global eradication of polio

7/31/2019 Global Eradication of Polio

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WHO/V&B/99.31ENGLISH ONLY

DISTR.: GENERAL

World Health Organization Geneva 1999

DEPARTM ENT OF VACCINES ANDBIOLOGICALS

Global eradication of poliomyelitis

Reports of the:

Fourth meeting of the Global Technical Consultative Group forPoliomyelitis Eradication,Geneva, 1-2 June 1999

Global Commission for the Certification of the Eradication ofPoliomyelitis,Geneva, 2 June 1999


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Report of the Global Technical Consultative Group, 19992

The D epartment o f Vaccines and Biologicalsthanks the donors whose unspecified financial support

has made the production of this document possible.

This document was produced by theExpanded Programme o n Immu nization

of the Depar tment of Vaccines and BiologicalsO rdering code: WH O / V & B/ 99.31

Printed : D ecember 1999

This document is available on the Internet at:www.who.int/gpv-documents/

Copies may be requested from:World H ealth O rganization

Vaccines and BiologicalsCH -1211 Geneva 27, Switzerland

Fax: +22 791 4193/4192 E-mail: [email protected]

World H ealth O rganization 1999

This document is not a formal publication of the World H ealth O rganization (WH O ), and all rights arereserved by the O rganization. The do cument m ay, however, be freely reviewed, abstracted, reprodu cedand translated, in part or in wh ole, but not for sale nor for use in conjun ction with com mercial pur poses.

The views expressed in documents by named authors are solely the responsibility of those authors.

Maps : The designations employed and th e presentation of material on maps included in th is document donot imply th e expression of any opinion wh atsoever on the part o f the World H ealth O rganizationconcerning the legal status of any coutnry, terriroty, city or area or of its authorities, or concerning the

delimitation of its frontiers or boundaries. Dotted lines represent approximate border lines for whichthere may no t yet be full agreement.


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3WHO/V&B/99.31

Contents

L ist of abbrev iations ....................................................................................................... iv

1. Report of the Fourth meeting of the Global Technical ConsultativeGroup for Poliomyelitis Eradication, Geneva, 1-2 June 1999........................ 1

1.1 Introduction ..................................................................................................... 11.2 Status and coordination of the global polio eradication initiative ............ 21.3 Comm itment for acceleration of the global polio eradication initiative.. 51.4 Acceleration of supplementary polio immunization .................................. 61.5 Acceleration of AFP surveillance................................................................. 91.6 The G lobal Polio Laboratory N etwork ..................................................... 111.7 Containment of wild poliovirus and stopping immunization

against po lio ................................................................................................... 12

Annex 1: Agenda .................................................................................................... 14Annex 2: L ist of participants ................................................................................. 16

2. Report of the Global Commission for the Certification of theEradication o f Poliomyelitis, Geneva, 2 June 1999 ........................................ 23

2.1 Agenda item 1 Reports on activities of the regionalcommissions ................................................................................................... 23

2.2 Agenda item 2 Implications of cross-membershipbetween the Global Certification Commission and theTechnical Consultat ive Group .................................................................... 24

2.3 Agenda item 3 - Issues arising from the TechnicalConsultat ive Group Meeting ...................................................................... 24

2.4 Agenda item 4 - Formal reviews of regional certification ...................... 252.5 Agenda item 5 - O ther business ................................................................. 25


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AFP acute flaccid paralysis

AFRO WH O Regional O ffice for Africa

IPV inactivated polio vaccine

N ID national immunzation day

O PV oral polio vaccine

SN ID sub-national immunization day

TC G Technical Consultative Group

U N I C E F U nit ed N atio ns C hild rens Fund

VVM vaccine vial monitor

WH O World H ealth O rganization

List of abbreviations


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5WHO/V&B/99.31

1.Report of the Fourth meeting of the

Global Technical Consultative Groupfor Poliomyelitis Eradication,

Geneva, 1-2 June 1999

1.1 In troduct ion

From 1-2 June 1999, the fourth meeting of the Technical Consultative Group (TCG)

on t he Glo bal Eradication of Poliomyelitis was convened at the World H ealthO rganization in Geneva. The TC G r eviewed the current status of global polioeradication and made recommendations on how to accelerate the initiative towardsits goal of final eradication of poliomyelitis by the year 2000, as well as the progresstowards eventual bio-containment of polioviruses and the certification of global polioeradication, anticipated by the year 2005.

The meeting was opened by D r M. Scholtz , Executive Director, H ealth Technologyand Pharmaceuticals Cluster of the World H ealth O rganization (WH O ) in Geneva.In welcoming participants, Dr Scholtz emphasized that, only one week earlier, theWorld H ealth Assembly unanimously endorsed the resolution of WH O s ExecutiveBoard in January 1999 to accelerate the polio eradication initiative. This resolutionfurther commits WH O Member States to ensuring that the goal for global polioeradication and wild poliovirus containment is attained.

Dr Scholtz expressed his hope that the TCG would provide technical guidance onhow to best accelerate the initiative, with emphasis on the major poliovirus reservoircount ries and countr ies affected by conflict. H e also noted the specific need to improvethe quality of some poliovirus laboratories within the global poliovirus laboratorynetwork, part icularly in the African Region. The urgent need to accelerate surveillancefor acute flaccid paralysis (AFP), especially in conflict-affected countries, wasstressed.

Dr W. O renstein of the C enters for D isease Control and Prevention of the UnitedStates of America served as chairman of the meeting, with Dr P. Figueroa of theMinistry o f H ealth, Jamaica, as rapporteur. This report summarizes the technicaldeliberations of the third meeting of the TC G and contains the main recommendationsof the TCG .


