WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Transcription

1 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC REPORT THE INFORMAL SIXTH MEETING OF THE SUBREGIONAL COMMITTEE FOR CERTIFICATION OF POLIOMYELITIS IN PACIFIC ISLAND COUNTRIES AND AREAS Suva, Fiji, October 2002 Manila, Philippines November 2002

2 REPORT THE INFORMAL SIXTH MEETING OF THE SUBREGIONAL COMMITTEE FOR CERTIFICATION OF POLIOMYELITIS IN PACIFIC ISLAND COUNTRIES AND AREAS Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Suva, Fiji October 2002 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines November 2002

3 NOTE The views expressed in this report are those of the participants of the meeting of the Subregional Committee for Certification of Poliomyelitis Eradication in Pacific Island Countries and Areas and do not necessarily reflect the policies of the World Health Organization. Keywords: Poliomyelitis / Certification / Pacific islands This report has been printed by the Regional Office for the Western Pacific of the World Health Organization for the participants in the meeting of the Informal Sixth Meeting of the Subregional Committee for Certification of Poliomyelitis Eradication in Pacific Island Countries and Areas, which was held in Suva, Fiji, from 10 to 11 June 2002.

4 CONTENTS 1 INTRODUCTION Objectives Organization Opening session 1 2 PROCEEDINGS Global and regional overview of poliomyelitis eradication Global status WHO South-East Asia Region WHO Eastern Mediterranean Region WHO African Region WHO Western Pacific Region 2.2 Overview of maintaining poliomyelitis-free status after certification in PICs Review of AFP cases reported in 2001 and from January to September Retrospective reviews Laboratory issues Laboratory containment of wild-poliovirus infectious and potentially infectious materials Progress report on maintaining poliomyelitis-free status after certification 11 3 CONCLUSIONS 11 4 ACTION POINTS AFP surveillance system Classification of AFP cases Retrospective reviews Laboratory containment of wild poliovirus infectious and potentially infectious materials Progress report on maintaining poliomyelitis-free status after certification Future activities of the Subregional Committee 15 ANNEX ANNEX 1 - MEMBERS OF THE SUBREGIONAL COMMITTEE FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN PACIFIC ISLAND COUNTRIES AND AREAS

5 1. INTRODUCTION 1.1 Objectives The Subregional Committee for the Certification (SRCC) of Eradication of Poliomyelitis in Pacific Island Countries and Areas (PICs) held an informal sixth meeting in Suva, Fiji, from 10 to 11 October 2002, with the following objectives: 1.2 Organization (1) to review the progress of maintaining poliomyelitis-free status after certification; (2) to review and make a final classification of all acute flaccid paralysis (AFP) cases reported during 2001 and 2002 (January to September); and (3) to review the draft progress report on maintaining poliomyelitis-free status after certification, to be submitted to the Regional Certification Commission for its eighth meeting to be held from 7 to 8 November 2002 in Manila, Philippines. The meeting was attended by the five members of the Subregional Committee and a WHO Secretariat (see Annex 1). Dr David Morens attended the committee as a Temporary Adviser to WHO. 1.3 Opening session The Chairperson addressed the committee, requesting Dr Morens to continue to serve as rapporteur. Representatives from United Nations Children's Fund (UNICEF) and the Fiji Ministry of Health were present during the meeting. 2. PROCEEDINGS 2.1 Global and regional overview of poliomyelitis eradication Global status In 2001, the global poliomyelitis eradication programme noted several areas of progress, with an 80% decline in the number of cases (2979 to 483); a reduction of infected countries from 20 to 10 under circumstances of good, or at least acceptable quality surveillance for cases of AFP; two years without poliovirus type 2 globally; and Bangladesh and the Democratic Republic of Congo with zero poliomyelitis cases for one year. In 2002, wild poliovirus transmission continues in three high transmission areas (India, Pakistan/Afghanistan, Nigeria/Niger) and three low transmission areas (Horn of Africa, Egypt and Angola).

