WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Transcription

1

2 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC REPORT FOURTEENTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao People's Democratic Republic 9-10 December 2008 For internal use only Manila, Philippines February 2009

3 NOTE The views expressed in this report are those of the participants of the fourteenth meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization. Keywords: Immunization / Poliomyelitis prevention and control / Certification This report has been printed by the Regional Office for the Western Pacific of the World Health Organization for the participants of the fourteenth meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region, which was held in Vientiane, Lao People's Democratic Republic, from 9-10 December 2008.

4

5 CONTENTS 1. INTRODUCTION Objectives Organization Opening ceremony PROCEEDINGS Global overview of poliomyelitis eradication (as of December 2008) Regional overview of the situation after poliomyelitis-free certification including country highlights CONCLUSIONS General Country specific conclusions and recommendations Page ANNEXES: ANNEX 1 - TIMETABLE ANNEX 2 - LIST OF PARTICIPANTS ANNEX 3 - SUMMARY SHEETS (PER COUNTRY) TO REVIEW COUNTRY PROGRESS REPORTS

6 1. INTRODUCTION The Regional Commission for the Certification of Poliomyelitis Eradication (RCC) in the Western Pacific Region (WPR) continues to meet on an annual basis in order to review and support maintenance of poliomyelitis-free status and certification standard quality requirements and to fulfil its reporting mandate to the Global Certification Commission (GCC). 1.1 Objectives The objectives of the RCC at its fourteenth meeting were: (1) to review progress reports from all countries and areas on maintaining the poliomyelitis-free status; (2) to review status of laboratory containment of wild poliovirus infectious/potentially infectious materials; and (3) to make recommendations for maintaining the Region's poliomyelitis-free status. 1.2 Organization In one of its most successful public health endeavours ever, the Lao People's Democratic Republic successfully eliminated poliomyelitis in 1996 and was officially certified as poliomyelitis-free in October 2000, together with all other Member States in the WHO WPR. However, as poliomyelitis has not yet been globally eradicated, wild poliovirus continues to be brought back into poliomyelitis-free countries and repeated regional and transcontinental spread has particularly occurred from Nigeria and India. Such wild poliovirus importations had recently also been confirmed into less expected places like Myanmar (2007), Australia (2007) and Singapore (2006) and with increased international travel into the Lao People's Democratic Republic and in-country population movements, it could likewise happen there. In this context, the Lao People's Democratic Republic decided to provide oral poliovirus vaccine (OPV), along with vitamin A and deworming tablets, in high-risk areas during its Child Health Days, held from 8 to 22 December High-risk areas selected included international travel entry points, areas with a high population density, areas with mobile populations, including tourist destinations and low-coverage areas. Over children under five years of age were targeted in 58 priority districts in 12 provinces. A second dose of OPV would be offered in early February To observe this poliomyelitis vaccination campaign and support the efforts the Lao People's Democratic Republic is undertaking to maintain its poliomyelitis-free status, the RCC held its annual meeting in Vientiane from 9 to 10 December This offered an important advocacy opportunity to emphasize the significance of and requirements for maintaining the country's poliomyelitis-free status, which is not only a national interest but also of importance for the whole Region. The meeting was attended by six of the seven commission members and a WHO Secretariat. Annex 1 includes the meeting timetable, and Annex 2 contains a list of participants. The opening ceremony was attended by members of the National Certification Committee (NCC) and officials of the Ministry of Health (MOH).

7 Opening ceremony Dr Dongil Ahn, WHO Representative in the Lao People's Democratic Republic presented the opening remarks of Dr Shigeru Omi, the WHO Regional Director in the Western Pacific. Dr Omi expressed that he was very pleased that this important meeting was held in Vientiane and sincerely thanked the Government of the Lao People's Democratic Republic for the opportunity and hospitality. He shared his strong sense of the Lao People's Democratic Republic being one of countries in the Region most vulnerable to wild poliovirus importation and subsequent large poliomyelitis outbreaks because in recent years the routine immunization coverage against poliomyelitis has been low and many children may no longer be protected against the disease. In this context, he applauded the Government of the Lao People's Democratic Republic for its decision to conduct two rounds of supplementary immunization activities against poliomyelitis. He was particularly pleased that OPV administration was integrated into the Child Health Days which are significantly supported by UNICEF, one of WHO's most important partners to provide health and well-being to children. Dr Omi recalled that this approach built on the successful national measles immunization campaign held in 2007 but stressed the need to accelerate improvements in routine immunization coverage especially through implementation of the new mother and child health (MCH) package. Dr Omi summarized that two weeks before the RCC meeting, the global Advisory Committee on Polio Eradication (ACPE) met in Geneva to review the situation of the global programme and decide how the 2009 to 2010 milestones should be adjusted given that major 2007 to 2008 milestones were not achieved in four endemic and five re-infected countries. The meeting also discussed what needs to be considered for areas with sub-optimal OPV efficacy, particularly northern India, and whether the tactics being employed in Nigeria, Pakistan and Afghanistan address the chronic gaps in supplementary OPV immunization activities. It also addressed what further measures can reduce the risks and consequences of international spread of polioviruses. To support its Member States, WPRO, in close consultation with all key partners, developed a 'Regional Strategic Plan for the Maintenance of Polio-free Status '. This strategy spells out technical requirements, clarifies roles and responsibilities for certification bodies in the period between regional and global certification, and is to be used for advocacy purposes and fund-raising. The document was presented to RCC at this meeting for endorsement. Furthermore, Dr Omi expressed how particularly pleased he was that China and Japan were submitting their final quality assessment reports on phase 1 wild poliovirus laboratory containment to the meeting, indicating that survey activities have been completed and national inventories have been established. The completion of phase 1 for the whole region would be another historic event in public health.

8 -3-2. PROCEEDINGS 2.1 Global overview of poliomyelitis eradication (as of December 2008) Endemic countries Nigeria In 2008, 783 wild poliovirus cases have been reported (714 type 1 and 68 type 3). The ongoing type 1 poliomyelitis outbreak in the north of the country continued to spread, as new associated cases were reported from neighbouring countries in West Africa. The risk of additional importations into these countries depends fully on the quality of supplementary immunization activities (SIAs) in northern Nigeria. In late November to early December, nationwide staggered integrated measles campaigns with monovalent oral polio vaccine type 1 (mopv1) were conducted. While monitoring data indicate overall good quality was achieved in the southern states, the activity in highest-risk northern states was again affected by suboptimal quality, such as inadequate vaccinator and supervisor performance and poor microplanning, in particular in the highest-risk Local Government Areas (LGAs) of Bauchi, Kano, Kaduna, Katsina and Zamfara. More than 60% of children in these states remained under-immunized like those having less than three doses of OPV, and these areas accounted for more than 70% of the country's type 1 cases. Kano State remains the global epicentre of type 1 poliomyelitis, accounting for nearly 30% of the worldwide type 1 burden. In Nigeria, the re-invigorated high-level political commitment at the national level must be urgently translated into field-level improvements in operational quality. Key to achieving this is increased political engagement at state and LGA levels. Nationwide Immunization Plus Days (IPDs) were planned for late January 2010 and again in February. India In 2008, 546 wild poliovirus cases have been reported (66 type 1 and 480 type 3). Aggressive outbreak response was continuing in western Uttar Pradesh, to stop an ongoing type 1 poliomyelitis outbreak. Virtually all type 1 poliomyelitis reported from India over the past six months was related to this ongoing outbreak. Western Uttar Pradesh had been free of endemic type 1 poliomyelitis for nearly 18 months, before being re-infected in mid-2008 from neighbouring Bihar state. National Immunization Days (NIDs) were held on 21 December, using mopv1 in Bihar, Uttar Pradesh and key re-infected areas, and trivalent OPV in the rest of the country. The second NID round will be held on 1 February Pakistan and Afghanistan In 2008, 116 wild poliovirus cases have been reported in Pakistan (79 type 1 and 37 type 3); and 31 wild poliovirus cases have been reported in Afghanistan (24 type 1 and seven type 3). In Afghanistan, preparations were ongoing for the next NIDs, planned for 11 to 13 January Polio was largely restricted to security-compromised areas in the country's southern region. To increase access, windows of opportunity in key high-risk districts

9 -4- are increasingly being used in between large-scale campaigns to deliver an additional dose as and when areas become accessible. In Pakistan, despite overall good nationwide coverage during SIAs, the quality of operations was inconsistent across some areas. Due to very efficient poliovirus transmission in the country, these remaining vaccination coverage gaps must be urgently filled. In the transmission zones of North West Frontier Province (NWFP) and Sindh, ongoing coverage gaps were primarily due to hampered access to populations in security-compromised areas of NWFP, and suboptimal campaign quality in Sindh, with inadequate vaccinator performance and suboptimal microplanning. While some improvements were noted in Sindh during recent campaigns, key to overcoming the operational challenges is increased political ownership at the district level. In NWFP, despite efforts to increase access to populations during large-scale activities, more than 15% of the target population in this area was again missed due to insecurity during the NIDs on 24 November Strong progress continued to be achieved in the re-infected areas, notably Punjab, as evidenced by the steep decline in type 1 cases over a relatively short period during the previous months, despite the 'high season' for poliovirus transmission. Punjab had been poliomyelitis-free, but became re-infected in mid-2008 by an importation from security-compromised areas of NWFP Re-infected countries West Africa In 2008, 35 wild poliovirus cases have been reported from six countries (type 1: three in Benin, four in Burkina Faso, nine in Ghana, one in Mali, 13 in Niger and three in Togo; type 3: two in Niger). The confirmation of new poliomyelitis cases in Benin, Burkina Faso, Ghana and Togo underscored that West Africa continues to be at risk of international spread of poliomyelitis from northern Nigeria. The risk of further circulation or additional importations into these western African countries depends fully on the quality of SIAs in northern Nigeria and of the outbreak response activities in the re-infected countries. Large-scale emergency outbreak response activities were continuing in these six countries in west Africa, and the feasibility of conducting preventive campaigns in other high-risk countries, notably Côte d'ivoire, was explored. It is important that countries across west Africa strengthen disease surveillance for acute flaccid paralysis (AFP), in order to rapidly detect any poliovirus importations and facilitate a rapid response. Chad In 2008, 33 wild poliovirus cases have been reported (one type 1 and 32 type 3). Confirmation of new cases from the east, south and the west of the country provided further evidence that Chad was affected by widespread geographic transmission of both type 1 and type 3 poliomyelitis. With suboptimal outbreak response activities implemented in 2008 (in quality, scope and timeliness), and subnational surveillance gaps, the risk of further spread of poliomyelitis within Chad and bordering countries is high.