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1.2 Status and coordination of the global polio eradication initiative

While substantial obstacles must still be overcome in some geographic areas toeradicate polio, the G lobal TCG was impressed with the tr emendous progress madesince its last meeting in July 1998. It is of particular note that, as of the end of 1998,wild po liovirus t ransmission was limited to several remaining foci of transmission inSout h Asia and Africa. O f 48 countries endemic or possibly endemic at th is time,wild virus is still documented in 22 countries. Transmission is probable onepidemiological grounds in 13 countries where surveillance is still poor; it is lesslikely on epidemiological grounds, but still possible, in another 13 countries wheresurveillance quality is still insufficient (Figure 1).

Figure 1: Wild poliovirus, December 1998

Known wild virus (22 countries)

Possible wild virus (13 countries)

Probable wild virus (13 countries)

Surveillance activities have improved in many endemic countries. All countries withknown or suspected wild poliovirus transmission have conducted nationalimmunizat ion days (N ID s) and established surveillance for acute flaccid paralysis

(AFP), with the exception of the Democratic Republic of Congo and Sierra Leone.All remaining countries considered as major global reservoirs are intensifyingimmunization efforts to interrupt transmission (Figure 2).


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Figure 2 : Preliminary plan of action for acceleration of supplementaryOPV immunization in priority countries (as of June 1999)

Considerable additional external funding has been provided by the internation al polioeradication partnership. N inety-five per cent of the financial resource needs for theglobal eradication initiative for the next six months have been pledged. However,significant additional funding will be needed to support the global initiative from theyear 2000 onwards, particularly in the coun tries that constitu te major global poliovirusreservoirs or polio-endemic countries affected by conflict (Figure 3).

The TC G was especially impressed with the leadership for the initiative at the highestlevel of WH O , evidenced m ost recently by the creation o f a special task force toaddress administrative challenges within WH O . The TC G welcomed t he newpartners who have joined the polio eradication effort and applauded the ongoingcommitments of longstanding polio eradication partners. The TCG appreciated theefforts of the Secretary General of the U nited N ations to suppor t negotiations fordays of tranquillity for polio immunization in countries affected by conflict,particularly in the Democratic Republic of the Congo (DRC).

Extra rounds of 'intensified' NIDs

NIDs plus extensive sub-nationalimmunization days or 'mopping-up'


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Figure 3: Resource requirements for global polio eradication, 1999-2005(as of June 1999)

While there has been significant progress, major challenges remain, with only18 months remaining to meet the year 2000 target. The eradication initiative needsurgent acceleration in all endemic countries. It is critical to achieve eradication asclose as possible to the target date because of the potential for fatigue in maintainingeradication activities in those areas that have long been polio-free. In addition, afterthe year 2000 it will be more difficult to sustain the current high levels of externalfunding needed for supplementary immunization activities, surveillance andcertification of polio eradication up to the year 2005 (Figure 3).

The TCG is convinced that the established strategies are the basis for success,provided the highest possible quality in their implementation is achieved. Thesestrategies include achieving high levels of routine polio immunization, conductingN ID s, surveillance for AFP, and house-to-house mopping-up immunization activities

in high-risk areas. The experience of the last 12 months has again demonstrated thathighest priority must be given to maintaining and improving the quality of all polioeradication activities (i.e., to ensure success throu gh sufficient p lanning, supervision,manpower and financial resources).

5 Conflict affected areas

5 Reservoir countries

External Resources RequiredConflict Areas = US$ 140mReservoir Countries = US$ 710mOther Countries = US$ 400mTOTAL = US$ 1250m

Received/Projected = US$ 850mSHORTFALL = US$ 400m

Angola, DR Congo, Afghanistan,Somalia, S.Sudan

India, Nigeria, Pakistan,Bangladesh, Ethiopia


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Recommendations:

a) Polio eradication activities should be used to strengthen measles control andother disease control goals. This will require strategic planning, focusing onmortality reduction and the p rovision of guidelines for:

improving and sustaining routine immunization coverage, incorporating vitamin A supplementation, conducting outbreak investigations to generate more accurate data on age

distribut ion, vaccination status and other risk factors impor tant for refiningimmunization strategies.

b) Countries still endemic for polio should exercise caution in embarking onmeasles elimination campaigns prior to completing polio eradication.

1.3 Commitment for acceleration of the global polio eradication initiative

The successful completion of the global eradication effort will require the highestpossible commitment at all levels, not only within th e United N ations agencies, butfrom individuals involved in polio eradication everywhere. This includes politicaland civic leaders, public health officials, health care providers, voluntary organizations,and other national and international partners. Facilitating this commitment requiresthe rapid dissemination of lessons learned to the appr opr iate levels in relevant countr ieswhere these can be applied to further improve and optimize the implementation of the eradication strategies.

Recommendations:

a) WH O and UN ICEF representatives at regional and country levels must givetheir full support to critical polio eradication activities. In a joint letter of commitment sent to r egional and country representatives of both or ganizationsearlier th is year, the Executive Director of UN IC EF and the D irector-G eneralof WH O express their hop e that representatives will advocate, implement,moni tor and repor t on cr i t ica l pol io eradicat ion ac t iv i t ies . Countryrepresentatives of both organizations should monitor and report on progressin their country of assignment at regular intervals. The secretariat shoulddevelop repor ting formats and evaluation criteria for consideration by WH Oand U N ICEF.

b) WH O and UN ICEF staff should work with ministries of health to assure thatcommitments to polio eradication made at the 1999 World H ealth Assemblyare translated into action.

c) WH O and UN ICEF staff should seek the commitment and support for allaspects of the polio eradication effort from relevant non-governmentalorganizations and other voluntary organizations, especially in count ries affectedby conflict.

d ) W H O an d U N I C E F sh o u ld e st ab lish m ech an ism s at t h e resp ec tiveheadquarters, regional and country levels to ensure that all importantinformation and data related to polio eradication, including lessons learned

and updates on optimal strategy implementation, are rapidly shared and


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communicated to all relevant polio partners. A range of approaches should beused to share information, including intercountry and interregional workshops,exchange of visits and electronic data, including e-mail and presentation of data on worldwide web sites.

e) W H O sh o u ld en su r e t h at al l r eco m m en d at io n s m ad e b y t h e W H OAdministrative Task Force on staff recruitment, on strengthening the capacityto manage funds at country level, on the streamlining of administrativeprocedures, and on other issues are implemented as soon as possible.

f) Given the dynamic nature of the global eradication initiative, and the emergenceof urgent unforeseen needs for technical suppor t, WH O and UN IC EF shouldestablish a pool of trained staff and expert teams who can be rapidly deployedat regional, national or subnational levels.