6 - 2 - On 21 June 2002, the Regional Commission for the Certification of Poliomyelitis Eradication in the European Region certified the WHO European Region as free of indigenous wild poliovirus transmission. The last known case of paralytic poliomyelitis caused by indigenous wild poliovirus in the Region occurred in south-east Turkey in November The European Region is the third of the six WHO regions to be certified as poliomyelitis-free, following certification of the Region of the Americas in 1994 and of the Western Pacific Region in An estimated 3.4 billion people globally (56% of the world's population) now live in countries and territories certified free of endemic wild poliovirus transmission WHO South-East Asia Region During 2001, national immunization days (NIDs) were conducted in Bangladesh, India and Nepal. Between December 2001 and March 2002, Bangladesh, India and Nepal conducted two rounds of synchronized NIDs. Since 2000, these supplementary immunization activities (SIAs) have been intensified through the use of house-to-house vaccination following one day of fixed site activities. In addition to NIDs, each of the countries conducted subnational immunization days (SNIDs) in 2001 and In 2001, in response to the detection of wild poliovirus in India, 17 mop-up immunization campaigns, covering a total of 9.8 million children aged <5 years, were conducted. Of the 61 mop-up campaigns currently planned in 2002, 15 had been completed by June 2002, covering 43 million children aged <5 years. In addition to mop-up campaigns, selected high-risk districts in two northern states of India conducted an additional two rounds of house-to-house immunization as a pre-emptive measure during the spring of 2001 (covering 34 million children <5 years) and the spring of 2002 (covering 8.9 million children aged <5 years). AFP surveillance in Bangladesh, India and Nepal is facilitated through a network of surveillance medical officers (SMOs) who receive special training and are responsible for assisting the local health authorities in a defined area. As of June 2002, India had 239 officers, Bangladesh had 33 and Nepal had 14. Since 2000, Bangladesh, India and Nepal have exceeded annual non-poliomyelitis AFP rates of 1/ under age 15, with adequate specimens taken from >80% of AFP cases, thus achieving certification-quality AFP surveillance at the national level. As of June 2002, non-poliomyelitis AFP rates were below one in 10 states in India, accounting for 15% of the total population in India. Six states, accounting for 8% of the total population in India, report timely stool collection rates below 80%. During 2001, the non-polio enterovirus (NPEV) isolation rate (target: >10%), a marker of laboratory performance and the integrity of the reverse cold chain for specimens, was 10% to 30% in different laboratories of India (total: eight laboratories), 29% in Bangladesh and 29% in Nepal. Since the last wild-poliovirus-positive cases occurred in Bangladesh (August 2000) and Nepal (November 2000), India has been the only country in the South-East Asia Region with indigenous wild poliovirus transmission. India reported a total of 268 wild-poliovirus-confirmed poliomyelitis cases in 2001, an incidence essentially unchanged from 2000, when 265 cases were reported. Of the 268 cases reported in 2001, the isolated virus was type 1 (P1) in 209 cases (78%), type 3 in 56 cases (21%) and a mixture of P1 and P3 in three cases (1%). From January through June 2002, India reported 159 wildpoliovirus-confirmed cases (131 [82%] P1 and 28 [18%] P3), compared with 31 wild-poliovirus-confirmed cases during the first half of As of 7 October 2002, 546 type 1 wild-poliovirus-confirmed cases and 50 type 3 wild-poliovirus-confirmed cases from 61 districts were reported, with intratypic differentiation (ITD) for 97 cases still pending.

7 - 3 - Despite the progress made, continuing transmission during 2002 in northern India poses a significant challenge to the South-East Asian Region and the global eradication initiative. Circulation of poliovirus type 3 in 2002 has been primarily restricted to western Uttar Pradesh (UP). The geographical range of poliovirus type 1 circulation in Bihar has diminished since 2001; however, the spread of wild poliovirus to non-endemic districts of Uttar Pradesh and to other states in India indicates the urgent need to implement SIAs of improved quality. The principal reasons for failing to immunize children during immunization campaigns are: (1) failure of immunization teams to correctly identify all eligible children; (2) poor or nonexistent field supervision in many areas; and (3) poor participation of families in underserved communities. The conditions in these areas greatly favour transmission of wild poliovirus because of high population density and poor sanitation and hygiene. Also, susceptible children accumulate rapidly as a result of large annual birth cohorts and low routine immunization coverage, and only the highest possible quality of SIAs will allow interruption of virus transmission. The basic strategies of AFP surveillance and intensive oral polio vaccine (OPV) campaigns to supplement routine immunization programmes have proved successful in eradicating poliomyelitis in nearly all states of India, the other nine countries of the South-East Asia Region and around the world. In order to interrupt transmission in northern India, innovative measures will be needed to increase community involvement and improve the quality of SIAs. Based on the analysis of standardized independent observer checklists and programme management reviews, many new approaches were implemented in India during the latter half of 2001 and the first half of These included: (1) deploying follow-up vaccinator teams to find and immunize children missed by primary teams; (2) increasing the number of SMOs working in high-risk districts; (3) changing the ratio of supervisors to vaccination teams during SIAs from 1:5 to 1:3 in selected high-risk areas; (4) creating a network of social mobilization persons at the district, block and village levels to generate demand and promote acceptance of immunization; (5) retraining of vaccinators and supervisors to improve interpersonal communication skills; (6) forming a national operations group comprised of Ministry of Health and national and international partners to facilitate rapid implementation of strategic decisions; (7) increasing the number of field monitors; and (8) carrying out more extensive analysis of available data on SIA quality. The impact of these interventions will continue to be monitored during the SNIDs planned for September and November 2002 in Uttar Pradesh, Bihar, and parts of five other high-risk states. Both Bangladesh and Nepal are intensifying AFP surveillance and SIAs in response to the detection of poliomyelitis cases in border districts of India, in addition to ensuring high routine OPV3 coverage in these areas. Bangladesh is expanding its SNIDs in August and September 2002 to include all districts neighbouring India. Nepal is planning an aggressive OPV campaign in the border area with India in October and November The emerging epidemic in central and eastern UP highlights the importance of maintaining close communication and cooperation across borders to minimize the risk of reintroduction of wild poliovirus to areas that have interrupted transmission WHO Eastern Mediterranean Region Based on epidemiological and genetic sequence data, Afghanistan and Pakistan constitute a single epidemiological block of poliovirus transmission and, with northern India and Nigeria/Niger, represent one of the three remaining global reservoirs for poliovirus transmission. Improvements in the quality of supplementary immunization and AFP surveillance during the past two years have brought both countries close to interrupting wild poliovirus transmission.

