e88105 polio eradication

7/24/2019 E88105 Polio Eradication

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Certification of

Poliomyelitis Eradication

EUROPEANREGIO

NDECLAREDPOLIO-FREE

Fifteenth meeting of the EuropeanRegional Certification Commission

Copenhagen, 1921 June 2002


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Fifeenth meeting othe European Regional Commission

or the Certicationo Poliomyelitis Eradication


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KEYWORDS

POLIOMYELIIS prevention and controlCERIFICAIONEPIDEMIOLOGICAL SURVEILLANCE standardsIMMUNIZAION PROGRAMMES

CONAINMEN POLIOVIRUSESNAIONAL HEALH PROGRAMMESEUROPE

World Health Organization 2005

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Fifeenth meeting othe European Regional Comm

or the Certicationo Poliomyelitis Eradicatio


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ABSTRACT

Te feenth meeting o the European Regional Commission or the Certicao Poliomyelitis (RCC) was held at the World Health Organization (WHO) REurope, Copenhagen, Denmark on 1921 June 2002. In this unique meeting,

national documents prepared by all 51 Member States o the Region in order decision: to certiy the European Region o WHO as poliomyelitis ree. Temeeting were to assess progress made towards certication o poliovirus eradRegion, to discuss ongoing activities or the post-certication period (that is, immunization services, polio surveillance and the regional polio laboratory nMember States on the regional and global situation regarding polio eradicatioconsisted o two plenary and our private sessions. Certication was based on

detailed scientic data provided by each country and supplemented by WHOwith an emphasis on national poliovirus surveillance. Each National Certicaprovided an offi cial statement summarizing the evidence that their country hindigenous wild poliovirus transmission or the previous three years. In additspecial presentations to the Commission during the meeting. Based on careuo the evidence presented, the RCC concluded that the transmission o wild pinterrupted in all 51 Member States o the European Region and, on 21 June 2

certied the European Region to be poliomyelitis ree. Te RCC emphasized eradication has been achieved, importation o wild poliovirus rom polio-endand thereore each Member State and WHO must sustain the highestlevels oand surveillance.


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Introduction

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Te ceremony o signing o the certicate at the Ny CarlsbergGlyptotek

Statements o Dr Marc Danzon, Regional Director or Europe o

the World Health Organization; Sir Joseph Smith, Chairman o thEuropean Regional Certication Commission; Mr Rudol Horndl

Representative o Rotary International; Mr Philip OBrien, Region

Director or Europe o the United Nations Childrens Fund

(UNICEF); Dr David Fleming, Acting Director, Centres or Disea

Control and Prevention, Atlanta, USA; Ellyn Ogden, Representat

o US Agency or International Development; Dr Daniel aranto

Director, Department o Vaccines and Biologicals, WHO, GenevaDr George Oblapenko, Medical Offi cer, WHO Regional Offi ce or

Europe

Te European Regional Certication Commission

Plenary Session o the European Regional Certication Commissi

on 20 June 2002

Plenary Session o the European Regional Certication Commission 21 June 2002

Private Sessions o the RCC

Contents


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I N T R O D U C T I O N

W O R L D H E A L T H O R G A N I Z A T I O NE U R O P E A N R E G I O N

R E G I O N A L C O M M I S S I O N F O R T H E C E R T I F I C A T I OO F P O L I O M Y E L I T I S E R A D I C AT I O N

SI R JOSEPH SM IT H CH AI R MA NSIR JOSEPH SMITH, CHAIRMAN DR G E OR G E F DR EJE RDR GEORGE F. DREJER

CERTIFICATE

T H E C O M M I S S I O N C O N C L U D E ST H E C O M M I S S I O N C O N C L U D E S

F R O M E V I D E N C E P R O V I D E DF R O M E V I D E N C E P R O V I D E D

B Y T H E N AT I O NA LB Y T H E N AT I O N A L

C E R T I F I C AT I O N C O M M I T T E E SC E R T I F I C A T I O N C O M M I T T E E S

O F T H E 5 1 M E M B E R S TAT E SO F T H E 5 1 M E M B E R S T A T E S ,

T H AT T H E T R A N S M I S S I O NT H A T T H E T R A N S M I S S I O N

O F I N D I G E N O U S W I L D P O L I O V I RO F I N D I G E N O U S W I L D P O L I O V I R

H A S B E E N I N T E R RU P T E DH A S B E E N I N T E R R U P T E D

I N A L L C O U N T R I E S O F T H E R E G II N A L L C O U N T R I E S O F T H E R E G I

T H E C O M M I S S I O N O N T H I S D AT H E C O M M I S S I O N O N T H I S D A

D E C L A R E S T H E E U R O P E A N R E G ID E C L A R E S T H E E U R O P E A N R E G I

P O L I O M Y E L I T I S F R E E .P O L I O M Y E L I T I S - F R E E .


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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D I C A T I O N F I F T E E N T H M E E T I N G O F T H E E U R O P E A N R E G I O N A L


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Sir Joseph Smith, Chairman o the Regional Certication Commission (RCCand Dr Roberto Bertollini, Director o echnical Support, gave an opening adWHO Regional Director. Secretaries or the meeting were Dr George Oblapenlu and Dr Steven Wassilak. Rapporteur or the meeting was Dr Ray Sanders. Tis provided in Annex 1, and the list o participants in Annex 5.

Tis report o the historic meeting begins with the ceremony o signing the ceberg Glyptotek and then the RCC and the design o the certication process iTe materials documenting the two plenary sessions are presented and discusprivate meetings o the RCC are also reected in this report.

SCOPE AND PURPOSE


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L A C O M M I S S I O N C O N C L U TL A C O M M I S S I O N C O N C L U T,

S U R L A B A S E D E S D O N N E SS U R L A B A S E D E S D O N N E S

C O M M U N I Q U E S PA RC O M M U N I Q U E S P A R

L E S C O M M I S S I O N S N AT I O N A L E SL E S C O M M I S S I O N S N AT I O N A L E S

D E C E R T I F I C AT I O ND E C E R T I F I C A T I O N

D E S 5 1 TAT S M E M B R E SD E S 5 1 T A T S M E M B R E S ,

Q U E L A T R A N S M I S S I O NQ U E L A T R A N S M I S S I O N

D U P O L I O V I R U S S AU VA G ED U P O L I O V I R U S S A U VA G E

I N D I G N E A T I N T E R R O M P U EI N D I G N E A T I N T E R R O M P U E

D A N S T O U S L E S PAY S D E L A R G I OD A N S T O U S L E S P AY S D E L A R G I O

L A C O M M I S S I O N D C L A R EL A C O M M I S S I O N D C L A R E

A U J O U R D H U I L A R G I O N E U R O P EA U J O U R D H U I L A R G I O N E U R O P E

I N D E M N E D E P O L I O M Y L I T E .I N D E M N E D E P O L I O M Y L I T E .

O R G A N I S AT I O N M O N D I A L E D E L A S A N T R G I O N E U R O P E N N E

C O M M I S S I O N R G I O N A L E P O U R L A C E R T I F I C AT I O ND E L R A D I C AT I O N D E L A P O L I O M Y L I T E

CERTIFICAT

SI R JOSEPH SM IT H PR SI DEN TSIR JOSEPH SMITH, PRSIDENT DR G E OR GE F DR EJE RDR GEORGE F. DREJER


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A N H A N D D E R V O N D E N N AT I O NA N H A N D D E R V O N D E N N AT I O N

Z E R T I F I K A T I O N S A U S S C H S SZ E R T I F I K A T I O N S A U S S C H S S

D E R 5 1 M I TG L I E D S TA AT E ND E R 5 1 M I T G L I E D S T A AT E N

V O R G E L E G T E N F A K T E N K O MV O R G E L E G T E N F A K T E N K O M

D I E K O M M I S S I O N Z U D E M S C HD I E K O M M I S S I O N Z U D E M S C H

D A S S D I E B E RT R A G U N G V OD A S S D I E B E R T R A G U N G V O

E I N H E I M I S C H E M P O L I O W I L D VE I N H E I M I S C H E M P O L I O - W I L D V

I N S M T L I C H E N L N D E R NI N S M T L I C H E N L N D E R ND E R R E G I O N U N T E R B R O C H E N W O RD E R R E G I O N U N T E R B R O C H E N W O R

