WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

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1 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC REPORT ELEVENTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Manila, Philippines 3-7 December 2005 Manila, Philippines April 2006

2 (WP)/ICP/IVD/1.1/001-A Report series number: RS/2005/GE/51 English only REPORT ELEVENTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Manila, Philippines 3-7 December 2005 Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines April 2006

3 NOTE The views expressed in this report are those of the participants of the eleventh 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 eleventh meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region, which was held in Manila, Philippines, from 3 to 7 December 2005.

4 CONTENTS 1. INTRODUCTION Objectives Opening Remarks Opening ceremony PROCEEDINGS Global overview of polio eradication Regional overview of the situation after polio-free certification Progress reports from each country and area on maintaining polio-free status after certification CONCLUSIONS General Country specific conclusions and recommendations FUTURE MEETING OF THE REGIONAL CERTIFICATION COMMISSION Page

5 1. INTRODUCTION The eleventh Meeting of the Regional Commission for the Certification of Poliomyelitis Eradication (RCC) was held in conjunction with the First Meeting on Laboratory Containment of Wild Polioviruses in the Western Pacific Region. For its 10 th meeting the RCC had requested that all countries in the Region that had completed the laboratory survey and inventory activities submit a detailed descriptive report to the RCC documenting the laboratory survey and inventory process and comparing it where possible against a best practices model that had been developed in the meantime. The RCC was very encouraged by the quality assessment reports received from all but three countries concerned. In order to give the work represented in these reports the critical review deserved, the RCC recommended the WHO should establish a process of further expert review and feedback mechanisms, including the possible hosting of a regional containment meeting similar to meetings successfully conducted in other WHO regions. 1.1 Objectives The objectives of the RCC at its eleventh meeting were: 1) to update National Certification Committees (NCC) and National Containment Coordinators on the progress of the Global poliomyelitis (polio) eradication efforts and containment activities; 2) to review progress reports from all countries and areas on maintaining polio-free status; and to make recommendations for maintaining the Region's polio-free status and requirements for global certification. 3) to review progress of laboratory containment of wild poliovirus infectious/potentially infectious materials in the countries; and to update NCCs and National Coordinators on the status of implementation of the Phase I Regional containment plan of action; 4) to review quality assessment of the national containment documentation conducted in countries and provide feedback on completeness of phase I; and 5) to brief the participants on approaching Phase II of the Global Action Plan (GAP) as well as the 3 rd edition of the GAP, which is currently under preparation. 1.2 Opening Remarks The meeting was attended by all seven commission members, NCC chairpersons/members (or their representatives) from all countries, national laboratory containment coordinators (or their representatives) from all countries and a WHO secretariat. Annex 1 includes the meeting timetable, and Annex 2 contains a list of participants. 1.3 Opening ceremony Before welcoming the audience, Dr Shigeru Omi, the Regional Director, gave recognition to the resignation of Dr Shudo Yamazaki, Director Emeritus, National Institute of Infectious Diseases (NIID) in Japan, who resigned from the RCC effective from November 2004 due to a

6 - 2 - heavy workload and commitments in his current post. Dr Omi expressed appreciation for Dr Yamazaki's expertise and significant contributions for the past four years as Vice Chairman of the RCC. Dr Omi then introduced as new member of the RCC, Dr Nobuhiko Okabe, Director, Infectious Disease Surveillance Center, NIID, Tokyo and expressed his confidence that Dr Okabe's expertise and wide experience in the field of infectious diseases would contribute much to the work of this RCC and to the success of the meeting. Dr Omi summarized that while facing the emergence of new diseases like severe acute respiratory syndrome (SARS) and avian influenza, unexpected challenges still exist from the well-known traditional infectious diseases. The global polio eradication programme continues to make good progress in most endemic areas. The risk of wild poliovirus being imported into polio-free areas remains a threat as long as it exists in certain parts of the world. From the beginning of 2004 to date, such importations occurred in 18 previously polio-free countries. In particular, the recent polio outbreak in Indonesia has brought the disease back to the doorstep of the Western Pacific. In 2005, the number of polio cases due to importations was, for the first time, significantly higher than cases due to endemic transmission. Dr Omi warned that there is much at stake. Being certified as polio-free in 2000 is one of the biggest public health achievements in the Region and the huge investment made by all Member States and partners must be protected by maintaining quality surveillance and immunization systems. Approaches that achieved polio-free status serve now as the platform for new goals like measles elimination and hepatitis B control as well as strengthening routine systems. Dr Omi reported that this was also discussed at the recent Regional Committee Meeting last September. Dr Omi reiterated that maintaining polio-free status includes accurate and updated national inventories of wild poliovirus infectious and/or potentially infectious materials still retained in laboratories to ensure that they are safely stored under required bio-safety conditions. Preparing for the synchronous cessation of oral poliovirus vaccine (OPV) use will require appropriate containment of all poliovirus strains and thus it is also of great importance that phase I wild poliovirus containment will be completed as soon as possible in the Region to protect the current polio-free status and prepare for the next phase. Therefore, Dr Omi welcomed that the 11 th RCC meeting devoted substantial time on containment discussions and has for the first time gathered together wild poliovirus laboratories containment coordinators and specialists from all countries. Dr Omi expressed satisfaction that all countries concerned already prepared quality assessment reports on the conduct of national laboratory surveys and establishment of inventories and was also looking forward to the RCC's conclusions as to whether activities have been sufficient or more needs to be done. Planning for future polio immunization programmes will be based on risk assessment of neighbouring nations that have not only reliably eradicated polio, but are also in control of polioviruses in laboratories. Dr Omi emphasized that commitment to polio eradication remains high, thanks to visible progress in the hardest endemic areas and powerful new tools like monovalent OPVs (mopv). Still, he warned that guards cannot be let down as recent outbreaks in previously polio-free countries like Yemen and Indonesia have demonstrated that with the right conditions, wild poliovirus will not remain modest but rapidly spread and paralyze large numbers of children. Dr A. Adams was requested to continue to serve as Chairperson, Dr N. Okabe was requested to serve as Vice-Chairperson, and Dr A. Salonga was requested to continue to serve as Rapporteur.

7 PROCEEDINGS 2.1 Global overview of polio eradication In Africa, transmission of indigenous poliovirus had not been detected in Egypt or Niger for more than six months and appears to have been interrupted. Imported poliovirus was eliminated from 10 of the 15 African countries that had experienced importations since 2003 as a result of a series of five coordinated polio immunization campaigns conducted in 25 countries under the auspices of the African Union. Following the resumption in October 2004 of nationwide polio immunization campaigns in Nigeria, the number of states in that country reporting poliovirus to date in 2005 declined by 32% and the number of polio cases fell by 20% (as compared with 9 November 2004). In Asia, since the introduction of monovalent oral polio vaccine type 1 (mopv1), the locally circulating poliovirus had not been detected in any of the three remaining poliovirus reservoirs in Mumbai, India and was further restricted to 14 of the 107 districts in Uttar Pradesh and Bihar. In Pakistan in 2005, only type 1 poliovirus was detected in nine out of 126 districts, with a 57% decline in the number of circulating wild poliovirus lineages as compared to In Afghanistan, a few cases of paralytic polio due to types 1 and 3 polioviruses were detected in the southern region in During 2005, 12 countries reported imported poliovirus and, for the first time, the number of polio cases in countries newly affected was higher than in countries endemic for the disease (873 compared to 655 as of 22 November 2005). Northern Nigeria constitutes the last reservoir of indigenous wild poliovirus in Africa and appears to be the only significant remaining reservoir of types 1 and 3 poliovirus concurrently in the world. Because of the heavy disease burden and risk of exportation, large-scale supplementary immunization activities (SIAs) with an appropriate combination of monovalent and trivalent oral polio vaccines are required every four to six weeks until poliovirus transmission is interrupted. Wild poliovirus transmission in Afghanistan, India and Pakistan is now restricted to a single serotype, type 1 or 3, in any given geographical area. Large-scale supplementary immunization activities that reach more than 95% of children in the infected areas with the appropriate mopv are required every four to six weeks until poliovirus transmission is interrupted. With the acceleration of wild poliovirus eradication, all countries must implement recommended activities for the bio-containment of wild polioviruses, enhance and sustain surveillance for circulating polioviruses and evaluate long-term polio immunization policy options. Multi-year and flexible financing commitments are needed to cover the unmet funding requirement of US$ 750 million for , of which US$ 200 million is immediately required for activities in These funds are needed to buy OPV, conduct polio immunization campaigns, implement emergency outbreak response, sustain highly sensitive disease surveillance, and provide technical support to Member States. Recognizing that 57% of all polio cases reported in 2005 have been from outbreaks in previously polio-free countries, the Advisory Committee on Polio Eradication (ACPE) undertook

8 - 4 - a detailed analysis of the response to such outbreaks between 2003 and The ACPE found that the risk of prolonged transmission and further national and international spread of poliovirus was related to (1) the speed of the initial immunization response, (2) the geographical extent of the response, (3) the proportion of children vaccinated in the target population, (4) the use of mopv, and (5) the total number of immunization rounds conducted. The ACPE therefore issued standing recommendations to Member States for responding to circulating polioviruses in polio-free areas. It also issued recommendations to the WHO Director-General and the spearheading partners to support responses to polio outbreaks in Member States reporting polio cases due to imported viruses, and reaffirmed the measures countries at particularly high risk of importation could consider adopting in order to reduce that risk. The effective implementation of these recommendations requires immediate recognition of any circulating poliovirus as a potential international health threat, and appropriate responses. 2.2 Regional overview of the situation after polio-free certification As of 29 November 2005, a total of 5166 acute flaccid paralysis (AFP) cases with onset in 2005 had been reported resulting in an annualized non-polio AFP rate of 1.38 per under age 15. Adequate stool specimen collection rate was 88%. Poliovirus isolation and typing results are available within 28 days of receipt for 96% of specimens and all but one laboratory exceeded the target of 80%. The non-polio enterovirus isolation (NPEV) rate was 10% with several laboratories achieving rates at or below 5%, which maintains concerns about possible decreased virologic sensitivity. Measures continue to be taken to strengthen basic laboratory techniques where required. Intratypic differentiation (ITD) results were available within 14 days of receipt for 97% of poliovirus isolates of AFP cases. ITD results were available for 85% of AFP cases within 60 days of onset of paralysis and for 97% within 90 days of paralysis onset. Standard ITD was applied to 211 poliovirus isolates from AFP cases and 203 poliovirus isolates from non-afp sources. Respectively 20 and 10 isolates had discordant ITD results and were sequenced. While no wild polioviruses have been detected since 1999, the surveillance systems for AFP cases were able to quickly detect episodes of vaccine-derived polioviruses (VDPV) in The People s Republic of China (2004) and Lao People's Democratic Republic in Reported routine immunization coverage with poliovirus vaccine has been maintained at levels similar to previous years but serious immunity gaps in some areas continue to exist as indicated by the recent VDPV episodes. SIAs with OPV have been further reduced, mainly due to lack of funding, and strong priority is placed on strengthening routine immunization systems, however, progress is often slow. Particular OPV coverage problems exist in Lao People's Democratic Republic, Papua New Guinea, several Pacific island countries and areas (PICs) and high-risk communities and populations in China and the Philippines. The risk for wild poliovirus importation into countries in the Western Pacific Region continues, especially when polio outbreaks occur in close geographical proximity and in places with frequent population movements (e.g. the 2005 polio outbreak in Indonesia). The polio laboratory network in the Western Pacific Region is comprised of one global specialized (Japan), two regional reference (Australia and China), 10 national and 31 Chinese provincial polio laboratories. All were reviewed for 2005 accreditation and are, except for the provincial laboratory in Tibet, currently performing under general WHO standards.

9 - 5 - A type 3 VDPV (1% divergence in VP1) was identified from an adult AFP case in Japan (Nagasaki Prefecture) in From the epidemiological background, this index case is supposed to be an intrafamilial contact infection. Type 3 poliovirus (with 0.7% divergence in VP1) was isolated from a healthy vaccinee (his daughter). Mutation site between index case and vaccinee on VP1 is almost identical. The virus was not isolated from another healthy contact (his wife). Additional laboratory investigations were conducted. A detailed report on further clinical, epidemiological and immunological findings was included in the national progress report. A type 2 VDPV (1.2% divergence in VP1) was isolated from a two-year-old boy in China (Anhui Province) that received four doses OPV, with last, fourth dose on January On 30 July, he developed a febrile illness and two days later, AFP of the right leg. By August, his left leg was also paralyzed. On examination 15 October, 2.5 months after onset, the boy remains almost completely paralyzed, unable to sit or walk, and showed marked muscle atrophy and loss of deep tendon reflexes. The village where the boy comes from as well as surrounding villages have reported high immunization coverage. Stool samples of 22 contacts of the case were cultured but all negative. The child appeared to be immuno-compromised, has low antibody titres against all three types poliovirus and continued to shed virus. Divergence in VP1 had increased to 2.33% in the type 2 VDPV isolated from a follow-up stool sample taken in October and an additional type 3 VDPV was found with 2.67% divergence, both findings indicating that these viruses are ivdpvs. Further details are included in the national progress report. Particularly in view of the polio outbreak in Indonesia, several Regional activities were undertaken in 2005 to enhance wild poliovirus preparedness, including: (1) regular information sharing with national programmes through the Expanded Programme on Immunization (EPI) country officers, WHO representatives (WRs) and NCC chairpersons, usually in individualized communications to encourage questions and discussions; in the PIC with this is being done through the Pacific Public Health Surveillance Network (PPHSN); (2) targeted strengthening of AFP surveillance in key countries like China (reduction of stool specimen shipment time), Philippines (establishing a core group of national EPI surveillance monitors to strengthen supportive supervision at lower levels) and Papua New Guinea (field visits to conduct active AFP search); (3) technical support to update wild poliovirus importation preparedness plans in key countries (including Malaysia and Philippines); (4) mission to Malaysia to conduct in-depth review of all relevant AFP surveillance and polio immunization data and work towards short-term and mid-term activities to strengthen AFP surveillance in the areas concerned; (5) technical planning support for OPV SIAs conducted in southern Mindanao, Philippines in late August and September, synchronized with Indonesia National Immunization Days (NID) dates, while the WR/PHL also provides ongoing support to work on strengthening routine immunization to be intensified in other high-population-density/high-risk areas; (6) targeted OPV mop-up immunization has been conducted in Cambodia (October) and in Viet Nam (November and December) while the extent of SIAs in high-risk populations in China in the winter season 2005/06 would depend on external funding available;