8 - 4 - Although recent events in Afghanistan have posed many challenges to surveillance and immunization activities, data from the first four months of 2002 indicate that the programme was only temporarily affected and that progress towards poliomyelitis eradication has resumed. The improved quality of SIAs and addition of extra targeted NID rounds in Afghanistan before September 2001 appear to have prevented a widespread resurgence of poliovirus in the country during the crisis. Poliomyelitis eradication activities in Afghanistan continued during the critical period, with implementation of NIDs in late September and November 2001 and continuation of essential surveillance activities. The fact that during the crisis poliomyelitis eradication activities in both Afghanistan and Pakistan were also used to provide broader humanitarian relief is evidence of the profound dedication and commitment of the health staff in both countries. The AFP surveillance system in Pakistan is robust and now provides a sound basis for programmatic decisions. Surveillance quality in Afghanistan was only temporarily affected and shows strong signs of recovery. Rapid restoration of the AFP system in remaining endemic regions of Afghanistan bordering Pakistan is now a top programme priority. Both countries have conducted intense SIAs targeting high-risk populations during the summer of 2002, followed by NIDs in September and October. From early 2003, mopping-up activities to interrupt the final chains of virus transmission will be implemented in response to any isolation of wild poliovirus. Immunization and surveillance activities are closely coordinated between the two countries and include synchronization of SIAs, establishment of border immunization posts and regular exchange of data. The international technical advisory group (TAG) guiding the programme in both countries since early 2001 has stated that, while both countries appear to be on track to stop transmission of poliovirus by the end of 2002, several risks potentially threaten this success: escalation of conflict and deterioration of security in the Region; sudden large population movements that might spread the virus to areas where it is now absent; persistence of virus transmission in reservoirs shared between the two countries; failure to reach high-risk groups in SIAs; decline in political commitment, complacency or inability to balance competing priorities; and shortfall in human and financial resources WHO African Region During 2000 to 2001, there was substantial progress towards poliomyelitis eradication in Nigeria. Increasingly sensitive surveillance quality indicated elimination of multiple poliovirus strains and possible interruption of transmission in the south of the country, where no wild polioviruses have been isolated since July Remaining areas of transmission are located in the north-western states (type 1) and in the north-central and north-eastern states (type 3). Key achievements over the past two years include the creation of an expanded AFP surveillance medical officer infrastructure covering all parts of the country, implementation of an intensified house-to-house immunization strategy during NIDs and SNIDs, and supplementation of hundreds of thousands of children with vitamin A during poliomyelitis immunization campaigns. Despite this progress, Nigeria remains one of the three global poliovirus reservoirs where very low routine OPV immunization coverage and high population density favour poliovirus transmission. A joint national/international review in February 2002 highlighted several of the challenges that remain for the eradication of poliomyelitis in Nigeria. The review team found inadequate management of SIAs at lower levels, citing that microplanning, training of vaccinators and day-to-day monitoring of immunization activities were inadequate. In addition, the team found consistent reports of delays in paying immunization teams, resulting in considerable conflict and lack of motivation.