D I E K O M M I S S I O N E R K L R TD I E K O M M I S S I O N E R K L R T

D I E E U R O P I S C H E R E G I O N H ED I E E U R O P I S C H E R E G I O N H E

Z U R P O L I O F R E I E N R E G I O NZ U R P O L I O F R E I E N R E G I O N

ZERTIFIKATW E L T G E S U N D H E I T S O R G A N I S A T I O N

E U R O P I S C H E R E G I O N

R E G I O N A L K O M M I S S I O N F R D I E B E S T T I G UD E R P O L I O - E R A D I K A T I O N

SIR JOSEPH SMITH VORSITZENDERSIR JOSEPH SMITH, VORSITZENDER DR G E OR G E F DR EJE RDR GEORGE F. DREJER


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5 1 ,5 1 ,

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SI R JOSEPH SM IT H CH AI R MA NSIR JOSEPH SMITH, CHAIRMAN DR G E OR GE F DR EJE RDR GEORGE F. DREJER


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he historic decision to certiy the European Region o the WorldHealth Organization (WHO) poliomyelitis-ree was announced thismorning at the meeting o the European Regional Commission orthe Certiication o Poliomyelitis Eradication (RCC) in Copenhagen.his decision is the most important public health milestone o the newmillennium. It means there is no longer wild poliovirus circulation inthe European Region. It means that some 873 million people living inthe Regions 51 Member States do not need to ear contracting endemic

wild poliovirus any more.he European Region has been ree o indigenous poliomyelitis or

over three years. Europes last case o indigenous wild poliomyelitis oc-

C H A P T E R 1 T H E C E R E M O N Y O F S I G N I N G O F T H E C E R T I F I C A T E A T T H E N Y C A R L S B E R G G L Y P T

curred in eastern urkey in 1998, when the virus paralysed a two-year-old unvaccinpoliovirus imported rom poliomyelitis-endemic countries remains a threat. As wein 2001 alone, there were three poliomyelitis cases among Roma children in Bulgaralytic case in Georgia all caused by poliovirus originating rom the Indian subcon

remember a decade ago, imported poliovirus paralysed 71 people and caused 2 deain the Netherlands that reused vaccination.

he path to a poliomyelitis-ree European Region began in 1988, ollowing the cHealth Assembly to eradicate poliomyelitis. A partnership was set up, spearheadedInternational, the US Centers or Disease Control and Prevention (CDC) and UNI

Opening remarks by Dr Marc Danzon, Regional Director, WHO Regional Offic

he ceremony o signingo the certiicate

at the Ny Carlsberg Glyptotek

PLENARY SESSION OF

HE EUROPEAN REGIONAL CERIFICAION COMMISSIOON 21 JUNE 2002


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Commission in Paris in March 1996. It was an historic meeting, where the Re

Commission was just starting this work and had questions to clariy and deincedures and criteria or certiication. Six years have elapsed since that meetinboth the eradication programme and certiication activities have matured thrintensiied eorts to reach the highest quality level possible, enabling the Regpoliomyelitis! Since the Global Poliomyelitis Eradication Initiative was launched in 1988,been certiied poliomyelitis-ree: the WHO Region o the Americas in 1994 an

Paciic Region in 2000. Poliomyelitis cases have dropped rom an estimated 31988 to just 480 reported cases in only 10 poliomyelitis-endemic countries in Success, which we are celebrating today, is the result o a great collaborativber States, the hard work o public health workers in the ield, and a solid intecoordination with WHO, particularly with Rotary International, CDC AtlantSeveral donor nations o the Region, as well as charities, have contributed subbrating a truly international collaboration or the beneit o our children in al

However, we cannot rest. Activities must continue to sustain high levels o coverage, with supplementary immunization activities where needed, and to ratory-based surveillance and containment o polioviruses, until global eradiSo, polio-eradication work is not over till its over globally! And it will continuknow, the Regional Oice has received irm commitments rom all ministriesimmunization and surveillance.

It is a great pleasure or me to congratulate you all on this tremendous achiEuropean Region but also or the global eorts to eradicate poliomyelitis. It is

open this historic meeting.


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he WHO European Region stretches rom Greenland in the north-west to the lthe east, and rom the northern shores o Europe and Asia to the Greek island o CIts 873 million people live in 51 dierent countries, which include urkey, Israel an

Statement by Sir Joseph Smith, Chairman, Regional Certification Comm

republics. o certiy as polio-ree this large, disparatsound evidence and careul scientiic judgement.

he Global Certiication Commission (GCC) setples and criteria or certiication in 1995. he GCC the term eradication should apply only to global ccommissions should initially certiy interruption oindigenous wild poliovirus, a status that in brie maree. Guided by the GCC recommendations, includto certiication, or a polio-ree saety-margin o 3 ylance and testing to exclude any possible silent transpean Regional Commission (RCC) irst met in 1996 Certiication only becomes possible as a result o tion. hroughout its work, the Commission has kepthe intensive immunization campaigns that have led

o polio transmission in the Region. hese include not only national programmes, vaccinations o the MECACAR and MECACAR-plus operations, coordinated collaborating countries o the WHO European Region and WHO Eastern Mediter

year, rom 1995 to the present.

Staging by epidemiological groups of countries

he Commission agreed that it would be essential to address its task in a structuredmeeting in 1996 the RCC thereore accepted a WHO proposal to review countries sive epidemiological groups. he irst our groups comprised the western, nordic-and southern countries thought to have been ree o polio or more than 8 years. N

would be the central/eastern, recently endemic countries believed to have brought between 3 and 8 years earlier. he sixth MECACAR group in the eastern part o seventh, the Russian Federation, had all experienced endemic polio within the prevtook part in the MECACAR operations.


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or many years. his also proved to be the case in many western European co

cians saw little need to prove what they perceived as the sel-evident absence othe RCC and WHO gave much attention to the value o other evidence.

Although AFP surveillance has been the single most important tool, the Coployed a range o additional inormation including: national health statistics;lance; environmental surveillance; laboratory tests or poliovirus; risk groupsment; and Manuals o Operations.

National health statisticsNational mortality and morbidity statistics, polio vaccination rates throughouported poliomyelitis cases year-by-year were documented, together with the nhead o population. UN statistical data and a WHO Report in 2000 on healthwere also taken into account. hese data were used collectively as indicators ocessibility o health services, and indirectly as indicators o the likelihood thatparalysis would, in practice, be seen by doctors and appropriately investigated

Enterovirus surveillance

Enterovirus surveillance tests or poliovirus excretion by inected persons, bysurveys or the use o routine diagnostic laboratory tests. he value o such eages, numbers and national distribution o the populations tested, and the nattested patients.

Environmental surveillance

he culture o sewage samples or poliovirus is an indirect means o detectingin the population sample rom which the sewage is derived. his procedure, tsurveillance, has been developed and applied in several countries and has prople, in Finland and in the Netherlands, to monitor localities where groups whreligious reasons live. he method has also been useul elsewhere, such as mo

Laboratory tests for poliovirus

hese tests underpin surveillance and it is thereore essential to ensure that thWHO thereore established a regional network o accredited reerence laborato meet appropriate perormance standards and regularly to pass tests on blithe validity o their results.


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the preparation o national inventories o laboratories that may hold stored sample

viruses. Documentation o the completion or near completion o this irst phase orequirement or Regional certiication.

Manual of Operations

he Commission agreed a ormat o tables, inormation and comment in which thsets should be provided, set out in a Manual o Operations. he use o this uniorormat acilitated interpretation and analysis o data and helped in identiying whe

missing.

The certification process

he health minister o each country was asked by the WHO Regional Director to ependent National Certiication Committee (NCC), whose members should be sentists not directly involved with eradication activities. he NCCs task would be to cwhen appropriate approve, inormation collected by national sta and documentedManual o Operations or submission to the Commission or review. In this way,eect, an independent judgement o the polio status o their own countries. hrough successive meetings, held in dierent countries o the Region, the Comthe national documentation sets. Prior to meetings, all members studied the documaddition, two members took a lead assessment role or each country. WHO oicerpendent evaluation. he Commission then met to discuss and agree preliminary cthe NCC chairpersons gave spoken presentations. he national representatives coutioned in order to clariy uncertainties and, ater urther deliberation in camera, th

were presented to the National Certiication Committees.



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In due course, NCCs provided updated inormation, including the responses

and recommendations o the RCC reviews. his iterative process was supplemselected key areas by Commission members, including parts o the Region wipolio, such as Albania, Azerbaijan, Bulgaria, Georgia, the Kosovo area, UzbekRCCs work was urther supported by the reports o technical visits to countrand consultant experts to assess the quality o surveillance. Prior to Regional certiication, each NCC was asked to sign a statement o believed their country to have been ree rom indigenous wild poliovirus tran

3 years. Such a ormal statement, signed by senior proessionals who know thvalued by the RCC.