10 - 6 - (7) close collaboration between the Regional Office for the Western Pacific and the Regional Office for South-East Asia including technical support provided to NID planning in Indonesia; close coordination with the United Nations Children's Fund (UNICEF) Regional as well as Country Offices; and (8) preparation of an emergency protocol for the EPI Western Pacific Regional Office if any Member State would report importation. Approval of a new set of International Health Regulations (IHR) by the WHO World Health Assembly (WHA) in May 2005 has established roles for countries and WHO in identifying and responding to public health emergencies and sharing information about them. WHO country offices, together with the Global Outbreak Alert and Response Network (GOARN), provide operational support to countries in identifying and responding to disease outbreaks. The purpose of the IHR is to ensure the maximum protection of people against the international spread of diseases, while minimizing interference with world travel and trade. They include a list of diseases whose occurrence must be notified to WHO, which include polio, smallpox and SARS. It has been agreed in the meantime, and supported by several episodes of circulating VDPV in recent years, that continued use of live attenuated polioviruses contained in OPV after interruption of global transmission would ultimately be incompatible with eradication. Safely stopping use of OPV will require: confirmation of interruption of wild polioviruses (i.e. global certification of eradication); appropriate containment of all polioviruses in laboratories and vaccine-production facilities; continued poliovirus surveillance and notification capacity that meet international standards globally; a WHO/UNICEF managed stockpile of mopv with internationally agreed mechanisms for use; processes for synchronously stopping OPV use globally. Preparations for a polio-free world are increasingly important as the world moves closer to the global interruption of wild poliovirus circulation. An important aspect of those preparations is effective laboratory containment of all wild poliovirus infectious and potential infectious materials to ensure that wild polioviruses are not reintroduced to the world after interruption of transmission. Detailed documentation from countries demonstrating that all laboratories with such materials have been identified will be required for Global certification of polio eradication. Preparing for the synchronous cessation of OPV use will require appropriate containment of all poliovirus strains. The ability to document the quality of containment activities will be essential to Member States in providing a comprehensive record and assessment of activities implemented to date. It will also provide national and regional authorities with a high degree of confidence in the containment process, against which important decisions on future polio immunization policies can be made. Data collected on the first phase of containment, and the capacity to maintain it in an active and accessible form, will be required for some years to come, and will form the core body of information used to determine activities necessary in later phases of the containment process. Future poliovirus laboratory containment requirements will be defined in a 3 rd edition of the WHO Global Action Plan, which is currently under preparation.

11 - 7 - There are currently six countries in the Western Pacific Region holding wild poliovirus infectious and/or potentially infectious materials; Australia, China, Japan, New Zealand, Philippines and Republic of Korea. Plans are developed to at least destroy materials in the Philippines shortly. In preparation for this RCC meeting, WHO conducted an external review of national submissions, modelled after the successful approach used in the WHO Regional Office for Europe. All laboratory containment quality assessment reports submitted underwent external review by several senior containment experts and, after consolidation of their conclusions on the thoroughness and reliability of the national surveys and inventories, findings were presented and recommendations made to the RCC in a standard summary sheet. The external reviewers were: Dr Walter Dowdle (Taskforce for Child Survival and Development, Atlanta and National Containment Coordinator for the USA) Dr Heath Kelly (Head Epidemiology Unit, Victorian Infectious Diseases Reference Laboratory [VIDRL], Melbourne) Dr Lye Munn Sann (former Director, Institute of Medical Research [IMR], Malaysia, now at University Putra Malaysia) Dr Ray Sanders (former WHO Global Polio Laboratory Network Coordinator, now freelance consultant) Mr Chris Wolff (WHO Global Poliovirus Laboratory Containment Coordinator, Geneva) Work Sheets were provided with checklists to systematically evaluate whether the country has satisfactorily addressed each described area, following the guidelines for documenting the quality of Phase 1 wild poliovirus laboratory containment activities and best-practice model which had identified six key elements: (1) Strong political endorsement and support for containment. (2) A realistic national plan of action. (3) An effective containment coordinator and national task force. (4) A comprehensive national laboratory list. (5) A high quality laboratory survey. (6) A complete and active national laboratory inventory. A Reviewer s Summary Sheet was provided to record overall conclusions and recommendations. An informal meeting of the key external reviewers was conducted to consolidate the findings and recommendations to the RCC and clarify on other key general points for the RCC's consideration.

12 Progress reports from each country and area on maintaining polio-free status after certification Australia The NCC and Polio Expert Committee (PEC) have remained active. PEC meetings by teleconference were scheduled four times a year in line with reporting dates to WHO Headquarters Geneva, for inclusion of data into the global AFP surveillance report published quarterly in the Weekly Epidemiological Record (WER). Cases were reviewed by the PEC and classified prior to reporting of data to WHO. The average monthly return rate of report cards from Australian paediatricians to the Australian Paediatric Surveillance Unit (APSU) was 91.4% for the period 1 January 31 December The response rate for the period 1 January 30 September 2005 was 87%. The definition of AFP was amended at the PEC meeting on 12 August 2005 following a recommendation of the RCC 2004 report. It is now modelled on the global case definition of AFP. There were 62 notifications of AFP in 2004, with 49 cases categorized as eligible by the PEC; 45 cases were classified as non-polio AFP cases, while four cases were not reviewed due to no clinical information being received, resulting in a non-polio AFP rate of 1.13/ under age 15. Adequate stool samples were taken in 37% of cases. There were 46 notifications of AFP between 1 January and 30 September Sixteen cases of AFP were classified by the PEC as eligible non-polio AFP cases, resulting in a non-polio AFP rate of 0.53/ ; 14% had adequate stool samples taken. Eleven notifications were duplicates indicating a sensitive surveillance system. In June 2005, poliovirus type 3 Sabin-like was isolated from three faecal specimens from a six-month-old child from Queensland. Onset of symptoms occurred 52 days after OPV was administered to the infant. The case was the subject of an extraordinary meeting of the PEC on 18 July 2005, with a follow-up review at the regular quarterly meeting on 16 August The PEC classified the case as non-polio AFP, diagnosed as transverse myelitis with the isolation of a Sabin-like poliovirus type 3 that may have a possible association. In August 2005, poliovirus type 3 Sabin-like was isolated from two faecal specimens collected from a four-month-old infant in Queensland. The onset of symptoms occurred seven days post-vaccination with OPV. Testing with mice confirmed the infant as positive for a type B/E toxin producing Clostidium botulinum and the PEC classifed the case as infant botulism. A patient greater than 15 years of age presented with AFP ten days post-vaccination with OPV. Vaccine was administered prior to travel to Indonesia, where the onset of symptoms occurred. Poliovirus type 2 Sabin-like was isolated from a faecal specimen collected 23 days post-vaccination. The case was reviewed by the PEC in October 2005 and is still pending classification. Further clinical information has been requested from the treating clinician. The PEC will review the case again at an extraordinary meeting in December After notifying a case of AFP, clinicians are requested to complete a questionnaire on the clinical presentation of the patient. The PEC resolved on 11 May 2004, that if the questionnaire has not been returned after three months, despite contact by mail on three separate occasions over this period, the case would be subject to a final review at the next meeting of the PEC. Such

13 - 9 - cases would be reported to WHO as polio compatible if no other classification could be reached on the information available. This decision is under review, in collaboration with the Australian NCC. As noted in the EPI/Western Pacific Regional Office weekly AFP surveillance and polio laboratory update, Australia continues to fail to reach the required indicator for the percentage of AFP cases with a follow-up examination for residual paralysis at 60 days after the onset of paralysis. For the reporting period 1 January 31 December 2004, follow up at 60 days was 28% and 19% for the period 1 January 30 September On 15 March 2001, the PEC had decided not to seek further information from the 60-day follow-up questionnaire if enough information was available from the initial questionnaire and available laboratory data to make a definitive diagnosis of the AFP case as non-polio AFP. This decision was reviewed again on 10 August 2004 and it was agreed that the PEC would continue with this protocol. Since 15 March 2005, the EPI/Western Pacific Regional Office weekly AFP surveillance and polio laboratory update now includes a footnote to clarify the low rate of follow up for cases of AFP in Australia. For presumptive diagnoses for AFP cases with onset of symptoms between 1 January - 31 December 2004, Guillain-Barré syndrome (GBS) was the single most common diagnosis (44% of confirmed cases) followed by transverse myelitis (8%). The National Polio Reference Laboratory for Australia is located at VIDRL, North Melbourne. The laboratory also serves as the National Reference Laboratory for the PICs and Brunei Darussalam, and is a Regional Reference Laboratory for the Western Pacific Region. The laboratory retained full accreditation status as a WHO Regional Reference Laboratory. The immunization status of all children under seven years of age is recorded on the Australian Childhood Immunisation Register (ACIR). The data on the ACIR is used to calculate immunization coverage across Australia. The Immunisation Coverage: Australia 2001 research study report, as conducted by the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), suggested that childhood immunization coverage is underestimated by approximately 2%-3%. For polio, the coverage rates at 30 September 2005 for age cohort calculated at 30 June 2005 are as follows: 92.3% at 12-<15 months and 95.2% at 24-<27 months. As of 1 November 2005 inactivated polio vaccine (IPV) has replaced OPV as the method of providing immunization against polio. The national inventory of wild type poliovirus stocks and potentially infectious materials was completed in It contained 16 different organizations, which held poliovirus and potentially infectious material. The inventory now contains 11 organizations, which hold poliovirus and potentially infectious material with the majority of samples being reference strains derived from either clinical specimens or vaccine strains. All the laboratories on the national inventory operate to a high standard and are aware of and comply with appropriate standards (AS/NZS :2002, Safety in Laboratories, Part 3: Microbiological aspects and containment facilities) of bio-containment for all samples on the inventory.

14 Brunei Darussalam During the year 2005, the NCC continued its work, to ensure that all aspects of the post-eradication activities are sustained and conducted accordingly. These include surveillance, immunization and laboratory containment activities. The AFP surveillance framework adopted prior to certification, continued to be maintained, with particular emphasis on coverage and completeness of the AFP surveillance from the selected reporting sites. During the year 2004 and until October 2005, the performance of AFP surveillance was maintained at the highest possible standard. The zero report of AFP case during this period was substantiated by the absence of AFP case detection during the six monthly (July/Dec 2004; Jan/June 2005) and annual retrospective reviews (Year 2004) of the reporting sites. Two cases of AFP were reported since the last progress report. The non-polio AFP rate for January to October 2005 is 1.67 (and was 0.83 in 2004 with 100% adequate stool specimen collection); one of the cases had adequate stool samples taken, for the other case they were collected on days 15 and 16 after onset. The NCC, which also acts as the Expert Panel, reviewed the two cases which were initially reported as AFP cases in June Subsequent investigations and discussions conclusively discarded the two cases as non-polio AFP; one had a diagnosis of GBS, the other one of medulloblastoma. The routine EPI integrated its tenth antigen, the Haemophilus influenzae type B (Hib) vaccine in April Coverage for all antigens including polio vaccine during the year 2004, continued to be maintained at high levels both nationally and sub-nationally. OPV3 coverage in 2004 was reported 92.2% The reintroduction and outbreak of polio reported in 20 previously polio-free countries, received great concern in Brunei Darussalam. The country is at risk of importation particularly in view of regional and sub-regional population movement. In response to this, the national contingency plan previously outlined has been reviewed alongside with risk assessment. Laboratory facilities for viral isolation are still unavailable in the country. Previous arrangement for analysis of stool specimens from all AFP cases with the Regional Reference Laboratory in Australia, continued to be maintained. During the initial screening for laboratory containment purposes 12 laboratories located in nine institutions, were all determined to be handling clinical specimens not potentially infectious in nature. No other laboratories had been identified during the year 2004 and to date. A new biosafety level 3 (BSL-3) laboratory facility has been completed within the Department of Scientific Services, Ministry of Health Complex, however, as yet it is not fully operational. A second BSL-3 laboratory is also being planned to serve the Veterinary Services, based with the Department of Agriculture Cambodia As the NCC also functions as Expert Panel, meetings are held as cases for classification arise. In 2004, the NCC reviewed two cases and in 2005 three cases. All have a presumptive diagnosis. The objective of the NCC meetings is to determine the outcome of any cases for polio compatibility and to provide technical advice to the National Immunization Programme (NIP) on polio eradication activities. The NCC also meets once a year to review the performance of polio eradication in Cambodia. The non-polio AFP rate in Cambodia has always been much higher than the 1.0 per for populations under the age of 15 years expected. A stronger possibility is there may

15 be over-diagnosing of flaccid paralysis. This issue has been discussed with well trained pediatricians in major reporting sites in Cambodia such as Kuntha Bopha Children's Hospital (KBH) and Jayavarman VII in On the other hand, for the provincial and health centre staff, considering the limited capacity for diagnosis of AFP, the diagnosis should be as simple and easy as possible so as not to discourage their detection of AFP. In 2004 many diagnoses from KBH were changed to hypotonie and some improvements made in accuracy, which is one of the causes of the reduction in the number of AFP reporting in The non-polio AFP rate was 1.59 compared to 3.13 in However, in 2005 AFP reporting was improved after a surveillance workshop and was 1.87 as of November In Cambodia, 60-day follow-up examinations have been conducted by NIP central staff in 2003 because of the limited knowledge and capacity of provincial staff. However, this system had caused lack of responsibility of provincial level staff and delayed follow-up examinations through waiting for NIP to visit the field. In 2004 the NCC decided that 60 days follow-up of all AFP should be conducted by relevant provincial staff and at no later than 90 days of onset. NIP central staff should only support when provinces request special investigation. Follow-up diagnosis should also be simple for provincial staff, such as weakness of limbs or whether the case can move or walk. In 2004, follow-up was conducted more than 90 days after paralysis onset for 11 cases and for 14 cases as of November In 2004, for the first time in Cambodia, the adequate stool sample rate reached was 80% and as of November 2005 it had shown further improvement to 81%. In 2004 no active search was conducted. In October 2005 during the special high-risk area OPV campaign, active search was conducted and one additional AFP detected from Kg. Speu province. Although the rejection of access to the admission records of KBH has been a serious problem in Cambodia, during the NCC meeting in November 2005, the director of KBH in Phnom Penh only agreed to allow access to the records for national NIP staff. Cambodia does not have a national laboratory for viral isolation and all AFP samples are tested at the Regional Reference Laboratory in Japan (NIID). In 2004, the average duration between sample collection and receipt at NIP was four days, NIP to NIID was nine days and NIID to receiving result was 22 days. The total average duration to receive the final result was 35 days. As of November 2005, the average duration between sample collection and receiving at NIP is four days, NIP to NIID six days and NIID to receiving result 22 days. The total average duration to receive the final result is 32 days (less than five weeks). In 2004, Sabin like poliovirus type 1 and 2 was isolated from one AFP case. In 2005, Sabin like poliovirus type 2 was isolated from one AFP case. The NIP, with assistance from WHO, completed a modified data quality audit (DQA) in 2002, which found that the immunization reporting from all levels (health centre, operational district and province) is 84% accurate. The 16% inaccuracy is mostly attributed to mistakes made when transferring data from tally sheets to registers. If the reported national coverage figures are adjusted according to the DQA, then the coverage figure is close to the confidence interval of the demographic health survey (DHS) results. In 2003, DQA was conducted again and showed 98% accuracy, suggesting a sufficient accuracy of reporting. However, these demographic issues are a constant problem for the NIP to determine the target population affecting coverage data. In 2003, the Ministry of Health was advised by the Ministry of Planning to use new demographic figures (which are adjusted by province and total population) with an increase to , but the target population for those under the age of