9 - 5 - Though significant progress in surveillance was noted, further improvements are needed in the geographical representativeness of quality indicators and the NPEV rate to ensure that poliovirus transmission is not occurring undetected. Finally, the team noted insufficient social mobilization efforts targeting ethnic minorities and other high-risk groups frequently missed by SIAs. AFP surveillance in Madagascar detected a cluster of four cases of paralytic poliomyelitis from which type-2 vaccine-derived polioviruses have been isolated. Preliminary data indicate that these cases, in the Toalgnaro district of Toliara province in south-east Madagascar, had onset of paralysis between 21 March and 12 April None of the children affected had been fully vaccinated. A small-scale house-to-house immunization response was undertaken by provincial authorities in March and April Genetic sequencing studies of these vaccine-derived viruses show substantial genetic drift and recombination with non-polio enteroviruses. These findings appear compatible with an outbreak of paralytic poliomyelitis due to a circulating vaccine-derived poliovirus (cvdpv). The three previously described outbreaks of cvdpv occurred in areas with low routine OPV coverage and suboptimal AFP surveillance, where SIAs had not been conducted for a number of years. Immunization coverage data from a survey conducted in Madagascar in 2000 indicate that only 37% of children aged <1 year in 1999 had received the minimum three doses of OPV. In 2001, the non-poliomyelitis AFP rate was 0.4 case per population aged <15 years, i.e. considerably below the target level of 1. A joint mission by the Ministry of Health of Madagascar, WHO and UNICEF was conducted to: (1) perform a field investigation of the cases to verify early reports; (2) review health facility records for potentially missed cases; (3) enhance the quality of AFP surveillance nationwide; and (4) plan for a nationwide house-to-house immunization response WHO Western Pacific Region The Regional Commission for the Certification of the Eradication of Poliomyelitis in the Western Pacific Region (RCC) submitted its progress report on the Region maintaining poliomyelitis-free status to the Global Commission for the Certification of the Eradication of Poliomyelitis (GCC). During its seventh meeting, held in Geneva on 12 April 2002, the GCC reviewed and endorsed the report of the RCC. The GCC commended countries of the Western Pacific Region on their achievements and concurred with the Regional Commission's finding on the countries successful efforts to sustain and document poliomyelitis-free status following regional certification, and urged all countries of the Western Pacific Region that had not yet completed phase 1 laboratory containment activities to reach this important milestone by the end of The next meeting of the RCC is scheduled from 7 to 8 November 2002 and will be held in Manila, Philippines. The previous format for country progress reports will be used again with the main sections continuing to be: performance of AFP surveillance; supplementary surveillance activities; laboratory surveillance; immunization activities; laboratory containment of wild poliovirus infectious/potentially infectious materials;

10 - 6 - areas of special concern; and post poliomyelitis-free activities for sustainability. The regional annualized non-poliomyelitis AFP rate, as of 7 October 2002, is 1.12 per children aged under 15 years, with all but one of the countries endemic at the beginning of the poliomyelitis eradication initiative meeting the required target. Concern exists about the low performance of Papua New Guinea, with an annualized rate of 0.52 achieved so far in Adequate stool specimen collection rates above 80% were only achieved by China, the Philippines and Viet Nam. The percentage of AFP cases with inadequate stool sample collection but follow-up is generally acceptable but still low in Viet Nam. Final classification of AFP cases has greatly improved, with only 5% still pending 90 days after onset. The performance of the poliomyelitis laboratory network in general remains high. Currently 91% of laboratory results are available within 28 days of receipt of specimens. Timeliness lower than 80%, however, is noted in the national poliovirus laboratories (NPL) in New Zealand and five subnational laboratories in China, and queries for possible reasons have been sent. Almost all ITD results (98%) are available within 28 days of receipt of isolates at the laboratories, but the required 80% of ITD results available within 60-days of onset has not yet been reached, although significant improvements in 2002 to 78% have been achieved, particularly in China. This is partly due to late collection of stool samples, but is mainly attributed to long shipment times from the point of the collection to the NPL. Very positive developments took place in AFP surveillance quality in the Philippines, with all but one region achieving an annualized non-poliomyelitis AFP rate above 1 per under age 15 years. Adequate stool collection exceeds 80% in all but two regions. No new VDPV was detected, supporting the assumption that the nationwide immunization response to the VDPV-associated poliomyelitis outbreak in 2001 successfully interrupted virus circulation. Two rounds of NIDs were conducted in February and March 2002, targeting all children under five years of age and delivering OPV vaccine to approximately 70% of the target group using a house-to-house approach. 2.2 Overview of maintaining poliomyelitis-free status after certification in PICs Following action points made during the last meeting of the PIC SRCC, letters were sent by the WHO Secretariat in February 2002 to all national coordinators to re-enlist their help in rejuvenating the reporting system. Presentations were made at the recent EPI managers meeting in September 2002 on the purpose and performance of the AFP surveillance system. However, it must be noted that not all national coordinators are EPI managers. Acute fever and rash surveillance is receiving high priority for the maintenance of measles elimination in the PIC and is perceived as an opportunity to support interest and focus on AFP surveillance. Modified surveillance forms, including rash and fever, have been distributed since the beginning of The hospital-based surveillance network now includes 58 hospitals distributed in all 20 countries and areas, and active involvement of 20 national coordinators, 58 hospital coordinators, and about 200 key paediatric clinicians. The Secretariat presented results of the monthly reporting for 2001 and 2002 to date. The reporting mechanism in most countries continues to require a copy of the completed monthly form to be sent from the hospital coordinator to the national coordinator and copied to WHO at least every three months. The WHO office received copies of 21% of expected forms for 2001 (147 out of 696)