WHO Eastern Mediterranean Region (EMR)

EMR has made great progress in polio eradication despite marked socioeconcountries, as well as protracted conlicts. Nevertheless, in 2002 endemic polioparts o the EMR, and people moving illegally across borders might carry wiltries o the European Region. he two WHO regions have thereore collaborathe MECACAR operations. Members o the two commissions have attendeand a report on EMR has eatured in most RCC meetings.

Wild poliovirus importation

Until wild poliovirus has been eradicated globally, recently inected travellerstries may carry the virus to other parts o the world. Consequent outbreaks amgroups must be prevented by maintaining high immunization rates and by su

detect and respond to importations quickly. Provided there is convincing evidis rapidly stopped, the Global Commission has concluded that importation evstatus o a region already certiied by its Commission.

he RCC evaluated reports on the two importation events identiied in theperiod ollowing the detection o the last case o indigenous inection in urkhe irst importation event, in March 2000, was among the Roma people o Bcultured rom two aected children and a urther two who remained well. h

single isolate rom a child with meningoencephalitis in Georgia in Septembermolecular genotyping showed the strains to have originated in the Indian subtries undertook appropriate investigations and vigorous immunization campplace in neighbouring countries, with special attention to Roma in the case oExtensive sampling subsequently ound no evidence o continued transmissio


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Presentations by the NCCs o 16 key countries were also heard at this meeting.

or various reasons, such as a need to clariy the extent to which surveillance had rriods o conlict, or to evaluate urther the progress made in containment. O partiwere presentations rom Bulgaria and Georgia on their recent importations o wildIndian subcontinent. he RCC concluded in March 2002 that it probably could in June 2002 certiy thlio-ree provided certain missing items o inormation were supplied and ound to and provided no new imported virus transmission episodes occurred beore then.

emphasized that, until wild virus was eradicated globally, polio outbreaks due to viremained possible, especially among at-risk groups. It was thereore essential that atained high levels o polio immunization and surveillance. In the event, at its iteenth meeting on 21 June 2002, ater consideration o the provided, including reports o assessment missions to key countries by CommissioWHO teams, the Regional Commission declared that indigenous wild poliovirus tbeen interrupted in the WHO European Region, and the Region was declared poli

The future

Immunization and surveillance

In view o the risk rom imported wild viruses, the WHO Regional Committee or 2000 a resolution to maintain high levels o polio immunization and surveillance ucation has been achieved. Underlining the continuing importance o this resolutioDirector in 2002 asked all ministers o health to provide inormation on their uturtaining polio immunization and surveillance, including an action plan or dealing w

tion o wild virus.

Containment

he WHO Global Action Plan on Laboratory Containment proceeds in phases. Fothe Region, countries addressed the irst, laboratory inventory phase o this actionthrough the subsequent phases now becomes necessary. By the time o global certipoliovirus samples must have been destroyed or conined in biosaety level 3 conta

Annual Updates

he RCC intends to meet annually in the uture to consider concise updates rom ewill include ongoing surveillance and immunization data, as well as progress reporwhich will also be monitored by means o validation exercises and consultant repo



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sion o indigenous wild poliovirus has been interrupted throughout the Regio

he Commission greatly appreciates the work o the chairpersons and memRegions 51 countries, who have invariably answered the Commissions questiresponded willingly to recommendations.

he RCC would like to record thanks to its Secretary, Dr David Salisbury, band expertise he brought to our assessments and or his excellent work as rapo our meetings. We also thank Dr Nikolaj Chaika and Dr Ray Sanders, who wthe remaining meetings.

here are many others to whom thanks are due, including the experts whthe RCC, and the WHO ield oicers who work in the countries o the Regionlio eradication Rotary International, CDC Atlanta, UNICEF and USAID hparticipants in the eradication programme, but their representatives have alsotors to our meetings. he RCC especially appreciates the work o the members o the WHO poliOice, Copenhagen. It is a particular pleasure to recognize the outstanding leOblapenko, and the ine contributions o his senior colleagues, Dr Galina LipWassilak. Among those upon whose work the RCC depends are the secretariMs Johanna Kehler and Ms atiana Michaelson, whose unailing and ever helinvaluable.


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hank you or that kind introduction. As a European citizen, I am very proud, hto be able to witness this historic event. But speaking on behal o the more than 1.2o Rotary in 163 countries and especially on behal o the more than 250 000 Europ

Statement by Mr Rudolf Horndler, representative of Rotary Internatio

can also express our happiness and pride in having remilestone and I can assure you that we will do everyt

ensure that nothing derails our dream o a polio-reeto invite you to ollow me on a short review o Rotaryour ight against Polio. In 1979, Rotarians in the Philippines, with the helpFoundation, carried out the irst nationwide immunitries ollowed. Encouraged by the success o these nacampaigns, Rotary International in 1985 started its ihumanitarian activity: the ight against polio. Contrary to a widely held belie, even among Rotawhen Rotary International irst turned its attention acrippling disease, Rotary did not intend, plan or prompolio. All we planned and promised in 1985 was to ra

then calculated at US$ 120 million, to provide ree, oral poliovirus vaccine to immuo the world by 2005, Rotarys 100th anniversary. But instead o the goal o US$ 120 million, more than US$ 220 million was reach

pledges, where European countries were among the top achievers. hrough additiinterest, by the year 2005, Rotarys inancial contribution to the global ight against Pwill have reached US$ 500 million. And besides the money, Rotary International covolunteer eort o its huge membership and others they could mobilize, helping emobilization and the logistics o the immunization campaign. hereore, when in May 1988 the World Health Assembly committed its Membto the global eradication o polio, Rotary International was ready and willing to

coalition o partners to achieve this high goal, spearheaded by WHO, Rotary InterUNICEF and joined by the health authorities o all polio-endemic countries. his diately highly successul example o public and private sector cooperation. Rotarys primary roles within the coalition were to provide vaccines, mobilize voimmunization campaigns, coordinate eorts among coalition partners, advocate o



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A very special challenge arose when the Kosovo Albanians reused vaccina

authorities. Again, Rotarians could convince them o the beneits o the immlenges arose and were also overcome in other central/eastern European count he WHO European Region consists not only o geographic Europe, but, sUnion belonged to it as a whole, the Region now extends not only over all o tbut also the Newly Independent States. It thereore extends rom the Atlantic rom the Polar Sea to the Himalayas and the Black Sea, and shares borders wcountries like Aghanistan, Iran, Iraq and Pakistan, belonging to the WHO E

Region.But not until 1995 were coordinated immunization activities between thesegions developed, and with the decisive help o my predecessor as Chairman oPolioPlus Committee, past Rotary International Director, Mario Grassi, Operstarted.Operation MECACAR stands or the coordinated poliomyelitis eradication eCaucasus and central Asian republics. his is a crucial area or polio eradicatisome o the last countries where wild poliovirus is still circulating. Without Operation MECACAR, we would probably not be able to celebrattoday. It is a pity that my good riend Mario Grassi, who worked so hard to acnot live to join in this celebration.

Yet, in spite o this success and todays extraordinary achievement, our greagainst polio worldwide is a unding gap o US$ 275 million. his could threanate every child by 2005. Eradicating polio is Rotarys top priority. o help ill the US$ 275 million u

launch its second membership undraising drive with the goal o raising US$ 2002 and July 2003.

Rotary is also continuing

In addition, Rotary is continuing its eorts to convince national governmentsinvest in a polio-ree world. Special public and private sector advocacy task oand still are, active and also quite successul. Donor governments have alread

US$ 1 billion to polio eradication. hese donor governments include the Netdonations in Europe, and also our host country Denmark and my own countr Already, Rotary is quite oten asked, What comes ater polio?. o this tpossible answer: he question o whether Rotary will ever join a new healthdecided upon the completion o polio eradication. Until we inish this job, we


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I am delighted, on behal o UNICEF, to participate in todays historic announcemo the European Region as polio ree is themajor public health success story or theRegion and a giant step toward global achievement o polio eradication. his goal w

Statement by Mr Philip OBrien, Regional Director for Europe, UNIC

the recent UN Special Session or Children:A World which the worlds nations re-committed to achieving

tion o poliomyelitis by the end o 2005. he certiication o Europe as polio ree is a testamnerships, which over the last 14 years have worked soacross the 51 countries o the Region to reach this minership that enabled us to support the routine vaccina partnership that allowed us to run successul NationDays, but also one which has helped to provide vacciconlict zones, diicult territories and to carry out amder immunization activities. Great progress has been ing the Regions most hard-to-reach children: minoriisolated by conlict, as well as reugee and internally d

UNICEF echoes the tributes we have heard today tgovernments and individuals that have collectively created a polio-ree Europe. hdeserved, and we in UNICEF are pleased that we have been able to play a part in thas well as the global campaign.