10 -5- The key remains to urgently improve the quality of operations, as more than 40% of children were regularly missed during activities this year. Full political engagement and accountability, beginning with the President's office downward, is urgently needed. Horn of Africa In 2008, 23 wild poliovirus cases have been reported from two countries (22 type 1 from the southern Sudan/western Ethiopia cross-border area; one type 3 in West Darfur, Sudan). Outbreak response campaigns continued across the Horn of Africa with the overriding priority to stop the type 1 outbreak in southern Sudan/western Ethiopia. The key challenge is to increase access to populations in remote and/or conflict-affected areas. Central Africa (Angola, Democratic Republic of Congo and Central African Republic) In Angola, 26 wild poliovirus cases have been reported, three type 1 and 23 type 3. In December, accelerated routine immunization activities were conducted. During such activities, a range of vaccines, including trivalent OPV, were offered to communities using a fixed site approach. Further campaigns were planned for January In DR Congo, five wild poliovirus cases have been reported (four type 1 and one type 3). A type 3 case was reported in the south (Kasai Occidental), the first in the country since September 2000, genetically-related to type 3 circulating in neighbouring Angola. An emergency outbreak response mop-up was conducted in the affected area with monovalent OPV type 3 (mopv3), targeting 300,000 children under the age of five years. Further mopv3 campaigns were planned for early February In the meantime, outbreak response to the type 1 outbreak in the east of the country was continuing with mopv1. Additionally, preventive campaigns were carried out in the west of Uganda, Burundi and Rwanda, to prevent spread of type 1 poliomyelitis from DR Congo. There was large-scale movement of refugees from DR Congo in particular into Uganda. In CAR, two wild poliovirus cases have been reported (both type 1). The risk of further importations from both Chad (to the north) and the Democratic Republic of Congo (to the south) remains high. Asia (Nepal) In 2008, six wild poliovirus cases have been reported (all type 3). Nepal remains at risk of importations from India, and continues to conduct preventive immunization activities as well as outbreak response mop-ups. 2.2 Regional overview of the situation after poliomyelitis-free certification including country highlights Certification process Since certification, the RCC has continued to meet on an annual basis to review written progress reports from all countries and areas with particular emphasis on ongoing surveillance, maintenance of high immunization rates, wild poliovirus importation preparedness, progress with laboratory containment of wild poliovirus infectious/potentially infectious materials and evidence of continued political commitment on the part of governments.

11 -6- Active National Certification Committees (NCCs) remain in place in almost all countries and some, in places with small populations and limited technical expertise, also function as expert panels to review and classify AFP cases as required. Immunization coverage Reported routine immunization coverage against poliomyelitis has been maintained at levels similar to previous years and at certification time; with the large majority of countries achieving over 70%. Figure 1: Reported national polio3 coverage (data source: WHO/UNICEF Joint Reporting Form on Immunization/JRF data for 2007; 2006 JRF data 2006 for Guam; 2005 JRF data Brunei Darussalam) However, the reported coverage may overestimate protection as it is known that immunity gaps continue to exist in some areas, particularly in the Lao People's Democratic Republic, Papua New Guinea, some Pacific island countries (PICs) and areas, and high-risk communities and populations in China and the Philippines. This has also been indicated by various vaccine derived poliovirus (VDPV) episodes in the Region. There is great variety among national immunizations schedules. In 2008, 12 countries and areas used inactivated poliovirus vaccine (IPV) and 24 used OPV, of which two (Japan and Macao/China) were planning to shift to IPV in the near future. With the Region free of wild poliovirus for over 10 years, risks of vaccine associated paralytic poliomyelitis (VAPP) and VDPV emergence increasingly influence vaccination policy changes. Two countries still report giving an OPV birth dose and 20/36 countries provide poliomyelitis vaccine booster doses. Supplementary immunization with OPV has been gradually reduced since certification, mainly due to lack of funding, and is usually conducted in high risk areas.

12 -7- Quality of poliomyelitis / AFP surveillance In the majority of countries in the Region, poliomyelitis surveillance is based on reporting and investigation of AFP cases; with public health staff at various levels supposed to conduct active searches for cases on a regular basis. In several countries and territories, like Australia, Hong Kong/China, New Zealand, Singapore, all practitioners or key physicians, mainly paediatricians and other hospital clinicians, are supposed to notify AFP cases involving children less than 15 years of age to designated surveillance units which will further coordinate complete investigation. Surveillance including laboratory data are regularly submitted to WHO, reviewed for data quality and system performance levels and published in the weekly poliomyelitis surveillance bulletin. All other surveillance standards should be maintained at certification levels as recommended by the RCC or other global poliomyelitis advisory bodies. Since certification, over 75,000 AFP cases have been investigated and the overall key quality indicators have remained stable; with a regional non-poliomyelitis AFP rate consistently above 1 per 100,000 children under 15 years of age and the adequate stool sample collection rate almost reaching 90%. Figure 2: Regional non-poliomyelitis AFP rate and percentage of cases with adequate stool samples, 1992 to 2008 (dataset as of 17 November 2008, annualized for 2008) Non-polio AFP rate non-polio AFP rate % AFP cases with adequate specimens 20% 27% 45% 71% 79% 83% 86% 86% 90% 88% 88% 88% 88% 88% 89% 90% 85% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % AFP cases with adequate specimens Although there is variation between the years, most countries maintain adequate levels of AFP case reporting and the RCC requests that regular data analysis at appropriate subnational levels is being conducted to identify and respond to surveillance gaps. Countries that did not yet achieve a minimum rate of 1 in 2008 at the time of the RCC meeting included Australia, Mongolia, New Zealand, the PICs, Papua New Guinea and Singapore. The Republic of Korea, to date, has conducted a special active AFP study in the greater Seoul area from 2001 to 2007 and environmental surveillance projects, supplemented by case reporting from 105 sentinel hospitals.

13 -8- Figure 3: Non-poliomyelitis AFP rate by country in the WPR, 2006 to 2008 (data set as of 25 November 2008) Non-polio AFP rate Australia Brunei Darussalam Cambodia China Hong Kong, China Korea, Republic of Lao PDR Macao, China Malaysia Mongolia New Zealand PIC Papua New Guinea Philippines Singapore Vietnam In several countries AFP surveillance is being supplemented by stool surveys in healthy children or collecting stool samples from AFP case contacts. Others identify polioviruses through enterovirus surveillance systems. Vaccine derived polioviruses Since certification, three poliomyelitis outbreaks occurred due to cvdpv; in 2001, in the Philippines (three AFP cases and one positive contact); in 2004, in China (two AFP cases and four positive contacts); and from November 2005 to January 2006, in Cambodia (two AFP cases and one AFP case without VDPV but epidemiologically linked). All outbreaks were stopped with OPV campaigns. Fast evolving type 2 and 3 ivdpvs were detected in a child with X-linked agammaglobulinemia (XLA) and AFP in China in 2005 which continued shedding until it died in Twenty four ambiguous VDPVs (avdpv) have been reported in the WPR; of which half were identified proactively through AFP surveillance since 2003, and the other half through retrospective laboratory testing after the new intratypic differentiation (ITD) standard test requirements had had been introduced. Among these avdpv episodes, in four instances, VDPVs were also isolated from healthy contacts indicating limited transmission (China in 2000, Lao People's Democratic Republic from November 2004 to February 2005; China in 2006 and 2007). However, as in each event, not more than one AFP case was identified, the current definition of cvdpv was not applicable.

14 -9- Regional poliovirus laboratory network The poliomyelitis laboratory network in the WPR in 2008 is comprised of one global specialized (Japan), two regional reference (Australia, China), nine national and 31 Chinese provincial poliovirus laboratories. Figure 3: Polio laboratory network in the WPR PHI Global Specialized Lab (1) CCDC Regional Reference Lab (2) KCDC NIID National Lab doing ITD (3) National Lab w/o ITD (6) NIHE GVU RITM China Provincial Lab (31) Pasteur I. IMR SGH IMR(to VIDRL) VIDR L IESR All laboratories participate in annual proficiency tests provided by the Global Poliomyelitis Laboratory Network and undergo regular external accreditation. All laboratories, except the provincial laboratory in Tibet (China), are currently accredited and performing under general WHO standards. Three national-level laboratories (Hong Kong/China, New Zealand, Singapore) are also accredited for ITD. Countries and areas without their own poliovirus laboratories have access to an accredited laboratory within the regional network; Brunei Darussalam, Papua New Guinea and the PICs submit their samples to the Regional Reference Laboratory in Australia, Macao/China to the laboratory in Hong Kong/China and Lao People's Democratic Republic and Cambodia to the Global Specialized Laboratory in Japan. Poliovirus isolation and typing results in 2007 were available within 28 days of receipt for 96% of samples (95% in 2008; with all national-level and provincial laboratories achieving the target). The non-polio enterovirus (NPEV) isolation rate was 9% (same in 2008), slightly below target at similar levels as in previous years. Regular analysis is required at country levels if minimum rates may indicate problems either during sample storage and transportation (reverse coldchain) and/or laboratory testing. Availability of ITD results within 14 days of receipt was 58% (76% in 2008) and 52% within 60 days of paralysis onset (37% in 2008); these decreased performance indicators were mainly due to continued global shortage of ELISA ITD reagents and new, stricter bio-safety requirements in China, affecting timely transportation of specimens and isolates.

15 -10- The new checklists, emphasizing the timely reporting of cell sensitivity testing and management, supervision and biosafety, have been introduced to the global poliomyelitis laboratory network in January It is also planned to introduce the new test algorithm for poliovirus isolation and characterization for the Region's poliomyelitis laboratory network as recommended by the Global Poliomyelitis Laboratory Network Meeting in June 2006 and by the 17 th meeting of the Technical Advisory Group (TAG) on Immunization and Vaccine Preventable Diseases in the WPR in July Meanwhile national laboratories are still encouraged to perform neutralization test for polioviruses. It is expected to reduce the laboratory reporting time for poliovirus isolation and ITD from 42 days to 21 days by implementing the new algorithm. Figure 4: Poliomyelitis laboratory network performance indicators, 2005 to 2008 (dataset as of 17 November 2008) 100% 97% 96% 96% 95% 99% 94% % 83% 76% 88% 79% 73% 88% 86% 60% 58% 55% 52% 60% 63% 40% 40% 37% 20% 10% 10% 9% 9% 0% NPEV isolation rate % NPL results within 28 days ITD within 14 days of receipt ITD within 28 days of receipt ITD within 60 days of onset ITD within 90 days of onset Risk assessment for spread of imported wild poliovirus The risk for wild poliovirus importation into countries in the Region continues, especially when poliomyelitis outbreaks occur in close geographical proximity and/or places with frequent population movements such as the 2005 poliomyelitis outbreak in Indonesia. The risk was further confirmed by recent importations into less expected places like in Australia and Singapore. One of the requirements for Regional certification for countries had been to have a national preparedness in place and consider detection of wild poliovirus as a national public health emergency. Several Member States outside the Pacific have current plans available which take standing recommendations the Advisory Committee for Polio Eradication (ACPE) made in 2004 and the subsequent WHO World Health Assembly (WHA) resolution (WHA59.1) as well as new reporting requirements under the International Health Regulations (IHR) 2005 into account or are in the process of updating national plans (e.g. Australia, China, Lao People's Democratic Republic). Wild poliovirus laboratory containment