11 - 7 - and to date 47% of the forms expected for 2002 up to June (163 out of 348). This represents a very significant decrease in reporting completeness in 2001 (90% in 1999 and 54% in 2000) with certain improvement during the first six months of In 1999, only one of 58 hospitals failed to submit a report and only two others submitted fewer than half of expected reports. In 2000, 18 of 58 hospitals from six of 20 PICs failed to submit a report. In 2001, 37 of 58 hospitals failed to submit a report. During the first six months of 2002, 28 of 58 hospitals have not yet submitted a report. Many forms may be held at hospital or national level and cluster signing continues to be very common. There appears to be a serious decline in interest in post-certification activities with often suboptimal understanding by clinicians. The performance standard related to AFP surveillance activities was discussed further in detail. Standard: at least 80% of expected reports will be received on time. The standard was not met in either 2001 (21%) or 2002 (47% January to June) and raises serious concerns that the surveillance system needs to be enhanced. 2.3 Review of AFP cases reported in 2001 and from January to September 2002 As requested by the Commission, detailed case and follow-up information was obtained for children with case number and from New Caledonia. Both cases had adequate stool samples taken that tested negative for poliovirus at the Victorian Infectious Disease Research Laboratory (VIDRL), and both children were found to have fully recovered and were thus discarded as non-poliomyelitis AFP. The virological algorithm was used for case classification. The algorithm and classification categories adopted by the Committee are displayed below: Virological classification of AFP cases Classification categories (1-5, a, b) Wild poliovirus 1. confirm residual 2. compatible paralysis, Pending: AFP died, or expert a) 60-day follow-up inadequate lost to follow-up review specimens b) expert review 3. discard No wild no residual poliovirus paralysis 4. discard two adequate specimens 5. discard

12 - 8 - Of the 17 cases presented and reviewed, the Committee discarded four cases as non-poliomyelitis based on negative laboratory results, for each, of two adequate stool specimens (category 5). Four other cases lacked residual paralysis at 60 days, and were thus discarded (category 4). Four cases were discarded after detailed review and discussion of clinical and laboratory data available. Regarding a further four cases, either 60-day follow-up information was not available or the clinical and laboratory information available was not considered sufficient. These were retained as pending (category a and b), and will receive final classification through electronic discussion by the Committee members. One case was discarded as not AFP. A summary of the Committee s expert review is provided in the table below: Case Number Country Classification Category Solomon Islands New Caledonia New Caledonia Solomon Islands 2B Solomon Islands 2B Fiji Fiji Samoa Tonga Solomon Islands Fiji New Caledonia Vanuatu 2A FSM New Caledonia 2A Fiji NOT AFP Fiji 4 During the preparations for the recent annual meeting of PIC EPI managers, New Caledonia updated its AFP surveillance data and submitted brief summary notifications on an additional seven potential AFP cases with onset in 2001 and The Committee reviewed the information provided and discarded four cases as not AFP, but requested additional information on three cases. Once obtained, these data will be electronically shared among all committee members to arrive at a final classification as soon as possible. The achievement of performance standards related to AFP case finding and investigation in 2001 and 2002 to date was discussed. Standard: at least one annual case of AFP per children under age 15 per year. This standard was met in 2001 with 11 cases reported, resulting in a non-polio AFP rate of 1 per under age 15. In 2002 up to the end of September, seven cases were reported, resulting in an annualized non-poliomyelitis AFP rate of 0.9 per under age 15. From 1997 to September 2002, 71 AFP cases were reported, resulting in an overall non-poliomyelitis AFP rate of 1.1 for those (almost) six years.