Last year, with unds rom Rotary International, the American Government, theDisease Control and Prevention, and other donors, we were able to procure and dedoses o oral polio vaccine (OPV). In the past 3 years, UNICEF procured and delivlion doses o OPV, worth over US$ 10 million, to countries in the WHO Europeancountry oices have worked with a range o partners to secure the cold chain, moband advocate with political leaders to ensure polio eradication activities. We must not be complacent. In 2001, we had polio cases in Bulgaria and Georg

children o the minority Roma community were inected with poliovirus o Indianchildren had not been vaccinated. We need to attainand maintainhigh levels o rotion coverage, including against polio, doing everything in our power to protect alcan do this together, I do not doubt. Witness the excellence o the work WHO has dto do in support o improved immunization and surveillance systems.



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I t is my great honour and a distinct pleasure to represent the Centers or Dition (CDC), and the Government o the United States o America to celebrateregion o eradicating polio orever rom the ace o the earth. his work has b

Statement by Dr David Fleming, Acting Director, US Centers for Disease Control

Member States o the WHO European Region, uthe World Health Organization. It is indeed an historic accomplishment or wlaboured so long and hard should be proud. I beeradicate polio can serve as a model or uture pthe European Region and elsewhere, demonstrawhen there is vision, leadership and a common he story o polio eradication in this Region he groundwork or the initiative was laid in 19into being o creating a coordinated action invo

tries in this Region and in the WHO Eastern Mstamp out the last vestiges o polio. his new intion MECACAR, aimed to reach every child witsynchronized National Immunization Days to s

sion across major portions o the continents o Europe and Asia. he eort hathe lessons learned, in particular the collaboration among national governmecause, have inluenced the approach to polio eradication worldwide.

Poliomyelitis eradication is the model or building close linkages between mence and public health implementation on a global scale. he challenge beorextend all o the lessons in cooperation learned rom Operation MECACAR iareas. We are also challenged to complete the inal phase o polio eradication wide, thus preserving orever the legacy o Operation MECACAR. CDC takes this opportunity to thank the member countries o the EuropeaInternational, UNICEF, USAID and all the other partners involved in this ini

nity CDC has had to participate in, contribute to and learn rom this historic I would like to end my remarks on a personal note. he sta at CDC will athe good memories o the many riends and colleagues in the European Regiohad the pleasure o working. Many o you are here today, so I take this opportyour historic work on this triumphant occasion. he experience CDC has ha

d l l d h k l d b h h d


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O n behal o USAID Director Andrew Natsios, I would like to thank the Certision or inviting USAID to participate in this auspicious event. I congratulate all Mthe WHO European Region on this occasion or achieving your goal o certiicatio

Statement by Ms Ellyn Ogden, Representative of the US Agency for International

Perhaps more than any other public health programme, polio eradication releclic health proessionals and humanitarians to leave no child behind. Polio-eradicatopened our eyes to marginalized groups and un-reached children: those most vuln

and disability. We must not orget them, or the other health conditions they conroeradication as a oundation or strengthening all health services, and as a bridge to Although we are here to celebrate the European Regions polio-ree status, we mjust how ragile that status is. here is still a long road ahead beore we can ultimator polio altogether, and maintainingpolio-ree status until that day may be more dterruption o wild virus transmission. In the absence o disease, it becomes harder high and to detect low levels o transmission. In addition, inishing containment is

Europe is not the same as when we started polio eradication in 1988, and it contWe must be prepared to meet the public health challenges o the changing environmovements and political crises warrant ongoing attention and revisions to plans ascontinue to monitor routine immunization coverage at the subnational level in thewith particular attention to high-risk groups, which may require supplemental imm

progress in other aspects o your immunization provery proud o the hard work done by vaccinators, vo

o health and all the organizations working in partnthis goal, including Rotary International. he leadership provided by WHO in both Europdle East has been strong and steady, including the uMECACAR collaboration. his has helped to meet lenges in a transparent and proessional way, and ovproblems as they have arisen. I want to give special tOblapenko it is a joy and a privilege to work with nizes the great dedication o all WHO Regional Oito assure that the integrity o polio eradication data is greatly valued by all donor agencies and sets a higprogramme.



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rom the region, donors and partners will wash their hands and walk away ro

that the job is done. Nothing could be urther rom the truth. In order to protbillion investment in polio eradication worldwide, it is incumbent on all o usindeed, to identiy new partners. here is also an opportunity to build on the the hallmark o the polio programme, to strengthen routine immunization andiseases o public health importance. We would like to see broader ownershipease-control initiatives, including all donors in the Region. USAID hopes you share this vision o the uture and that all countries in thmeet the challenges o the post-certiication era. We believe our money has bRegion and that it has been very well utilized or the best o all goals: the prevdeath o children. We also know that the job is not over until its over the Ammains committed to polio eradication through USAID and CDC. USAID conthe global polio-eradication programme. Our investment o over $US 240 mito support supplemental immunization campaigns, the laboratory network, stions and research or polio eradication. In the past year, we have expanded suSudan and Somalia, in addition to maintaining our inancial and technical su

countries in Arica, South Asia and the Near East. Most o our aid is channellcies such as WHO, UNICEF, the Core Group o NGOs and other USAID techBASICS. But apart rom the technical aspects o polio eradication, what is remarkabindividual lives are changed in unoreseeable ways by this dreadul virus. Whomany lives would be touched by the virus that passed child to child rom Iwere some children paralysed and others not? hese are some o the mysterie

As a child, my grandather told me that I should be proud that I am the desand princesses. I dont know i this is true or just amily olklore, but I do knodren are Roma or not, on whichever shore or in whichever country they live, one step closer to being polio-ree orever, because o your eorts. You, the vohealth workers in your countries, are the real heroes o this story. I am sure thdren rom your own countries, were here today, they would thank you. Again, we extend our heartelt congratulations to you all.


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I am here today to speak rom the perspective o the Global Polio Eradication Inlike to begin by expressing my thanks to you, the European Region and congratulamental achievement. he European Region has made a great contribution to the g

Statement by Dr Daniel Tarantola, Director, Department of Vaccines and Biological

cate poliomyelitis. You have done your job very neagreat thanks rom the regions where polio is still a r

ight goes on. he Global Initiative also thanks donors in the Euthe support you have given to polio-eradication pronomically deprived countries o polio-endemic regicontinue to ace the great costs o polio eradication,ing the very lives o health-care workers as they reacwho need to be immunized. We still have a long way to go. Untilglobaleradicatis has been certiied, we need to continue to immunneed to maintain the surveillance system. We need tso that it remains saely stored in secure laboratorieagain. o do this we need people, like the many thou

workers around the world who have been trained, mobilized and inspired by the port. And we also need people like the Rotary and Red Cross volunteers who, in onalone, vaccinated 125 million children in just a ew days. We need people and we n

he expenses incurred in the Global Polio Eradication Initiative are high. For this a unding gap o US$ 60 million. his sounds enormous, but it is small compared wbeneits o the eradication campaign, a campaign that continues to contribute to mreduction o death and disability caused by one disease. In our global vision o polio eradication, the monumental achievement we are cbut one step into the uture o public health. he Polio Eradication Initiative will lelegacy, beginning with its strengthening o routine health services. Stronger routin

strengthen human development, and stronger human development can help alleviawill urther reduce human illness and suering. From the global perspective, thereing something even more wonderul than Polio-Free Europe today. We are celebrathat has brought together health-care workers, volunteers, donors and others into agreater uture or all o our children.