1.4 Acceleration of supplementary polio immunization

The TCG notes the enormous p rogress made in reducing wild poliovirus tr ansmissionin major poliovirus reservoir countries, such as India (Figure 4).

Figure 4: Reported polio incidence, India, 1994-1998

* Adjusted for surveillance sensitivity of 10% before June 1997

1994 1995 1996 1997 19980

2

4

6

8

10

12

NIDs NIDs NIDs NIDs

T h o u s a n

d s o

f p o

l i o c a s e s

The TC G is convinced, however, that the interrupt ion of wild poliovirus transmissionby the end of the year 2000 will only be possible with additional nationwideimmunization rounds, in addition to two y early roun ds of N IDs. This is particularlyobvious in countries, or sections of countries, where routine immunization coverageis low and birth cohorts are large, leading to the rapid accumulation of large numbersof susceptible children in the intervals between N ID s. The presence of a sufficientnumber of susceptible children, combined with high population density and poorsanitation, establishes an ideal enviroment for the sustained transmission of wildpoliovirus.


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It is critical to achieve the very highest levels of coverage in both routine andsupplementary immunization activities. Immunizing house-to-house, or family-to-family in areas where families are not likely to come to a fixed immunization post(i.e. urban slum areas, border and other inaccessible areas, or areas with migrant anddisplaced populations), is more likely to achieve opt imal coverage, particularly amonghard-to-reach popu lations, compared t o N ID s utilizing solely or predominantly fixed-post immu nization. As a result, N ID s in remaining polio-endemic countr ies willneed to be intensified to include a large house-to-house oral polio vaccine (O PV)delivery component.

There is neither a set formula nor a single approach for implement ing polio eradicationstrategies in all countries. Acceleration must be tailored to individual countries andregions, depending on their epidemiologic situation and operational realities.

Intensified and additional rounds of N ID s/sub national immunization days (SN ID s)will be associated with substant ially increased resource requirements. However, thenet benefits justify the additional costs by accelerating the eradication of polio.

Recommendations:

a) Additional N ID or SN ID rounds must be conducted in the global reservoircount ries (Bangladesh, Ethiop ia, Ind ia, N igeria, Pakistan) and mo st conflict-affected areas (Afghanistan, Angola, DR Congo, Somalia, southern Sudan).

b) N oting that India contributes the majority of polio cases reported globally(60 to 70% ), and based on t he unique epidemiological picture in this coun try,the TCG endorses the plan for India to conduct four consecutive nationwideN ID roun ds from O ctober 1999 to January 2000, followed by two SN IDrounds in the spring of 2000 in eight high-risk states. All efforts should bemade to ensure that the quality of vaccine used during supplementary rou ndsis maintained.

c) The TCG also supports the current plans to conduct three nationwide roundsin Angola, DR C ongo and N igeria in 1999, and the combination of two N IDsfollowed by extensive mopping-up covering more than 80% of Pakistan.

d) All other remaining polio endemic countries should be closely scrutinized toestablish, by end-August 1999, whether additional nationwide rounds arerequired or whether subnational rounds would stop transmission.

e) All NID s and SN IDS should be intensified by incorporating a significantcomponent of house-to-house, or family-to -family immunization, targeted ata minimum to high risk populations. These house-to- house effort s shou ld coverlarge populations, particularly in countries representing major reservoirs orthose affected by conflict. In some polio-endemic countries house-to-houseimmunisation may need to cover the entire target population nationally.

f) Improving the quality of N IDs/SN IDs must be a priority and incorporate thefollowing elements:


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preliminary walk-through to ensure the feasibility and logistic capacity tocover all populations,

mapping to ensure that al l geographic areas are assigned to animmunization team,

schedules and maps for supervisory visits, increasing the number of immunization teams and ensuring adequate

numbers of trained supervisors, systematic training in vaccine transportation and storage, as well as the

use of vaccine vial monitors (VVMs) to ensure the availability of potentvaccine,

measuring the number of children never previously vaccinated (zero-dosechildren), and

systematic monito ring and review of NID s/SNID s in order to improvetheir quality.

g) Identification of pockets of unimmunized children, through site visits duringN ID s /SN ID s or th e analysis of AFP case data, should lead to immediatesupplementary O PV immunization in that locality.

h) In countries affected by conflict, extensive mopping-up immunization activitiesshould be conducted whenever the opportunity arises through a break inhostilites. Current U nited N ations efforts to facilitate days of tranquillityand ceasefires to allow the conduct of supplementary immunization activitiesshould continue. The TCG welcomes the draft statement by the Un ited N ationsInteragency Standing Committee (IASC) to facilitate Days of Tranquillityand truces.

i) Community and religious leaders should be fully involved in planning andimplementing N ID s.

j) H ealth workers should be reimbursed for their additional expenses involvedin house-to-house immunization.

k) Consideration should be given to the use of cash or non-cash incentives forhigh-quality performance in surveillance and during intensified N IDs / SN ID s.The implications of these incentives on other health programmes should beconsidered. Partner agencies in each country should agree on the type andlevel of incentives offered.

l) Given that high-level O PV immunization coverage will need to be sustained

at least thr ough certification of eradication, ministries of health, WH O ,UN IC EF, and other partn ers must continue the systematic strengthening of rout ine immunization services.

m) Successful polio eradication will require intensive social mobilization/ communication efforts to assure that: all persons involved are aware of the eradication effort and its impo rtance, all target children receive O PV dur ing supplementary immunization

rounds, particularly t hose who were not previously immunized, and polio eradication activities are used to promote routine immunization and

use of health services.