13 - 9 - The number of cases expected and reported per country from 1997 to September 2002 presented as follows: Country # AFP cases expected # AFP cases reported Country # AFP cases expected # AFP cases reported Fiji Tonga 2 2 Solomon Kiribati 2 6 Islands French 4 3 Am. Samoa 1 1 Polynesia Vanuatu 5 4 CNMI 1 - Samoa 4 4 Marshall Islands 1 - F.S. Micronesia 3 5 Other 1 1 New Caledonia 4 15 Guam 3 1 Total Standard: all AFP cases must be investigated. This standard was met for AFP cases with onset in 2001 and Full case investigations were obtained on all reported AFP cases and retrospectively on the AFP cases identified in retrospective case reviews. Standard: at least 80% of AFP cases should have two adequate stool specimens. This standard was not met in 2001 or, to date, in Of the 11 cases with onset in 2001, only four (36%) had two adequate stool specimens; three cases had either one sample taken or two obtained in an untimely manner. Four cases had no specimen taken. For the seven cases with onset in 2002, the rate of timely stool sample collection was 29%. One case had stool specimens collected but not within 14 days of onset, and four cases had no stool samples taken. Year # AFP cases by active surveillance # total AFP cases # (%) with adequate stools (25) (36) (18) (32) (36) 2002 (9 months) (29) Total (30)

14 Standard: all stool specimens should be examined in an accredited laboratory. This standard was met for all cases with onset in 2001 and 2002 to date, and all specimens were successfully transported to VIDRL. Standard: at least 80% of AFP cases should have a 60-day follow-up examination. This standard was not met for 2001, with only seven cases (64%) having follow-up examinations. Of those AFP cases with onset in 2002, 43% have had follow-up examinations, but for two cases notification was only received very recently and follow-up examinations are expected to be conducted in a timely fashion. Year # AFP cases by active surveillance # total AFP cases # (%) with 60-day follow-up (67) (82) (82) (79) (64) 2002 (9 months) (43) Total (72) Additional surveillance quality indicators as recommended by the TCG and Western Pacific Region TAG are presented as follows: Percentage of AFP cases with inadequate stool samples and 60-day follow-up available (target: 80%). Year # AFP cases # AFP cases with inadequate stools # (%) with 60-day followup (56) (86) (78) (77) (43) 2002 (9 months) (60) Total (67) 2.4 Retrospective reviews Since the last meeting of the Subregional Certification Committee, retrospective record reviews for AFP cases have been conducted in Fiji, Kiribati, Samoa, Solomon Islands and Tonga. As a result, five cases of AFP not previously reported through the routine surveillance system were identified as follows: two cases in Labasa (Fiji) with onset in 2002 and one case each in Samoa (onset in 2001), Solomon Islands (AFP case aged 16 years) and Tonga (onset in 2001).

15 Laboratory issues The Committee reviewed the status of collection and transport of stool specimens to the reference laboratory under reverse cold chain conditions. Currently, all countries use VIDRL and excellent support continues to be provided by VIDRL, with copies of all documentations received by VIDRL now being sent to the WHO Secretariat together with stool results. 2.6 Laboratory containment of wild poliovirus infectious and potentially infectious materials The WHO Secretariat has completed assembly of a subregional inventory of laboratories that may hold wild poliovirus infectious or potentially infectious materials in the PICs. All laboratories were contacted and submitted the information required. The Guam Naval Hospital Laboratory completed the questionnaire and finally submitted the signed copy. While monitoring subregional laboratory practices and poliomyelitis risk by contacting laboratories routinely to request information on specimen receipt and storage, special attention has to be paid to laboratories with tissue-culture capacity. 2.7 Progress report on maintaining poliomyelitis-free status after certification The Committee complied, where applicable, with the sections recommended by the WHO Secretariat for the progress report. 3. CONCLUSIONS The committee continues to support AFP case detection through prospective hospital-based surveillance. It believes that this is the best means of obtaining information to document that the subregion remains poliomyelitis-free. However, since certification in mid-2000, there has been a significant decline in most of the key surveillance indicators. The Committee believes that this decline, which continues into 2002, is a serious problem requiring urgent attention. The goal is to re-establish the level of surveillance/reporting achieved in 1999/2000, leading up to subregional and regional certification. The Committee notes that, although 58 hospitals in all 20 countries continue to constitute the active AFP surveillance network of the PICs, the required regular reporting to WHO has significantly decreased since 2000; 37 out of 58 hospitals failed to submit reports in 2001 and 28 hospitals have failed to do so in 2002 so far (January to June). While acknowledging that many forms may be held at hospital and national levels, the Commission is very concerned that AFP cases may be missed, as supported by retrospective record review having identified several unreported cases. The Commission discussed as possible reasons: the misconception that after certification of poliomyelitis-free status AFP surveillance is no longer required; the low priority given to the continuation of poliomyelitis eradication activities; the high turnover of coordinators and key clinicians involved in the system, and the fact that new staff not always aware of the requirements; and insufficient prompting and follow-up.