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I could not sleep last night ater I learned the Commission would declare three. I was wondering how dierent it is to live in Polio-Free Europe? I must aany dierent, and I realized that it will take some time or us to truly understaevent, the meaning o the words: POLIO-FREE EUROPE. his is a great day he road to poliomyelitis-ree Europe was long and hard, and there are magreat thanks. I would like to begin by thanking everyone who contributed thesouls to our common goal: the eradication o poliomyelitis in the European Rbe proud o this great success. he Certiication o Europe as polio-ree is a wnership successul cooperation o many dierent countries, organizations, i

Statement by Dr George Oblapenko, Medical Officer, WHO Regional O

good will. It is an excellent example o successmake a new generation the children o the 21and wealthy! hanks to all o us!

here are many individuals who must get sptraordinary contribution to this success. I wouing Dr Ralph Henderson,Director o the WHon Immunization, who irst presented the casethe World Health Assembly, which endorsed ttion Initiative on 13 May 1988, and called all cthis humanitarian work.

he key to the success o polio eradication inwas Operation MECACAR, which was a uniqution. Eighteen countries o the European and E

Regions joined orces and coordinated polio-eradication activities between 19hard work to deliver polio vaccines to children in the most remote corners o a success and high levels o immunization coverage and surveillance were maMECACAR was not just the cooperative eort o governments and ministries

nary dedication and hard work o many people. I recall an encounter back in the irst round o Operation MECACAR. It was in Kazakhstan, close to the bolocal district health authority, the Chie Oblast Medical Oicer and I were goo National Immunization Day (NID) activities in a remote settlement. On ouman he was an ophthalmologist returning rom that remote village, where h


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also would like to express our great thanks and appreciation to Dr Marc Danzon,t

Director, who has continued to actively and strongly support this important prograhis time, energy and ull trust. And, as we give thanks and recognition on this very bright and beautiul day, I wour partners and riends who have departed and could not celebrate with us today

Dr Mario Grassi,the irst chairperson o Rotarys European PolioPlus Committpromoted polio eradication and supported implementation o appropriate strateRegion, particularly in the ormer Yugoslavia.

Dr Bruno Martainwas the UNICEF Coordinator or Immunizations, includingin our Region during our most diicult years, 19931997. Bruno was particularimplementation Operation MECACAR in Caucasian republics.

Dr Henrik Zoffmann,ormer director o WHOs Expanded Programme or Immprovided strong support to the European Regional programme.

Dr Ko Kejarom the core o the Expanded Programme on Immunization (EPI)ters, who practically initiated polio eradication eorts in urkey.

Dr Ivan Masar,who was coordinator o EPI in Slovakia. Ivan contributed a lot to the Regional immunization and polio-eradication programmes; he was the chEuropean Advisory Group and we have gained rom his epidemiological expertexperience.

I particularly would like to recall the name o Dr Mirzobalie Jacheev,Chie MedVachshskiy district, in ajikistan. He was assessing the quality o NIDs in 1995, in ajikistan. UNICEF was able to stop ighting or a week o tranquillity. Howev

visit, an armed group rom Aghani territory targeted Dr Jacheevs car and Dr Ja

he Polio eam thanks and salutes all o our riends and colleagues or the roles ththis great achievement. We know quite well that one o most important strategies ieorts is high-quality surveillance, and in Europe, the Regional Polio Laboratory Nsential in assuring quality polio surveillance. I would like to express great cordial thgists and sta o all o the laboratories that have played such a key role in our succe

have worked very hard to provide the programme with investigation results in a timvery oten worked through nights and weekends. It is also very important to recogpean Polio LabNet is highly proessional and reliable, thanks to the hard work o Dthe Regional Coordinator, who is both a great virologist and manager. Partnership! It would be diicult to over-estimate the role o partnership in this



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In the spirit o this great partnership, I eel strongly that I have to name some

not able to attend this historic ceremony, colleagues who worked all these yeathe irst Coordinator o the Global Polio Eradication Initiative; Dr Mark Pallvirologists rom the CDC/Atlanta; Mr Bob Keegan,Public Health Manager, CTangermann,WHO headquarters; Dr Mary Agocs,CDC/Atlanta and Dr Brtor o the Global Polio Eradication Initiative, WHO headquarters. I do not have the words to express my great appreciation and my deep thaneam. For many years, this team has worked hard and under great pressure, topolio-ree Europe a reality. I recall many midnight work sessions to inalize edocuments and how, during the 1996 polio outbreak in Albania, Dr Steve Wasend e-mails at three in the morning. he spirit o the European Regional Polhighly motivated and target-oriented just what was needed to get the job douse this unique chance to cordially thank the WHO Regional Oice Polio eaconstant support you gave me. Finally, it is a great pleasure to thank the European Regional Certiication Ccation Commission is highly competent and since our irst meeting, in March

elegant style o working in a spirit o trust, balanced with critical scientiic inq So, let us enjoy this celebration! We all worked hard and we can be proud. Htain our victory until all transmission o polio has been stopped, worldwide, abeen contained. Wild polioviruses are still around the corner and high levels coverage and high-quality AFP surveillance are the key elements in sustaininIts not over until its over!


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he ollowing terms o reerence were approved:

to validate the plan o action and timetable or certiication or polio eradicRegion; to ratiy or change the proposed quality o surveillance or certiication in t

endemic and endemic countries o the Region;

to state the documentation that will be needed rom each country o the Retion;

to approve and update as necessary the protocol or collection o national i

veillance data or certiication and polio eradication; to develop, i needed, innovative methods or veriying polio eradication inor high-risk areas in recently endemic and endemic countries, where thecriteria or certiication have not been met;

to conduct site visits, i required, to review or veriy the status o polio-eradvidual countries;

to review the polio-eradication documentation o each country/zone on an

port the indings and required actions to the Regional Director and approp to bring unresolved certiication issues to the attention o the Global Commtion o Eradication o Poliomyelitis or discussion;

to certiy, i and when appropriate, the eradication o circulating wild poliopean Region o the World Health Organization, and to provide the Global documentation necessary to endorse Regional certiication.

he Commission considered the relevance to the European Region o the g

mended at the First Meeting o the Global Certiication Commission in 1995

The design of the Regional certification process

he health minister o each country was asked by the WHO Regional Directopendent National Certiication Committee (NCC), whose members should btists not directly involved with eradication activities. he NCCs task would bwhen appropriate approve, inormation collected by national sta and docum

Manual o Operations or submission to the Commission or review. In thiseect, an independent judgement o the polio status o their own countries. hrough successive meetings, held in dierent countries o the Region, thethe national documentation sets. Prior to meetings, all members studied the daddition, two members took a lead assessment role or each country. WHO o

d t l ti h C i i th t t di d li i


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he stage was inally reached in 2001 when no indigenous wild poliovirus inec

ported in the region or the past three years and certiication might soon become mission decided to undertake this task in two stages, and to address not only the evrom polio and progress in laboratory containment, but also the capacity o countrrespond to virus importation, and their plans or sustaining polio control ater cert

A penultimate review was made, or which inormation in an approved ormat wall countries. Commission members studied these documents and then met to discteenth meeting in March 2002. he RCCs assessment was greatly helped by a comtion prepared by the WHO Regional Oice.

Presentations by the NCCs o 16 key countries were also heard at this meeting. or various reasons, such as a need to clariy the extent to which surveillance had rriods o conlict, or to evaluate urther progress made in containment. O particulathose presentations rom Bulgaria and Georgia on their recent importations o wilIndian subcontinent. he RCC concluded in March 2002 that it could probably, in June 2002, certiy tree, provided certain missing items o inormation were supplied and ound to be

provided no new imported virus transmission episodes occurred beore then.Prior to Regional certiication, each NCC was asked to sign a statement o the re

believed their country to have been ree rom indigenous wild poliovirus transmissthree years. Such a ormal statement, signed by senior proessionals who know thebeen valued by the RCC. On the evening o 20 June 2002, the RCC unanimously concluded to declare thethe World Health Organization as Region POLIOMYELIIS-FREE.

he Commission emphasized that, until wild virus was eradicated globally, polivirus importation remained possible, especially among at-risk groups. It was therecountries sustained high levels o polio immunization and surveillance.