16 -11- Maintaining poliomyelitis-free status includes accurate and updated national inventories of wild poliovirus infectious and potentially infectious materials still retained in laboratories to ensure they are safely stored under bio-safety conditions required. In 2005, all countries, except China and Japan, had prepared laboratory containment quality assessment (QA) reports, which were subjected to external review by several senior containment experts. After the consolidation of their conclusions on the thoroughness and reliability of the national surveys and inventories, findings were presented and recommendations made at the 11 th RCC meeting in December The RCC subsequently concluded that 34 countries have successfully completed phase I laboratory containment (national/subregional survey and inventory). With China and Japan submitting their final QA reports to the 14 th RCC meeting in December 2008, concluding about completion of phase 1 for the whole region was in sight. There are currently four countries in the Region holding wild poliovirus infectious and/or potentially infectious materials: Australia, China, Japan and the Republic of Korea. The RCC has reminded all Member States that a major objective of phase 1 wild poliovirus laboratory containment is to encourage laboratories to eliminate unnecessary wild poliovirus (including VDPV) infectious and potential infectious materials and provide documentation of actions. It also highlighted that implementation of poliovirus laboratory containment is independent of global certification and could be required as early as Future poliovirus laboratory containment requirements will be defined in the third edition of the WHO Global Action Plan, which is currently under preparation. Regional Strategic Plan for the Maintenance of Poliomyelitis-free Status Currently, it is expected that interruption of wild poliovirus transmission may occur globally the earliest at the end of 2010, and global certification earliest end of The challenge to the Region and its Member States continues to be to sustain AFP surveillance and poliomyelitis immunization at the levels needed for the early detection of and response to both, wild poliovirus importations and emergence of circulating vaccine-derived poliovirus. To support Member States in this task, the EPI, in close consultation with all key partners, developed a Regional Strategic Plan for the Maintenance of Polio-free Status to spell out technical requirements, clarify roles and responsibilities for certification bodies in the period between regional and global certification, and to be used for advocacy purposes and fund-raising. 3. CONCLUSIONS 3.1 General Based on annual progress reports received from all Member States of the Region, and following discussion of these reports at its 14th meeting, the RCC concluded that all countries of the Region have remained free of circulating poliovirus during Since the 13th RCC meeting, no country in the Region reported isolation of wild poliovirus, either from an AFP case or from other sources.

17 -12- The summary sheets used by the RCC to assess country progress reports are included in Annex 3. The review particularly focused on report quality, adequacy of preparedness for wild poliovirus importation, concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality and any gaps in immunization against poliomyelitis. The continued poliomyelitis-free status of the Region is the result of continued strong efforts in all Member States, supported by the NCCs and the RCC, to maintain both highly sensitive AFP/poliomyelitis surveillance systems and high levels of immunity against poliomyelitis in the population. The RCC also noted with great satisfaction the 'breakthrough' made in laboratory containment of wild poliovirus. Following an exhaustive laboratory survey and validation of phase I, both China and Japan presented full reports describing the process used to produce complete and accurate current national inventories of laboratories holding poliovirus infectious materials Persisting threat of re-importation of wild poliovirus The RCC once again expressed great concern at the overall lack of progress towards interrupting wild poliovirus transmission globally. Only one of the four main poliomyelitis eradication 'milestones' set at the global poliomyelitis eradication stakeholders' meeting in February 2007 was achieved; this is assuring adequate funding for the Global Polio Eradication Initiative (GPEI) six months in advance. However, transmission of both type 1 and type 3 wild poliovirus continues in the four endemic countries, with intensity of transmission of wild poliovirus type 1 increasing in Nigeria. Wild poliovirus transmission is ongoing in nine previously poliomyelitis-free countries following importation from endemic/infected countries. The RCC noted that the lack of progress, particularly in northern Nigeria, would once again require to shift the anticipated timeline until global eradication from end of 2009 to end of 2010 or later. By implication, the threat of wild poliovirus importation for countries of the WPR remains, and the RCC urged all WPR Member States and key partners to continue vigorously implementing all relevant activities to maintain the poliomyelitis-free status Draft regional strategic plan for maintaining poliomyelitis-free status The RCC appreciated that following its recommendation at the 13th meeting in December 2007, a detailed 'Regional Strategic Plan for the Maintenance of Poliomyelitis-Free Status ' has been drafted. The RCC fully endorsed the draft plan, which should, following final comments and suggestions at the 14th meeting, be finalized and distributed as soon as possible. Copies of the plan should be provided to other RCCs and the GCC. The RCC understood that, depending on progress towards interruption of transmission globally, the plan may need to be adjusted in the future. The RCC strongly encouraged that the strategic plan be used by all poliomyelitis eradication stakeholders at regional and country levels to 1) guide and implement all necessary activities during the period up to global certification of the interruption of wild poliovirus transmission, 2) for advocacy on continued commitment and 3) fund-raising purposes.

18 -13- The RCC also noted that some additional WHO support may be needed in order to translate the provisions of the plan, particularly on manpower, finances and political commitment, into action. It is suggested to the WHO Secretariat to develop a short additional guideline on how the plan should be used. In addition, opportunities should be sought by WHO country and Regional Office staff to directly brief NCC chairpersons and other relevant programme staff on activities suggested under the strategic plan. Also, where appropriate, RCC members may visit individual countries to promote and discuss the plan Maintenance of AFP surveillance The RCC was satisfied to see that the majority of WPR Member States were able to maintain AFP/poliomyelitis surveillance quality during 2008 at the necessary level of sensitivity or 'certification standard'; this includes the reporting of AFP cases and completeness of collection of adequate stool specimens. However, while overall quality levels have been maintained, review of country performances revealed that gaps exist at sub-national level in several Member States and need to be immediately addressed to ensure timely and reliable identification of circulating polioviruses. It was noted that several country progress reports mentioned the need for continuous efforts to retrain and sensitize new surveillance staff and clinicians on AFP surveillance, particularly in public health offices and priority health facilities with high staff turnover. The RCC strongly encouraged all national immunization programmes to deal with this important training need; also through better integrating AFP surveillance with surveillance for other vaccine-preventable diseases, or even with overall communicable disease surveillance. Poliomyelitis laboratory network The RCC was satisfied that the Regional poliomyelitis laboratory network continues to provide valuable high-quality laboratory support to Member States, noting in particular the contribution of the Regional Reference Laboratories in Australia and China and the Global Specialized Laboratory in Japan. As mentioned before, the RCC considered it vital to maintain high quality poliomyelitis laboratory testing capacity in the Region; with access for all Member States to such facilities, to ensure very timely availability of virological information to Member States and the GPEI on potential wild poliovirus importations or VDPV circulation. WHO should advocate with national authorities and partner agencies for continued support to the network. The RCC commended the introduction of the new algorithm for virus isolation in key laboratories (Australia, Hongkong/China, Malaysia, Philippines and Singapore) and targeting ITD reporting times to be reduced to seven days from receipt/availability of isolates. The RCC noted the current plan of WPRO EPI to conduct a real time PCR training in 2009 for selected laboratories (Australia, China, Japan, Malaysia, Singapore); followed by a laboratory network meeting later in the year.

19 -14- Maintaining high immunity levels The RCC noted that, once again, available data on immunization activities indicate that, overall, countries were maintaining high levels of immunity against poliomyelitis, with some notable exceptions like Lao People's Democratic Republic, Papua New Guinea and some subnational areas in the Philippines. Also, several country progress reports did address the RCC recommendation made last year to include more district level analysis towards better defining areas and populations of low coverage and possible immunity gaps. While these efforts are commendable, the RCC indicated that further strengthening in this area would be required, also to allow to better target corrective action. The RCC requested all countries, in the future, to supplement reported administrative immunization coverage in their progress reports with relevant survey and other data, for validation purposes, also at the appropriate subnational level. The RCC was satisfied to see promising developments in several countries like in Cambodia and Lao People's Democratic Republic, following last year's recommendation on the need for WPR countries to take on greater responsibility for an uninterrupted vaccine supply. Wild poliovirus laboratory containment The RCC commended China and Japan on submission of the final reports on phase 1 wild poliovirus laboratory containment in accord with the WHO Global Action Plan for Laboratory Containment, 2nd edition. Based on reviews of these reports and findings from the external technical review panel, the RCC concluded that the phase 1 containment activities documented by China and Japan provided a complete and accurate national inventory of laboratories with wild poliovirus infectious and potentially infectious materials. The risk of wild poliovirus materials being retained by an unidentified laboratory in either country is low. With these final reports, the RCC declared phase 1 wild poliovirus laboratory containment, laboratory surveys and national inventories, complete for the whole of the Region. The RCC was pleased that the number of laboratories holding wild poliovirus infectious materials has been reduced to total of 43 in four countries (Australia, China, Japan, Republic of Korea) with three laboratories retaining only potentially infectious materials (China and Hong Kong). The RCC encouraged all laboratories to consider destruction of materials that are no longer essentially required. With completion of phase 1 national survey and inventory in the Region, all countries should create/maintain a permanent focal point or office within/under the MOH to: (1) maintain and update the national database and national inventory current and provide institutional memory; (2) maintain communications with institutions listed on the inventory to keep them informed of progress in poliomyelitis eradication and changes in national laws or regulations relating to poliovirus containment, (3) serve as the technical resource for MOH on poliovirus containment and the focal point for technical liaison with WHO; and (4) prepare the country for Phase 2 and implementation of containment requirements one year after detection of wild poliovirus anywhere in the world.

20 -15- As the phase 1 exercise, particularly in large countries like China and Japan with complex laboratory infrastructure, provides important lessons on how to successfully conduct national surveys and establish national inventories, the national containment coordinators should jointly explore with WHO how the lessons learnt on best practices can be made available to other countries and regions. RCC terms of reference The terms of reference (TOR) for the RCC and NCCs were established in 1996, several years before the Region was certified as poliomyelitis-free. In view of the considerable changes in the work of the bodies since certification, the RCC discussed a revised set of TORs for the Commission and the following set was agreed upon: (1) to review annual progress reports from each country or other political entities on maintaining poliomyelitis-free status, including poliovirus laboratory containment, to communicate feedback on findings and recommendations on required actions to the respective NCC and MOH, as well as to the Regional Director (WHO Secretariat); (2) to regularly review technical recommendations from advisory groups such as the ACPE and the regional Technical Advisory Group on Immunization and Vaccine Preventable Diseases TAG, and consider their relevance for maintaining certification standard performance levels to ensure maintaining the Region's poliomyelitis-free status; (3) to bring unresolved certification issues to the attention of the GCC; (4) to advise NCCs on how best they should function as an active national oversight bodies in terms of adequate membership, frequency of meetings and definition of responsibilities; (5) to conduct site visits, as required, to review and verify the status of activities to maintain poliomyelitis-free status in specific countries, including to support the activities of NCCs, and to advocate for the implementation of RCC recommendations; and (6) to reaffirm certification of wild poliovirus elimination in the WPR to the GCC towards global certification of poliomyelitis eradication, according to criteria established by the GCC. The revised TORs will be still presented to the GCC, GPEI and the WHO Regional Director (WHO Secretariat) for comments and endorsement. NCC terms of reference The RCC appreciated the review of the NCCs TORs conducted by the WHO Secretariat and noted that only a few countries have so far updated them since certification. The RCC recommended that all other NCCs review and update their TORs to support the NCC work in the best possible way; supported by guiding principles/best practices to be compiled and supplied by the WHO Secretariat. The RCC strongly felt that closer interaction with NCCs is required; for example, in form of NCC chairpersons attending RCC meetings and targeted site visits by RCC members as required.