16 one year should be 2.6% of the total population, decreasing to (22% reduction from Ministry of Health estimate in 2002). While coverage always faces difficulties in reflecting reality, the number of children with administered OPV3 has shown a declining trend since However in 2003, the reported administered doses of OPV3 increased by children more than 2002, which indicates a substantial improvement of EPI activities in In 2004, the Ministry of Health decided to adopt the new Ministry of Planning figure (total population and target under one is 2.6% of total population, ). This would affect the denominator of coverage calculation resulting in 10%-15% higher coverage than In 2004 reported administrated doses of OPV3 was (coverage 86%) with 4631 more children vaccinated than in In 2005, the NIP/Ministry of Health, due to the recent large outbreak of wild poliovirus and VDPV in Indonesia, had concerns about areas with lowest coverage such as mobile Vietnamese villages along the Tonlesap river, lake and slums, Muslim communities (Cham), Khmer and Vietnamese slum areas in Phnom Penh and the migrating Khmer population at the Thai border. The NIP had sufficient vaccine stocks of OPV, diphtheria-pertussis-tetanus (DPT) and measles for those populations available at the central level and for provincial stocks. Also, the operational budget of around US$ was available, mainly supported by UNICEF (US$ ) and by WHO (US$ ). The NIP decided to conduct the special vaccination campaign in October 2005 and selected the high-risk area as 10% of the total population, targeting children under five years of age. The vaccines administered were OPV, DPT and measles regardless of their previous vaccination history and Vitamin A capsules and Mebendazole tablets were also given. The NIP understood well that in those areas this would only be the first dose for some children and routine vaccination efforts would have to follow. The NIP produced multi-language communication leaflets to encourage all mothers to return to nearby health centres for follow-up vaccination after this campaign to reach those at high risk. The high-risk campaign was conducted by 415 teams at 131 health centres within 35 operational districts in 16 provinces. Preliminary results showed the OPV coverage achieved was 87%. A comprehensive national contingency plan was prepared in the event of wild poliovirus importation. There were no further developments for wild poliovirus laboratory containment. The NCC members realized the existence of insufficient communication with the National Containment Coordinator. On 24 November 2005, the NCC and the National Containment Coordinator reviewed past documentation from The NCC and the Containment Coordinator discussed the need for updating the inventory of laboratories and freezers in the near future China The NCC has remained active and held its 10 th meeting on 14 November 2005 in Beijing. The objectives of that meeting were to review the progress of polio eradication activities since the last meeting in 2004, and to review and endorse the national update report for submission to the 11 th RCC meeting.

17 Since 1995, the national non-polio AFP case rate has exceeded 1.0 per population zero to 14 years old. In 2004, the reported non-polio AFP rate exceeded the minimum target in 29 (94%) of China s 31 provinces, with the exception of Liaoning province and Tibet autonomous region; the rate of Liaoning province was 0.93 and the rate of Tibet was In 2004, there were a total of 55 (16.2%) of 339 prefectures that reported less than the expected number of AFP cases, including 14 prefectures that expect less than one AFP case each year. From January through September 2005, there were a total of 130 (38.1 %) of 339 prefectures that reported less than the expected number of AFP cases, including 14 prefectures that reported zero case. Most of the prefectures reporting fewer than expected cases are in remote areas. From January 2000 through September 2005, only one prefecture has not reported any AFP cases. It is Jiayuguan city in Gansu province, and the population under 14 years old is The overall rate for adequate stool specimen collection was 87% in There were five provinces with a rate <80%: Jiangxi (77%), Guizhou (76%), Xinjiang (70%), Tibet (25%), and Ningxia (75%). From January to September 2005, there were also five provinces, where the percentage of AFP cases with adequate stool specimens was <80%: Jiangxi (73%), Guizhou (78%), Beijing (79%), Tibet (25%), and Qinghai (74%). In China, high-risk AFP cases are defined as AFP cases that meet the following three criteria: 1) inadequate stool specimens; 2) less than five years old; and 3) less than three doses of OPV prior to onset of paralysis. A cluster of high-risk AFP cases is defined as two or more high-risk AFP cases in the same or adjacent counties with onsets of illness within a two-month period. From January 2004 through September 2005, there were 209 high-risk AFP cases (2004: 117 cases; January-September 2005: 92 cases). Of these, 17 cases with onset during 2004 formed eight clusters, and six cases with onset during January-September 2005 formed three clusters. In 2004 and January-September 2005, several supplementary surveillance activities were undertaken in silent areas, those reporting fewer than expected AFP cases, and areas with low rates of adequate stool collection. These activities included retrospective hospital record reviews, house-to-house searches for unreported AFP cases and enterovirus studies in stool specimens collected from children without paralysis. In Tibet, surveys of 200 healthy children were conducted along the border with Nepal in 2004 and of 160 healthy children in From the 200 specimens collected in 2004, the polio laboratory isolated and identified polioviruses and NPEV from 20 samples. The poliovirus isolates have been forwarded to the national polio laboratory for ITD and were all Sabin-like. Work on the 160 specimens collected in 2005 is still in progress. In each province, expert panel meetings are supposed to be conducted at least four times a year. In 2004, 10 provincial expert panels met less than four times; these were Beijing (1), Tianjin (1), Liaoning (1), Zhejiang (2), Anhui (2), Henan (3), Hunan (3), Tibet (0), Ningxia (2), and Xinjiang (1). If there is inadequate information to rule out polio as a probable diagnosis, the case is supposed to be classified as polio-compatible; all other cases are discarded. Fifteen AFP cases were classified as polio-compatible in 2004 and two in In some provinces, all AFP cases are being reviewed by the expert panel. The frequency of most probable diagnoses assigned to cases discarded were GBS, trauma, and non-poliomyelitis for 37%, 14% and 6%, respectively. In August 2004, type 1 VDPV was isolated from two AFP cases and two contacts in Yaoshang Village (population 2370), Wanlan Township, Zhenfeng County and Qianxinan

18 Prefecture, Guizhou Province. The first case was a three-year-old boy with zero-dose OPV history and paralysis onset 13 June 2004; the second case was a one-year-old boy with zero-dose OPV history and paralysis onset 11 July Both cases are clinically compatible with polio. Type 1 VDPV was also isolated from three of 21 contacts of these two AFP cases as well as from a contact of a polio-compatible case from the same area (paralysis onset on 22 May 2004). Rapid coverage surveys in the area showed very low routine immunization coverage ranging from 2% to 60%. Reported measles incidence in Zhenfeng County was 230 cases per in A rapid survey of 59 children <5 years old in Yaoshang Village found that 38 (64%) had a history of zero-dose OPV. Although province-wide SIAs have been conducted every year since 1996, coverage in past years has declined. Mopping-up activities targeting children <4 years old were conducted in Qianxinan and Anshun Prefectures August and September One SIA round was conducted in the remaining seven prefectures September Another round of supplementary OPV immunization was carried out in the entire province during measles SIA November Qianxinan, Anshun and Bijie Prefectures conducted a third and fourth round OPV SIA 5-10 January 2005 respectively while other six prefectures targeted children without immunization history. Reported coverage for all rounds is high (>90%) and was confirmed by rapid coverage assessments conducted. In 2005, AFP surveillance was able to identify a type 2 VDPV (11 nucleotide substitutions in VP1 region) in an AFP case in Liuan city, Anhui province. The boy was born on 1 July 2003 and lived in Zhangchong village, Luzhen township, Shucheng county, Liuan city. He had received OPV 4 times with the last OPV given in January He developed a fever on 30 July and then paralysis the following day in his right leg. A national team examined the child on 15 October The muscles of both legs were atrophic, muscle power was one-fifth normal, deep tendon reflexes of the knee and the heel were disappearing and the clinical diagnosis was polio. Shucheng county is a poor county in Liuan city. Luzhen township is a mountainous township, with the main sources of income being agriculture. There were 13 villages in Luzhen township with a total population of and a birth rate of 10%. Zhangchong village is also located in the mountains seven kilometres away from the township and with a total population of 960. The national investigation team conducted an OPV coverage survey in the village and several neighbouring villages and found 96% of children checked had been fully immunized. Active search for AFP cases was conducted in Liuan city hospital and Shucheng county hospital and medical records in 2004 and 2005 were checked. Six AFP cases were found in Liuan city hospital and two were unreported. Two AFP cases were found in Shucheng county hospital and both were unreported. Stool samples were taken from 22 contact children and no poliovirus was found. Two rounds of SIAs in Liuan and neighbouring areas would be conducted in 5 November and 5 December The child appears to be immuno-compromised, has low antibody titres against all three types poliovirus and continues to shed virus. Divergence in VP1 had increased to 2.33% in the type 2 VDPV isolated from a follow-up stool sample taken in October 2005 and an additional type 3 VDPV was found with 2.67% divergence, both findings indicating that these viruses are ivdpvs.

19 The China National Polio Reference Laboratory (NPRL) has been fully accredited as a WHO Regional Reference Laboratory since The NPRL is responsible for distributing annual proficiency tests to provincial laboratories (since 2004 proficiency test panels were prepared by Rijksinstituut Voor Volksgezondheid En Milieu [RIVM] in the Netherlands) and conducting on-site accreditation reviews for each provincial laboratory every one, two or three years according to the function of the provincial laboratories and their previous accreditation status. A total of 14 provincial polio laboratories had been accredited by on-site accreditation review in the end of 2004 and For the proficiency test, 32 laboratories (all 31 provincial laboratories and China NPRL) have scored 100% for From January 2000 to September 2005, 2391 poliovirus isolates underwent ITD by both PCR-RFLP and ELISA in China NPRL. From January 2005 to the present, all viral isolates that have discrepant ITD results were sequenced according the WHO manual and a type 2 VDPV was detected by sequencing analysis on 14 October From 1997 to 2004, there were 20 VDPVs found in China with one cvdpv episode in Details of all VDPVs are included in the annual progress report. Coverage data have been routinely reported in China since Data are sent by each vaccination site to township hospitals and then to county, prefecture and provincial health departments for aggregation and analysis. Since 1988, reported coverage for BCG, OPV3, DPT3 and measles vaccine (MV) have exceeded 90%. Reported coverage, however, is likely to greatly overestimate actual coverage as it is based on the number of reported children registered for EPI that are immunized. Unregistered and unreported children are not included. To know the current status of EPI in China, a nationwide immunization coverage survey was conducted from October to November of 2004 as part of a nationwide EPI work review. In all 31 provinces households were investigated, with children born between 1 January 2001 and 31 December 2003 checked. Coverage is generally lower in the underdeveloped areas of western China, and in floating populations. Of all the counties sampled, the BCG coverage of 11 counties, the OPV coverage of 28 counties, the DPT coverage of 33 counties and the MV coverage of 37 counties was under 85%. The BCG coverage of 19 counties, the OPV coverage of 49 counties, the DPT coverage of 55 counties and the MV coverage of 59 counties was under 90%. Most of the low coverage counties are located in central and western China. To sustain high-level routine coverage, national guidelines have been issued recommending delivery of at least six rounds of immunization services each year, and routine vaccines including BCG, OPV, DTP, hepatitis B vaccine (HBV) and measles are provided for free (a small administrative fee is allowed). Technical strategies to improve routine coverage combined with OPV supplementary immunization are being developed by the China Center for Disease Control and Prevention (China CDC) and will be issued with the support from WHO in China. Immunization services in underdeveloped areas receive some funding support from the Government of China, and have been targeted for international support through the World Bank Health Project 7, Japan International Cooperation Agency's (JICA) Strengthening EPI Project, Global Alliance for Vaccines and Immunization (GAVI), Ministry of Health, WHO/UNICEF Accelerated Measles Control and Strengthening Routine Immunization Services Project Guizhou, China and by the Governments of Australia and Luxembourg. In addition to strategies to improve routine coverage, at least two rounds of OPV SIAs have been conducted each year since These campaigns have generally covered million children zero to three years of age each year and have been critical in immunizing

20 children that are difficult to reach through routine immunization services. It is anticipated that large-scale annual SIAs will be continued for the foreseeable future, especially focused on areas of bordering indigenous poliovirus epidemic counties and low routine immunization coverage. Such campaigns require external funding support, though international support decreased sharply before last winter's campaign. Two rounds, with emphasis on reaching unimmunized children in high-risk and low-coverage areas, were conducted in December 2004 and January Because of the climate conditions, Tibet and Xinjiang were conducted in March/April The lowest reported coverage by province is 92.5%. To accelerate the effort of laboratory containment, with the suggestions and support of WHO, an office for poliovirus laboratory containment was established in China CDC. Its main function include assisting the Ministry of Health to develop a further action plan and coordinate and organize all related activities. According to the GAP II, all biomedical laboratories should be included into the national survey. Based on the WHO database software, a Chinese version was developed and tested. The software will be distributed to all related agencies soon and be critical for future phases of containment as polio eradication progresses. The data will be collected and stored in an electronic database to facilitate risk analysis and data management. In November 2005, a meeting in the Ministry of Health was held to discuss the national plan of action. A nationwide strategic plan for data collection of all biomedical laboratories was passed in the meeting and will soon be carried out. The strategic plan was divided into three steps: first, to conduct the survey of biomedical laboratories within Ministry of Health; second, to carry out pilot project (within all relevant ministries) in one or two selected provinces; and finally, to finish all biomedical laboratories registration beyond Ministry of Health and the two selected provinces Hong Kong SAR The NCC has remained active and convened its 7 th meeting in November 2005 to particularly discuss the response plan to wild poliovirus importation. The target of detecting at least one AFP case per population aged below 15 years was achieved in 2004 (1.3 per ), and the rate was 1.8 up to the 40 th week of 2005 (annualized rate of 2.3 per as of week 40). The targets for most of the other surveillance indicators were achieved in 2004 and the first three quarters of Adequate stool sample collection rate was 100% in 2004 and 87% so far in The Expert Panel consists of three senior consultant pediatricians from three different hospitals and is using the WHO protocol for case classification. During the first 40 weeks in 2005, there were two reported cases with inadequate stool specimens and residual paralysis. Both cases were reviewed by the Expert Panel in October One case was classified as non-polio AFP and the other one as not AFP. The Virology Division of Public Health Laboratory Services Branch (PHLSB), the designated polio reference laboratory for Hong Kong, has remained fully accredited by WHO since 1997 and accredited for ITD since The PHLSB identified three positive VDPV isolates from two non-afp cases via laboratory surveillance in So far, no person-to-person transmission of VDPV has been documented.