C H A P T E R 2 T H E E U R O P E A N R E G I O N A L C E R T I F I C A T I O N C O M M I S S I O N


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T H E C H A I R P E R S O N O F T H E R E G I O N A L C E R T I F I C A T I O N

SIR JOSEPH SMITHJoseph Smith qualiied in medicine at the University oior hospital appointments and national service in thjoined the Public Health Laboratory Service to train aFrom 1960 to 1965 he was Lecturer and Senior Lectureology and immunology at the London School o Hygie(LSHM), and researched upon the pathogenesis and1965 he became Consultant Bacteriologist to the RadclLecturer in Bacteriology to the University o Oxord, ctetanus. Ater appointments as Head o Bacteriology Laboratories, and as a amily doctor in inner London, hDirector o the Epidemiological Research Laboratory oratory Service [PHLS]. His research interests there in

and immunoprophylaxis o inluenza, diphtheria and pthor or joint author o some 140 scientiic publicationsDirector o the National Institute or Biological Standar1985 to become Director o the Public Health LaboratoWales, rom which appointment he retired 1993. He sto the University o Nottingham, 1989-94. He was knig

Sir Joseph Smith has served on a range o oicial commKingdom Department o Health, many relecting his cmunisationimmunization, including: Committee on Sman, Biological Subcommittee); Joint Committee on Vnization (chairman, Subcommittees on inluenza and Joint Sub-committee on Adverse Reactions to Vaccineon AIDS; and British Pharmacopoea Commission (ch

Committee). He has been a member o the Medical Rechairman o several o its advisory bodies, including thDevelopment, ropical Medicine Research Board, SimAIDS Vaccine Clinical Studies Committee, Working GEncephalopathies, and as a member o its Biological R


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M E M B E R S O F T H E R E G I O N A L C E R T I F I C A T I O N C O M M I S

PROFESSOR MARGARETA BTTIGERMargareta Bttiger qualied in medicine at the Karolinska holm in 1954. Afer training in paediatrics at Bellevue HospCity and in both paediatrics and bacteriology at the KarolinStockholm, she began working at the polio and virological National Bacteriological Laboratory, Stockholm, in 1957. F

she conducted extensive research on live and inactivated poing in her doctoral thesis and dissertation at the KarolinskaFrom 1967 to 1971, she was an associate proessor at the Kaand held a research ellowship rom the Swedish Medical R1971, she returned to the National Bacteriological LaboratoDepartment o Epidemiology, with access to laboratory acher studies on vaccines. In 1976, she was appointed Full Proo the Epidemiology Department. Proessor Bttiger was co

National Epidemiologist o Sweden, a position that she heldment in 1993.

During this time, Proessor Bttiger continued to do bothenvironmental studies o polio in addition to research in epidemiological interest. Evaluations o the introductions vaccinations against measles (rom 1971 onwards), rubella ((since 1978) and MMR (since 1982) were perormed. Vacc

diseases were also studied (diphtheria, tetanus, BCG, pertuslio always held a central place in Proessor Bttigers work a

Proessor Bttiger has been involved in the analysis o all ease outbreaks in Sweden since 1971. From 1983 on, AIDS nant research area. She is the author or co-author o 250 been a member o a number o Swedish and European coBttiger was an expert adviser to both the global and Eur

Organization advisory groups or the Expanded Programma member o the Board o the Swedish Medical Research CData Inspection Board. In addition, she worked with the Epin AIDS Research o the European Union, was a member oo the Swedish National Board o Health, the Swedish Foodth AIDS C i i th S di h G t



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DOCTOR WALTER R. DOWDLEDr Walter Dowdle is a member o he ask Force or Childopment, Atlanta, Georgia, where he serves as Director, PoliContainment Preparedness, US Department o Health and consultant to WHO on the Global Poliomyelitis Eradication

Prior to joining he ask Force, Dr Dowdle was Deputy DirDisease Control and Prevention (CDC), Atlanta, 19871994tor, CDC, 19891990 and 1993. He was Director o the WH

Center or Inluenza, 19681979; Associate Proessor, SchooUniversity o North Carolina, 19641984; and Honorary FeSchool or Medical Research, he Australian National Univ19721973.

A doctoral graduate o the University o Maryland, College joined CDC as a virologist and served as Chie, Respiratory

Director, Virology Division; Assistant Director or Science; Inectious Diseases; and Associate Director or HIV/AIDS. sive experience in virus research, vaccine development/evallation o immunization policy. Dr Dowdles current active sinclude polio, inluenza, HIV and malaria.

He has received wide recognition during his career and is a

proessional societies. He received the Sigma Xi Lietime Acor Public Health Science in 1995, CDCs Champion o Prev1993, and the Surgeon Generals Exemplary Service Award ithe US Presidential Distinguished Executive Award in 1982President o the Armed Forces Epidemiologic Board rom 1President o the American Society or Microbiology rom 1served on numerous scientiic and editorial boards.

Dr Dowdle received his undergraduate and masters degreeso Alabama. He is married to Mabel Irene Dowdle. hey haHe served in the US Army/US Air Force Medical Corps in Grom 1948 to 1952.



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DOCTOR GEORGE F. DREJERDr Drejer qualied in medicine at the Leyden Univeresidencies in obstetrics and paediatrics and a course iRoyal ropical Institute in Amsterdam.

From 1967 to 1975, Dr Drejer was superintendent anhospitals in the Cameroons. It was here that he becamaspects o poliomyelitis, through direct experience. Btrained as a general paediatrician in the Juliana ChildreDr Drejer served the next 20 years as a general paediatrseveral hospitals in the Hague beore becoming a senioogy and head o the neonatal intensive care unit at thetal. Afer he nished his clinical career in the Hague hor two years or the Kilimanjaro Christian Medical Cepaediatric education in rural hospitals in northern anappointed as a senior consultant and lecturer in paedbeth Central Hospital and the College o Medicine o

in Blantyre, with a special interest in perinatology.Dr Drejer has served on a number o committees adifferent missions reecting his interest in internatiograduate education in Europe and Arica, including: liomyelitis afer 10 years o immunization in Burkinpaediatrics in Angola, Mdecins Sans Frontires (MSworkgroup o MSF or continuing the education o m

mania in the Netherlands.

Since 1996, Dr Dreyer has been a member o the WHor the Certication o Eradication o Poliomyelitis.



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PROFESSOR SERGEI DROZDOVSergei Drozdov qualiied in medicine at the Kuban State Krasnodar, Russia, in 1952. hat year, he joined the InstituAcademy o Medical Sciences o the USSR, in Moscow, or In 1956, Dr Drozdov graduated with the degree o Candiences in virology. In 1955, he was appointed to be a Junior Sestablished Institute o Poliomyelitis and Viral EncephalitidMedical Sciences o the USSR. In 1958, Dr Drozdov was ption o Senior Scientist and, in 1959, he became Head o th

demiology o Poliomyelitis. In 1965, Dr Drozdov received o Medical Sciences (DMSci) in virology and epidemiologyDr Drozdov was a Medical Oicer in the Viral Diseases Uneva, Switzerland. In 1971, he was appointed Deputy DirecPoliomyelitis and Viral Encephalitides. Since 1972, ProessDirector o the Institute.

In 1978, Proessor Drozdov was elected as a CorrespondingAcademy o Medical Sciences o the USSR, and in 1984, he bber o the Academy (FM RAMS).

Proessor Drozdovs research interests and ields o proessiclude the virology, epidemiology, prevention and eradicatiotick-borne encephalitis; hemorrhagic evers; rotavirus gastr

mental virology; and biological saety in virological laboratactivities o Proessor Drozdov are presented in more than 3in scientiic journals and bulletins, our monographs and seproessional manuals. In addition, the Institute o Poliomyecephalitides conducts research in basic science and medicalpoliomyelitis, enteroviral diseases, tick-born encephalitis, harenaviral diseases, hepatitis and rabies. he Production De

stitute, which was established in 1957, manuactures poliovas vaccines or tick-borne encephalitis, rabies and yellow ev

Since 1995, Proessor Drozdov has been a member o the mission or the Certiication o Eradication o Poliomyeliti




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DOCTOR DONATO GRECODonato Greco was born in Naples, Italy, in 1947. He remedicine and surgery rom the University o Naples intraining in medicine and public health, earning speciatious, ropical and Subtropical Diseases rom the UnivPreventive Medicine and Hygiene rom the UniversityMedical Statistics rom the University o Rome in 1982public health at the London School o Hygiene and roCenters or Disease Control and Prevention, in Atlanta

panded Programme on Immunizations course in Mosas a physician in the clinical wards o the D. Cotugno HDisease in Naples or 9 years beore moving to the Instin Rome to establish the Laboratory o Epidemiology a

In 2004, ater 26 years at the Laboratory o Epidemioloprimarily on inectious disease epidemiology, he assum

ties o Director General o Disease Prevention o the Itand director o the newly ounded National Center orDuring this time, Dr Greco has been an author o morlications.

For more than 20 years, Dr Greco has strengthened glohis participation in committees, commissions and adv

European Union and the World Health Organization. been the director o the WHO Collaborating Centre oSurveillance, Instituto Superiore di Sanit, Rome.

Since 1996, Dr Greco has been a member o the WHOor the Certiication o Eradication o Poliomyelitis.



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PROFESSOR BURGHARD STCKBurghard Stck did his medical training at the Freie Universny, rom which he obtained his MD degree in 1955. From 1did an internship and residencies in neurology, internal medat the University Hospital, Freie Universitt Berlin. A NAOto New York to work at the Sloan-Kettering Institute or Cao umour Immunology rom 1962 to 1964. In 1966, Dr Doctor o Medical Science degree and, until 1974, he was anat the Childrens Hospital o the Freie Universitt Berlin. H

o Paediatrics in 1971. For twenty years, rom 1974 to 1994,Head o the Paediatric Department, University-Hospital Berlin.Proessor Stck was a Member o the National Advisory Conization, Robert Koch-Institut, Berlin, rom 1977 to 1998. Hber o the Immunization-Committee o the German AssociDiseases (DVV) rom 1975 to 2002.