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1.5 Acceleration of AFP surveillance

The ultimate test for evaluating the success of the eradication effort is high-qualitysurveillance. Such surveillance data are crit ical to determining high-r isk populations,the need for extra N IDs, SN IDs and mop-ups (targeted house-to-house immunizationefforts in addition to N ID s and SNIDs), and determination of whether continuingpolio transmission is the result of lack of immunization or vaccine failure.

Figure 5: AFP surveillance in countries affectd by conflict

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1996 1997 1998 1999

S. Sudan

Somalia

Liberia

Afghanistan

A F P

r a

t e s

1 / 100.000

The TCG noted with satisfaction the visible progress in AFP surveillance in almostall remaining polio-endemic count ries, particularly in India and N igeria. The excellentprogress in establishing sentinel surveillance systems in several countries affectedby conflict (Figure 5) should be a model for effort s in other such countries and areas.Progress in surveillance was slow, however, in a number of other priority countries.

The gold standard for the final classification of AFP cases remains the collection of two adequate stoo l specimens with timely pro cessing in a WH O accredited laboratory.The role and significance of the 60-day follow-up examination in case classificationand for identification of areas at high risk of continued poliovirus transmission wasdiscussed at the meeting. The TCG agrees that the role of the follow-up exam inAFP surveillance (i.e. for AFP case classification or the detection of infected areas)is limited. The best way to reduce the need for 60-day follow-up examinations is tocollect stool specimens from a higher proportion of cases.


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Recommendations:

a) The effective, proven strategy of active, facility-based AFP surveillance musteither be adopted or the quality must be improved, as rapidly as possible intho se areas where certification standard surveillance has not yet been achieved.At this point in the eradication initiative this will require the recruitment andthorough training of a number of designated AFP surveillance officers.

b) Polio eradication staff at all levels must assure that complete AFP/p olio dataand laboratory results are made available on a weekly basis to regional andglobal levels. At t he national level, WH O representatives should wo rk tofacilitate the timely transmission of these data.

c) Surveillance for AFP in countries affected by conflict should employ thefollowing appr oaches: regular active surveillance by designated staff,

close supervision with strong central coordination, start by including large, accessible health facilities as surveillance sites, appropriate remuneration linked to performance, and collaboration with N GO s working in the country.There is a special need for external resources to support these surveillancesystems. As soon as feasible, the n umber of active surveillance sites should beexpanded to cover the entire population.

d) Regardless of where an AFP case is detected or reported, the AFP caseinvestigation mu st include an early visit (i.e. within 48 hrs) to the locality wherethe patient developed paralysis to determine whether

there are additional cases in the community, there is poor routine immunization coverage and the community was reached by the last N ID s.Corrective action must be taken if necessary.

e) The completeness of investigation of the locality of onset (i.e. village/d istrict)for all AFP cases should be monitored, and appropriate action t aken.

f) Major efforts need to be made to increase the proportion of AFP cases fromwhom two adequate stool samples are taken within 14 days of paralysis onset.

g) The 60-day follow-up examination for an individual AFP case should beretained. H owever, it does not need to be condu cted if the AFP case had aproper investigation at site of onset, two adequate stool specimens collectedwithin 14 days of onset and t imely analysis of the specimens at a WH O -accredited laboratory.

h) International AFP surveillance reviews should be reintroduced as a routineelement of the process of rapidly improving the quality of AFP surveillance incountries where AFP performance, as measured by standard performanceindicators, is chronically lagging.

i) In those countries where surveillance continues to be poor, WHO regionaloffices should critically evaluate whether the available human and financialresources are being used in the most efficient and p roductive manner, and seek

to resolve any remaining problems.


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j) AFP data must be systemat ically analy sed to defin e the charact er ist ics of confirmed and discarded cases and to take appropriate action to improvesurveillance if defects are identified. Cases of AFP in unvaccinated childrenshould lead to targeted supplementary immun ization activities. Cases occurr ingin vaccinated individuals should trigger careful evaluation of the cold chainand vaccine quality.

k) All polio cases in whom the infection occurred in another country, should beconsidered imported cases. All cases in which infection occurred within thecountry should be considered indigenous to that country, even if closelylinked epidemiologically to an imported case.

l) In areas with suboptimal surveillance, consideration should be given to activelysearch for recent AFP/ pol io cases dur ing N ID s/SN ID s and oth ersupplementary immunization activities, in order to identify previouslyundetected chains of transmission of poliomyelitis. This approach would beparticularly valuable in areas with limited access to health care facilities, as in

countries affected by conflict.

1.6 The Global Polio Laboratory N etwork

The G lobal Polio Laboratory N etwork has made substantial progress between 1997and 1998. H owever, in a number of critical geographic areas there has been a chron icfailure to reach accreditation standard performance (Figure 6). While some Regionshave been able to offset this problem by shipping specimens to another accreditedlaboratory, this has not been a viable solution for ensur ing proper specimen processingin all areas of the WH O African Region.

