Jezza Jonah D. CRUCENA Snurse III, Epidemiology Bureau Department of Health, San Lazaro Compound, Sta. Cruz, Manila Tel. No.: +632 917 566 7375, Email: [email protected] REPUBLIC OF KOREA Dr Hyungul JUNG, Deputy Scientific Director
OCTAC, 200, Osongsaengmyeong 2-ro, Osong-eup, Heungdeok-gu Chungcheongbuk-du 28160
Tel. No.: +8243 719 6822, Fax No.:+8243 719 6858 Email: [email protected]
Dr Hyekyung PARK, Director, Division of Infectious Diseases Surveillance 187 Osongsaengmyeong 2(i)-ro, Osong-eup, Heungdeok-gu, Cheongju-si Chungcheongbuk-do 28159
Tel. No.: +8243 719 7160, Fax No.:+8243 719 7188 Email: [email protected]
VIET NAM Assoc. Prof. DUONG Thi Hong, Vice Director, (Deputy EPI Manager) National Institute of Hygiene and Epidemiology, 1 Yersin Street Hai Ba Trung District, Hanoi
Tel. No.: +84 9711 588, Fax No.:+84 8213 782 Email: [email protected]
Dr NGUYEN Dac Trung, Researcher, National Institute of Hygiene and Epidemiology, 1 Yersin Street, Hai Ba Trung District, Hanoi
Tel. No.: +844 3972 1334/ +849 0215 7559, Fax No.:+844 3821 3782 Email: [email protected]
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2. TEMPORARY ADVISERS
Dr Piyanit THARMAPHORNPILAS, Senior Medical Advisor, Department of Disease Control,
Ministry of Public Health, Nonthaburi 11000, Thailand, Tel. No.:+66 89 969 0852, Fax No.:+66 2 590 3193, Email: [email protected]
Dr YIN Zundong, Deputy Director (Professor), National Immunization Programme, Chinese Center for Disease Control and Prevention, No.22 Nan Wei Rod, Xicheng District, Beijing 100050, People's Republic of China, Telefax No.: +8610 6317 4348, Email: [email protected]
Dr Chang Kweng LIM, Chief, laboratory of Arboviruses, Department of Virology 1, National Institute of Infectious Diseases, 1-23-1 Toyama Shinjuku-ku, Tokyo, Japan, Tel. No.: +81 905 660 15262,
Fax No.:+81 352 852 188, Email: [email protected]
Dr Susan HILLS, Medical Officer, Surveillance and Epidemiology Activity, Arboviral Disease Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins CO 80521, United States of America, Tel. No.: +01 970 266 2351/ 01 970 231 4928, Email: [email protected]/
3. OBSERVERS/REPRESENTATIVES
PATH Dr George William (Bill) LETSON, Scientific Advisor
Japanese Encephalitis, Center for Vaccine Innovation and Access PATH, 2201 Westlake Ave., Suite 2000, Seattle, Washington 98121 United State of America, Tel. No.: +1 206 302 4853
Email: [email protected]
CENTERS FOR DISEASE Dr Susan CHU, Senior Epidemiologist, Global Immunization Division CONTROL AND Centers for Disease Control and Prevention
PREVENTION 1600 Clifton Road, NE Mailstop A-04, Atlanta, GA 30329-4027 (CDC) United States of America
Tel. No.: +1 404 639 6084, Fax No.:+1 404 639 8676 Email: [email protected]
Ms Anyie LI, Fellow, Global Immunization Division Centers for Disease Control and Prevention
1600 Clifton Road, NE Mailstop A-04, Atlanta, GA 30329-4027 United States of America
Tel. No.: +1 404 718 5704, Fax No.:+1 404 639 8676 Email: [email protected]
4. SECRETARIAT
WHO REGIONAL OFFICE Dr Yoshihiro TAKASHIMA, Coordinator, Expanded Programme on FOR THE WESTERN Immunization, World Health Organization, Regional Office for the PACIFIC Western Pacific, United Nations Ave., 1000 Manila, Philippines
Tel. No.: +632 528 9746, Fax No.: +632 521 1036 Email: [email protected]
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WHO REGIONAL OFFICE Dr James HEFFELFINGER, Technical Officer, Expanded Programme on FOR THE WESTERN Immunization, World Health Organization, Regional Office for the
PACIFIC Western Pacific, United Nations Ave., 1000 Manila, Philippines (continuation) Tel. No.: +632 528 9033, Fax No.: +632 521 1036
Email: [email protected]
Dr Ananda AMARASINGHE, Technical Officer, Expanded Programme on Immunization, World Health Organization, Regional Office for the
Western Pacific, United Nations Ave., 1000 Manila, Philippines Tel. No.: +632 528 9032, Fax No.: +632 521 1036
Email: [email protected]
Dr Nyambat BATMUNH, Technical Officer, Expanded Programme on Immunization, World Health Organization, Regional Office for the Western Pacific, United Nations Ave., 1000 Manila, Philippines Tel. No.: +632 528 9741, Fax No.: +632 521 1036
Email: [email protected]
Ms Analisa BAUTISTA, Technical Officer, Expanded Programme on Immunization, World Health Organization, Regional Office for the Western Pacific, United Nations Ave., 1000 Manila, Philippines Tel. No.: +632 528 9025, Fax No.: +632 521 1036
Email: [email protected]
APW Dr Carsten MANTEL, Managing Director, MMGH Consulting GmbH Kuerbergstr.1, 8049, Zurich, Switzerland
Tel. No.: +49 171 3023 930, Email: [email protected] WHO PHILIPPINES Dr Kohei TODA, Medical Officer, Expanded Programme on
Immunization, WHO Representative in the Philippines, Ground Floor Building 3, Department of Health, San Lazaro Compound, Sta. Cruz, Manila, Philippines, Tel. No.: +632 528 9673, Fax No.: +632 310 6550
Email: [email protected]
WHO HEADQUARTERS Dr Ikechukwu OGBUANU, Medical Officer, Expanded Programme on Immunization Plus, Department of Immunization, Vaccines and Biologicals, World Health Organization, Avenue Appia 20, 1211 Geneva 27,
Switzerland, Tel. No.: +41 22 791 3003, Fax No.: +4122 791 0746 Email: [email protected]