Since 1996, Dr Stck has been a member o the WHO Euroor the Certiication o Eradication o Poliomyelitis.


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C H A P T E R 3 P L E N A R Y S E S S I O N 1


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Current situation in the European Rin the Eastern Mediterranean Reg

and globally

PLENARY SESSION OFHE EUROPEAN REGIONAL CERIFICAION COMMISSIO

ON 20 JUNE 2002

From let to right: Dr Ray Sanders, Dr Nedret Emiroglu,

Dr Donato Greco, Sir Joseph Smith,

Dr George Oblapenko and Dr Daniel arantola.

EUROPEAN SUBREGIONAL OVERVIEWIn 1996, the RCC recommended splitting the Region into six subregional zones to sis o a large and complex Region. hese subregions are:

1. Nordic/Baltic

2. Western

3. Central

4. Southern

5. Central/eastern

6. MECACAR, Russian Federation



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coverage is very good; with most countries either using inactivated poliovirusin combination with oral poliovirus vaccine (OPV). here are no indicationscinated populations in the subregion. Surveillance quality in the subregion is good. Although only Estonia, Latvihave acute laccid paralysis (AFP) surveillance systems, almost all countries hrus surveillance systems and several have environmental surveillance to provLaboratory quality control systems or enterovirus laboratories exist in DenmIceland, Latvia and Sweden. Laboratory containment activities are progressing well in almost all countr

ing only slow progress. Within the subregion there are a limited number o lapoliovirus, and these are all operating under biosaety level 2 (BSL-2)/polio c he likelihood o indigenous wild polio circulation is judged to be very lowtablished health systems with the capacity to provide good immunization covlance. he countries are also judged to have a strong capacity to detect any powild poliovirus.

2. WESTERN SUBREGION(Austria, Belgium, France, Germany, Ireland, Luxemburg, Monaco, NetherlanKingdom)

All countries in the subregion have good or very good health-care systems proservices. However, immunization coverage data is not available or several o thcurrently have no systems to collect this data. Despite this lack o data, routine

are generally believed to be strong with more than 90% o children reaching schmunized. A vulnerable subpopulation o approximately 300 000 individuals wreligious reasons exists in the Netherlands, and strong anti-immunization lobbcountries. All countries in the subregion, with the exception o the United Kin Only 50% o the countries had established AFP surveillance systems in 200o these was not impressive, particularly with regard to adequate stool collectsurveillance, several countries rely on data rom enterovirus surveillance netw

surveillance systems are well established, but the data they generate is complerize. Generally, countries lack data collection and management systems capabdata in a manner required or the polio-eradication initiative. In addition to eat least two o the countries, France and the Netherlands, have well-developedlance systems.



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3. CENTRAL SUBREGION(Belarus, Bulgaria, Czech Republic, Hungary, Poland, Slovakia, Slovenia)

Health-care reorm is progressing in most o the countries o the subregion, and hare either good or very good. he population has good access to immunization sersystems are believed to have the capacity to detect, diagnose and respond to paralymanner. Routine immunization coverage is very good in all countries, and all use OPV intion schedules, although several have now switched to a combined OPV/IPV regim

poliovirus importation into Bulgaria in 2001, extensive supplementary immunizatconducted in the country, and supplementary immunization o high-risk groups invakia were also undertaken. AFP surveillance quality is good in hal o the countries and moderate in the othcarry out enterovirus surveillance in support o AFP surveillance activities, and twcarry out environmental surveillance. In general, the level o supplementary surveater the importation into Bulgaria.

Good progress has been made with implementation o containment requiremenlaboratories have been identiied in the subregion as having wild poliovirus inectioperate under BSL-2/polio conditions. here is no indication o continued poliovirus transmission in Bulgaria or neighall evidence suggests that successul immunization campaigns prevented extendedvirus. he likelihood o continued transmission o indigenous wild poliovirus in thlow, due to good surveillance and high immunization rates.

4. SOUTHERN SUBREGION(Andorra, Croatia, Greece, Israel, Italy, Malta, Portugal, San Marino, Spain)

he countries in this subregion all have good or very good health services, with gonization and preventive health care. Immunization coverage levels are high, with cOPV alone or in combination with IPV.

Only seven o the nine countries have established AFP surveillance, and perormpoor, with particularly low stool collection rates. However, six o the countries havsurveillance with enterovirus surveillance o good quality, and three o the countrital surveillance programmes.

Containment requirements have been implemented in all countries except Port



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Health-care reorm is in a transition phase in this subregion; health services awith the population having reasonably good access to health care and immuncountries use OPV exclusively in their immunization schedules and coveragehere have been concerns, however, regarding under-vaccinated subgroups io Yugoslavia, and particularly in Bosnia and Herzegovina. Reports on recentnization campaigns carried out in these areas suggest that at least 90% o the treceived OPV. All countries have good AFP surveillance systems with good national indicgood subnational indicators. he only exception has been Bosnia and Herzeg

have recently been made to enhance surveillance and signiicant improvemen2002. he Republic o Moldova and the Federal Republic o Yugoslavia also henterovirus surveillance systems. Albania conducts annual stool surveys o he15 years o age, as well as diagnosis o children with diarrhoea. he Ukraine ho enterovirus surveillance, but the system ails to meet WHO quality assuranalso runs an environmental surveillance system. Containment requirements have been implemented in all countries o this

three national laboratories retaining wild poliovirus inectious materials in B No wild poliovirus circulation has been detected in this subregion since thto an importation o wild poliovirus into Albania and the Federal Republic orelatively good health systems that can detect cases o polio, the good immungood surveillance systems, it is considered that the likelihood o wild poliovirsubregion is very low.

6. MECACAR COUNTRIES AND RUSSIAN FEDERATION(Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Russian Federation,urkmenistan, Uzbekistan)

Countries in this subregion have 33% o the population o the Region, the leaservices and the highest inant mortality rates. hese countries represent a reczone, and had the last indigenous wild poliovirus and the last importation. Htransition period, but health services are generally satisactory and immunizacal services are adequate. All countries use OPV exclusively in their immunizhave relied on extensive supplementary immunization campaigns in the past maintain high immunization coverage. All countries use AFP surveillance or polio detection, although, as the ide



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tion o wild poliovirus through importation. hese countries include the Russian FCaucasus region), ajikistan, urkey (south east), Azerbaijan, Georgia and Uzbeki

IMPORTATIONS OF WILD POLIOVIRUS INTO COUNTRIES IN THE REGION:LESSONS LEARNTwo wild poliovirus importations were detected in the Region in 2001, in Bulgariaavailable evidence suggests transmission was very limited in both instances. With etransmission continuing in Pakistan/Aghanistan and northern India, the Region rtinued risk o importation. For this reason, the National Plans o Action or mainta

status, which all countries in the Region have been requested to prepare, are o the tance. All countries must be able to detect importation and act eectively to preveno circulation. Establishing a system to ensure eective action in preventing urtheimportations is the key to maintaining the Regions polio-ree status. Experience with other importations, into the Netherlands, the United States o ACanada in 1978; into the Netherlands and Canada in 1992; into China in 1999; andhave demonstrated that a rapid and extensive response to detection o wild poliovi

limiting transmission, preventing urther spread and maintaining public conidenceradication initiative. hese instances have also demonstrated that importation intis a relatively common event. O the two importations into the European Region in 2001, response in Bulgariaand eective. Intratypic dierentiation (ID) results were available within 10 daysvirus isolation, the surveillance system was enhanced within 3 days and National I(NIDs) were implemented within 30 days. All neighbouring countries undertook p

lowing the importation by enhancing surveillance and identiying and immunizinMolecular sequence data suggests that the virus originated in northern India, and evidence exists to support the conclusion that India is the most likely source. he stion, into Georgia, close to the border with Armenia and Azerbaijan, was detectedAn Azeri child with suspected meningitis was ound to be excreting wild poliovirubecause the case was not considered to be AFP, there were delays in sending the poID. here was also a slower response to the importation than in Bulgaria, althougenhanced, and supplementary immunization carried out. he origin o the virus isnorthern India, but in this case there is no clear supporting epidemiological eviden he principal lesson learned rom experience to date is to expect another imporcountries in the Region, particularly those neighbouring endemic areas, with closecultural ties with endemic areas or with under-vaccinated subpopulations, must im



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lem or the Region is that three o the endemic or recently endemic countriesand Sudan, are conlict areas and access to the children requiring immunizati

AFP surveillance perormance is now good in almost all countries in the Rtries having a case detection rate o 1 and 83% o cases having 2 stools in 200collection rate in Somalia in 2001 has been improved in 2002. In 2001, there wassociated cases in the Region: 116 in Pakistan, 11 in Aghanistan, 7 in SomalSudan. o date in 2002 there have been 23 conirmed cases: 19 in Pakistan, 2 iSomalia. Poliovirus type 1 and 3 continue to circulate in Pakistan and Aghanhas been detected recently in Somalia.