Figure 6: Countries served by a WHO-accredited poliovirus laboratory,as of June 1999 (data for WHO regions that have not been certified polio-free)

Served

Not served


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Recommendations:

a) Each WH O region should establish by mid-June 1999, a plan of action toensure that polio laboratory performance meets accreditation standards bySeptember 1999. These plans of action should identify the financial, human orother resources that are required, the partner agency responsible for resolvingeach issue and the timeframe in which it must be completed. If laboratories donot comply with accreditation standards, routine splitting of specimens fromAFP cases with parallel processing in accredited laboratories, should beinstituted by September 1999.

b) Given that the most viable option for AFRO is the urgent upgrading of existingfacil i t ies, priori ty must be given by partner agencies to support theimplementation of the Plan of Action of the Polio Laboratory Coordinator inthat region. For this reason, the AFRO laboratory coordinator should pr ioritizethe order of attention to each laboratory, based on the existing status of thelab, its strategic importance to the initiative and the projected rate of increasein workload based on the AFP surveillance system.

c) To facilitate the integration of laboratory personnel into the AFP surveillancesystem of each country, the WH O / EPI polio medical or t echnical officer inthat country should begin biweekly visits to the facility to assist with theresolution of logistic problems (i.e. communications, equipment, supplies).

d) Given the critical importance of virological data to the eradication initiative,and recognizing the intractability of some issues affecting the unaccreditedlaborator ies, WH O should direct its country representatives to assumeresponsibility for r esolving these prob lems. The necessary solutions may includeensuring appropriate financial remuneration to retain trained staff, adequate laboratory space, communications, and clearing equipment through customs.

e) In those laboratories which are still not accredited, WH O should immediatelyidentify and orient consultant virologists to work for periods of at least twomonths on site, to upgrade laboratory staff skills and resolve other technicalimpediments.

1.7 Containment of wild poliovirus and stopping immunization againstpolio

The TC G n otes that the World H ealth Assembly Resolution of 21 May 1999 onpolio eradication was unanimously passed by WH O Member States and endo rsedthe safe handling and laboratory containment of polioviruses.

The TCG supports the revision of the Proposed Global Action Plan for LaboratoryContainment of Wild Polioviruses based on the suggestions received dur ing the publiccomment period of the latter half of 1998. The major revisions include a change inthe containment level from maximum (BSL-4) to high (BSL-3) during Phase II,beginning one year after detection of the last wild poliovirus. This change is justifiedby t he high level of inactivated polio vaccine/ oral polio vaccine (IPV/ O PV)

immunization anticipated during th is Phase. The TCG further supports the exclusion


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of blood (or serum) and cerebral spinal fluid as potent ially infectious materials whencollected routinely or for non-polio epidemiological surveys and studies. Suchmaterials rarely contain poliovirus and represent an extremely low risk.

The TCG welcomes the progress made in both the ongoing and newly initiatedresearch studies to finalize the strategy for stopping immunization against polio.The TCG looks forward to the results of the studies so that a rational strategy forstopping immunization can be developed.

Recommendations:

a) By the end of 1999, the WH O Regions of the Western Pacific, the Americasand Europe should pilot the revised global action plan and guidelines forimplementing Phase I and pro vide feedback by the end of 1999 to WH Oheadquarters to guide further revision.

b) WH O headquarters should prepare a detailed plan of action for implementingthe containment plan and guidelines during the year 2000.

c) WH O headquarters should communicate the revised Phase II containmentrequirements to the IPV producers and explore with them plans to increasecontainment for vaccine production when O PV immunization stops.


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Tuesday, 1 June 1999

08:00-08:30 Regist rat ion08:30-08:45 O pening Dr M. Scholtz

Introductions and Election of O fficersAdministrative Remarks

Session 1: Global status and AccelerationPlans for the Eradication Initiative

08:45-09:15 Report on the Polio Eradication Initiative Dr B. Aylward Implementation of the 1998 TCG

recommendations Status of the laboratory network

Session 2: Rationale for Acceleration of Polio Immunization Strategies

09:15-9:25 Introduction and Rationale Dr C . de Q uadros09:25-09:35 Shifting from fixed-site to Dr J. Bilous

house-to-house immunizationduring N IDs: rationale andoperational implications.

09:35-10:00 Discussion - clarification

10:00-10:30 Coffee

10:30-10:50 Situation analysis & plan in countrieswith persistent circulation Pakistan (10 min.) Dr S. H adler Turkey (10 min.) Dr G . O blapenko

10:50-11:00 Discussion - clarification

11:00-11:30 Intensified N IDs & Increasing theN umber of Immunization Rounds AFR prio rity coun tr ies: N iger ia, Dr J.M. Okwo-Bele

Ethiopia, DR Congo, Angola(15 min.)

SEAR priority countries: India, D r J. Andrus/

Bangladesh (15 min.) Dr K.Banerjee

Annex 1 toReport of G lobal Technical Consultative Group:

Agenda


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11:30-12:30 Discussion and summary Chair

12:30- 12:40 Lessons in prioritization: polio D r A.M. H enao-Restrepoeradication and accelerated measlescontrol

12:40-13:00 Discussion

13:00- 14:00 L U N C H

Session 3: AFP Surveillance andLaboratory Network

14:00-14:15 Surveillance for wild poliovirus under Dr H. Jafaridifficult circumstances Afghanistan, Somalia, S. Sudan


14:45-15:00 Role of 60-day follow-up examination Dr M. O tten


15:15- 15:30 Rapid expansion of AFP surveillance: Dr R. Sandersimplications for the lab network

15:30-16:00 Coffee

Session 4: Stopping immunization andPoliovirus Containment

16:00-16 :10 Repor t of 1999 CDC/WHO meet ing Dr R. Su tt eron stopping immunization

16:10-16 :20 Update: p lan fo r b iocontainmen t o f Dr W. Dowdlewild polioviruses

16:20-17:00 Discussion and summary Chair

17:00 Adjourn

17:30-18:30 Special evening session: Dr M. WahdanChallenges to stoppingtransmission and certifyingeradication - case study: Egypt

Wednesday, 2 June 1998

08:30-09:45 Discussion of TCG recommendations

09:45-10:00 Close of TCG meeting


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Annex 2 toReport of G lobal Technical Consultative Group:

List of participants

Technical Consultat ive Group

Dr I. Arita, Agency for Cooperation in International Health,4-11-1 H igashi-machi, Kumamoto C ity 862, Japan

Dr R. Nath Basu, A73 Yojna-Vihar, N ew Delhi 110092, Ind ia

Dr N . Begg, Pub lic H ealth Laboratory Service, 61 Colindale Avenue,London NW9 5EQ, United Kingdom

Dr P. Figueroa, Department of Epidemiology, Ministry of H ealth, Kingston,Jamaica

Dr Ali Mohammed Jaffer Sulaiman, Ministry of H ealth, P.O . Box 393,Muscat, Sultanate of O man

Prof F.K. Nkrumah, N oguchi Memorial Institut e for Medical Research(N MIMR), University of G hana, P.O . Box 25, Legon, G hana

Dr W. O renstein, Centers for D isease Cont rol and Prevention,N ational Immunization Program, 1600 C lifton R oad, Atlanta, Georgia 30333,United States of America

Technical Advisers

Dr K. Banerjee, National Polio Surveillance Project, Gate N o. 31,2nd Floor, Jawaharial N ehru Stadium, N ew Delhi 110063, Ind ia

Dr S. Cochi, Centers for D isease Contr ol and Prevention, N ational ImmunizationProgram, 1600 Clifton Road, Atlanta, Georgia 30333, United States of America

Dr W. Dowdle, The Task Force for Child Survival and Development,The Carter Center, 750 Commerce Drive, Suite 400, Decatur, Georgia 30030,United States of America

Dr T. H ovi, National Public H ealth Institute, Mannerheimintie 166,SF-00300 H elsinki, Finland

Dr O . Kew, Centers for Disease Cont rol and Prevention, 1600 Clifton Road,Atlanta, Georgia 30333, United States of America

Dr T. Miyamura, N ational Institutes of Health (N IH ), 4-7-1 Gakuen,Musashimurayama, Tokyo 208, Japan


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21WHO/V&B/99.31

Dr H . van der Avoort , Laboratory of Virology, RIVM,Ant ionie Van Leeuwenhoeklaan 9, Box 13720 Bilthoven, The N etherlands

Dr D . Wood , Senior Scientist, Division o f Virology, N ational Institu te forBiological Standards and Control, Blanche Lane, South Mimms, Potters Bar,Hertfordshire EN6 3QG

Dr Jane Zucker, H ealth Section, UN IC EF, 3 UN Placa, TA 24A, Room 24 22,N ew York , N Y 10017, USA

Certification Commission

Dr H adi M. Abednego, Ministry of H ealth, Jalan Percetakan N egara 29,P.O . Box 223, Jakarta 10560, Indonesia

Prof A. Adams, National Centre for Epidemiology and Population H ealth,Australian N ational Un iversity, Canberra AC Y 0200, Australia

Dr Abdullah Deria, 28 Claudia Place, Augustus Road, London SW19 6ES,United Kingdom

Dr Ali Mohammed Jaffer Sulaiman,* Ministry of H ealth, P.O . Box 393,Muscat, Sultanate of O man

Prof Natth Bhamarapravati, Center for Vaccine Development, Institu te of Sciences & Technology for Development, Mahidol University at Salaya,N akhonchaisri, N akhonpatho m 73170, Thailand

Dr C. de Macedo, SMDB Conjunto 01 Casa 05, Lago Sul, Brasilia,DF 71680-010, Brazil

Prof S. G. Drozdov, Institute of Poliomy elitis and Viral Encephalitis of theAcademy of Medical Science of the Russian Federation, Moscow 142782,Russian Federation

Dr Rose Leke, Department of Immunology and Microbiology,Faculty of Medicine, University of Yaound, Yaound, Cameroon

Prof F.K. Nkru mah,* Noguchi Memorial Institu te for Medical Research(N MIMR), University of G hana, P.O . Box 25, Legon, Ghana

Dr D . Salisbury, Department of H ealth, Wellington H ouse, 135-155 WaterlooRoad, London SE1 8UG, United Kingdom

Dr R. Sutter, Centers for D isease Cont rol and Prevention, N ational ImmunizationProgram, 1600 Clifton Road, Atlanta, Georgia 30333, United States of America

Dr A. M. Van Loon, Research Laboratory for Infectious Diseases (RIVM),Antonie Van Leeuwenhoeklaan 9, P.O . Box 1, 3720 Bilthoven, The N etherlands

* Also serves as a member of the Technical Consultative Group (TCG )


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Dr F.C. Robbins, Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland,O hio 44106-4945, USA

Unable to attend

Prof Jan Kostrzewski (Chairman of Certification Commission ),Department of Epidemiology, N ational Institute of H ygiene,24 Chocimska Street, 00-791 Warsaw, Poland

Sir J. Smith , 95 Lofting Road, Islington, London , GB-N 1 1JF

Dr Wang Ke-An, Chinese Academy of Preventive Medicine (CAPM),27 N anwei Road, Beijing 100050, Peoples Repub lic of China

Partner Representatives

Rotary International, 1560 Sherman Avenue, Evanston, Illinois 62201Mr W. SergeantDr M. Diamond

United N ations Childrens Fund (UN ICEF)Dr D. Alnwick, UN IC EF, N ew York, USADr A. Magan, UN IC EF, Amman, JordanDr J-M. N diaye, UN IC EF, Abidjan, Cote dIvoireDr R. Davis, UN IC EF, N airobi, KenyaDr Ellen G irerd-Barclay, UN IC EF, Kathmandu, N epalRegional H ealth Adviser, UN IC EF, Geneva, SwitzerlandRegional H ealth Adviser, UN IC EF, Bangkok, Thailand

Basic Support for Institutionalizing Child Survival (BASICS),1600 Wilson Blvd, Suite 300, Arlington, VA 22209, USAMr R. Steinglass

Canadian International Development Agency (CIDA),200 Promenade du Portage, Hull, Quebec K1A 0G4, CanadaDr Y. Bergevin

Centers for Disease Control (CDC), Atlanta, Georgia, 30333, USA

Ms Anne-Renee H eningburgMr R. KeeganDr B. MoriniereDr M. PallanschDr Linda Quick

Department for International Development (DFID), 94 Victoria Street,London SW1E 5JL, United KingdomMs Julia Cleves


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23WHO/V&B/99.31

International Federation of Pharmaceutical Manufacturers AssociationsDr H. Chalumeau

Institute for International Cooperation, Japan International Coo peration

Agency, Tokyo, JapanDr Y. Ishii

United N ations Foundation, 1301 Connecticut Avenue N W, Suite 700,Washington DC 20036Dr Mary Agocs

United States Agency for International Development (USAID),Washington DC 20532 3700Dr Mary HarveyMs Ellyn O gden

CDC/World Bank Collaboration on Immunization, Task Force for ChildSurvival and Development, 750 Commerce Drive, Suite 400, Decatur,Georgia 30030, USA.Dr A. Hinman

Representatives fromDANIDAKFWMoFA, Japan

Observers

Mr R. Adams , 1101 N ational Press Building, Washington, D .C. 20045, USA

WHO Secretariat, Regional O ffices

Regional Office for Africa

Dr J-M. O kwo-Bele, H arare, ZimbabweDr M. O tten, Harare, ZimbabweDr J. M. Tapsoba, Harare, ZimbabweDr O . Tomori, H arare, Zimbabwe

Dr R. Beillik, WH O , Harare, ZimbabweDr D. Klaucke, WHO KenyaDr D. Nshimirimana, WHO, CameroonDr Reinhilde van de Weerdt, WH O , AngolaDr O . Babaniyi, WH O , EthiopiaDr R. Kezaala, WH O , EthiopiaDr P. Gbedenou, WH O , DR Co ngoDr S. O kiror, WH O , N igeria


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Regional Office for the Americas

Dr C. de Q uadros, PAH O , Washington D CDr G ina Timbini, PAH O , Washington DC

Regional Office for the Eastern Mediterranean

Dr M. H . Wahdan, Alexandria, EgyptDr R. Aslanian, Alexandria, EgyptDr T. Gaafar, Alexandria, EgyptDr H . Jafari, Alexandr ia, EgyptDr Esther de Gourville, Alexandria, EgyptDr E. Durry, WH O , YemenMr R. H ossaini, WH O , SomaliaDr S. H adler, WH O , Pakistan

Regional Office for Europe

Dr Colette Roure, Copenhagen, Denmark Dr G. O blapenko, Copenhagen, Denmark Dr Galina Lypskaya, Copenhagen, Denmark Dr S. Wassilak, Copenhagen, Denmark Dr S. Deshevoj, WH O , KazakhstanDr Nedret Emiroglu, WHO, Turkey

Regional Office for South-East Asia

Dr Abeykoon, N ew Delhi, IndiaDr J. Andrus, N ew Delhi, IndiaDr A Thapa, N ew Delhi, IndiaMr J. Fitzsimmons, N ew Delhi, IndiaDr G. H lady, WHO , IndiaDr D . Sniadack, WH O , Bangladesh

Regional Office for the Western Pacific

Dr J. Bilous, Manila, PhilippinesMr C. Maher, Manila, Philippines

WHO Headquarters, Geneva

Dr M. Scholtz, EXD/HTPDr D. Tarantola, DG ODr B. Melgaard, V&BDr Maria Neira, CDSMr M. Zaffran, V&BDr Julie Milstien, ATTDr J.-M. Oliv, EPIDr E. G riffiths, QSB

Dr Theresa Aguado, VAD


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25WHO/V&B/99.31

WHO Headquarters, Geneva (continued...)

Dr Maureen Birmingham, VAMDr B. Aylward, EPI

Mrs Jill Azia, EPIMs. Asa Cuzin, EPIMr P. Evans, ATTMr H . Everts, EPIDr D. Featherstone, VAMMs Delyse Glover, EPIMs Tracey Goodman, EPIMs. Patricia Guillot, EPIDr Anna-Maria H enao-Restrepo, EPIMs Rachel H orner, VAMDr H . Hull, EPIMs Jennifer Linkins, EPIDr B. N kowane, EPIMs Becky O wens, EPIMs Jenny Raper, EPIMs Karen Reid, EPI,Dr G. Rodier, CDSDr R. Sanders, VAMDr R. Tangermann, EPIDr J. Lloyd, ATTDr Y. Pervikov, ATTDr N. Zagaria, CEE, CDS

Childrens Vaccine Initiative (CVI)

Dr R. Widdus


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Report of the Global Certification Commission, 199926


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27WHO/V&B/99.31

2.Report of the Global Commission

for the C ertification of theEradication of Poliomyelitis,

G eneva, 2 June 1999

Present :Co-Deputy Chairs, presiding: Dr C. de Macedo, Sir J. SmithRapporteurs :

Dr A. Adams, Dr R. LekeMembers :Dr F. Nkrumah, Dr A. Deria, Dr M. Sulieman Ali Jaffar, Dr S. Droz dov, DrH .M. Abednego, Professor N atth Bhamarapravati, Dr Wang Ke AnMembers absent with apologies :Professor J. Kostrzewki, Chairman; Dr F.C. Robbins

Introduction

A meeting of the Global Certification Commission (GCC) was held from 10:30 to13:00 on 2 June 1999 in Geneva, following the meeting of the Global Technical

Consultative Group (TCG) on Polio Eradication which had been attended by mostmembers of the Commission.

2.1 Agenda item 1 Reports on activities of the regional commissions

Brief reports were received from each of the regions on the activities of theircommissions. It is notable that commissions are now constituted and active in all of the regions and plans of action have been developed for stimulating countries toproduce the information necessary for certification. The AMR Commission has notmet since 1994. The WPR C ommission is meeting in August 1999 in anticipationthat the region may be certified during the year 2000. The European Commission

is considering the scientific basis for alternate data for certification in the ind ustrializedcountries that will not be presenting acute flaccid paralysis (AFP) surveillance datafor certification. Detailed repor ts on activities are provided in the report s of each of the regional commission meetings.


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Report of the Global Certification Commission, 199928

2.2 Agenda item 2 Implications of cross-membership between theGlobal Certification Commission and the Technical ConsultativeGroup

Informal questions were recently raised about overlapping membership between theGlobal Certification Commission and the Global Technical Consultative Group(TCG ). The Global Certification Co mmission discussed the issue thoroughly. Itconcluded that the essential issue was whether members of the TCG could beconsidered as being actively involved in the management of the global eradicationinitiative. They concluded that the TCG was, in fact, a consultative group on ly.Since its recommendations need n ot be accepted by WH O staff and pro grammemanagers, the TCG and, by extension, regional technical advisory groups - couldnot be considered as actively involved in managing the initiative. Accordingly, theGCC did not feel that a limited cross-membership between the TCG and the GCCor the regional certification commissions and the regional advisory groups wouldpresent a conflict of interest.

Decision : The GCC agreed that, insofar as possible, new members of both Regionaland global commissions should no t be selected from the technical consultative groups.

The issue of employment of members of the regional and global commissions asconsultants for WH O was also discussed.

Decision : The GC C agreed that, under WH O rules, members of the commissionscould be termed as consultants for official business related to the commissions (i.e.attending commission meetings, coun try visits on official business of the commission,including site visits for consultation with national certification committees andtechnical visits to provide members with a field orientation to programme activities).

Decision : The GC C agreed that, in order to maintain the impartiality of thecommissions, WH O should not employ members of the regional and globalcertification commissions for assignments related to the technical implementation of the programme.

2.3 Agenda item 3 - Issues arising from the Technical ConsultativeGroup Meeting

a) Response of the WHO Director-General to the request of the GCC for

her personal support to ensure the success of the polio eradicationinitiative

Members of the GCC noted with satisfaction the Director-Generals increasinglyvisible support for the polio eradication initiative. O f part icular importance wereher participation in a national immunization d ay (N ID ) in Cte dIvoire, her letter,sent jointly with Ms Bellamy, to UN IC EF and WH O country r epresentatives, herconvening a meeting of ministers of health of priority count ries, the World H ealthAssembly resolution, her introduction of procedures to facilitate the administrationof the initiative, WH O s allocation o f excess casual income for polio and her personalinvolvement in fund-raising.

Decision : The GC C agreed to write a letter of appreciation to the D irector-General.


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29WHO/V&B/99.31

b) Egyp t

In r esponse to the presentation during the TC G meeting on p rogress towards polioeradication in Egypt, the GCC noted the difficulties encountered in Egypts nationalprogramme, particularly the persistence of low-level transmission despite repeatedNIDs.

Decision : The GC C recommended that a letter be sent to the Minister of Health of Egypt encouraging him and his staff to seek the final reservoir of wild poliovirus inthe countr y and to ensure that all children were immunized during upcoming house-to-house NIDs.

2.4 Agenda item 4 - Formal reviews of regional certification

Dr de Macedo expressed concerns about flagging enthusiasm for polio surveillancein the Americas. If surveillance performance declined, the American RegionalCertification Commission might not be able to provide all the data necessary for theeventual global certification of polio eradication. It was necessary to reinforce theimportance of maintaining surveillance for polio in the region and to ensure that allcountries of the Americas would be fully prepared for global certification.

Decision : After discussion, the GC C agreed that a formal review should be made of current surveillance data for the region, the regions strategy for containment of wild polioviruses and its plans for preparing documentation for final certification.Accordingly, the Region of the Americas should be requested to make a formalpresentation on the findings of this review at the next meeting of the GC C. It wasalso considered that the presentation should prove a valuable exercise for the GCC

in considering the data it will require from all regions for eventual global certification.

Decision : The GC C agreed that one of its members would meet with staff of theRegion of the Americas to discuss the preparation of the documentation on regionalcertification.

2.5 Agenda item 5 - Other business

a) Destruct ion of variola virus

Members of the G CC expressed their dismay at the decision by the World H ealth

Assembly, taken two weeks prior to the GCC meeting, to delay the destruction of the known remaining stocks of smallpox virus. Several GCC memb ers noted thatthis would have negative implications for the containment of wild poliovirus stockssince countries might now consider poliovirus stocks as national, rather than WH O ,property. They felt that the decision could make the eventual destruction of wildpoliovirus stocks more difficult to achieve.

Decision : The GC C recommended that a letter be sent from the commission to theDirector-General to express these concerns.


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b) Distribut ion of reports from the 1998 TC G and G CC meetings

The GCC was concerned that they had received their reports of the 1998 TCG andGCC only after great delay. This led to a general discussion of the need for membersto be fully informed on progress of the initiative.

Decision : The GC C felt that they should receive all the reports routinely distributedby the polio initiative, including programme updates from the Weekly EpidemiologicalRecord (WER), regular issues of Polio N ews, progress repor ts, technical report sand reports from the regional commissions. The WH O secretariat regretted thedelay in the production and distribution of the r eports of p rior y ears meetings andwill endeavour to produ ce the reports earlier and t o include GC C members on mailinglists for publications related to the initiative.

c) Next scheduled meeting of the GCC

The members of the GCC understood that the coordination of multiple meetingsduring the week of the TCG did not permit sufficient time for a full and formalmeeting of the G lobal Certification C ommission.

Decision : The GC C r ecommended that a formal meeting of the commission beorganized in the next six to nine months to consider, inter alia, issues related tocertification of countries not producing AFP surveillance data, the formal presentat ionof the Region of the Americas, and the information that will be required from regionalcommissions for the purposes of global certification.

global eradication of polio

Documents