21 In June 2005, VDPV (type 3) was isolated from a rectal swab of a five-month-old male infant presenting with fever associated with running nose and passage of loose stool. Clinically, the patient did not have any signs and symptoms of AFP. The infant was not immunocompromised and he had received trivalent OPV 20 days before admission to hospital. The infant lived with his parents who refused to save stool for investigation. For the few months before admission there was no travel history for the entire family. A follow-up stool sample of the infant collected in August 2005 was negative for VDPV. In July 2005, a seven-month-old male infant was admitted because of fever and suspected right upper-limb weakness. Clinically, the patient had no signs or symptoms of AFP. He enjoyed good past health and was not immunocompromised. Immunization was up-to-date (type I OPV given on 13 December 2004, followed by two doses of trivalent OPV on 26 February 2005 and 20 May 2005 respectively). The infant had a complete recovery within several hours was discharged in good clinical condition. A stool sample sent to virology laboratory for processing yielded type 2 poliovirus. ITD analysis by genetic sequencing showed nucleotide difference of almost 1% as compared with the vaccine strain. The VDPV was submitted to and confirmed by the WHO Global Polio Reference Laboratory in Japan. The infant had no travel history. He lived with four family members (parents, grandmother and aunt) and was taken care of by his mother. A follow-up stool sample collected in September 2005 was again positive for VDPV. Another follow-up stool sample was received on 10 November and was negative. These two patients were not epidemiologically linked as the polioviruses isolated were different in serotype. These two cases were probably classified as ambiguous VDPVs as both have no evidence of community circulation and both patients were not immunocompromised. The immunization coverage rates for polio vaccine have been maintained at 90% and above, based on service data. An immunization survey completed in early 2003 also supported the findings. However, threats from the importation of polio remain because of the highly mobile population and the many international visitors travelling to Hong Kong. A revised action plan is in place to contain any importation of wild poliovirus. Hong Kong has completed phase I laboratory containment of wild poliovirus. An inventory of laboratories has been established. Two laboratories had in their archives potentially wild poliovirus infectious materials and had destroyed the materials satisfactorily. Letters have been sent to research laboratories reminding them to keep the national coordinator for laboratory containment informed if clinical specimens are to be imported from countries where polio is still endemic. Through this mechanism, six vaccine strains were identified from one research laboratory in 2001, and they were destroyed under official witness Japan The NCC continues to meet on a regular basis to review and oversee strategies conducted to maintain polio-free status and ensure timely detection of imported wild polioviruses and vaccine associated polio cases. One of the main activities of the NCC is to provide recommendations for future polio vaccination strategy in Japan. Recommendations made include that the adoption of IPV for routine immunization is essential, that it is necessary to get national consensus for conversion from OPV to IPV, and in order to maintain high vaccine coverage rates it is suggested a combination vaccine with DPT be developed. These recommendations were reported to the National Committee for Prevention of Infectious Diseases and endorsed.

22 Considering the end game of the Global polio eradication programme, adoption of Sabin- IPV is an important factor and the NCC provided scientific merits of Sabin-IPV. The following new budgets related to polio control and eradication programme are ongoing; studies on the vaccine effects of polio and measles in Japan, development and quality control of combined poliovaccine (IPV-DPT) and studies on the containment of wild polioviruses. Above grants are all directly involved in polio control as well as post eradication polio control strategy. Together with routine enterovirus surveillance and laboratory activities, these grants are from the Ministry of Health, Welfare and Labour. In October 1998 the new "Law for Control of Infectious Disease" was established and polio was designated as a second grade infectious disease requiring immediate reporting to health authorities and strict investigation and control measures. Detailed guidelines for identification of polio and response were also established. However, this law only deals with polio caused by wild polioviruses. Vaccine-associated cases are not covered. This point is going to be clarified, when this law is revised. Vaccine-associated paralytic polio (VAPP) may not be included. Virological surveillance of enteroviruses has been the key element of Infectious Agents Surveillance in Japan since The Laboratory of Enteroviruses, Department of Virology II, NIID has been performed as the National Polio Reference Laboratory since 1962 and is fully accredited under WHO standards; it also functions as one of the regional reference laboratories. A nationwide laboratory network of 71 distinct public health laboratories (DPHLs) under the coordination of NIID remains effective. As part of annual infectious agents surveillance, stool samples are collected two months after the routine OPV vaccinations from healthy children at the ages of zero to six, and virus isolation and identification are conducted at DPHLs. All isolated poliovirus are further characterized at NIID. In 2004, 871 stool samples from 14 DPHLs were examined. Among them, one type 2 VDPV was isolated. The NPEV isolation rate in 2004 (12.5%) was relatively low compared with those in previous years. This may be due to no apparent large outbreak of particular serotype of enteroviruses. In Japan, routine OPV immunization is conducted twice a year (spring and autumn) and reported coverage has generally remained high (97.2% in 2002). The rate in 2003 was the lowest in these years (86.4% for first dose and 82.9% for the second dose). In 2004, age distribution and cumulative vaccination coverage (CVC) of OPV were studied. Randomly selected 3982 three-year-old children were tested for their one- or two-dose vaccine history through each city, town or village in Japan. History of measles vaccination was also included in this study and served as good control. Most of the first dose of OPV was taken at six and seven months. The second dose was frequently given at 12 and 13 months. The CVC rate of the first dose reached to 95.4% (93.4~96.0) at 36 months, whereas the CVC of the second dose at 36 months was 91.1% (90.1~91.9). In Japan, seroepidemiological studies on polioviruses have been conducted since 1978 as one of the additional polio surveillance activities to estimate the overall OPV coverage and to identify possible high-risk populations (specific age, group or area). In 2004, seroepidemiological analysis for three serotypes of polioviruses was carried out at seven DPHLs using serum samples from 1636 healthy individuals in 10 different age groups, supported by a grant-in-aid from the Ministry of Health, Labour and Welfare. The results showed an overall seropositive rate (over two years old) of neutralization (NT) antibody for all three poliovirus serotypes as 77.7%. The seropositive rates (over two years old) were high enough for type 1 (93.4%) and type 2 (98.2%), but relatively low (82.5%) for type 3 as

23 those in previous seroepidemiological studies in Japan. Although there was no particular high-risk population in the young age groups (under 20 years old), at least for type 1 and type 2 polioviruses, due to high overall OPV coverage throughout Japan, careful monitoring of the seroprevalence against polioviruses should be continued. Supported by a new research grant received in 2004 two main strategies in laboratory containment are being followed for a thorough wild poliovirus survey. This time governmental institutions and hospitals, defense, environmental and police agencies are included. In January 2005, the Ministry of Health, Labour and Welfare completed its affiliated hospitals, institutions and commercial diagnostic companies. Among facilities surveyed, 25 have wild polioviruses or materials potentially containing infectious wild polioviruses. This survey was done as a part of national survey of the Ministry of Health, Labour and Welfare for materials to be potentially used for bio-terrorism. Surveys by other Ministries are ongoing. The Japanese Government is now revising the "Law for Control of Infectious Disease" and polioviruses (wild polioviruses and VDPV except vaccine original strains) will be classified as Category C. If this revision is enforced, polioviruses, like other bio-terror agents, have to be registered. Their transportation is highly restricted and needs advance permission. The second strategy is based on GAP II and partially the draft GAP III. Targets are professionals who belong to scientific communities and associations related to virology and infectious diseases. Registration in the website at NIID will be requested through scientific meetings and academic journals of the associations. On the NIID home page, WHO s GAPII is translated and presented. In particular, definitions of polioviruses are clearly presented. Importantly, this survey will include all polioviruses except OPV strains approved for use by Japanese control authorities. Furthermore, target scientists include those who had published studies using polioviruses (not polio disease) in journals in 1990~2004 in Japan. In total, 332 papers have been published as original articles or meeting abstracts. The NCC will follow-up and make direct contacts with the corresponding authors or principal investigators Lao People's Democratic Republic Following the RCC recommendations, made at its 10 th meeting, the Lao People's Democratic Republic has strengthened AFP surveillance in the following ways: regular NCC meetings are held; there are no pending AFP cases from last year (although active search is in progress for a 2004 Lao case recently reported from Thailand); perceived weakness in active AFP surveillance at the district level throughout the country is being addressed; steps have been taken to develop the use of regular, timely and routine procedures for analysis and action on surveillance data; and organizational separation of immunization and surveillance activities at the ministerial level is improving. Lao People's Democratic Republic has maintained an AFP surveillance system sensitive enough to identify a type 2 VDPV case in November In 2004, there were 76 reported AFP cases, one AFP confirmed as type 2 VDPV, 74 discarded as non-polio (including one diagnosed

24 by the NCC as contact VAPP), and one case is pending. From 1 January 2005 to 31 October 2005, there have been 47 reported AFP cases; 44 have been discarded, and three cases are pending as of 31 October Non-polio AFP rate per children under 15 years of age was 2.9 in 2003, 3.0 in 2004, and 2.1 to the end of October In 2003, 63% of reported AFP cases had two adequate stool specimens collected within 14 days of onset. In 2004 and 2005 this was 68% (active case finding has not substantially altered these rates). There have been no suspicious clusters. All stool samples were sent to the regional reference laboratory in Japan and they were received in good condition with the exception of one having an empty stool container. From 2003 until 31 October 2005, five AFP cases with Sabin-like poliovirus isolates (three in 2003 and two in 2004) were reported from four different provinces (the two isolates from Vientiane Province were in different districts separated by four months); none were reported in Three Sabin-like isolate cases in 2003 were discarded by the NCC; one 2004 case was investigated with findings consistent with contact VAPP. The other Sabin-like poliovirus isolate case, was finally investigated in December 2004 and was found to be without residual paralysis and therefore discarded. In November 2004 an ITD discordant poliovirus isolate pair with sequence homology at 98.89% (10/903) difference to Sabin 2 and 4/385 difference to Sabin 1 was confirmed as type 2 VDPV (S2/S1 recombination). The VDPV was detected in Nonhai sub-district, Feuang District, Vientiane Province, in a 14-month-old male AFP case with residual paralysis at 60 days. Active search in the child s village and surrounding area health facilities accounting for 86% of the under 15-year-old district population resulted in four unreported cases of paralysis (none were AFP). Subsequent extensive epidemiologic testing and active search up to 10 months following onset revealed no further cases. Secondary community stool sampling found two close contacts infected. A third sampling of over 100 specimens in the immediate area resulted in no detected poliovirus including clearing of the case and positive contacts. Blood samples from the AFP case and the two VDPV positive contacts were tested for general immunoglobulin levels at the regional reference laboratory in Japan as well. Epidemiological investigation of both VDPV and positive contact cases did not raise a suspicion on immunodeficiencies. Low to zero immunization coverage was found in neighbouring villages in December (a population cluster of around persons) and rapid improvement in routine immunization (children <1) was planned along with supplemental OPV (children one to five) with two rounds for the district and its neighbours. Reported immunization coverage in the child s village was 0% for all antigens at baseline; reported in the Sub-District 26% for OPV3; in the district 44%, and in the province 40% to 51%. Further details on the case, epidemiological investigation, laboratory studies and immunization response can be found in the national progress report. Enhanced surveillance supported with reasonable confidence in the interruption of transmission. Whereas surveillance indicators are improved, operational processes strengthened, and progress in quality improvement is being made, the alarming decline in immunization coverage nationally continued and a sub-standard immunization response to the VDPV event in Feuang District, Vientiane Province, was conducted. The Minister of Health identified serious problems in immunization services and has encouraged remedial efforts for over a year. He continues to advocate for immunization improvements and has personally attended regional EPI managers' meetings. Logistics, human

25 resources, and management problems continue to plague the system in the face of unprecedented availability of funds. Whereas national coverage continues to decline, funding availability has doubled since 1999 to a US$ 3.2 million EPI budget in In 2004 the reported routine coverage of OPV3 fell to 46% and, in August 2005, the coverage rate is reported as 28% with combined drop out of over 33%. It is not foreseeable or reasonably possible to reach minimum standards by the end of the year as the number of un-immunized and under-immunized children exceeds the capacity of the NIP. Due to funding biases, fixed site programmes are almost entirely neglected for the more lucrative outreach activities. However, the overwhelming evidence indicates that even four rounds per year are not accomplished except by a few immunization teams. A detailed analysis of immunization behaviour was possible through the close observation of the VDPV response and lends insight to remediable action: 1) managerial and organizational changes (currently in progress), 2) attenuated reliance on 4 rounds outreach, 3) initiate more fix sites, 4) provide regular, systematic routine immunization services (with possibly other health initiatives), 5) use population-based planning for reaching every child, 6) monitoring operations and costs. The National Report on Phase I Wild Poliovirus Laboratory Containment Activities Laboratory Survey and National Inventory was completed in 2002, containment procedures were verified in 2004, and no changes occurred in The NCC approved a revised Plan of Action of the Response to Importation of Wild Poliovirus or the Detection of VDPV in Lao People's Democratic Republic Macao SAR The NCC has remained active and monthly telephone and/or mailing contact between members and national coordinator were maintained. AFP reporting sites remained unchanged and all reporting sites submitted 100% of expected reports within time limits. In 2005 (until 30 October), a non-polio AFP rate was achieved at 1.0 per population under 15 years; the rate in 2004 was 2.5. All three cases reported had adequate stool samples taken. All cases had a diagnosis available. The expert panel is composed of four senior pediatricians, including one pediatric neurologist. Some members of the panel are also in the NCC. Every AFP case was expected to be reviewed by at least two members of the expert panel. In the review, a detailed history collection and a physical examination will be completed immediately after the case is reported to the hospital coordinator. Approximately 60 days after onset of paralysis, all AFP cases will be reviewed by at least one member of the expert panel. For cases without adequate stool samples tested and with residual paralysis, or death or loss of follow up, at least three members reviewed all case clinical information and complete a physical examination if possible. There is no laboratory with enterovirus isolation facility in Macao. All stool samples of AFP cases are sent to the Virus Unit, Department of Health, Hong Kong SAR, a WHO accredited reference laboratory. The schedule and practice of polio immunization remained the same as in previous years, i.e. five dose trivalent OPV. With the same data management system as before, the coverage OPV3 immunization among infants at first birthday is sustained at 90.2% in 2004, 84.6% coverage of fourth dose among children at second birthday and 88.1% at fourth birthday, and 76.5% coverage of fifth dose among children at seventh birthday (most children received their fifth dose vaccination at primary one school when the average age is six years) was achieved.