21 -16- Future reports to the RCC should always include NCC discussion on their concerns and recommendations, including statements without current concerns, reflecting discussions and conclusions on this aspect. While the RCC reiterated that there was the continued key role of NCCs to support translation of RCC recommendations into action plans, it also recognized that comprehensive support by the WHO Secretariat was required for this task. The important inter-relationship of the three-tiered certification bodies GCC, RCC and NCCs to function as a comprehensive entity to support maintaining the Region's poliomyelitisfree status should be recognized and appreciated. Finally, the RCC thanked the NCCs, the Pacific island Subregional Certification Committee (SCC) and country teams for the timely assembly and submission of quality update reports. 3.2 Country specific conclusions and recommendations Australia The RCC appreciated how recommendations made during its last meeting were taken into consideration and responded to. Various activities undertaken to strengthen the quality of AFP surveillance indicated that the programme, to maintain the country's poliomyelitis-free status, remained active and committed. The RCC concurred with the consensus reached on the issue of AFP cases not reaching final classification due to insufficient information; that the poliomyelitis compatible classification should be used while indicating cases as surveillance failures ("zero evidence" compatible cases). The RCC appreciated the preliminary results of the Paediatric Acute Enhanced Disease Surveillance pilot study and agreed to its potential as timely surveillance tool, to supplement the quality of the current AFP surveillance system and looked forward to receiving more detailed information on study outcomes. The RCC repeated its appreciation for the substantial support the poliomyelitis laboratory at the Victorian Infectious Diseases Reference Laboratory (VIDRL) is providing to the Regional poliomyelitis laboratory network and applauded the continued high performance. The RCC commended that the 'Acute Flaccid Paralysis and Poliomyelitis Outbreak Response Plan for Australia' has been finalized and endorsed by the Australian Health Protection Committee. Brunei Darussalam The RCC concluded that AFP surveillance and routine immunization quality remained at certification standards in Brunei Darussalam and preparedness to detect and respond to wild poliovirus importation appeared adequate. Cambodia The RCC concluded that, overall, AFP surveillance and routine immunization quality remained at certification standards in Cambodia. The RCC concurred with the conclusions of the NCC that the general sensitivity of the AFP surveillance systems appeared sufficient but also remained concerned with the lack of active AFP surveillance in provincial hospitals and particular population areas in the country like

22 -17- in the western part. Such incomplete active surveillance could adversely impact preparedness to detect and respond to wild poliovirus importation and VDPV emergence in a timely fashion. In view of continued problems in universal AFP surveillance quality, the RCC recommended to the WHO Secretariat to consider conduct of a targeted AFP surveillance review. While overall reported routine coverage remained high at around 80% and was supported by the results of the recent demographic health survey, there was variance at the sub-national level. As routine immunization activities in high-risk areas such as minority villages, migrants, mobile population and urban slums were often limited, targeted SIAs or other specific catch-up immunization activities as considered appropriate seemed still required in risk areas and populations with continuously lower coverage. EPI partners should consider support for it as a matter of priority to reduce vulnerabilities in maintaining the country's poliomyelitis-free status. Advocacy support for both strengthening surveillance and immunization coverage, in form of site visits by RCC members or other RCC activities, could be useful. China The RCC concluded that, overall, AFP surveillance and routine immunization quality remain at certification standards in China. The RCC noted that the China poliomyelitis laboratory network experienced temporary delays in specimen transport, processing and reporting due to factors beyond its control. However, in view of the important role of the China laboratory network to maintenance of the poliomyelitis-free status in China and of its key role within the global network, it is essential that WHO standards for timeliness of reporting are adhered to. The RCC noted that the updated 'National Emergency Plan for Imported Wild Poliovirus and VDPV Cases' will be published in 2009 and requested to receive a copy with the next progress report. The RCC commended China on its very thorough, comprehensive and clear final report on phase 1 wild poliovirus laboratory containment and the systematic and dedicated approach taken to complete the work. The RCC acknowledged that several aspects made the survey particularly challenging in China; including a very large number of laboratories, the large number of ministries to participate and the complexity of systems. The RCC recognized the strengths of the survey in China, particularly that central government support/directives and responsible persons at each administrative level had greatly facilitated the survey process and made the following recommendations to maintain the significant achievements; for China itself and the global polio eradication initiative: (1) As most, if not all, wild poliovirus materials held under locked storage in the provincial laboratories of the polio laboratory network appear no longer relevant to operations they should be transferred to the National Laboratory or destroyed. The Government of China is requested to notify the RCC when decisions are made and action taken on the fate of these materials. (2) The national inventory should be maintained by the National Containment Group and regularly updated in consultation with provincial CDC staff and subsequently submitted to RCC through the annual progress report. Formal arrangements should be made to identify where the national data will be kept, under whose responsibility, what updating process will be followed.

23 -18- (3) The MOH should consider this comprehensive final report as an important reference document for ensuring institutional memory and work with the WHO Secretariat to further strengthen the report by adding information on aspects the external expert review recommended. (4) The MOH and the National Containment Group, with support from WHO, should develop a maintenance plan on future management of survey and inventory data. Hong Kong (China) The RCC concluded that AFP surveillance and routine immunization quality remained at certification standard in Hong Kong (China) and preparedness to detect and respond to wild poliovirus importation appeared to be adequate. The RCC appreciated the information that VDPVs identified by the programme have been transferred to a bio-safety-level-3 facility but continued to encourage their destruction as the sequence results would be available. With the storage of these materials, Hong Kong (China) is currently included in the Regional inventory on wild poliovirus infectious and potentially infectious materials. Macao (China) The RCC concluded that AFP surveillance and routine immunization quality remained at certification standard in Macao (China) and preparedness to detect and respond to wild poliovirus importation appeared to be adequate. The RCC noted the shift from OPV to IPV in December Japan The RCC concluded that poliomyelitis surveillance and routine immunization quality, overall, remained at certification standard in Japan and preparedness to detect and respond to wild poliovirus importation appeared to be adequate. The RCC repeated its appreciation for the substantial support the polio laboratory at the National Institute of Infectious Diseases (NIID) has provided to the Regional and Global poliomyelitis laboratory network and applauds the continued high performance. The RCC commended Japan on its thorough and detailed final report on phase 1 wild poliovirus laboratory containment and the dedicated approach taken by containment specialists to complete the work. The RCC acknowledged that several aspects made the survey particularly challenging in Japan, including a large number of laboratories, the complexity of systems, a wide-ranging restructuring of ministries in 2001, retention of information by individual ministries, amalgamation of universities and sequential national containment coordinators. The RCC recognized the strengths of the survey in Japan, particularly a long history of compliance with ministerial requests, facilitating an environment of trust; most laboratories located within the Ministry of Health, Labor and Welfare (MOHLW) system, where compliance of local governments is high, extensive technical and management support provided through NIID and laboratories having high standards. The RCC made the following recommendations to maintain the significant achievements; for Japan itself and the global polio eradication initiative:

24 -19- (1) National authorities should be vigilant and alert for indications of previously unidentified laboratories. Efforts to persuade all laboratories to destroy unnecessary wild poliovirus materials should be increased. (2) The MOHLW should consider this comprehensive final report as an important reference document for ensuring institutional memory and work with the WHO Secretariat to further strengthen the report by careful review for any data discrepancies and adding information on aspects the external expert review recommended. (3) The MOHLW and the National Containment Coordinator, with support from WHO, should develop a maintenance plan on future management of survey and inventory data. Lao People's Democratic Republic The RCC thanked the Government of Lao People's Democratic Republic for hosting the 14th meeting of the RCC, and for the invitation for RCC members to participate as observers in the Child Health Days held from 8 to 22 December 2008 which were used for OPV vaccination in high-risk areas. The RCC also commended Lao People's Democratic Republic for improving AFP surveillance quality in 2008 compared to 2007 but highlighted the need for making these improvements sustainable. The RCCs noted the various plans developed for strengthening routine immunization but remained concerned that continued relatively low levels of routine OPV coverage in parts of the country were associated with an increased risk of spread, should wild poliovirus be introduced, or VDPVs emerged. The RCC considered the strengthening of routine immunization as an urgent priority, but substantial increases in coverage will take time. The current OPV SIAs will only be able to significantly lower the risks if high coverage is achieved in each round. Therefore, Lao People's Democratic Republic should take all opportunities, like having other antigen SIAs or Child Health Days, to provide supplementary poliomyelitis immunization to ensure that no more than three years go by without a high coverage supplementary immunization activity; to reduce the number of susceptible children as they accumulate over time in conditions of suboptimal routine immunization coverage. EPI partners should consider support for such activities a matter of priority. The RCC commended that the national preparedness plan for wild poliovirus importation and cvdpv has been finalized. Malaysia The RCC appreciated how recommendations made during its last meeting were taken into consideration and responded to. The RCC concluded that, overall, AFP surveillance and routine immunization quality remained at certification standard in Malaysia. The RCC, however, noted that surveillance gaps have evolved again in some areas, particularly Sabah, and should be analysed and addressed in view of frequent contacts and population movements with poliomyelitis endemic areas. This should be supported by development of a current national plan for importation of wild poliovirus.

25 -20- To further evaluate the observation of a very low NPEV isolation rate, the programme may consider a targeted review of the integrity of the reverse cold chain which would also benefit other surveillance systems that rely on laboratory testing of temperature- sensitive agents. Mongolia The RCC concluded that, overall, AFP surveillance and routine immunization quality remained at certification standard in Mongolia. The RCC requested the WHO Secretariat to facilitate that the NCC remains fully functioning and provides coordinated active oversight. Likewise, regular functions of a poliomyelitis expert panel need to be ensured. The RCC noted that the progress report did not include any information on a current importation preparedness plan and laboratory containment and requested the WHO Secretariat to work with the programme to ensure requirements for both are met. New Zealand The RCC concluded that AFP surveillance and routine immunization quality, overall, remained at certification standard in New Zealand and expected preparedness to detect and respond to wild poliovirus importation to be adequately addressed in the national response plan currently under development. The RCC would appreciate to receive a copy of the plan with the next progress report. The RCC commended the destruction of the last remaining potentially wild poliovirus infectious materials. Pacific island countries and areas Recalling its previous conclusion on challenges to achieve sustainable quality of AFP surveillance and subsequently recommending to particularly focus on PICs with larger populations for strengthening surveillance quality and wild poliovirus importation preparedness, the RCC noted that the chronic problems to reach certification standard AFP surveillance remained and still no importation response plans were in place in main population centres like Fiji. Also, there is currently is no functioning group providing continuous oversight for maintenance of poliomyelitis-free status and certification standard quality performances in the PICs, including extending recommendations and advocacy efforts to countries. The RCC was most concerned to learn that the SRCC has not been able to perform some of its key functions effectively in recent years; such as an active and continuing role in reviewing the AFP surveillance system and providing guidelines for Pacific island countries on certification standard performance to maintain their poliomyelitis-free status. In order to maintain the globally applied certification standard structure to the 20 PICs, the RCC recommended strengthening the inter-country SRCC as a matter of urgency; with updated TORs and a membership to actively advocate for translation of RCC recommendations into programme actions. Noting the continued challenges in AFP surveillance, the RCC recommended the WHO Secretariat to develop means to address the chronic problems in an integrated approach; with PIC EPI managers, surveillance coordinators and the PIC SRCC.