16 The Committee notes that a non-poliomyelitis AFP rate of 1 per children under age 15 was achieved in 2001, but that the annualized rate in 2002 (0.9 per children under age 15) has not yet reached the minimum requirement. The Committee appreciates the retrospective record reviews conducted in Fiji, Kiribati, Samoa, the Solomon Islands and Tonga but is worried that the finding of unreported AFP cases supports the assumption that the system is not yet sensitive enough and is thus missing cases. The Committee continues to be very concerned that the adequacy of stool specimen collection remains very low, with 36% in 2001 and 29% in 2002 so far. The Committee believes that this unsatisfactory situation has four principal causes, similar to those noted above for hospital reporting percentage decline: (1) a fall-off in enthusiasm and effort once certification was achieved; in some cases made worse by the erroneous belief that surveillance is no longer required; (2) delayed AFP detection/reporting, which results in delayed specimen collection and case follow-up; (3) the high turnover of key staff without retraining and orientation of their replacements; and (4) competing priorities. The Committee was able to provide final classification for two AFP cases with onset in 1999 and one case with onset in 2001 that had been kept pending after the last meeting. The committee further reviewed 17 cases with onset in 2001 and 2002 and was able to classify all but four cases awaiting additional information. Two of these cases had been identified by retrospective record review with onset in Two cases with onset in 2002 had either laboratory results or follow-up still pending. The Committee also reviewed brief information provided by New Caledonia on an additional seven potential AFP cases with onset in 2001 and 2002, submitted during the recent annual meeting of PIC EPI managers. Four cases were discarded as non-afp, while additional information was requested for the other three cases. The Committee noted that delays in provisional classification of cases have become a serious problem, with 75% pending at 90 days, often due to stool specimen and follow-up delays. This reflects at least two things: (1) that the Committee has only met annually to date; and (2) that there have been serious reporting and follow-up problems, as noted above. The Committee noted that the inventory of laboratories that may store wild-poliovirus infectious materials or potentially infectious materials has been finally completed, but also noted that when monitoring subregional laboratory practices and poliomyelitis risk in the future, special attention has to be paid to laboratories with tissue-culture capacity. The Committee decided to apply the WHO recommendations on the structure and content of the progress report for submission to the RCC for its next meeting from 7 to 8 November The Committee thanked VIDRL for their continuous excellent cooperation and guidance in virological surveillance for PICs. From January 2001 to September 2002, specimens for 10 AFP cases were successfully transported in good conditions to Melbourne, Australia, for laboratory analysis,

17 demonstrating the viability of the system. 4. ACTION POINTS 4.1 AFP surveillance system 1) The Committee and the Secretariat will communicate with national authorities (e.g. Ministers of Health) to enlist their political commitment for the continuing importance of the AFP reporting system and their active support for national public health surveillance, particularly the national and hospital coordinators. 2) The Committee recommends that wherever possible the national coordinator should be a senior officer within the EPI programme of the country. 3) The Committee recommends that national and hospital coordinators ensure that all clinicians participating in the reporting system understand the purpose and procedures of the AFP surveillance system. 4) The Committee Chairperson will send out letters, on Subregional Committee letterhead and under her signature, with an attached packet of the meeting report and progress report on maintaining poliomyelitis-free status to national authorities. In addition, a letter and information packet will be sent separately to the national coordinators by the Chairperson. 5) The Committee and the Secretariat will continue to make efforts to set up electronic reporting and communications, and to look for ways and means of integrating these efforts with the existing Pacific Islands Public Health Surveillance Network (PPHSN) system. 6) The Committee requests that the Secretariat provide quarterly feedback to all national and hospital coordinators, electronically where feasible, otherwise by fax or mail, listing countries, coordinators/contact information, and AFP reporting and performance data, together with other information about surveillance activities concerning AFP and fever and rash. 7) In view of the growing importance of electronic communication for basic public health surveillance and reporting, the Committee draws attention to the importance of national and hospital coordinators having access to functioning equipment and Internet connections in the workplace. 8) The Committee and the Secretariat will encourage the PICs to integrate other surveillance activities, e.g., for fever and rash (capable of detecting measles, rubella and dengue), with AFP reporting as a means of strengthening the motivation to report AFP cases and also to demonstrate that the reporting system has long-term value beyond poliomyelitis eradication. Consideration will also be given as to how such enhanced surveillance can be linked to anticipated future surveillance activities that will maintain measles elimination in the PICs. 9) The Committee recognizes that its recommendations will place a greater burden upon the WHO Secretariat. It requests that Western Pacific Regional Office and the WHO Representative in the South Pacific ensure that there continues to be adequate administrative and secretarial support for AFP surveillance activities.