Although Pakistan continues to have widespread circulation, the number oreduced dramatically over the past 2 years, with only 13 districts with wild po2002. he major endemic oci now span the border areas between Pakistan anlia, with two cases detected to date in 2002, AFP surveillance is good but stooat 62% and need to be improved. Egypt had ive cases detected in 2001, in two2002, no cases have been detected, but wild poliovirus has been isolated romat ive dierent sites along the Nile. he last wild poliovirus positive sample w

Great progress has been made in polio eradication in the Eastern Mediterrpast 2 years. he challenge now is to maintain the progress that has been madpolio eradication.

REGIONAL OVERVIEW: ARE WE READY FOR CERTIFICATION?At its ourteenth meeting, in March 2002, the RCC reviewed the documentatdeined the additional documentation required and set the ollowing precond

provision o strong evidence that the importation o wild poliovirus into Bbeen appropriately controlled; demonstration that Member States have achieved substantial progress tow

containment o wild poliovirus;

receipt rom all 51 Member States o high-quality updated documentation together with Plans o Action to maintain polio-ree status post-certiicatio

he governments o Bulgaria and Georgia have both submitted documentatio

the importation o wild poliovirus in 2001, and their assessments that the impully controlled. In addition, members o the RCC have visited both countrieslogical situation and review the activities undertaken. he response in both copositive, with rapid implementation o supplementary immunization activitie

d i i d ill d i d t ti i i ti



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he quality o surveillance or wild poliovirus has shown a steady improvementyears, with the Regional average non-polio AFP rate in 2001 at 1.15 and 81% o rep

two stools. his level o quality has been maintained in the irst quarter o 2002. Msamples rom AFP cases, and an additional 3000 samples rom contacts o cases, arnually in the Regional polio laboratory network, with more than 75% o results bei28 days o the samples being received in the laboratory. AFP surveillance is strongmany countries o the Region by enterovirus surveillance and environmental survethe network o laboratories involved in enterovirus surveillance more than 158 000investigated or poliovirus between 1999 and 2001. No indigenous wild poliovirus

detected in the past 3 years.

Attempts have also been made to assess the likelihood o circulation o indigenoususing a composite surveillance index. Criteria or this index include quality o healsurveillance activities and duration o polio-ree status. Based on this assessment, astrongly suggests that all countries in the Region have good capability to detect in acase o paralytic poliomyelitis.

Assessments have also been made o the potential risk o re-establishing circulatvirus ollowing an importation. Six main criteria have been used or this assessmencoverage; the population immunity proile; the proportion o high-risk subpopulatsurveillance; the quality o epidemiological or public health services; and the level this assessment, the only countries that can be considered at high risk or re-establtion are Bosnia and Herzegovina, the Netherlands, the north Caucasus region o thtion, ajikistan and the south-eastern regions o urkey. At lower risk are Azerbaij

and Uzbekistan. he WHO Regional Oice has developed and distributed a template or proposo Action or maintaining polio-ree status. he plan should address actions requirlevels o routine immunization coverage, with supplementary immunization activiate, actions to sustain high-quality laboratory-based surveillance and actions to coo wild poliovirus. Comprehensive plans have been received rom 45 o the 51 Memstatements o strong commitment together with highlights o key actions to be undreceived rom the remaining 6 countries.

In summary, the preconditions or certiication set by the RCC have all been mehas been presented to the RCC or consideration. he WHO Secretariat strongly bgion is now ready or certiication.



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rom coverage surveys. here is also greater scrutiny o data at a subnational aggregated national data suggesting high coverage may hide signiicant deici

or subnational populations. here is also greater emphasis on timeliness o detion services, rather than on simple coverage igures. Concern also exists overreported-disease incidence may be due to under-detection or under-reportino disease. Overall, there is now greater emphasis on the quality o inormatiocompleteness, timeliness and accuracy. Countries in the Region are now being encouraged to improve immunizatito increase coverage and reach all eligible individuals in their populations. o

improved access to their populations by using innovative approaches, such aspulse campaigns. hey need to improve the level o utilization o the services ing the level o vaccination dropouts and dissuading the use o alse contraindCountries are being encouraged to adopt strategies that are target oriented, aigroups in their populations: the urban poor, remote rural areas, minority grotions. o provide immunization services to these diicult-to-reach groups, stlevel will be required, together with capacity building to improve local manag

Other areas o the immunization programme that are gaining renewed attelogistics and saety o immunizations. Although o high priority there are, antations in the national resources available to ensure that requirements in theseIt is essential that capacity exist at local levels, that the inrastructure is maintand maintenance o equipment, and that local management is adequate or th Vaccine Vial Monitors (VVMs) have been introduced and accepted and aran increased use o auto-disable (AD) syringes and saety boxes, and adverse

munization (AEFI) surveillance systems have been established in many counstrengthened, however, to be ully unctional. Countries are being encouragedment o vaccine supplies, particularly through monitoring at each level, and tments o capacity at subnational levels. Saety o immunizations is now o mao both saety o injections and waste disposal management. Assessments are there is strong Regional promotion o AD syringes and the use o saety boxes he Global Alliance or Vaccines and Immunization (GAVI) is an internatpartners, including national governments, international organizations such aChildrens Fund (UNICEF), the World Health Organization (WHO), the Woro philanthropic institutions. GAVI provides unding support or new and unas hepatitis B, Haemophilusinluenzaetype B (Hib) and yellow ever. It also pimmunization services and or injection saety. An algorithm is used to assess



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with GAVI has also had an impact on strengthening immunization services througo programme assessments, development o multi-year immunization plans, resou

and coordination, and an emphasis on injection saety. It has provided an opportuimmunization inrastructure and capacity, and to apply the lessons learnt to other Region. In general, countries in the Region have strong, unctional immunization prograexisting inrastructures are operating under stress. here is oten a lack o politicalthe long-term goals o immunization, relected in the paucity o resources allocatedtion services. he sustainability o established systems must be ensured, by mainta

that has been made, by improving the inrastructure and by better monitoring o aimproved quality and eiciency. he establishment o multi-year national immunisential to this process, ideally providing a clear analysis o the national situation, idand setting clear priorities and uture directions or the immunization services. he Region is actively pursuing disease control initiatives in polio eradication, dmeasles elimination and congenital rubella syndrome (CRS) prevention. Polio eradhugely successul, and much can be learnt rom this success. Diphtheria now appea

control, with a very low level o transmission ater the outbreak in 1994. he incidhas dropped in the past 20 years, with most countries using the combined measles(MMR) vaccine. he incidence o rubella, however, continues to be high in the Rushe Strategic Plan or Measles and CRI calls or the interruption o measles transmtogether with the prevention o CRI (to a level o less than 1 case per 100 000 live bthese goals, six key strategies have been identiied:

achieve and sustain very high coverage with two doses o measles vaccine

provide a second opportunity or measles immunization target populations susceptible to rubella ensure protection o women o childbearing age strengthen surveillance systems improve availability o inormation on immunization.Critical components o these strategies include ensuring social and political suppomobilization o resources, strengthening routine immunization programmes and s

veillance, in particular the adevelopment o an appropriate laboratory network. Future work o WHO includes ocusing on the national level, by assessing natioorities, supporting country-level activities, mobilizing technical and inancial resonational capacity and providing guidance in line with Regional priorities. Regionab i d th h b tt h i ti d i ti


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Aspectso post-certiication

activities

POLIOMYELITIS ERADICATION: GLOBAL PROGRESS,POST CERTIFICATION STRATEGIES AND PLANShe past eighteen months have seen a dramatic all in the number o reported polirom 2 971 in 2000, to 498 in 2001. Less than 200 cases o poliomyelitis were repormonths o 2002. he drop in reported cases is very signiicant, especially given the

o acute laccid paralysis (AFP) surveillance worldwide. Between the years 2000 ano polio-endemic countries has dropped rom 20

e88105 polio eradication

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