26 -21- Finally, the RCC noted that while low AFP surveillance performance remained a concern at least in several countries with frequent contacts and populations movements with endemic areas, relatively high immunization coverage in main population centres provided some reassurance for maintaining the Pacific poliomyelitis-free. Papua New Guinea The RCC appreciated the frank and comprehensive report and recognized the NCC efforts in supporting the national EPI programme in its challenges to maintain the gains that were made in While also recognizing the approach to integrated disease surveillance, the RCC was alarmed about the significant decline in AFP surveillance in 2008 and multiple chronic problems resurfacing but particularly that no stool samples so far have laboratory results. The RCC was concerned about shipment delays to VIDRL and requested the WHO Secretariat to receive results of the current laboratory testing as soon as they become available. In this context, the RCC noted the plan to send, while the Institute of Medical Research (IMR) shipment center in Port Moresby is still being established, to coordinate sample shipment to VIDRL at the National Department of Health (NDOH) surveillance unit. In order to ensure reliability of virological results, assessment of the integrity of the reverse cold chain may need to be considered. The RCCs noted the national initiative to improve immunization coverage in low performing districts but remained concerned that continued relatively low levels of routine OPV coverage in parts of the country were associated with an increased risk of spread, should wild poliovirus be introduced, or for emergence of circulating VDPVs. The RCC considered the strengthening of routine immunization as an urgent priority, but substantial increases in coverage would take time. Therefore, PNG should take all opportunities to provide supplementary poliomyelitis immunization (usually at least two doses at the recommended interval) to ensure that no more than three years go by without a high coverage supplementary immunization activity; to reduce the number of susceptible children as they accumulate over time in conditions of suboptimal routine immunization coverage. EPI partners should consider support for such activities a matter of priority. Philippines The RCC commended the Philippines for the ongoing efforts to maintain high quality surveillance and routine immunization coverage and welcomed the updating of the guidelines on preparedness and response to wild poliovirus importation. However, the RCC noted that there were gaps in subnational AFP performances in several large regions and cities which needed to be addressed as they might otherwise adversely impact preparedness to detect and respond to wild poliovirus importation and VDPV emergence in a timely fashion. As the report did not contain information on the current set-up and work of the NCC, the RCC was not yet assured of its active oversight functions and would like to be updated in the next progress report. The RCC was concerned about the low reported coverage in Region VII and parts of Mindanao. As noted in the report, the RCC would like to draw particular attention to Regions VII, IX, XI and ARMM. These four regions have annualized reported coverage that is below 70%. Regardless if this is an issue of delayed reporting or truly low coverage, not having clear

27 -22- understanding of the situation places these regions at high risk of sustained outbreaks if importations should occur or VDPVs emerge. Further, they have high contact with international and national travel, possibly also poliomyelitis affected areas and ARMM's ongoing conflict with concomitant internal displacement and disruption of health service delivery further increase its risk. The RCC would therefore appreciate an update specifically covering Regions VII, IX, XI and ARMM, containing the following: (1) updated 2008 complete national coverage with regional breakdowns; and (2) action plans developed for these regions to improve coverage and reporting. The NCC should take an active role in monitoring implementation of these recommendations and submit the update to the RCC by 31 March The RCC noted that the progress report lacked information on wild poliovirus laboratory containment. Republic of Korea The RCC concluded that, overall, poliomyelitis surveillance and routine immunization quality remained at certification standard in the Republic of Korea and preparedness to detect and respond to wild poliovirus importation appeared to be adequate. As the report did not contain information on the current work of the NCC and future plans while this NCC would serve until the end of 2008, the RCC would like to be updated about its continued oversight functions in the next progress report. Support from the WHO Secretariat should be sought if necessary. Singapore The RCC concluded that AFP surveillance and routine immunization quality, overall, remained at certification standard overall in Singapore and preparedness to detect and respond to wild poliovirus importation appeared to be adequate. Viet Nam The RCC concluded that, supported by strong and active oversight of the NCC, AFP surveillance and routine immunization quality, overall, remained at certification standard in Viet Nam and preparedness to detect and respond to wild poliovirus importation appeared to be adequate. However, the RCC noted that there were gaps in subnational AFP performances in several large provinces and cities which needed to be addressed as they might otherwise adversely impact preparedness to detect and respond to wild poliovirus importation and VDPV emergence in a timely fashion. The RCC concurred with recommendation of the NCC on maintaining the vigilance for sustained quality of surveillance and immunization activities at national and subnational levels. The RCC would appreciate to receive a copy of the national importation preparedness plan with the next progress report.

28 -23- The RCC was informed that Viet Nam would conduct a comprehensive national EPI review in the first half of 2009 and encouraged that this exercise be used for also a detailed review of activities supporting maintenance of poliomyelitis-free status. For consideration of future options for poliomyelitis immunization and vaccine supply, close consultation with the WHO Secretariat was recommended.

29 FOURTEENTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF 24 November 2008 POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Lao People's Democratic Republic 9-10 December 2008 ENGLISH ONLY TENTATIVE TIMETABLE Time Tuesday, 9 December 2008 Time Wednesday, 10 December Registration 1. Opening ceremony Welcome remarks by the Responsible Officer Opening remarks by the Regional Director (to be given by WR, Laos) Welcome remarks by the Government of the Lao People's Democratic Republic Self-introduction, Election of Officers (Chair, Vice-Chair, Rapporteur) Remarks by the Regional Certification Commission (RCC) Chairperson Administrative announcements; Group photo Review of country reports on maintaining poliomyelitis-free status (contd.) a) Australia b) Brunei Darussalam c) Cambodia d) China e) Hong Kong (China) f) Japan g) Lao People's Democratic Republic h) Macao (China) i) Malaysia j) Mongolia COFFEE BREAK COFFEE BREAK Maintaining a poliomyelitis-free status in the Lao People's Democratic Republic: achievements and challenges Global overview of the poliomyelitis eradication programme including outcomes of the Advisory Committee for Polio Eradication (ACPE) - November Continuation of country report review: k) New Zealand l) Pacific island countries and areas m) Papua New Guinea n) Philippines o) Republic of Korea p) Singapore q) Viet Nam LUNCH BREAK Summary of conclusions and recommendations of the 13 th RCC Meeting Discussion on draft conclusions and recommendations Regional overview of maintaining poliomyelitis-free status, including performance of regional poliomyelitis laboratory network Presentation of draft conclusions and recommendations on maintaining poliomyelitis-free status Reviewing and evaluating the risks for maintaining the poliomyelitis-free status in the Western Pacific Region COFFEE BREAK LUNCH BREAK Individual review of country reports on maintaining poliomyelitis-free status COFFEE BREAK Individual review of country reports on maintaining poliomyelitis-free status (contd.) 9. Closing ceremony

30 ANNEX 2 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL FOURTEENTH MEETING OF THE REGIONAL WPR/2008/DCC/04/EPI(3)/2008/IB/2 COMMISSION FOR THE CERTIFICATION 3 December 2008 OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao People's Democratic Republic 9-10 December 2008 ENGLISH ONLY INFORMATION BULLETIN NO. 2 PROVISIONAL LIST OF REGIONAL CERTIFICATION COMMISSION (RCC) MEMBERS AND SECRETARIAT 1. REGIONAL CERTIFICATION COMMISSION Dr Anthony I. Adams (Chairman, Regional Certification Commission) No. 6/2-4 Chapman Crescent, Avoca Beach New South Wales 2251 Australia Tel: (612) Fax: n/a aarr@netspeed.com.au Dr Nobuhiko Okabe (Vice-Chairman, Regional Certification Commission) Director Infectious Disease Surveillance Center National Institute of Infectious Diseases Toyama Shinjuku Tokyo Japan Tel: (813) (Ext 2501) Fax:(813) okabenob@nih.go.jp

31 WPR/2008/DCC/04/EPI(3)/2008/IB/2 Page 2 Dr Olen M. Kew Molecular Virology Section MSG-10 Respiratory and Enterovirus Branch National Centre for Infectious Diseases Centers for Disease Control and Prevention 1600 Clifton Road N.E. Atlanta, Georgia United States of America Tel: (1 404) Fax:(1 404) omk1@cdc.gov Professor Nguyen Dinh Huong Health Policy Adviser Viet Nam Red Cross Society 104 C10 Giang Vo. Badinh Ha Noi Viet Nam Tel: (844) /4376 Fax: (844) ngdhuongn@yahoo.com.vn Dr Aida M. Salonga** Head, Neurology Section Department of Neurosciences University of the Philippines-Philippine General Hospital Taft Avenue Manila Philippines Tel: (632) , local 2405 Fax: (632) aida_salongamd@yahoo.com.ph Dr Steven Gary Fite Wassilak Medical Epidemiologist Centers for Disease Control & Prevention Global Immunization Division Mailstop MS-E05 Clifton Road Atlanta, Georgia United States of Amercia Tel: (1 404) Fax: (1 404) sgw1@cdc.gov **unable to attend

32 WPR/2008/DCC/04/EPI(3)/2008/IB/2 page 3 Dr Hui Zhuang Professor, Department of Microbiology Beijing Medical University 38 Xue-Yuan Road Haidian District Beijing People's Republic of China Tel: (8610) Fax: (8610) zhuangbmu@126.com 2. SECRETARIAT WHO Western Pacific Regional Office Dr Yang Baoping Regional Adviser Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) Fax: (632) yangb@wpro.who.int Dr Sigrun Roesel Medical Officer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) Fax:(632) roesels@wpro.who.int Dr Su Haijun Technical Officer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) Fax: 632) haijuns@wpro.who.int

33 WPR/2008/DCC/04/EPI(3)/2008/IB/2 Page 4 WHO/Lao People's Democractic Republic Dr Dong Il Ahn WHO Represenative Lao People's Democratic Republic Ban Phonxay, 23 Singha Road Vientiane Lao People's Democratic Republic Tel: (856) Fax: (856) ahnd@lao.wpro.who.int Mr Keith Feldon Technical Officer World Health Organization Ban Phonxay, 23 Singha Road Vientiane Lao People's Democratic Republic Tel: (856) Fax: (856) feldonk@lao.wpro.who.int Dr Somphavanh Seukpanya Immunization Aide World Health Organization Ban Phonxay, That Luang Road Vientiane Tel: (856) Fax: (856) seukpanyas@lao.wpro.who.int WHO Headquarters Geneva Dr Rudolf Tangermann Medical Officer Strategy Implementation Oversight and Monitoring World Health Organization CH-1211 Geneva 27 Switzerland Tel: (4122) Fax: (4122) tangermannr@who.int