18 ) The Committee recommends that national and hospital coordinators seek to integrate training in AFP surveillance into pre-service and in-service training activities. In support of this, the Secretariat will prepare subregion-specific training materials, such as power point slide and overhead presentation materials, and provide these to all coordinators. 11) The Committee encourages national and hospital coordinators and key clinicians to maintain contacts with private health care providers and to inform them about the importance of reporting suspected AFP and fever/rash cases. 12) The Committee recommends that national authorities develop information, education and communication materials for their populations, addressing the importance of poliomyelitis and measles control, and of public health activities supporting control measures. 4.2 Classification of AFP cases 1) The Committee recommends that, between annual meetings, the Committee work electronically to resolve existing cases and cases arising via electronic communications between the members and the Secretariat. 2) The Committee, furthermore, requests that additional information be provided on cases whose classification is pending, including newly reported cases from New Caledonia. 4.3 Retrospective reviews The primary importance of active prospective surveillance as the foundation of AFP surveillance is re-emphasized. As an adjunct, national coordinators will be asked to conduct, in 2003, one-year baseline retrospective reviews for the year 2002 in all 20 PICs at all 58 hospitals. In future years, annual retrospective reviews will be encouraged for all PICs and will be requested from those PICs identified as having AFP reporting problems. The Secretariat will develop a standard review and reporting format for this purpose. 4.4 Laboratory containment of wild poliovirus infectious and potentially infectious materials In follow-up to action point from the 2001 report, in 2003 the Secretariat will re-assess subregional laboratory compliance by requesting follow-up information on specimen storage and receipt from high-risk laboratories, identified to date as the Institut Pasteur, New Caledonia; the Institute Louis Mallardé, French Polynesia; and the Guam Naval Medical Hospital. 4.5 Progress report on maintaining poliomyelitis-free status after certification The Committee again thanks the many key clinicians, hospital coordinators, and national coordinators for their considerable efforts on behalf of maintaining the subregion s poliomyelitis-free status after certification. In view of recent events outside the subregion, including instances of poliovirus importations and poliomyelitis outbreaks caused by cvdpv in the Philippines and Madagascar, the Committee strongly believes that AFP surveillance must be enhanced in the subregion, and that national authorities, national coordinators, hospital coordinators, key clinicians and all public health personnel should be fully aware, vigilant and committed to maintaining the AFP surveillance system as a means of keeping the subregion poliomyelitis-free.

19 The Committee notes the continuing risk of poliovirus importations by immigrants and travelers to the Region, and urges the PICs to recognize this risk and remain vigilant against poliovirus importations. The Committee again recommends that the Secretariat take all necessary steps to support and enhance the AFP surveillance system, with the expectation that such surveillance must be maintained at a high level for at least several years leading up to, and beyond, the cessation of global poliovirus circulation, and for the support of control and elimination of other childhood diseases, such as measles. The Committee recommends that it continue to meet approximately annually, with interim business, such as AFP case classification, follow-up and provisional classification conducted electronically. 4.6 Future activities of the Subregional Committee The Subregional Committee proposes that it next meet in approximately October As a means of enhancing surveillance and increasing subregional visibility and authority for the importance of poliomyelitis eradication, and to stimulate and encourage PICs that are experiencing significant surveillance problems, the Committee also recommends considering the possibility that future meetings rotate annually among various selected PIC venues, focusing particularly on PICs identified by the Committee as key and problematic sites. The Committee has begun to draft a report, for publication, of the subregion s approaches and efforts leading up to certification. It now proposes to complete and finalize this draft, with the aim of submitting a paper for publication to an appropriate peer-reviewed public health or biomedical science journal in 2003.

20 ANNEX 1 MEMBERS OF THE SUBREGIONAL COMMITTEE FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN PACIFIC ISLAND COUNTRIES AND AREAS Dr Lisi Tikoduadua (Chair) Dr Siaosi Aho Dr John Adams Dr Isamu Abraham Dr Eliane Chungue SECRETARIAT Dr M. O Leary Dr D. Morens Mr F. Rousar Dr S. Roesel