26 A new questionnaire survey for wild poliovirus laboratory containment was completed in September No new laboratory or any infectious/potentially infectious materials were identified since the last report Malaysia The NCC continues to function and did not only review the progress report presented but continues to review major areas of concern in activities related to post-certification, to monitor and address problems in order to sustain polio-free status and deliberate and support implementation of latest recommendations made by WHO at the 15 th Technical Advisory Group (TAG) Meeting held this year in Beijing and the 10 th RCC meeting last year. AFP surveillance is well established in Malaysia with distribution of reporting sites corresponding with population density of the country. The non-polio AFP rate was maintained at high levels achieving 1.3 per children under age 15 in 2004 and improved to a current annualized rate of 1.7 in 2005 to date. However, below target reporting of AFP cases was noted in Sabah and Sarawak (with almost 2 million children under 15) with low performance since 2002, in Johor with borderline performance for several years and declining performance in Kelantan and Pulau Pinang since Adequate stool specimen collection is maintained at about the same level as last year but the required rate of 80% has yet to be achieved. To supplement this sub-optimal performance, all AFP cases are being reviewed by the expert panel to ensure that clinical investigation and management results concur with a final diagnosis other than polio. All of the AFP cases with onset in 2004 and most of the AFP cases in 2005 to date have a final clinical diagnosis available. The most frequent diagnosis is GBS (24% in 2004; 20% in 2005), followed by viral encephalitis (8% in 2004 and 2005) and transverse myelitis (6% in 2004; 5% in 2005). About 93.9% of the AFP cases with onset in 2004 have a follow-up result available and the percentage of cases with follow-up results in 2005 is 83.3% at this time. It is anticipated that most of the cases will have a follow-up result by the end of the year. The national polio laboratory continues to function at very high performance levels and has been fully accredited under WHO standards since National coverage for OPV3 has been maintained at over 90% since 1996 and this rate is also achieved by all 130 districts in The national coverage has been sustained at 95.2% in Reported lower coverage in Kuala Lumpur attributed to a large proportion of immunizations given by the private sector and not included in the coverage reports has been assessed by a coverage survey conducted in 2000 and the results confirmed that 89% of children had completed their third dose of OPV and DPT before the age of one. The polio outbreak in Indonesia was of particular concern to Malaysia with frequent population movements. In response to this, the national contingency plan prepared in 2000 has been reviewed alongside with risk assessment and updated. The process of laboratory containment of wild poliovirus infectious and potentially infectious materials has progressed well and the first phase has been completed at the end of The national inventory is being continually updated to include newer facilities with freezer storage for related clinical samples and to monitor searches conducted/declarations made by these facilities.

27 Mongolia The NCC is supported by a technical working group to evaluate the performance of the AFP surveillance system. NCC and technical working group meetings were held twice in 2005 and recommended to the Ministry of Health to conduct supplementary surveillance activities during the OPV SIAs. These activities identified two AFP cases. In 2004, a total of seven AFP cases were reported resulting in a non-polio AFP rate of 0.8 per children aged under 15 years. All AFP cases had been fully immunized with OPV3. Completeness of AFP reporting including zero reporting was 97% in As of 21 November 2005, a total of eight AFP cases have been reported, resulting in an annualized non-polio AFP rate of above one. All cases had adequate stool samples taken. Completeness or routine AFP reporting including zero reporting was 92.7% from January to November. Based on findings of supplementary surveillance activities, the National Center for Communicable Diseases conducted targeted activities to strengthen surveillance such as on-thejob training and supportive supervision in five provinces. Retrospective record reviews (RRR) were conducted in Ulaanbaatar City and two other provinces as well as in Orkhon province, which had an unusually high number of AFP cases in a single year. In 2004, routine immunization coverage in cities and districts was reviewed three times and was 99%. For the first nine months of 2005, OPV3 coverage was 97.2%. Despite high reported routine coverage every year an average 400 children miss vaccination and are covered by special SIAs. Reasons are migration, mainly to the big cities where these families are not registered and subsequently not in the immunization records. In May and October 2005, 758 children who had missed routine immunization were vaccinated New Zealand The NCC has remained active and conducted teleconferences on 17 February and 18 August The NCC also functions as the Expert Panel. Paediatricians have a high rate of returning AFP response cards monthly to the New Zealand Paediatric Surveillance Unit (NZPSU). During 2004 the response rate was 94%, and during 2005 (up to August) 93%. All cases of AFP in persons <15 years of age were reviewed half-yearly by the NCC. The number of AFP cases for 2004 and estimated number for 2005 are not substantially different from that for 2002 and 2003 when an audit showed NZPSU surveillance to have high sensitivity. A comparison of 2000 and 2001 AFP cases identified by the NZPSU and hospital discharge records showed NZPSU surveillance to have high sensitivity. The non-polio AFP rate for 2004 was 1.5 per children under 15 years (12 cases). For the period January to August 2005 the annualized rate was 0.87 per children under 15 years. In 2004, 50% of cases had adequate stool samples, and for the period January to August 2005 this figure was 17%. When paediatricians report a diagnosis of AFP, the NZPSU helps ensure that stool samples are received within 14 days of onset of paralysis. Usually, all AFP cases have a final diagnosis available. New Zealand s National Polio Laboratory (at the Institute for Environmental Science and Research [ESR]) maintained full accreditation for poliovirus isolation as well as for ITD.

28 Vaccination changed from OPV to IPV in February This was associated with a decline and disappearance of OPV circulating in the community. Paediatric inpatient and enterovirus surveillance detected OPV strains only within one month following the switch to IPV. Environmental surveillance with samples taken from sewerage plants in three major population centres reached zero in June However, OPV strains were again detected six, eight and 11 months after the OPV to IPV switch. These late isolates are likely due to visitors to New Zealand from an OPV using country. The polio immunization schedule is for IPV to be administered at age six weeks, three and five months, and four years. While precise immunization coverage estimates are not available at this stage, coverage is estimated to be approximately 89% after dose 3 (reported in 2005 coverage survey of two- to three-year-old children). Until 2007, children age 11 will be given IPV to complete four doses of polio vaccine. The National Immunisation Register (NIR) is being implemented for the birth cohort in District Health Boards (DHBs). Once the NIR is fully operational in all DHBs the NIR will provide New Zealand with an accurate record of immunization coverage for the birth cohort. No wild-type poliovirus or materials containing wild-type poliovirus is currently being kept in New Zealand laboratories other than the ESR polio reference laboratory. An investigation by the ESR of laboratories identified as having poliovirus in 2000/2001 showed the virus had been stored appropriately. Stocks of poliovirus have subsequently been destroyed except in the ESR where they are securely stored Pacific island countries and areas (PIC) The PIC Sub-regional Certification Committee (SCC) has remained active and continues to also function as the expert review group with most case classifications done through discussions. Of the 58 reporting sites in the Hospital Based Active Surveillance System (HBAS), 28% and 33% of sites have provided full reports for 2004 and until June 05 respectively. It is gratifying to note that full reporting appears to be improving in Fiji (comprising the most number of sites and target population), which has increased to 52% (until June 05) from 14% in The overall report submission rate for 2004 was 55%. While still below peak reporting rates in the lead up to polio-free status this is encouraging in that it points to a trend of stabilization of reporting performance above the low point achieved in 2001 (21%). For 2005, report submittal performance (as of October 2005) was 50% (until June 05) and 42% (until Sept 05) and represents an improvement on the corresponding time in 2004 (32% and 25% respectively). For 2004, the non-polio AFP rate was 1.2/ under age 15. For 13 AFP cases detected during 2004, the country breakdown was Fiji (6), Vanuatu (2), New Caledonia (2), Solomon Islands (1), Marshall Islands (1) and Federated States of Micronesia (1). Of the larger population centres, only Fiji, Vanuatu and New Caledonia reported the expected number of AFP cases, while Solomon Islands appear to have underreported. For 2005, the number of AFP cases is so small (3) that all sites appear to be underreporting, though zero reporting through the HBAS system is improving. Overall adequate stool specimen collection rate for 2004 was 62%; for the 2005 cases none had adequate stool samples taken. In 2004, most cases had a presumptive diagnosis available with a large number perceived as GBS. Laboratory testing for AFP cases continues to be conducted at the regional reference laboratory in Australia. A key issue for stool collection in 2004 was delays between stool

29 collection and receipt at VIDRL. In many instances this was in excess of 20 days and has been highlighted with national and hospital coordinators at the Pacific EPI meeting and country visits by the WHO Secretariat. The HBAS manual was reviewed and updated, and distributed to all 58 HBAS reporting sites, both as a hard copy and accompanying CD. This was the first major update of the original AFP/EPI Surveillance Folder developed by the WHO in Key amendments included: an updated AFP case investigation form; a new acute fever and rash (AFR) case investigation form that replaces the original "suspected measles" case investigation form which is more inclusive of similar diseases such as rubella and dengue; a new neonatal (NT) case investigation form; and a new AFR laboratory request form and updated specimen shipping guidelines that reflect new changes by the United Nations for shipping substance classification. In addition, this manual can be accessed on the PPHSN website to allow for wider dispersal, more rapid updating, and greater integration with PPHSN activities. It is hoped this site will allow both WHO and PPHSN in the future to provide improved feedback to the Pacific Region on issues surrounding EPI diseases surveillance for polio, measles, rubella and tetanus. Between November 2004 and November 2005 technical country visits took place in Samoa, Tonga, Federated States of Micronesia, Kiribati, Solomon Islands, Vanuatu, Tuvalu, Cook Islands, and the Northern Mariana Islands. During all visits, HBAS reporting performance was reviewed with the national and hospital coordinators, outstanding reports followed up and updates given to staff on the current status of the global polio eradication initiative. The WHO conducted a successful trial to use for reporting under the HBAS system. This trial commenced in October It involved the WHO Suva Office sending an automated to the HBAS national coordinators on the first day of every month requesting them to advise if cases of AFP, AFR and NT have or have not been detected at any of their countries HBAS reporting sites within the preceding month, and if so, how many. Replies via are required to reach WHO by the seventh of the month. WHO and PPHSN collate and review country reports and provide a summary to all Pacific countries via PacNet-Restricted ( list server for senior Ministry of Health personnel in the Pacific) by the 10 th of the month. This is intended to act as an early alert for Pacific countries of emerging events (e.g. measles or rubella outbreak) and allow individual countries to enhance their surveillance activities accordingly. For simplicity, the trial initially targeted countries with only one HBAS reporting site. The Commonwealth of Northern Mariana Islands, Cook Islands, Tuvalu and Palau agreed to participate. The trial ran from October 2004 to March Initial trial results were encouraging. All participating countries provided a least one report via during the trial period. The overall report submission rate (within seven days of the start of the month) for the six-month period was 38%. This figure increases to 54% and 75% if reports within 10 and 20 days of the start of the month respectively are included. The system has been expanded to all Pacific countries that have only one reporting site under the HBAS system (and access). A retrospective record review (RRR) protocol was finalized and distributed to all HBAS reporting sites as part of the update of the HBAS manual. Only one RRR was conducted in Kiribati between October 2004 and October 2005, which failed to identify any missed cases of AFP. Immunization coverage is generally high across most PICs, but not all of the high reported coverage rates are considered accurate. Most countries are reporting third dose polio vaccine

30 coverage rates in excess of 80%, but 2004 immunization coverage reports have yet to be received from American Samoa, French Polynesia, New Caledonia, Vanuatu, and Wallis and Futuna. Kiribati and Samoa both reported third dose polio vaccine coverage for 2004 that was significantly below previous years coverage, however, this probably does not reflect an abrupt decline in EPI performance. Country visits by WHO Secretariat to both countries in 2004 and early 2005 identified problems with immunization coverage assessment methodology, especially the use of inconsistent/incorrect denominators and it is likely that both countries have been over reporting immunization coverage rates for a number of years. Immunization coverage surveys were conducted in Fiji and Solomon Islands in 2004/2005. The third dose polio coverage rate for Fiji (nationally) was 76%, with little variation across the three administrative divisions of the country. For the Solomon Islands, the coverage survey was not representative of the whole country, but basically found that only 50% of children were being fully immunized before reaching their second year of life. The Western Pacific Regional Office updated the Generic Plan of Action for the "Response to Importation of Wild Polio Virus in the Pacific Islands", which was endorsed by the SCC. This was distributed to all EpiNet Teams in the Pacific, and is also available on the PPHSN website. The PIC sub-regional inventory for wild polioviruses had been completed in The inventory does not contain any laboratory holding wild poliovirus infectious or potentially infectious materials Papua New Guinea The only person currently left in the NCC is the chairperson, who mainly prepares the annual progress report. Most of the indicators for 2004 were lower than for 2003, with an AFP rate of 0.52 being the lowest since 2000, and with only 42% of cases having adequate stool collection. The figures for 2005 up to the end of October represent a slight improvement on both the AFP reporting rate (0.72) and adequate stool collection (50%) and it is expected that they will improve over 2004, but will almost certainly fall short of the benchmarks. As was the case in 2004, there is an uneven distribution of the AFP cases with five of the six cases reported from the Southern region being reported from the National Capital District (NCD). These cases account for 36% of the total of 14 cases reported so far. Of the five NCD cases, four had adequate stool collection and were negative. All 12 of the reported AFP cases in 2004 were discarded by the expert group as non-polio as have 13 of the 14 cases reported in 2005 to date. Overall, nine of the 14 AFP cases had at least one stool sample taken and all were negative. Twelve (86%) of the 14 cases have been followed up and one child, with a classic presentation and progression of GBS, unfortunately died. As of 31 July 2005 active weekly surveillance reporting from sentinel sites was at 63%, slightly less than in 2004 but considerably better than previous years. The difficulties of telephone communication and excess responsibilities placed on the surveillance officers are significant contributing factors. In the light of the poor performance over the last few years, the senior surveillance officer has highlighted the following contributing factors:

31 reduced level of awareness, among both health workers and the public; lack of cooperation and coordination between surveillance officers and clinicians; reduced level of National Department of Health (NDOH) visits and support to provinces; lack of commitment by some responsible officers; multiple responsibilities of surveillance officers; and shortage of funds for programme support. The following steps have been taken to deal with these factors: a training workshop for provincial and district health workers on recognition, reporting and investigation of Urgently notifiable disease/conditions ; supervisory visits to provinces; efforts to increase telephone contact with provinces; facilitation of process of stool shipment; incorporation of measles surveillance into AFP surveillance network; and presentation by the senior surveillance officer on the current situation and problems involved at the annual meeting of the Papua New Guinea Paediatric Society in September The National Polio Laboratory at the Institute of Medical Research in Goroka obtained a proficiency test score of 100% in 2003 and 96% in 2004 and remains fully accredited. A total of 59 stool samples from AFP patients have been tested since January 2004 resulting in the isolation of 12 NPEV but no polioviruses. Culture of 204 stool samples from children with aseptic meningitis in the same period has resulted in the isolation of 22 NPEVs and 11 polioviruses, all sabin-like. Routine immunization coverage rates for 2004 were again low with DPT3 at 62%, OPV3 at 49% and measles vaccine at 50%. However, SIAs with measles vaccine, also including one dose OPV and vitamin A, have now been completed in all provinces. It is likely, based on the available results from 17 of the 20 provinces that the activities reached between 95% and 100% of the target population. Provincial figures, however, ranged from 63% to 123% of the target population, and analysis of the data by districts revealed some with coverage as low as 50%. Two important processes have occurred in the last two years. The SIA concept has now been firmly established into the EPI programme and planning is in the early stage for the next round, scheduled to begin in 2008, and the Interagency Coordinating Committee (ICC) is now functional. In addition, and of considerable importance, is the designation of immunization as one of the four priorities identified by the NDOH in its Mid-Term Expenditure Framework (MTEF). The objective is to achieve 98% coverage of vaccination by the year WHO has assisted with the production of a multi-purpose plan which contains, in considerable detail, an outline

32 as to how this objective might be reached. Implementation of this plan will, however, require considerable input in funding and staffing, and it will require considerable drive and direction from all levels of health management. The importation of wild poliovirus and its subsequent spread in some of the Indonesian provinces has alerted health authorities, particularly those involved in the AFP surveillance programme, to take stock of Papua New Guinea s preventative measures and outbreak preparedness. The following have occurred to date: recommendation by the EPI technical committee that a task force be set up; review of the 2000 Plan of Action on Preparedness and Response to Wild Poliovirus Importation; special routine immunization campaign by Sandaun provincial health authorities focusing specifically on the health centres in the border area; visit by the Senior Surveillance Officer and the WHO adviser on vaccination to the Western Province to assess the situation and encourage the health authorities and health workers to scale up their surveillance and immunization activities; at its most recent meeting, the EPI committee noted that the plan of action contains within it the composition of a National Response Team. The EPI committee is extremely concerned that the previous EPI manager has left the department and his temporary replacement is leaving at the end of December The national inventory for wild polioviruses had been completed in The inventory does not contain any laboratory holding wild poliovirus infectious or potentially infectious materials Philippines The Philippines was able to generally sustain a quality AFP surveillance system. Currently, the annualized national AFP rate is 1.04 per children below 15 years of age. Six regions did not reach the target annualized AFP rate. Adequate stool collection rate was maintained above 80%. Of 287 reported AFP cases 232 (or 80.8%) have adequate stool specimen collection. Significant improvement was observed in three regions, however, nine regions had rates below 80%. In two regions performance has declined as compared to A total of 317 reported AFP cases were classified by the Expert Panel Committee this year. After thorough review of all available clinical and epidemiological data, 259 cases were discarded as non-polio, 30 were discarded as not AFP and 28 were still pending final classification. Stool samples that were positive for poliovirus on culture were later determined to be Sabin-like. An evaluation of the EPI disease surveillance system was held from 20 to 30 June 2005 in four regions. The review was conducted by several teams composed of staff from the US Centers for Disease Control and Prevention (CDC), WHO, UNICEF, National Epidemiology Center (NEC) and the Regional Epidemiology and Surveillance Units (RESU) of some Centers for Health Development (CHDs). Supportive supervision was also conducted during the evaluation, thus some previously silent hospitals became active in reporting cases.

33 The Secretary of Health granted exemption for Regional EPI Surveillance Officers (EPISO) from the hiring ban as a consequence of the Executive Order No. 366 or Rationalization Plan. This has secured the position of the EPISOs in the RESUs. NEC is presently updating the EPI Disease Surveillance Manual of Operations. In 2006, a WHO-funded National EPI Surveillance Team will be created to continue the EPI Surveillance evaluation and supportive supervision in the rest of the country. The National Polio Reference Laboratory (Research Institute for Tropical Medicine [RITM]) has maintained its full accreditation since 2003 to date. The Philippines achieved 78% annualized OPV3 coverage for January June This represents a 2% increase compared with There was improvement in 10 regions compared with 2004, while six decreased and one remained the same. The Autonomous Region of Muslim Mindanao (ARMM) apparently declined greatly from 2004 to However the reporting was incomplete (a common problem with the region). Regions IX, XI and ARMM achieved less than 70% OPV3 coverage for the period. The densely populated regions in and around the National Capital Region (NCR), Iloilo City, and Cebu and surrounding metropolitan areas, despite OPV 3 coverage about 80%, (particularly Davao with coverage below 80%) contribute a very large number of unimmunized children to the pool of susceptibles. OPV 3 coverage among AFP cases has shown an increasing trend from 68% in 2000 to 79% in Likewise, percentage of AFP cases with no dose of OPV has decreased from 17% in 2000 to 8.7% in This data suggests there is a national 13% dropout from OPV1 to OPV3. While nationally, there was a stock-out of OPV and other vaccines between , vaccines have since been sufficient. In part due to the past national stock situation, many health centres still lack sufficient vaccine and others are concerned about opening vaccine for only a few children. While vaccine often did not reach health centres in sufficient quantity, expired vaccine was found in a recent commission on audit report in several regions. These regions had the following OPV 3 coverage: II (84%), IVA (80%), NCR (84%), VI (78%), VIII (86%), XI (68%), XII (74%). Expired vaccine at the regional level in the presence of not fully immunized children, demonstrates the critical need to strengthen the distribution system from the regions to all health centres. A 95% OPV 3 coverage is considered critical to protect the Philippines from importation of poliovirus and cvdpv. EPI has recently conducted supplemental immunization activities in the south in response to the threat posed by the current polio outbreak in Indonesia. Of the estimated children ages zero to 5 years old 93% were given two doses of OPV for both rounds in August and September EPI has been engaged in many activities to strengthen the routine immunization coverage including a recently launched, more aggressive approach to intensify outreach immunization activities to un-reached populations through the Reaching Every Barangay (REB) Strategy. The EPI also continued to conduct training for EPI mid-level and cold chain managers. Monitoring and supervision are being institutionalized to ensure capacity-building of health workers so that they will be able to carry out their duties properly and effectively. The RITM as national laboratory containment coordinator has completed the inventory of laboratories in the database, including newly licensed laboratories and those in medical and paramedical colleges and universities. Questionnaires and inventory forms were again distributed to all laboratories included in the previous survey and the newly identified biomedical facilities. This activity commenced 15 December 2003 and was completed 19 January 2004.

34 Department of Health regional offices and local government health departments have worked together to facilitate retrieval of the questionnaires. Despite numerous follow-ups, retrieval of the survey questionnaire was slow primarily due to incomplete addresses and incorrect or no contact information in the registry. In view of this, recommendations were made by some WHO officers to perform a risk assessment of all laboratories in the inventory. All newly identified laboratories were considered high risk as there not yet an existing profile of their facility. Old laboratories were reassessed based on the following criteria: potential to collect (category/function) potential to store (presence of freezers/liquid nitrogen tanks), and plans for acquiring clinical materials from polio endemic countries or for research This resulted in a list of 691 priority laboratories for follow up. As of August 2005, a total of 417 (60%) responses from the 691 priority laboratories were received. This included 129 responses from old laboratories (197) and 288 from newly identified laboratories (494). Aside from the University of the Philippines College of Public Health and the RITM, Virology Department (also the National Polio Laboratory), no other facilities have been identified storing wild poliovirus infectious or potentially infectious materials The Republic of Korea Since 2003, five members of the NCC including a chairperson have continuously played an active part in maintaining polio-free status. The NCC has met regularly to discuss issues related to the national documentation for polio eradication. The AFP surveillance system was expanded to 104 hospitals, covering all paediatric training hospitals in Korea. In addition, the web-based AFP surveillance system was established in May This internet-based surveillance system will assist the attending physicians in reporting AFP cases more easily and quickly than the previous telephone or fax-based surveillance system. In order to supplement this regular AFP reporting system, prospective active AFP surveillance has been conducted at five major hospitals in Seoul since November AFP surveillance is based on these two systems including regular zero reporting from the sentinel hospitals across the nation. All suspected and reported AFP cases have results of follow-up examinations available and have been reviewed by an expert panel. In 2004, 545 reports of monthly zero reporting including 37 cases of AFP were received from 93 hospitals nationwide. This makes 53.8% of completeness in reporting. When considering timeliness of reporting, which means monthly reporting within the first week of the following month, 495 cases (91%) were reported on time. During (as of September), 10, and two AFP cases were found, respectively, through this surveillance study. Including the prospective AFP study (active surveillance) and the regular reporting system, a total of 37 cases in 2004 and 15 cases in 2005 (September) were investigated achieving an annualized non-polio AFP rate of 0.38 and 0.22 (estimated annual AFP rate), respectively. All cases had stool samples taken, have follow-up results available and were reviewed by the expert panel. In cooperation with the Korean Paediatric Society, AFP surveillance targeting the nationwide sentinel hospitals has been strengthened. In addition, the nation-wide enterovirus

35 surveillance system has been maintained and will be strengthened by participation of a greater number of Institutes of Health and Environment and hospitals during The Division of Enteric and Hepatitis Viruses in the National Institute of Health (NIH), Korea Centers for Disease Control and Prevention (KCDC), which was designated as the National Polio Laboratory, is fully accredited under WHO standards. The National Polio Laboratory is also conducting nation-wide enterovirus surveillance. All polioviruses detected through the enterovirus surveillance, mainly targeting aseptic meningitis patients, have been isolated and identified at NIH, KCDC. In July 2004, a suspected non-vaccine recipient case (VAPP) case was investigated. The patient was a nine-year-old boy, and presented with bilateral asymmetrical upper and lower extremity paralysis. He did not receive any trivalent OPV several years before the onset of the symptoms. Motor power on left and right extremities was grade 3 to 4 and 4 to 5 (on grade 5 scale), respectively, and deep tendon reflex on physical exam was decreased, although sensory response on the affected limb was intact. Spine magnetic resonant imaging (MRI) and pelvic ultrasonography were within normal limit. Electromyelography showed denervation potential and nerve conduction study revealed low amplitude of compound motor action potential with normal sensory nerve conduction velocity. One of the two stool specimens from this patient revealed poliovirus type 1 and 3. Sequence analysis showed that poliovirus type 1 was 100% identical to Sabin 1 and poliovirus type 3 had two point mutations (5 NCR region- T472C and VP1 region- T2493C). His paralytic extremities slowly recovered and fully recovered three months after the symptom appeared. After an NCC meeting, the case was finally classified as VAPP. The Korea Advisory Committee on Immunisation Practices (KACIP) also reviewed this case for national vaccine-injury compensation. The immunization level for polio has been sustained at the level of 90%-95% (estimated) since the 1980 s. From 2002, the use of IPV has been made possible by the recommendation of the Korean Paediatric Society. Since 2003, the NIP established by the Division of Vaccine Preventable Disease Control in KCDC has recommended IPV, OPV or mixed schedule. The KACIP also recommended the introduction of IPV in the NIP in 2004, and so Public Health Centers (PHC) as well as the providers in private sectors have used only IPV since November Now in 2005, IPV is fully recommended and supported in NIP. To increase the country s level of preparedness for the importation of wild poliovirus and provide a public health emergency response and coordination of partners at national level, the task force team (TF) for polio eradication has been established this year. This taskforce will make all decisions on response to wild poliovirus importation. Phase I of laboratory containment of wild poliovirus infectious/potentially infectious materials has been completed. After sending screening forms to Institutes, Universities and Hospitals in and , there have been replies from 645 laboratories. Four laboratories were found to have relevant samples so far. These laboratories were reviewed by NIH, KCDC in 2004 and we have confirmed that all relevant samples were stored safely at least under the bio-safety level (BSL)-2/polio conditions. Three laboratories destroyed their wild poliovirus samples upon recommendation of the NIH, KCDC. The wild poliovirus samples in one laboratory were transferred to the new BSL-3 facility in NIH, KCDC Singapore Since the NCC was formed in December 1996, the composition has remained the same. The NCC has also been meeting annually to review AFP cases and to monitor the various surveillance activities.

36 In response to the increased risk of importation since 2004, the Ministry of Health released a circular on 16 July 2004 to all public hospitals, neurologists, paediatricians and internal medicine specialists in private practice emphasizing the need to maintain vigilance in surveillance for polio. Furthermore, on 23 August 2005, a professional circular was disseminated to all medical practitioners, chief executive officers (CEOs) and chairpersons of medical boards (CMBs) of restructured hospitals, private hospitals and polyclinics and Directors of National Centres informing them of WHO recommendation that all travellers to countries where there is ongoing transmission of polio, regardless of age, should be up-to-date with vaccination against polio particularly for Hajj and Umrah pilgrims. It also requested medical practitioners remain vigilant and refer all cases of AFP promptly to the hospital. In 2005, the surveillance system identified 1.4 non-polio AFP cases per population in the target population. In 75% of the AFP cases, two adequate stool samples were collected within the specified time. Follow-up examination for residual paralysis at 60 days after the onset of paralysis occurred in all cases. Of 14 cases in , nine were diagnosed as GBS and two as transverse myelitis. The Virus Laboratory, Department of Pathology, Singapore General Hospital, was designated by WHO as the National Laboratory for Polio in It has remained fully accredited, also for ITD functions. Besides stool specimens from AFP or suspected AFP cases, the National Laboratory also received stool samples from other sources for poliovirus isolation. In 2004, a case of post-vaccination infantile pyrexia occurred three weeks after OPV had been given to a three-month-old infant. Poliovirus 1 and 2 was isolated in his stool. The infant subsequently recovered with no permanent sequelae. Over the last four decades, immunization coverage has remained high. From 2000 to 2004, the immunization coverage for polio in infants has been consistently over 90%. Singapore s Ministry of Health preparedness plan is currently based on the Guidelines on Response to Importation of Wild Polio released by the Western Pacific Regional Office in Updates from the generic protocol developed for Pacific Countries and recommendations by the Ad Hoc Expert Consultative Group on Polio and Public Health released 23 September 2005 will be reviewed in 2006 by NCC. The national inventory for wild polioviruses was updated for Survey questionnaires were sent out to all public and private institutions that might have laboratories containing any infectious material. As of August 2005, a total of 211 laboratories have been listed in the national laboratory list. All have confirmed that there is no infectious or potentially infectious material retained in their laboratories Viet Nam In response to the current global polio situation with increasing possibility of polio importation from the endemic countries to others and the number of outbreaks in the former polio free countries, the NCC organized the 15 th meeting on 2 June 2005 with the participation of Professor Nguyen Dinh Huong (RCC member), EPI leaders, the leaders of two national reference laboratories for enteroviruses (in Ha Noi and Ho Chi Minh City), and other related members. The meeting discussed the problems and planned rapid actions in order to sustain the polio-free status in Viet Nam as well as in the Region. The NCC strongly recommended strengthening all necessary activities including AFP surveillance, both in the laboratory and in the field, OPV

37 immunization and laboratory containment for infectious materials. The NCC also paid attention to the increased use of mass media for communicating the necessity of being vigilant for wild polio importation and the importance of maintaining the goal of polio-eradication for the entire population. As a result, Vietnamese EPI prepared the national contingency plan for wild virus importation. The surveillance system at all levels has continually and regularly monitored AFP cases: up to 31 October 2005, a total of 333 AFP cases were detected with the rate of 1.04 per children <15 years old of which 96.1% two adequate stool specimen were collected within 14 days of onset. To date, 299 AFP cases were discarded as non-polio. The non-polio AFP rate in 2004 was 1.24 and 95% of all cases had adequate stool samples taken. In 2005, 33 active search rounds for unreported AFP cases have been implemented in all district and provincial hospitals in areas with sub-optimal surveillance indicators. A total of 14 AFP cases were found by active search at provincial and district hospitals to date. This included one case from the Northern Region, ten cases from Central Region and three cases from Southern Region. No case was found in Central Highland Region. In 2005, both National Laboratories for Enteroviruses in Ha Noi (National Institute of Hygiene and Epidemiology [NIHE]) and in Ho Chi Minh City (Pasteur Institute) demonstrated good performance virus isolation and typing. Both laboratories were fully accredited under WHO standards. Routine OPV coverage among children under one year of age was maintained at high levels, reaching 73.6% as of 30 September To ensure high coverage with OPV to prevent spread of imported of wild poliovirus and circulation of VDPV, SIAs have been conducted every year in provinces near border with neighbouring countries. In November and December 2004, SIAs were carried out in 19 provinces, including nine provinces in the North, six provinces in the South and four provinces in Central Highland Region, mostly located along the border with Cambodia and Lao People's Democratic Republic, targeting children under five years old with coverage of 97.18%. In 2005, the activity was implemented in November and December in 30 provinces covering a total of three million children under five years old. The increase in the number of provinces to be involved in supplemental immunization is intended to respond to the current global polio situation and to strengthen herd immunity among susceptible population. Training programmes for health care workers have been carried out more intensively with five courses organized at the provincial level, 80 courses at the district level and 50 courses at the commune level. The report system maintained stability and timeliness.. For laboratory containment, no infectious or potentially infectious materials for poliovirus have been identified to date. In 2004, two new laboratories, namely Diagnostic Laboratory of Welcome Company (Ho Chi Minh City) and the Laboratory for Microbiology of French- Viet Nam Hospital (Ha Noi) were investigated. These laboratories were invented in October 2005 and the result showed no infectious or potentially infectious material containing poliovirus 3.

38 CONCLUSIONS 3.1 General The RCC noted that all countries again submitted high quality progress reports on maintaining polio-free status, with NCCs remaining active in almost all countries. The RCC particularly commended countries for the attention paid to the country-specific recommendations made during its previous meeting. Based on the detailed progress reports, the RCC felt it safe to draw the following important general conclusions: Western Pacific Region Member States continue to give priority to polio eradication activities, to protect their own polio-free status and that of the Region. AFP surveillance and immunization activities remain at similar quality levels as the past five years and no significant declines have (yet) occurred in the majority of countries. The Region has remained polio-free during 2005, despite the much increased risk of a wild virus importation (new polio outbreaks globally, including a large polio outbreak in Indonesia). In many countries, the overall level of preparedness for an importation of wild poliovirus (ability to rapidly detect and appropriately respond to an importation/circulating poliovirus) has further improved. In view of the global polio situation, particularly the threat of importation faced by the Western Pacific Region countries through the large polio outbreak in Indonesia, the RCC was concerned that sufficient visibility and awareness of the global polio situation and of eradication efforts be maintained. Every opportunity should be used to inform health leaders in countries of the Region about the global and regional polio situation, as well as on the need to maintain surveillance and immunization activities at appropriate levels to sustain polio-free status. The Global Certification Commission (GCC), now chaired by Dr Tony Adams, specifically requested during its meeting in April 2005 that, to maintain the necessary awareness and support for polio activities, polio eradication should become a standing agenda item for the WHA, for WHO Regional Committee meetings, and for other appropriate inter-country meetings. The RCC also noted again the urgency of maintaining and increasing the level of available funding to support polio activities, specifically AFP surveillance including the polio laboratory network. While several countries in the Region depend on external funding to maintain activities of appropriate quality, funds made available through WHO last year were either just meeting needs or insufficient. The RCC was concerned, however, that no significant improvements compared to its review in late 2004 had occurred in two Member States Lao People's Democratic Republic and Papua New Guinea.

39 In Lao People's Democratic Republic, the RCC was seriously worried that the inability of the immunization programme to improve the very low levels of routine coverage, as well as low performance during polio SIAs, has led to a further deterioration of the levels of immunity against polio in young children. The further widening of the immunity gap in Lao People's Democratic Republic has increased the risk that polioviruses, whether imported wild virus or emerging circulating VDPV, would cause a larger outbreak. This situation poses a grave risk for the children of Lao People's Democratic Republic and of neighbouring countries, and may threaten the poliofree status of the entire Western Pacific Region. As shown during recent polio outbreaks, the financial and opportunity cost (disease burden, financial resources, programme credibility) of responding to and controlling an outbreak in a setting like Lao People's Democratic Republic will far exceed the resources needed to implement preventive measures to improve the quality of routine vaccination and of SIAs. In Papua New Guinea, main aspects of EPI performance remain poor, with severe infrastructural and management problems at most levels, and improvements need to occur urgently. While remaining very concerned overall, the Commission noted, however, that due to the geographical position and population distribution, the risk of a major outbreak of either imported wild virus or emerging cvdpv is somewhat lower in Papua New Guinea compared to Lao People's Democratic Republic. The RCC requested the WHO Secretariat, in light of countries having updated their national wild poliovirus importation preparedness plans, to further explore recommendations on vaccine use in polio outbreak control for IPV using countries as well as general access to OPV stocks, also monovalent types. The RCC appreciated the update on the impressive work now conducted in the Region to strengthen routine immunization services, combined with efforts towards reaching the two new regional immunization goals of regional measles elimination and hepatitis B control by the year The RCC was convinced that the work to strengthen routine immunization and forward the two new goals will be of great benefit also for country activities in maintaining polio-free status. The RCC suggested a strong focus on assuring that well-functioning AFP systems are sufficiently utilized to strengthen surveillance for other vaccine-preventable diseases and other diseases of public health importance. The RCC has reviewed the quality assessment reports from Member States, mission reports from the Secretariat and findings from the external technical review panel, and has concluded that in accord with the WHO Global Action Plan for laboratory containment, 2nd edition: Australia, Brunei Darussalam, Cambodia, Lao People's Democratic Republic, Hong Kong SAR (China), Macao SAR (China), Malaysia, Mongolia, New Zealand, Pacific Island Countries, Papua New Guinea, Singapore, and Viet Nam have completed Phase I. These countries are commended for the quality of the laboratory surveys and the thoroughness of the quality assessment reports. The Philippines and the Republic of Korea also are commended on their quality reports and should complete Phase I when results from the current follow-up surveys are submitted to the RCC in mid-2006.

40 Japan has made great progress towards completion of Phase I and should submit its quality assessment report to the RCC at its next meeting, tentatively scheduled for December China has made considerable progress in strategic planning and establishing goals for the laboratory survey and inventory. However, experience in countries worldwide indicates that achievement of these goals will require multi-sector endorsement and full support of the highest levels of government. The NCC was requested to urge the Government of China to facilitate completion of Phase I to meet Regional and Global containment goals. China should submit a progress report at the next RCC meeting, tentatively scheduled for December 2006, and a final report in mid Countries should regularly update National Inventories to reflect any change in laboratory status, which may include either the addition or destruction of wild poliovirus materials, including VDPV. In the event of a wild poliovirus importation or VDPV detection, countries should track isolates and location of samples collected during the investigation. Laboratories retaining materials from the investigation or collected from the area for other purposes should be added to the National Inventory, with work restricted to BSL-2/polio conditions. Countries should identify laboratories on the national database that by nature of their virology activities are at risk of having virus stocks that may be mislabeled or inadvertently contaminated with wild poliovirus. As Phase II draws closer, such laboratories will need to confirm that its stocks are wild poliovirus free. Wild poliovirus containment, Phase II, will be implemented when one year has passed since the last isolation of wild poliovirus. Preparing for Phase II has been an integral part of Phase I and will be ongoing until Phase II is implemented. The current description of Phase II in the Global Action Plan 2 nd edition is incomplete in view of the recent goal to stop routine post eradication use of OPV. Accordingly, Phase II and III activities will be revised in the forthcoming 3 rd edition of the Global Action Plan. The RCC noted that the new Phase II and III requirement will likely include a framework for country specific laws, regulations, or edicts that prohibit the retention of wild poliovirus except in government approved facilities with bio-containment conditions accredited by national and international bodies. The RCC urged WHO, Geneva, to disseminate the proposed 3 rd Edition early in 2006 in order to provide countries sufficient time for response and national planning. Finally, the RCC thanked the NCCs, the Pacific island SCC and all country teams for the timely assembly and submission of quality update reports. The RCC particularly found their specific conclusions and recommendations on the status of their national polio eradication programmes useful to guide its own and appreciates the informative and frank discussions presented. 3.2 Country specific conclusions and recommendations Australia The RCC noted, based on the thorough progress report submitted, that activities continued to maintain polio-free status in Australia but AFP surveillance performance remains below required quality standards.

41 The RCC commended the national programme for amending the AFP standard case definition to be now modelled after the global one and thorough analysis done for every AFP case. The RCC noted that the issue of AFP cases with information insufficient to classify them remains under discussion of the polio expert committee and NCC. The Commission repeated its appreciation for the substantial support the polio laboratory at VIDRL is providing to the Regional polio laboratory and applauded the continued high performance. The Commission noted the shift to IPV effective 1 November The Commission commended Australia on continued laboratory containment activities to remain in close communication with the laboratories on the national inventory of wild poliovirus infectious materials and encourage further destruction of wild poliovirus and potentially infectious materials. The RCC also commended the Government of Australia for its support of the polio outbreak control in Indonesia as this indirectly supports maintaining the polio-free status of the Western Pacific Region Brunei Darussalam The RCC was impressed with the continued high quality of activities conducted and the strong government commitment to maintain the country s polio-free status. Based on the thorough progress report submitted, the RCC concluded that AFP surveillance and routine immunization quality remain at certification standard. The RCC commended Brunei Darussalam for comprehensive measures taken to enhance wild poliovirus importation preparedness Cambodia The RCC noted from the thorough progress report that the quality of AFP surveillance has further improved in several areas and certification standard stool specimen collection rate achieved for the first time in 2004 has been maintained. The RCC was impressed that the time interval between stool sample collection and laboratory results has been shortened to the lowest duration ever due to further reduced shipment times. The RCC also noted further improvements in reported routine immunization coverage under a comprehensive coverage improvement plan (CIP). However, the RCC remained concerned that despite very recent progress in one large hospital, conduct of active surveillance still remains very limited in several key national paediatric hospitals. Resolving this issue should be urgently pursued. The RCC commended Cambodia for comprehensive measures taken to enhance wild poliovirus importation preparedness, including conduct of targeted OPV SIAs in high-risk areas. The RCC commended Cambodia to have established dialogue and collaboration between the NCC and national containment coordinator to maintain an accurate list of laboratories in the country.

42 China Based on the comprehensive and forward-looking report submitted, the RCC was very impressed with China s continuing strong commitment to maintain polio-free status. The RCC commended China for the continued government support and funding for large-scale annual SIAs with OPV to maintain high population immunity, as well as sustaining the high performance of the polio laboratory network. The RCC commended China how surveillance data are being used to identify and correct weaknesses; i.e. high-risk AFP clusters analyzed and supplementary surveillance activities conducted in areas with weak AFP surveillance. Based on the comprehensive discussions included in the report, the RCC concluded that an appropriate surveillance and immunization response was conducted following the detection of cvdpv in Guizhou in 2004 and circulation ceased. The RCC also commended China on the comprehensive investigation conducted on an ivdpv-associated AFP case in The RCC emphasized that investigations in China are of particular relevance to Global Polio Eradication Programme due to being a large polio-free country with diverse conditions, quality immunization programme linked to a sensitive surveillance system and widely varying degrees of risk. The behavior of OPV virus in China informs the Global Polio Eradication Initiative (PEI) on most appropriate endgame strategies; no comparable detailed information is currently available elsewhere. The RCC noted some areas of concern, including low routine immunization coverage among the floating population and the lack of inclusion and follow up of unreported AFP cases found on house-to-house searches and hospitals record reviews. The RCC noted that in , more than 50 unreported AFP cases were found, including 11 unreported AFP cases in Tibet. As previously requested, the RCC would like to see discussions in the next progress report on how these cases are reported to the AFP surveillance system and reviewed/classified by the expert panels, as required. Another concern is the possibility of over-discarding of AFP cases as the number of polio compatible cases remains very low. The RCC noted that immunization coverage and AFP surveillance performance in Tibet continue to be low and recommended resolving these issues within the broader national strategy to prevent cross-border transmission. The RCC recommended to the national programme to review national wild poliovirus importation plan submitted in 2000 with the national certification documentation and update as may be required. China has made considerable progress in strategic planning and establishing goals for the laboratory survey and inventory. However, experience in countries worldwide indicates that achievement of these goals will require multi-sector endorsement and full support of the highest levels of government. The NCC was requested to urge the Government of China to facilitate completion of Phase I to meet Regional and Global containment goals. China should submit a progress report at the next RCC meeting, tentatively scheduled for December 2006, and a final report in mid-2007.

43 Hong Kong SAR The RCC was impressed with the continued high quality of activities conducted to maintain Hong Kong s polio-free status. Based on the thorough progress report submitted, the RCC concluded that AFP surveillance quality remains at certification standard. Reported routine immunization coverage also continues to be high and the RCC is interested in being informed about results of the recent serosurvey in the next progress report. The RCC commended Hong Kong for comprehensive measures taken to enhance wild poliovirus importation preparedness Macao SAR The RCC was impressed with the continued high quality of activities conducted to maintain Macao s polio-free status. Based on the thorough progress report submitted, the RCC concluded that AFP surveillance and routine immunization quality remain at certification standard. The RCC commended Macao for ensuring measures are in place to detect and respond to wild poliovirus importation and ensuring preparedness remains adequate Japan The RCC was impressed, based on the comprehensive report submitted, about Japan s quality activities to maintain polio-free status. The RCC appreciated presentation and discussion of reported OPV vaccination coverage by prefecture and reassuring results of thorough and detailed seroepidemiological studies and coverage surveys conducted in 2004 and The RCC repeated its appreciation for the substantial support the polio laboratory at NIID is providing to the Regional polio laboratory and applauded the continued high performance. The RCC commended the Government of Japan for its substantial contribution to the polio immunization campaigns in Indonesia; supporting the outbreak control also supports maintaining the polio-free status of the Western Pacific Region Lao People's Democratic Republic The RCC noted with great concern that Lao People's Democratic Republic remains the country in the Western Pacific Region at highest risk to suffer a renewed outbreak should wild poliovirus be imported and for the emergence and possible spread of cvdpv. The RCC acknowledged the thorough update report submitted. The report makes it very clear that the quality and sensitivity of AFP surveillance continues to be adequate, allowing in late 2004 the detection of type 2 VDPV from an AFP case and several healthy contacts. However, it also reflects that the immunity gap created by the failure of both routine and SIAs to reach sufficient coverage of target children in Lao People's Democratic Republic is widening further.

44 The documented VDPV episode confirms that the persistently low level of immunity against polioviruses continues to increase the risk of further, potentially more dangerous cvdpv outbreaks (type 1 cvdpv), as well as the risk of an outbreak following possible wild virus importation. A poliovirus outbreak in Lao People's Democratic Republic, a land-locked country bordering six other countries, would not only create a high risk of importation for neighboring countries, but would also have grave consequences for the polio-free certification status of the entire Western Pacific Region. The RCC acknowledged the efforts of the Ministry of Health, and particularly of WHO, UNICEF and other donor agencies, to improve routine immunization activities in the Lao People's Democratic Republic. The RCC appealed to the Government and to all EPI and polio partners to be fully aware of the very high-risk situation caused by the continued absence of an efficient vaccination programme in the Lao People's Democratic Republic. The RCC reminded all groups concerned that immediate and efficient action by Ministry of Health, supported by polio partners, is needed to rapidly improve the coverage of routine vaccination activities, particularly OPV3 coverage, for children everywhere in the country. The RCC suggested that the Regional Director of the WHO Western Pacific Region consider meeting with the Lao People's Democratic Republic health leadership in order to agree on the most important immediate and longer-term steps towards strengthening the quality of routine and SIAs in Lao People's Democratic Republic as rapidly and efficiently as possible. The RCC commended Lao People's Democratic Republic for updating its national preparedness plan for detection of and response to imported wild poliovirus and cvdpv but its implementation may be seriously jeopardized should the current lack of capacity for quality immunization activities continue Malaysia Based on the thorough progress report submitted, the RCC concluded that AFP surveillance quality remains close to certification standards in most parts of the country. Reported routine immunization coverage also continues to be high but the RCC would appreciate having figures added on state and/or district performance in future reports. The RCC remained concerned about the continued low AFP surveillance performance in Sabah, particularly in view of the current large polio outbreak in Indonesia, as well as the generally low NPEV isolation rate. The RCC noted that in order to validate the assumption that very low OPV3 coverage from Klang Valley is due to majority of services provided by practitioners but not reported the national programme is planning to repeat the coverage survey already conducted in The RCC commended Malaysia for several comprehensive measures taken to enhance wild poliovirus importation preparedness, including updating the national plan Mongolia The RCC noted from the progress report that the quality of immunization activities has remained high and AFP surveillance has been supplemented where not reaching required standards and commends Mongolia on these efforts to maintain polio-free status.

45 However, the RCC was not able to assess the quality of the national polio laboratory as no information was provided in the report. The RCC would like to receive performance updates; as already stated in 2004, the RCC considered the laboratory a vital component of virological surveillance in the country. The RCC acknowledged receipt of the wild poliovirus laboratory containment quality assessment report New Zealand The RCC noted from the progress report that the quality of immunization activities has remained high as IPV3 coverage estimates were presented for the first time based on a recently conducted coverage survey. AFP surveillance quality continues to meet quality standards for reporting of cases but stool specimen collection rate is low. The RCC commended New Zealand for ensuring measures are in place to adequately detect and respond to wild poliovirus importation preparedness. The report did not elaborate further on activities to enhance wild poliovirus importation preparedness. The RCC appreciated that the wild poliovirus laboratory containment quality assessment report was re-submitted in October 2005 following the WHO recommended format Pacific island countries and areas The RCC was impressed by the various activities conducted in 2005 to strengthen AFP surveillance within the framework of integrated EPI surveillance but noted very low reporting of AFP cases this year, also from the larger population centres, as well as the very low adequate stool sample collection rate. Based on the thorough report the RCC noted that routine immunization coverage is low in some countries and may have been for several years, bearing the risk that larger numbers of susceptible children may have accumulated. This should be taken into consideration when assessing risk for maintaining polio-free status in terms of surveillance results, population movements and geographical position. The RCC commended the development of a substantially updated generic protocol for response to wild poliovirus importation and encourages all countries in the PIC to adjust it to their national requirements Papua New Guinea The RCC appreciated the frank and comprehensive report prepared and submitted by the NCC chairperson and his continued dedication to the responsibility while currently no other members have remained in the RCC. The RCC urged that new NCC members be appointed as soon as possible. The RCC remained concerned about the weak performance of AFP surveillance and routine immunization. The RCC notes once more that a new national EPI Manager needs to be urgently appointed and stronger supervision provided for field surveillance officers.

46 While acknowledging that many of the challenges the programme is facing are beyond its control, the RCC reiterated the necessity to urgently improve AFP surveillance and vaccination activities. However, the RCC also predicted that a polio outbreak, either due to cvdpv or imported wild poliovirus, given the natural and infrastructural conditions in the country, would remain relatively localized. The RCC recommended that activities to increase preparedness for wild poliovirus importation should, besides updating the national plan, mainly focus on increasing immunity in large population centres and places with frequent international travel. The RCC acknowledged receipt of the wild poliovirus laboratory containment quality assessment report Philippines The RCC noted from the thorough progress report the sustained national commitment to maintaining polio-free status and attention given in this context to strengthening routine immunization services, particularly activities under the REB strategy. The RCC furthermore noted how it identifies current serious manpower challenges facing the national EPI system, and steps taken to meet these challenges. The RCC commended the Philippines for several activities recently taken to strengthen AFP surveillance quality and the continued risk analysis (i.e. AFP case clustering, timely detection of and response to hot cases and monitoring immunization status of AFP cases). Remaining areas of concern included AFP rates nationally and regionally only slightly above 1.0/ children under age 15, areas with AFP rates below 1.0 and large populations, low NPEV isolation rates in and possible new problems with specimen transport (expiration of Memorandum of Agreement with DHL). The RCC recommended to the national programme to continue identifying and immunizing high-risk populations with possible immunity gaps, especially in Metro Manila, Cebu and Mindanao but also other large population centres. The RCC concurs with the NCC conclusion that it is essential in quality routine immunization services to ensure adequate vaccine supply in vaccination centres at all times. The RCC commended the Philippines for comprehensive measures taken to enhance wild poliovirus importation preparedness, including updating the national plan of action, conduct of targeted OPV SIAs in high-risk areas in Mindanao and the directive to improve AFP surveillance at key ports of entry (Metro Manila, Davao and Cebu) in view of the current polio outbreak in Indonesia Republic of Korea The RCC was impressed with the continued high quality of activities conducted to maintain the Republic of Korea s polio-free status and the sustained national commitment, particularly expressed by establishing a special National Taskforce Team in The RCC commended the Republic of Korea for comprehensive measures taken to enhance wild poliovirus importation preparedness. The RCC acknowledged receipt of the wild poliovirus laboratory containment quality assessment report.

47 Singapore The RCC was impressed with the continued high quality of activities conducted to maintain Singapore s polio-free status. Based on the thorough progress report submitted, the RCC concluded that AFP surveillance quality remains close to certification standards and reported routine immunization continues to be high. The RCC commended Singapore for comprehensive measures taken to enhance wild poliovirus importation preparedness. The Commission also commended Singapore on continued laboratory containment activities to maintain an updated list of laboratories in the country and ensure that the national inventory of wild poliovirus infectious and potentially infectious materials remains accurate. The RCC lauded the Government of Singapore for its support to the polio outbreak control in Indonesia as this indirectly supports maintaining the polio-free status of the Western Pacific Region Viet Nam The RCC noted from the thorough progress report that the quality of immunization activities has remained high and AFP surveillance has been supplemented where it does not reach required standards and commends Viet Nam on these efforts to maintain polio-free status. Following its recommendations made during the 10 th meeting, that in order to maintain the performance gains made at the national polio laboratory in Ho Chi Minh City it is essential to further strengthen general management and have continued assistance from polio partners, the RCC was pleased to note that the laboratory is fully accredited for 2005 and The RCC recommended to the Ministry of Health to ensure sufficient human resources for both national polio laboratories as it considers them a vital component of virological polio surveillance in the country. The RCC commended Viet Nam for comprehensive measures taken to enhance wild poliovirus importation preparedness, including conduct of targeted OPV SIAs in high-risk areas. The RCC also commended Viet Nam on continued laboratory containment activities to maintain an updated list of laboratories in the country and ensure that the national inventory of wild poliovirus infectious and potentially infectious materials remains accurate. 4. FUTURE MEETING OF THE REGIONAL CERTIFICATION COMMISSION The RCC plans to continue meeting on an annual basis in order to fulfil its reporting mandate to the GCC. This meeting report will be submitted to the GCC and once its next meeting will have been scheduled, the RCC, through its WHO Secretariat, will prepare an update report on major developments since this meeting.

48 ELEVENTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF 1 DECEMBER 2005 POLIOMYELITIS ERADICATION IN CONJUNCTION WITH THE FIRST MEETING ON LABORATORY ENGLISH ONLY CONTAINMENT OF WILD POLIOVIRUSES IN THE WESTERN PACIFIC REGION Manila, Philippines, 3-7 December 2005 TENTATIVE TIMETABLE Time Monday, 5 December 2005 (maintaining poliomyelitis-free status) 08:00- Registration 08:30 08:30-09:00 1. Opening ceremony Welcome remarks by the Responsible Officer Opening remarks by the Regional Director Remarks by the Regional Certification Commission (RCC) Chairperson Group photo 09:00-09:30 COFFEE BREAK 09:30-09:40 09:40-10:10 10:10-10:40 2. Developments in certification and the 2005 meeting of Global Certification Commission 3. Global polio eradication 2005: risks and opportunities stopping endemic transmission controlling outbreaks in non-endemic countries strategic emphasis South-East Asia Region (SEAR): endgame India; challenge in Indonesia 10:40-11:00 COFFEE BREAK 11:00-11:30 5. Western Pacific Region (WPR) maintaining polio-free status in the context of EPI enhancing wild poliovirus importation preparedness polio laboratory network key to quality surveillance implementation of RCC 10 general recommendations Time Tuesday, 6 December 2005 (wild poliovirus laboratory containment) 08:00-09:00 09:00-09:30 09:30-09:50 8. Poliovirus laboratory containment the other half of eradication Global situation update Global Action Plan (GAP) II key elements for current work Time 08:00-08:10 08:10-09:00 9. How our neighbours do containment experience in SEAR 09:00-09: Quality assessment of Phase 1 in WPR 09:50-10:20 COFFEE BREAK 10:20-10: Update on poliovirus laboratory containment in China 14. Summary from Day 2 Wednesday, 7 December 15. Conclusions and recommendations on Phase 1 laboratory containment 16. Post eradication refining work on stopping OPV planning for the next phase laboratory containment GAP III development 09:40-09: Summary of Day 1 09:50 10:20 10:20-11:30 COFFEE BREAK 18. Draft conclusions and recommendations on maintaining polio-free status 11:30-12:00 6. Vaccine-derived polioviruses: "the OPV paradox" global updates regional summary :40-11: Update on poliovirus laboratory containment in Japan 11:30-12: Closing ceremony 12:00-13:00 LUNCH BREAK 13:00-15:00 7. Country summaries on maintaining poliomyelitis-free status surveillance performance immunization achievements issues and concerns 11:00-12:00 12:00-13:30 13:30-15: Country summaries Phase 1 laboratory containment (six key elements) a) Australia b) Brunei Darussalam c) Cambodia d) Hong Kong (China) LUNCH BREAK e) Lao PDR f) Macao (China) g) Malaysia h) Mongolia I) New Zealand j) PIC a) Australia b) Brunei Darussalam c) Cambodia d) China e) Hong Kong (China) f) Japan g) Lao PDR h) Macao (China) 15:00-15:30 COFFEE BREAK 15:30- i) Malaysia j) Mongolia k) New Zealand 17:45 l) PIC m) Papua New Guinea n) Philippines o) Rep of Korea p) Singapore q) Viet Nam 18:00 RD's reception at the Conference Lounge 15:00-15:30 COFFEE BREAK 15:30-17:00 k) Papua New Guinea l) Philippines m) Rep of Korea n) Singapore o) Viet Nam

49 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL ELEVENTH MEETING OF THE REGIONAL WPR/ICP/EPI/5.2/001/EPI(4)/2005//IB/2 COMMISSION FOR THE CERTIFICATION 1 December 2005 OF POLIOMYELITIS ERADICATION IN CONJUNCTION WITH THE FIRST MEETING ON LABORATORY CONTAINMENT OF WILD POLIOVIRUSES IN THE WESTERN PACIFIC REGION Manila, Philippines 3-7 December 2005 ENGLISH ONLY INFORMATION BULLETIN NO. 2 PROVISIONAL LIST OF REGIONAL CERTIFICATION COMMISSION (RCC) MEMBERS NATIONAL CERTIFICATION COMMITTEE (NCC) CHAIRPERSONS, LABORATORY CONTAINMENT COORDINATORS, TEMPORARY ADVISER, OBSERVER 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) Fax:(813) okabenob@nih.go.jp