34 ANNEX 3 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 AUSTRALIA The RCC thanked the NCC and its secretariat for a very comprehensive and informative report. The RCC applauded the timely and comprehensive investigation response to the wild poliovirus identified in July 2007 and based on the data available concluded that no further virus transmission has occurred. Highlighting that generally surveillance efforts and quality are good, the RCC noted that once more several cases notified as AFP from 2005 and 2006 were still pending final classification (due to insufficient information) and requested the expert panel to address the issue. Discussions were held by NCC, WPRO and the Global Polio Eradication Initiative; pls refer to separate communication. The RCC noted that the Paediatric Acute Enhanced Disease Surveillance pilot study commenced last August and looks forward to receiving the results once available. Preliminary results included in report. The RCC commended the continued high performance of the polio laboratory at the Victorian Infectious Diseases Reference Laboratory (VIDRL) and the particular involvement in the investigation in the recent wild poliovirus importation episode. As said before, the substantial support it is providing to the Regional polio laboratory network, not only as a Regional Reference Laboratory but also in its function as national polio laboratory for Australia, Brunei Darussalam, the Pacific island countries, and now Papua New Guinea, is highly valued. The RCC noted that the 'National Polio Response Strategy' will be finalized shortly and would like a copy to be included in the next progress report. As it may serve as a valuable example for other countries in the Region, the RCC encouraged collaboration with, comments from, WHO for its finalization; to ensure current requirements of the GPEI, including coordination aspects of IHR 2005 are reflected. The strategy has been completed and was endorsed by the Australian Health Protection Committee during its meeting 3-4 December The plan will soon be posted on the Australian Government Department of Health and Ageing website. Comments:

35 2008 progress report Australia Certification process NCC: 4 members, unchanged Expert Panel: 8 members; some changes in membership. 5 meetings in 2007 (1 attended by NCC chairperson and RCC chairperson); frequency according to WER deadlines and immediately if PV isolated. 5 meetings in 2008 (1 with attendance of NCC chairperson). Reviews all AFP cases, 60-day follow-up only required if insufficient info for classification. Presumptive diagnosis established for all AFP cases. Measures are being taken to address issues with pending cases. PEC makes detailed recommendations to the surveillance programme. AFP surveillance quality AFP surveillance system unchanged. Average monthly return rate 97% in 2007, 87% Jan Jun 2008 (over 1,300 paediatricians involved). Non-polio AFP rate: (0.8 based on notifications); so far (1.6 based on notifications). % adequate stool samples: %; %. 1 st sub-national level: several larger states do not achieve target. Preliminary PAEDS study results look promising. Polio reference laboratory fully accredited, provides significant support to specimen sending entities. Establishment of enterovirus and environmental surveillance considered. No VAPP, no VDPV. Immunization Reported IPV3 coverage: 91.8% (2007). Law amendment to allow recording of vaccinations given overseas etc. Supplementary immunization activities: none. Preparedness for wild poliovirus importation National plan finalized. Laboratory containment All 6 organizations on the national inventory contacted in 2008 to ensure their poliovirus related inventories are accurate and current. Only 2 hold relevant materials. Areas of concern expressed/issues mentioned None specific mentioned. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

36 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 BRUNEI DARUSSALAM The RCC thanked the NCC and its Secretariat for a thorough progress report and is impressed with the continued high quality of activities conducted and the active oversight of the NCC to maintain the country s polio-free status. Comments:

37 2008 progress report Brunei Darussalam Certification process NCC active, activities listed, meets regularly, serves also as expert panel, reviews all AFP cases, each has final diagnosis. AFP surveillance quality System unchanged, 6 reporting sites, routine reporting complete, almost all quality indicators met. Non-polio AFP rate/adequate stool collection rate: 3.27/50% in 2007, 1.63/100% in 2008 (Jan-Nov). Laboratory: VIDRL in Australia, good collaboration. Immunization Reported OPV3 95%, supported by 2007 coverage survey data. Preparedness for wild poliovirus importation Active, very comprehensive plan in place. with risk assessment. NCC chairperson also IHR national focal point. Population movements recognized; OPV status of children on pilgrimage checked. Laboratory containment Active laboratory list, no further facilities identified in Now BSL-3 laboratory under MOH, one more planned for Ministry of Agriculture (Veterinary Services) Areas of concern expressed/issues mentioned None specific mentioned. Areas of concern expressed/issues mentioned Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

38 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 CAMBODIA The RCC thanked the NCC and its secretariat for a very comprehensive and informative report and commends the NCC for the programme directions provided. The RCC commended Cambodia for the efforts made to secure vaccine supply for routine immunization and towards financial sustainability. The RCC noted that active AFP surveillance is still not being conducted universally in all relevant sites (i.e. provincial hospitals) and reminds the NEPI to continue pursuing solutions; also the involvement of relevant private hospitals and rehabilitation institutions. NCC summarizes current situation: 1) The majority of the AFP report still depends upon the Kunhta Bopha Children's hospital in Phnom Penh. 2) AFP report from provincial hospitals remains low. 3) Active AFP surveillance has not been performed well at provincial hospital by provincial EPI staff. While the RCC concluded that phase 1 wild poliovirus laboratory containment was successfully completed in Cambodia and no materials are currently held under the national inventory, it encouraged maintaining an active list of biomedical laboratories; in preparation of future containment requirements. Still no further action taken. Comments:

39 2008 progress report Cambodia Certification process NCC remains very active (activity summary provided in report), with unchanged membership, and met once in Serves also as expert panel, reviews potentially compatible cases (as per virological classification scheme; 7 in 2008) Detailed conclusions and recommendations provided. AFP surveillance quality Reporting sites unchanged; monthly routine reporting complete and timely but still no active searches conducted. Reliance on few private hospitals with sub-optimal collaboration Non-polio AFP rate/adequate stool collection rate: 1.8/87% in 2007, 1.26/89% in 2008 (Jan-Oct); analysis of subnational performance provided to lower levels. Laboratory: NIID in Japan, good collaboration, shipment time kept short. One suspected VAPP case in 2008 (details in report) Immunization Reported OPV3 in 2007: 82%. GAVI/HSS funds to be used for continuation of coverage improvement plan (CIP) in 10 ODs. No SIAs in Preparedness for wild poliovirus importation Comprehensive contingency plan in place (and tested during cvdpv episode in 2005/06), though lack of active surveillance may be an issue. Laboratory containment No developments; laboratory list appears inactive, NCC recognized this. Areas of concern expressed/issues mentioned Extensive, frank discussion on achievements and remaining problems Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

40 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 CHINA The RCC thanked the NCC and its secretariat for a comprehensive and informative report and commends the NCC for the programme directions offered. The RCC was impressed with the continued high quality of surveillance and immunization activities conducted The RCC commended the development of an updated 'National Emergency Plan for Imported Wild Poliovirus and VDPV Cases' and encouraged the NEPI to collaborate with WHO for its finalization; to ensure current requirements of the GPEI, including reporting and IHR 2005 coordination aspects are reflected. Finalization and issuance expected in The RCC commended that China continues to conduct of annual SIAs in order to address immunity gaps and maintain its polio-free status. While the RCC considered high quality SIAs - conducted in high quality - to remain important in China because of its proximity to polio endemic countries, the importance of reaching floating populations and other populations identified to be at high risk and achieving synchronized immunity, SIAs should not replace further strengthening routine immunization but be implemented where such efforts are not sufficient. As long as not specific guidelines have been received from WHO, SIAs in high risk areas will continue. The RCC continued reminding all polio partners that, while large portions of resource requirements are being provided by China, external funding continues to be critical to maintain high quality AFP surveillance including the polio laboratory network performance and to support internal fund raising for preventive SIAs by indicating the importance of China maintaining its polio-free status to the GPEI. External funding for surveillance and laboratory network has been provided but none for SIAs. The RCC reviewed the preliminary QA report on phase 1 wild poliovirus laboratory containment and endorses the findings of the WPRO mission reports of July and November In particular, the RCC urged the Ministry of Health and China CDC to maintain adequate staff (at least two full-time staff) at the national containment office to provide the leadership and management to: (a) provide adequate technical support for completion of the survey in the remaining 28 provinces; (b) analyse each provincial survey database (outside MOH) for completeness and bases for laboratory denominators, ensure data accuracy and validity, and consolidate final clean provincial data sets into a single national database;

41 (c) conduct detailed analyses of the survey data to assess the likelihood (level of risk) that a laboratory might possess wild poliovirus (including VDPVs) infectious or potential infectious materials e.g. through assessing cold chain and storage capacity; functions of laboratories; types of materials received and length of times materials retained, and research capacity; (d) identify duplicate strains and implement the polio laboratory network policy to destroy isolates and clinical materials at lower levels (provincial laboratories) once duplicates are available at a higher level (the National Laboratory) (e) compare the poliovirus distribution records (26/10/78-February 1997) of the Kunming Institute with survey results to confirm destruction of materials; (f) finalize the current national inventory of wild poliovirus infectious and potentially infectious materials and reconcile with previous reports; (g) prepare the final QA report describing the process and results of wild poliovirus containment and present the QA report to the NCC for endorsement and submission to the RCC by June 30, Final report on phase 1 wild poliovirus laboratory containment has been submitted separately and external quality assessment took place in October Comments:

42 2008 progress report China Certification process NCC unchanged, met 21 November Expert Panel: all but 4 provincial panels met 4 times in AFP surveillance quality Reporting units: over 9,000 sites; reporting completeness 98.7% in 2007 and 98% in 2008 (Jan-Sep). Non-polio AFP rate: ; 2008 (Jan-Sep) st sub-national level: all provinces achieve target except Tibet; in /346 prefectures reported less, this was 106/347 in 2008 Jan Sep. Percentage adequate stool samples: %; %. Supplementary surveillance activities in low performing areas. Polio laboratory: all accredited under WHO standards (except Tibet) in 2007 but timeliness problems continue due to stricter bio-safety requirements and shipment ban during Olympic Games. In 2008, 11 provincial laboratories were reviewed so far but accreditation will only be granted once isolates have been sent to RRL. Review of 2 laboratories in earthquake affected province still to be completed. Type 1 VDPV was detected in 2007 in three independent episodes in China; in one AFP case in Shanxi province, in two AFP cases and three contacts in Shandong Province and in one AFP case in Guangxi province. Similar investigation and immunization responses as before were conducted (details in 2007 report). No VPDV detection in VAPP compensation issue. Immunization Reported OPV3 coverage 2007: >90%; periodic coverage surveys identified areas with lower coverage Supplementary immunization activities: preventive SIAs in high-risk areas winter season 2007/08, target over 27 mio children <4yrs plus check-up immunization in all provinces and reported high coverage. Preparedness for wild poliovirus importation Revised plan to be issued in Laboratory containment Final QA report submitted. Areas of concern expressed/issues mentioned Major challenges discussed in detail by NCC. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

43 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 HONG KONG (CHINA) The RCC thanked the NCC and its Secretariat for a thorough progress report and is impressed with the continued high quality of activities conducted and the active oversight of the NCC to maintain the territory s polio-free status. The RCC noted Hong Kong's shift from OPV to IPV in February The RCC appreciated that Hong Kong responded to its recommendation to add VDPVs identified by the programme to the inventory of wild poliovirus infectious materials and encourages their destruction as the sequence results are available. Isolates retained and transferred to bio-safety level 3 (BSL-3) facility. Plan'. The RCC commended Hong Kong on its comprehensive 'Response to Importation of Wild Poliovirus Comments:

44 2008 progress report Hong Kong (China) Certification process NCC reviewed 2008 report but did not meet physically. Separate expert panel in place, adhering to virological case classification scheme. AFP surveillance quality AFP surveillance system unchanged, list of key physicians provided, regular communication. All major quality indicators met. Non-polio AFP rate/adequate stool collection rate: 1.5/64% in 2007, 0.9/100% in 2008 (Jan-Sep). Laboratory: fully accredited, also for ITD functions (good sequencing capacity). Extensive entrovirus surveillance. Immunization Shift to IPV in Feb 2007; reduced poliovirus isolation. High coverage reported for all age groups, coverage monitored for children born in HK and mainland China. School-based immunization programme (high enrollment rates). High coverage reported, supported by 2006 coverage survey, monitored for children born in HK and mainland China. No supplementary immunization deemed necessary. Preparedness for wild poliovirus importation Updated in 2006 to meet ACPE and WHA requirements, considered in line with IHR Laboratory containment VDPVs included in national inventory and now transferred to BSL3 facility.. Areas of concern expressed/issues mentioned International travel Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

45 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 JAPAN The RCC thanked the NCC and its Secretariat for a thorough progress report and the active oversight of the NCC to maintain the country s polio-free status. The RCC was impressed with the continued high quality of activities conducted, noting reporting requirements under the amended Infectious Diseases Law and the enterovirus surveillance network supporting timely detection of polioviruses in the country. The RCC particularly commended the continued high performance of the polio laboratory at NIID. The substantial support it is providing to the Regional polio laboratory network, not only as a Global Specialized Laboratory but also in its function as national polio laboratory for Cambodia and Lao PDR is highly valued. The RCC appreciated new approaches to analyse subnational OPV coverage presented in the report. The RCC reviewed the preliminary QA Report on phase 1 wild poliovirus laboratory containment submitted by Japan and concludes the proposed target completion date of 30 June 2008 is achievable pending availability of adequate resources. The RCC recommended that Japan: (a) provides clear justification and rationale for excluding categories of laboratories from the survey; (b) describes evidence for determining laboratory denominators to assure completeness of the national laboratory survey; (c) (d) prepares the final QA report describing the process and results of wild poliovirus containment; presents the QA report to the NCC for endorsement and submission to the RCC by 30 June Final report on phase 1 wild poliovirus laboratory containment has been submitted separately and external quality assessment took place in September The RCC also recommended in this context that Japan gives high priority to on-going discussion on revising the Infectious Disease Control Law, which includes the wild poliovirus reporting system, to strengthen infectious agent biosecurity and biosafety. Comments:

46 2008 progress report Japan Certification process NCC: unchanged; continued to meet on regular basis and oversees strategies to maintain polio-free status and ensure timely detection of imported wild poliovirus and VAPP cases. J-NCC also provides recommendations for polio vaccination strategy in Japan. Expert Panel: no formal AFP surveillance in place but J-NCC reviews all potential VAPP cases (2 in 2008). AFP surveillance quality Non-polio AFP rate: not applicable; enterovirus surveillance continues and in 2007, a total of 935 stool samples of healthy children were examined. Eight Sabin-like polioviruses were identified in Polio laboratory: fully accredited VAPP/VDPV: no new events. Immunization OPV2 coverage: 92.9% in 2006 but sub-national variance. Seroepidemiological survey in 2007 identified no particular high-risk population in young age groups. Shift to IPV planned in near future. Supplementary immunization activities: none Preparedness for wild poliovirus importation Infectious disease Control law amended in Laboratory containment Final QA report submitted. Areas of concern expressed/issues mentioned Nothing specific mentioned Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

47 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 LAO PEOPLE'S DEMOCRATIC REPUBLIC The RCC thanked the NCC and its secretariat for an informative report and commends the NCC for the programme directions provided. The RCC also appreciated that the NCC submitted a complete 2006 report on maintaining polio-free status in February 2007; including classification of 2006 AFP cases. The RCC remained very concerned about the decrease, both the quantity and quality, in AFP surveillance activities, and requests the NCC, with WHO and other polio partners, to appropriately bring the matter to the attention of senior health officials. SIAs. Surveillance performance increasing and low routine coverage to be temporarily addressed with OPV The RCC noted that OPV supply for routine immunization has been secured for the immediate time - mainly through bilateral donations; with contribution of the Government of the Lao People's Democratic Republic - but urges the Government to develop, with relevant partners, long-term plans to move to vaccine security. Because of the increasing amount of wild poliovirus importations confirmed also into less expected places (i.e., Myanmar, Australia, and Singapore) and the issue of cvdpv emergence in areas with low coverage, the RCC continued its concern about low population immunity in many areas in the country. The RCC encouraged the NEPI and relevant partners to determine most appropriate approaches to close those gaps rapidly; either through accelerated routine immunization activities or targeted SIAs. It may be useful to draw on experiences of the recently successfully conducted measles SIAs. OPV included for ~40% of children under 5 years in Child Health Days December 2008; to be followed by second round OPV vaccination. The RCC considered it very important to have an active national wild poliovirus importation plan in place and encouraged its immediate development; it should be included in the next report to the RCC. Final draft prepared and included in report, still awaiting final confirmation of taskforce members. Comments:

48 2008 progress report Lao PDR Certification process NCC very active again and met 4 times in NCC provided comprehensive discussion on concerns and recommendations. All AFP cases fully investigated prior to last NCC meeting on 56 Dec have been classified. AFP surveillance quality 96 reporting sites; completeness and timeliness of reporting 96% in Non-polio AFP rate increased from 0.7 in 2007 to 1.8 in Still, some large provinces report less than expected cases. Active searches conducted in all provinces in 2008 identified several missed cases. Adequate stool sample rate 67% in 2007 and 80% in Shipment time was further reduced. No polio laboratory in the country, testing at NIID, good collaboration. Immunization Reported OPV3 remains low and because of the persistent denominator discussions comparisons are made in total number of children immunized. In ,485 children received OPV3 compared to 82,031 in OPV added to Child Health Days in December 2008 for 40% of children under 5 years. Number of districts will be increased to 93 in 2 nd round (Feb 2009) and those not yet covered during CHD will have 3 rd round in Match Preparedness for wild poliovirus importation Final draft plan available, awaiting final confirmation of taskforce members. Laboratory containment No activities. Areas of concern expressed/issues mentioned Extensive NCC discussion included. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

49 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 MALAYSIA The RCC thanked the NCC and its secretariat for a comprehensive and informative report. The RCC encouraged continuation of active oversight by the NCC on Malaysia maintaining polio-free status; through regular meetings. NCC met in March 2008, chaired by Director General of Health, and discussed RCC recommendations and AFP surveillance performance and new immunization policy. The RCC was impressed with the continued high quality of activities conducted to maintain Malaysia s polio-free status and appreciates the work of the expert panel in ensuring comprehensive documentation of all AFP cases to support surveillance quality. The RCC appreciated conduct of a coverage survey in Kuala Lumpur in 2007, confirming the assumption of high OPV3 coverage. The RCC encouraged Malaysia to maintain an active plan for importation of wild poliovirus; particularly in view of the recognized frequent population movements to/from countries currently still polio endemic. Nothing mentioned in report. The RCC commended Malaysia for maintaining an active and current list of biomedical laboratories, in the context of future requirements of poliovirus laboratory containment. Comments:

50 2008 progress report Malaysia pls also see additional info provided to WHO comments Certification process NCC meeting held in March 2008 and membership and TORs reviewed. Expert panel met once in February 2008 and continues to review all AFP cases and provide final diagnosis for each. AFP surveillance quality Good description of the system but no concrete monitoring figures on completeness and timeliness of reporting. Non-polio AFP rate 2007: 1.1 and o.9 in 200* (Jan-Sep). While Johor State improved performance, Sarawak, Sabah and Selangor do not meet requirements in Adequate stool rate 78% in 2007 and 74% in The 60-day follow-up rate in 2008 is still very low at 34%. National polio laboratory fully accredited; poliovirus testing also for non-afp cases. Very low NPEV isolation rate. Immunization National reported OPV3: 98.5% in 2007 (KL %; coverage survey in 2007: 98%). Electronic data collection system introduced. Since October 2008, 8 states have shifted to IPV. No supplementary immunization. Preparedness for wild poliovirus importation Current status not mentioned. Laboratory containment Laboratory list updated in 2007 (since 2005 a total of 108 new institutions and laboratories were identified. Areas of concern expressed/issues mentioned None mentioned. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

51 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 MACAO (CHINA) The RCC thanked the NCC and its Secretariat for a thorough progress report and is impressed with the continued high quality of activities conducted. The RCC commended Macao on its comprehensive 'Protocol for Acute Response to Importations of Wild Poliovirus in Macao'. Comments:

52 2008 progress report Macao (China) Certification process NCC: new chairperson, otherwise membership unchanged, met once in Updated TORs. Expert Panel: 4 senior pediatricians, review protocol in place, all AFP cases to date with final diagnosis. AFP surveillance quality AFP surveillance system unchanged. Reporting units: 9 with 100% return rates. No AFP cases reported in 2007 and 2008 (probably statistical variance as population under 15 years is only 72,500. New enterovirus surveillance can supplement. % adequate stool samples: %. Polio laboratory: Government Virus Unit HK; good collaboration. Since Jan 2008 enterovirus isolation capacity established; identified 4 polioviruses so far in 2008 (in non-afp cases); ITD testing in HK. Some shipment delays were addressed by WPRO EPI Laboratory Coordinator. VAPP/VDPV: no events Immunization Reported OPV3 coverage 2007: 90%. Supplementary immunization activities: none Preparedness for wild poliovirus importation Comprehensive plan in place, revised Laboratory containment No new laboratories or materials. Areas of concern expressed/issues mentioned Increased arrival of visitors. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

53 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 MONGOLIA The RCC retained its general impression that polio surveillance and immunization activities have continued at good quality levels (information on the quality performance of the national polio laboratory was received from the WHO secretariat) but was concerned about lack of active oversight by the NCC and reporting to the RCC. While report indicates 3 NCC meetings in 2008, report submission was again very delayed and required significant WHO inputs. The RCC requested that this issue be discussed among relevant Ministry of Health and WHO officials to re-establish a fully functioning NCC. The RCC appreciated the information that OPV supply for routine immunization is provided by the Government of Mongolia. Comments:

54 2008 progress report Mongolia Certification process NCC work not clear. Also no mentioning how the expert panel is functioning but all cases in 2007 and all but one case in 2008 have final classification. AFP surveillance quality Non-polio AFP rate 1 in 2007 and 0.75 in 2008 (Jan-Sep), Adequate stool sample rates 100% in 2007 and 80% in Subnational performance monitored. And VPD surveillance training conducted in underperforming provinces. Quarterly feedback provided by national level on surveillance and immunization performance. The national polio laboratory is fully accredited and supplements AFP surveillance with enterovirus surveillance No VAPP, no VDPV event. Immunization Reported OPV3 coverage in 2007 was 99%; subnational level >94%., and 95% to date in Catch-up immunization provided every May and October in population centers. Preparedness for wild poliovirus importation Nothing mentioned. Laboratory containment Nothing mentioned. Areas of concern expressed/issues mentioned No discussion provided. However, decent quality AFP surveillance, high routine immunization coverage and low population density suggest fairly low risk. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

55 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 NEW ZEALAND The RCC thanked the NCC and its secretariat for a comprehensive and informative report and was impressed with the continued high quality of activities conducted to maintain New Zealand s polio-free status. In line with global recommendations and objectives of phase 1 laboratory containment, the RCC encouraged destruction of polioviruses still held in one laboratory which, in the absence of ITD, should be considered as potentially infectious wild poliovirus materials. Destroyed in March The RCC commended the development of an updated national emergency plan for imported wild poliovirus, including coordination of the NCC with the IHR focal point. Not yet completed. Comments:

56 2008 progress report New Zealand Certification process NCC: one new member (IHR 2005 national focal point), 2 teleconferences in 2008 (minutes provided). Expert Panel: unchanged, reviews all AFP cases and establishes presumptive diagnoses. AFP surveillance quality Reporting units: response rates 95% in 2007, 91% in 2008 (Jan-Jul). Several measures taken to address probable under reporting in Non-polio AFP rate: 2007: 0.55; in 2008 (Jan-Sep): 1.1. Adequate stool samples: %; %. Polio laboratory: fully accredited, also for ITD functions. Enterovirus laboratory network covering whole population; ESR tested 1601 samples in Immunization IPV3 coverage 2007: 87% (source: JRF). No supplementary immunization activities. Preparedness for wild poliovirus importation To be developed, patterned after Australia plan. NCC would work closely with IHR focal point Laboratory containment Polioviruses without ITD ( ) kept at ESR destroyed in March Areas of concern expressed/issues mentioned Nothing specifically mentioned. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

57 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 PHILIPPINES The RCC commended the NCC and its secretariat for a very comprehensive and informative report but lacks information on regular active oversight by the NCC. The RCC encouraged that this aspect be discussed among relevant Department of Health and WHO officials to ensure a fully functioning NCC as independent oversight body. Discussions are currently ongoing. The RCC appreciated, besides AFP case classification, the work of the expert panel conducting quarterly meetings, including surveillance, EPI and laboratory staff; particularly for monitoring the immunization status of AFP cases and recommending corrective actions for which examples were already presented in the report. The RCC commended the Philippines on the presidential executive order on immunization. The RCC also noted the development of an Integrated Disease Surveillance and Response System (PIDRS). The RCC noted that, in addition to continuing the Reaching Every Barangay (REB) approach, several other specific activities to improve reaching every infant with vaccination are pursued and considers particularly the focus on urban poor as important to maintain polio-free status. The RCC reiterated in this context its previous recommendation to ensure that a current national wild poliovirus importation preparedness plan is in place, given the continued risk of poliovirus importation into areas known to still have sub-optimal surveillance and immunization quality (e.g. areas with frequent population movements). Updated plan developed this year and to be implemented in Comments:

58 2008 progress report Philippines Certification process NCC: Once more no details provided. Expert Panel: quarterly meetings including surveillance, EPI and lab staff, reviewing all AFP cases. Presumptive diagnoses established and ranked. AFP surveillance quality The annualized non-polio AFP rate of 1.4 in 2008 is slightly lower than in 2007; three regions already reached the operational target at 2 (only country which has set in WPR). 1 st sub-national level: all but 5 Regions met minimum target of 1; weaker regions are supported by Surveillance Operations Support Staff. Percentage adequate stool samples: 75% (regional variance with 7 regions > 80%); NPEV isolation rate remained low at 5%. Good discussion also on other main performance indicators and activities described to strengthen AFP surveillance. Polio laboratory: fully accredited. VAPP/VDPV: no events Immunization Reported OPV3 coverage 87% in 2007 and 82% in 2008 (annualized). Several Department of Health memoranda and circulars have been issued in 2008 to improve immunization. No OPV SIAs conducted. Preparedness for wild poliovirus importation Updated plan developed (2008) and to be implemented in Laboratory containment Nothing mentioned.. Areas of concern expressed/issues mentioned Discussions in conclusions and recommendations. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

59 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 PACIFIC ISLAND COUNTRIES AND AREAS The RCC thanked the SRCC and its secretariat for a comprehensive and informative report. Having noted the SRCC's summary on challenges to achieve sustainable quality of AFP surveillance, the RCC encouraged to particularly focus on Pacific island countries s with larger populations for strengthening surveillance quality and wild poliovirus importation preparedness. As organizing actual meetings of the SRCC in its current composition has become increasingly challenging, the RCC suggested that the SRCC's work should focus on AFP case classification in the current approach of electronic review and discussions. At the same time the WHO Secretariat should ensure regular briefings of SRCC and Pacific island countries on all relevant aspects of maintaining polio-free status and facilitate the SRCC's reporting requirements to the RCC. Done. Relevant RCC findings and recommendations should continue to be communicated through the SRCC chairperson to the Pacific island countries; in providing written reports and direct updates at relevant EPI meetings. Chairperson PIC SRCC presented performance and requirements to keep Pacific polio-free at annual EPI managers meeting Comments:

60 2008 progress report Pacific island countries and areas Certification process Sub-regional Committee unchanged but did not meet since May Continues its functions as expert panel via discussions. Reviews all AFP cases and attempts to have final diagnosis for all. However, process very time consuming and does not allow timely classification. Situation requires attention and possibly restructuring of SRCC; to return to regular physical meetings and more active involvement of members in their respective countries. AFP surveillance quality Reporting completeness was 67% in 2007 but timeliness remains low at 21%. Form Jan-Nov 2008 figures are 52% and 24% respectively. Non-polio AFP rate 2007: 1.3, in 2008 (Jan-Sep) 0.9. Adequate stool collection rate 38% and 14% respectively. Reference laboratory in Australia conducts all AFP sample testing for the PIC, good collaboration. Immunization Reported polio3 coverage >90% in 12, 80-90% in 3 and <80% in 4 countries. No supplementary immunization activities conducted for polio. Preparedness for wild poliovirus importation After importation into Australia, reminders sent to all PIC MOH and info posted on PIC communication network (PPHSN). So far, Fiji and Solomon Islands requested for WHO support to develop national plans but plans were not yet developed Laboratory containment No new developments. Areas of concern expressed/issues mentioned Section on risk assessment included. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

61 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 PAPUA NEW GUINEA The RCC thanked the NCC and its secretariat for a very comprehensive and informative report and commended the NCC for the programme directions provided. The RCC commended Papua New Guinea for efforts made to revitalize the NCC, improve AFP surveillance performance, optimize timely and quality virological testing for polioviruses by shifting functions to the Regional Reference Laboratory in Australia and strengthen routine immunization. The RCC concurred with the NCC's assessment that further improvements are needed, particularly to increase population immunity, and maintaining the current gains could be challenging. But the RCC was impressed how with necessary commitment chronic issues can be addressed and performance improvements achieved; in very challenging conditions. Performance gains were not maintained in While the national rate seems to increase, the RCC noted that there are still substantial differences within the country in reported OPV coverage, requiring attention and encourages the plan to integrate OPV into the 2008 measles SIAs. Coverage improvement plan for 23 priority districts developed. Comments:

62 2008 progress report Papua New Guinea Certification process One NCC passed away, has been replaced. One meeting in 2008, provided clear and critical situation assessment and detailed recommendations. Expert panel active, reviews all cases. AFP surveillance quality AFP surveillance system unchanged. 19 reporting sites, high completeness of reporting in first half of 2008, then significant decline as responsible staff was transferred. Good non-polio AFP rate 2007 (1.2) decreased to 0.5 in 2008 (Jan-Oct); the adequate stool sample rate declined from 60% in 2007 to 17% in 2008%. Although national poliovirus testing functions were transferred to Regional Reference Laboratory in Australia, no AFP case samples were so far tested in 2008; shipment should have finally reached VIDRL this week. IMR specimen shipment center in Port Moresby delayed due to NCD requirements beyond control of NDOH and IMR. Immunization Reported OPV3 2007: 61% (compared to 75% in 2006); great variance in provinces. No supplementary immunization activities for polio. Preparedness for wild poliovirus importation National plan updated in 2007; including IHR 2005 requirements, currently circulated among NDOH senior officials for information purposes. Laboratory containment No new developments. Areas of concern expressed/issues mentioned Decreased performance levels after gains achieved in Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

63 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 REPUBLIC OF KOREA The RCC thanked the NCC and its secretariat for a comprehensive and informative report and was impressed with the continued high quality of activities conducted to maintain the Republic of Korea s polio-free status. Comments:

64 2008 progress report Republic of Korea Certification process NCC: meeting in 2008 planned in Dec? Report though was endorsed. Expert Panel: NCC serves; reviews cases according to virological case classification. AFP surveillance quality Reporting units: 105 hospitals (104 in 2008); reporting completeness declining (79% in 2007 and 64% in 2008). Non-polio AFP rate: ; (less priority due to large HFM disease outbreak); supplemented by enterovirus surveillance. Enterovirus sentinel surveillance expanded from 14 hospitals in 2006 to 23 hospitals in 2007 and 26 in In ,752 samples were tested and in 2008 (Jan-Oct) 3,155. % adequate stool samples: %; % Polio laboratory: fully accredited; no poliovirus isolation in 2007 and VAPP/VDPV: no events; shift to IPV in Immunization IPV3 coverage estimated. No supplementary immunization activities. Preparedness for wild poliovirus importation Current plan in place, considered sufficient to fulfill core capacities for IHR Laboratory containment No new developments. Areas of concern expressed/issues mentioned Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

65 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 SINGAPORE The RCC thanked the NCC and its secretariat for a comprehensive and informative report and was impressed with the continued high quality of activities conducted to maintain Singapore s polio-free status. The RCC noted that an active plan for response to wild poliovirus importation is in place (with coordination mechanisms between polio group and IHR 2005 National Focal Point). The RCC commended Singapore for regularly updating the national laboratory list and destruction of 2006 wild poliovirus materials; in the context of future requirements of poliovirus laboratory containment. Comments:

66 2008 progress report Singapore Certification process NCC unchanged, met once in Works also as expert panel. AFP surveillance quality AFP surveillance system unchanged. Non-polio AFP rate: 1.7 in 2007 and 0.7 in 2008 (Jan-Oct); adequate stool sampling rate 100% in 2007 and 80% in Special professional circular sent in 2008 to a;; registered medical practioners. National polio laboratory fully accredited, also for ITD functions; sequencing capacity established. Tested 711 samples in 2007 and 482 samples in 2008 for poliovirus. No VAPP or VDPV events; Sabin-like virus isolation in 2 non-paralysed child in 2007 and 3 Sabin-like poliovirus isolates in 2008 in non-afp cases. Immunization Reported OPV3 2007: 97%. No supplementary immunization activities. Preparedness for wild poliovirus importation Active plan in place; with coordination mechanisms between polio group and IHR 2005 National Focal Point. Laboratory containment National laboratory list updated in 2007, after that no new developments. Wild poliovirus materials 2006 destroyed. Areas of concern expressed/issues mentioned Nothing specific mentioned. Report quality? Preparedness for wild poliovirus importation adequate? Are there any concerns about specific aspects of AFP surveillance in light of challenges to maintain high quality? Are there any gaps in immunization against polio?

67 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL 14th MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Vientiane, Lao PDR, 9-10 December 2008 Main conclusions and recommendations, 13 th RCC meeting December 2007 VIET NAM The RCC thanked the NCC and its secretariat for a very comprehensive and informative report and commended the NCC for the active oversight and the programme directions provided. The RCC was impressed with the continued high quality of activities to maintain Viet Nam's polio-free status. The RCC commended Viet Nam for regularly updating the national laboratory list; in the context of future requirements of poliovirus laboratory containment. Comments: