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WHO-EM/EPI/298/E

Report on the

26th Intercountry Meeting of National Managers of the Expanded Programme on

Immunization

and

26th VPI Regional Technical Advisory Group Meeting

Cairo, Egypt 4–7 July 2010

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Document WHO-EM/EPI/298/E/YY.ZZ/PPP

CONTENTS

1. INTRODUCTION ............................................................................................................ 1

Table of Contents

SESSION 1: OPENING ...................................................................................................... 1

Celebration of the first vaccination week in EMRO Error! Bookmark not defined.

SESSION 2: GLOBAL AND REGIONAL BRIEFINGS ................................................... 2

EPI Global Overview ................................................................................................. 2

EPI Regional Overview ............................................................................................. 3

Follow-up on implementation of the recommendations of the 25th EPI Managers’ Meeting ........................................................... Error! Bookmark not defined.

Briefing on SAGE sessions of 2009 – 2010 .............................................................. 6

Global Burden of Disease Estimates for Hib, pneumococcal and rotavirus .............. 6

SESSION 3: ......................................................................................................................... 8

PROTECTING MORE PEOPLE IN A CHANGING WORLD: REACHING THE UNREACHED ........................................................................................................... 8

Introduction to the session ....................................... Error! Bookmark not defined.

Innovative approaches to improve routine vaccination coverage in low coverage countries ........................................................................................................... 8

1. IMMUNIZATION MONTH IN PAKISTAN ................................................................. 8 Community involvement in Lebanon ...................................................................... 12

Integrated interventions ........................................................................................... 13

2. GLOBAL ACTION PLAN FOR PNEUMONIA (GAPP) AND ENHANCED DIARRHEAL DISEASE CONTROL .......................................................................... 13

3. INTEGRATED CHILD HEALTH INTERVENTION IN YEMENERROR! BOOKMARK NOT DEFINED.

4. CHILD HEALTH DAYS IN SOMALIA: ACHIEVEMENTS AND CHALLENGES 14 Expanding immunization activities beyond infancy ................................................ 15

5. H1N1 VACCINATION: SUCCESSES AND CHALLENGES .................................... 15 6. GLOBAL STUDY ON SCHOOL-BASED IMMUNIZATION ................................... 17

SESSION 4: ACHIEVING REGIONAL TARGETS ........................................................ 18

Poliomyelitis Eradication ......................................................................................... 18

7. GLOBAL OVERVIEW ................................................................................................ 18 8. REGIONAL OVERVIEW ........................................................................................... 19 9. MONITORING ERADICATION ACTIVITIES AND PROGRESS .......................... 22 10.MONITORING IMMUNIZATION ACTIVITIES ...................................................... 22 11.MONITORING SURVEILLANCE QUALITY .......................................................... 22 12.MONITORING RISK .................................................................................................. 25 13.MONITORING RISK OF OUTBREAK AFTER WILD POLIOVIRUS IMPORTATION

...................................................................................................................................... 25 14.OUTBREAK PREPAREDNESS AND RESPONSE .................................................. 26 15.GUIDELINES AND REGIONAL EXPERIENCE ...................................................... 26 16.SIMULATION OF PREPAREDNESS PLAN IN OMAN .......................................... 27

Measles Elimination ................................................................................................. 27

Working groups: measles session ............................................................................ 29

Hepatitis B Control .................................................................................................. 30

17.BRIEFING ON GLOBAL ACTIVITIES AND INITIATIVES ON HEPATITIS CONTROL AND RESOLUTION ON WHA 2010 ......................................................................... 30

18.HEPATITIS B REGIONAL CONTROL TARGETS: RESOLUTION OF RC 2009 AND PROPOSED REGIONAL STRATEGY FOR ACHIEVING THE TARGET .............. 30

19.HEPATITIS B MONITORING AND EVALUATION TOOL ..................................... 34 20.WORK GROUP: HEPATITIS B .................................................................................. 35 SESSION 5: INTRODUCTION TO NEW VACCINES AND TECHNOLOGY ............. 36

21.UPDATE ON NEW VACCINE INTRODUCTION, GLOBAL AVAILABILITY OF THE NEW VACCINES AND THE VACCINES PIPELINE ................................................ 36

22.STRENGTHENING DECISION MAKING PROCESS FOR NEW VACCINES ...... 39 23.EXPERIENCE OF SUDAN WITH DECISION MAKING ON NEW VACCINES ... 40 24.CHALLENGING IN NEW VACCINES INITIATIVE IN LOW-INCOME COUNTRIES 42 25.COST EFFECTIVENESS ANALYSIS FOR NEW VACCINES INITIATIVE ........... 43

Challenges of new vaccines introduction in middle-income countries ................... 44

26.MOROCCO: DECISION TAKEN ON NEW VACCINES INITIATIVE .................... 44 27.IRAN: FUNCTIONAL NATIONAL REGULATORY AUTHORITY (NRA) AND

FUTURE PLAN FOR NEW VACCINES INITIATIVE .............................................. 44 28.HOW TO OVERCOME THE PERSISTING CHALLENGES ................................... 45 29.ESTABLISHING POOLED VACCINE PROCUREMENT SYSTEM IN THE EMR:

PROGRESS AND THE NEXT STEP .......................................................................... 47 30.ROLE OF UNICEF IN ASSISTING ESTABLISHING POOLED VACCINES

PROCUREMENT SYSTEM IN EMR ......................................................................... 48 SESSION 6: STRENGTHENING EPI LOGISTICS SYSTEMS ..................................... 52

Overview on: ............................................................................................................ 52

Cold chain and logistics tools .................................................................................. 52

Cold chain capacity estimation for new vaccine introduction ................................. 52

Vaccination Supplies Stock Management (VSSM) ................................................. 55

31.EXPERIENCE OF EGYPT IN USING VSSM ........................................................... 56 SESSION 7: INITIATIVE FOR STRENGTHENING EPI VACCINATION WEEK IN THE

EMR ......................................................................................................................... 58

32.VACCINATION WEEK IN THE EASTERN MEDITERRANEAN REGION: AN OPPORTUNITY TO PROTECT MORE PEOPLE ...................................................... 58

33.SUMMARY OF COUNTRY ACTIVITIES DURING VACCINATION WEEK IN 2010 IN EMR .............................................................................................................................. 58

Role of NITAGs in strengthening EPI ..................................................................... 60

RECOMMENDATIONS ................................................................................................... 62

34.PREAMBLE .............................................. ERROR! BOOKMARK NOT DEFINED. 35.POLIO ERADICATION ........................... ERROR! BOOKMARK NOT DEFINED. 36.HEPATITIS B DISEASE REDUCTION TARGET ...... ERROR! BOOKMARK NOT

DEFINED. 37.NEW VACCINE INTRODUCTION ......... ERROR! BOOKMARK NOT DEFINED. 38.IMPROVING ACCESS TO NEW VACCINESERROR! BOOKMARK NOT DEFINED. 39.EPI LOGISTICS SYSTEM ....................... ERROR! BOOKMARK NOT DEFINED. 40.VACCINATION WEEK IN THE EMR .... ERROR! BOOKMARK NOT DEFINED. 41.NATIONAL IMMUNIZATION TECHNICAL ADVISORY GROUP ............ ERROR!

BOOKMARK NOT DEFINED. ANNEX 2 .......................................................................................................................... 74

List of PARTICIPANTS ........................................................................................... 74

WHO-EM/EPI/298/E

1. INTRODUCTION

SESSION 1: OPENING

Twenty sixth Inter-country Meeting of National Managers of the Expanded Programme on Immunization was held in Cairo from 4 to 7 July 2010. The meeting was inaugurated by Dr. Hussein A. Gezairy, Regional Director, Eastern Mediterranean Regional Office of the World Health Organization.

Dr. Gezairy welcomed EPI managers, members of Regional Technical Advisory Group (RTAG), chairpersons of the National Immunization Technical Advisory Groups (NITAG), participants from United Nations Children’s Fund (UNICEF), representatives from Center for Disease Control and Prevention (CDC Atlanta), Global Alliance for Vaccine and Immunization (GAVI), Network for Education and Support in Immunization (NESI), Supporting Independent Immunization and Vaccines Advisory Committee (SIVAC), Canadian International Immunization Initiative (CIII) and staff from the WHO headquarters and country offices..

Dr. Gezairy commended EPI managers for their achievements during the recent years. He expressed his worries on the fact that poliomyelitis is still not eradicated in the Region. Dr. Gezairy reiterated that EPI is the backbone of polio eradication. The Regional Director repeated his personal and the Regional Office commitment to eradication of polio and he promised to do all possible to help Pakistan and Afghanistan to wipe out wild polio virus from the Region and to remove the last obstacles.

The Regional Director mentioned that Eastern Mediterranean Region was first to introduce hepatitis B vaccine into the routine immunization services and the result of this wise decision is manifesting. He spoke in details about the importance of the first Vaccination Week initiative that was organized during 24-30 April 2010 and he expressed hope that organizing this event will continue in the future, sustaining our achievements, increasing coverage and reaching the unreached. Dr Gezairy ended his remark by saying that “Think about every child to be your child. Keep this in your mind and you can make miracles.”

Participants adopted the provisional agenda (Annex 1). The list of participants is provided in Annex 2.

WHO-EM/EPI/298/E Page 2

Celebration of the first vaccination week in EMRO

In this session a film produced by EMRO was shown in which the Regional Director emphasized the importance of immunization and Vaccination Week initiative. For more details on the importance of vaccination week and issues related to this activity see Session 7: Initiative for strengthening EPI Vaccination Week in the EMR.

.

SESSION 2: GLOBAL AND REGIONAL BRIEFINGS

Global Overview

Dr. Thomas Cherian, Coordinator of EPI, IVB, WHO HQ

Close to a quarter of child deaths globally are caused by diseases for which vaccines exist. By scaling up coverage of vaccines to 90% globally and by introducing selected new vaccines, over 2/3 of these vaccine preventable deaths can be averted making a big contribution to reducing child mortality. This is the basis of the global immunization vision and strategies (GIVS).

While improvements have occurred in immunization coverage at global level, there are still many countries and communities that lack access to immunization services and more needs to be done to reach them. Improving data quality is a key to better performance through targeting the efforts. The WHO-UNICEF coverage estimates aims to adjust for limitations on administrative data by using data from other sources, such as surveys, vaccine stock management data and expert opinion etc .Countries are encouraged to improve the quality of empiric data particularly paying attentions to numerators and denominators.


pertussis (10%)tetanus (6%)other (<1%)

10.4 million deaths under 5 years of age2.45 million or 24% deaths under 5 from vaccine preventable diseases•1.16 million deaths under 5 years of age from diseases targeted by conventional EPI vaccines•1.29 million form diseases where licensed vaccine is available

While all regions, except SEAR, have achieved the 90% measles mortality reduction goal set for 2010, these gains may prove fragile if adequate follow up activities are not undertaken. Poor routine immunization performance, delayed implementation of follow up campaigns and poor data quality have contributed to recent large measles outbreaks in southern Africa. This risk needs to be clearly recognized and prompt action taken to correct the situation. It also further emphasizes the importance of strong routine performance as a key milestone for achieving measles elimination/eradication.

There has been impressive progress with the introduction of Hib vaccine which has been introduced in 157 countries. Pneumococcal vaccine has been introduced in 35 countries while more are in the pipeline for introduction through GAVI support. the demand from developing countries for new vaccines has been steadily increasing. It is expected that with the new SAGE recommendations, which now recommend global use of Rotavirus vaccine, increasing number of countries will uptake this vaccine.

While exciting new technologies, offering enormous benefits, are now available, many challenges need to be met and overcome if all communities are to benefit from them.

Regional Overview

Dr. Nadia Teleb, Regional Advisor/VPI, WHO, EMRO

The Eastern Mediterranean Region witnessed substantial progress towards

achieving the regional targets of immunization programmes during the past few years. In terms of routine vaccination, the regional coverage of DPT3-containing vaccine reached 87% in 2009. The number of un-immunized children in region dropped from 2.7 million in 2008 to 1.9 million in 2009. 16 countries have achieved the targeted DPT3 coverage of 90% or more. Improvement of routine vaccination coverage was observed in most of the 7 priority countries in EMR (Afghanistan, Djibouti, Iraq, Pakistan, Somalia, Sudan and Yemen). North Sudan reported 91% DPT3 coverage and Djibouti, Pakistan, Iraq and Yemen are close to achieving the target. Despite the continued concern about vaccination coverage in Somalia and southern Sudan, recognizable progress was observed in these countries/areas where reported DPT3 coverage in Somalia increased from 31% in 2008 to 51% in 2009 and the coverage of southern Sudan was 26% in 2008 and 43% in 2009. Strong partnership and implementation of the effective life saving interventions such as acceleration campaigns in Southern Sudan, Child Health Days (CHDs) in Somalia and integrated child health intervention in Yemen, in addition to expanding implementation of Reaching Every District (RED) approach, helped


achieving better coverage in 2009. Despite this achievement, within countries disparities in vaccination coverage is still observed in several countries, specially the priority ones, with variable proportions of the districts still reporting a coverage less than 80% and even less than 50% in some districts. still Neonatal tetanus elimination target wasn’t achieved in six countries iun the region

The global measles mortality reduction (90% reduction in 2010 compared to 2000 level) was achieved in the EMR 3 years before the target date. This reduction reached 93% in 2008. However, there is low probability that the regional measles elimination target by 2010 will be achieved considering the main constraints and challenges which include deteriorating security situation, funding gaps, presence of pockets of susceptible populations in presumably well performing countries. Stronger national and partners’ commitment and more stringent implementation of the measles elimination strategy are needed for sustaining the mortality reduction gains and achieving the elimination target. A new elimination target for the immunization programmes in the EMR was resolved by the Regional Committee of the EMR in 2009, that is, reduction of chronic hepatitis B viral infection to less than 1% among children less than 5 years of age by 2015. The regional coverage of hepatitis B vaccine (HepB3) is 85% and 14 countries are providing the first dose of HepB vaccine at birth. The vaccine has not yet been introduced in Somalia and Southern Sudan as they don’t qualify for GAVI support according to the criteria set by GAVI. The other high burden countries (Afghanistan, Pakistan, Sudan and Yemen) haven’t introduced the at birth dose. The main expected challenges are introduction of the birth dose in the remaining countries and achieving high coverage with birth dose implemented within 24 hours of life of the child.

New vaccines introduction gained momentum during the past 2 years with introduction of pentavalent vaccine in Sudan and Pakistan in 2008 and Afghanistan in 2009. Pneumococcal vaccine is in use in the 6 GCC countries and Rotavirus vaccine is in use in Bahrain and Qatar. Pneumococcal vaccine is expected to be introduced in Yemen in 2011. Morocco plans to introduce rotavirus and pneumococcal vaccine while Iraq is planning to introduce Hib and rotavirus vaccine in 2010. Still the main challenge in enhancing new vaccine introduction lies with the affordability of the vaccine for the Low middle income countries. 76% of infants in the LMICs of the region did not have access to Hib vaccine and none of them had access to Pneumococcal or Rotavirus in 2009. With the financial constraints facing GAVI as result of the global financial crises, GAVI eligible countries are also facing delays in GAVI decision for supporting new vaccines introduction to the low income countries. On the request of the member states, WHO EMRO & HQ in close collaboration with key partners including UNICEF MENA, UNICEF SD and CDC (Atlanta) is in the process of establishing pooled vaccine procurement system in the EMR to enhance new vaccines introduction, especially in the low income countries.


The main challenges continued to face the EMR are the inadequate technical and managerial capacity of national EPI in some countries and consequently the inability to respond to the multiple priorities, the perception of decision makers to EPI in some countries as a very well performing programme that have achieved all targets and, therefore, does not require additional resources Inadequate financial allocation necessary to meet the current requirements; the financial constraints facing introduction of new vaccines and implementation of measles elimination activities, specially the follow up campaigns; the volatile security situation in several countries leading to inability to implement the planned activities.

Follow-up on implementation of the recommendations of the 25th EPI Managers’ Meeting

All recommendations of 25 Intercountry meeting were implemented except one related to injection safety due to the inadequate financial resources

Discussions:

Both presenters delineated the success and achievements and the problems facing the immunization programmes. It was noted from the presentations that there are still six countries in the Region where neonatal tetanus is not yet eliminated. WHO/EMRO and other partners should develop programmes to build the capacity of the National Immunization programme Managers to be able to respond to their ever increasing responsibilities

Participants expressed concerns about the recent negative propaganda and rumors against vaccination by some groups at both country and global levels in relation to H1N1. Regional Advisor mentioned that apart from the propaganda that accompanied H1N1 vaccination, there has been no significant anti-vaccination propaganda in the EMR and fortunately this propaganda didn’t have negative effect on vaccination coverage in the region as indicated by the higher DPT3 coverage in 2009 compared to 2008.

In relation to global overview it was mentioned that disease surveillance would provide some indications about the situation but not a complete picture and full information about disease burden. Therefore, disease surveillance alone should not be interpreted for


estimation of diseases burden and there should be other parameters to give the full picture of the situation like burden of disease estimates.

Briefing on SAGE sessions of 2009 – 2010

The Strategic Advisory Group of Experst ( SAGE) was established in 1999 and restructured in 2005. It is principal advisory group to WHO for vaccines and immunizations providing evidence based guidance and holds two meetings per year

A summary of main recommendations from the four meetings of SAGE held in 2009 and 2010 was presented during the meeting. As of May 2006, all new position papers and updates are reviewed and endorsed by SAGE. In 2009 new WHO position paper was issued on HPV, while updated position papers were issued for Measles and Hepatitis B. A brief update to Rotavirus position paper was also issued in 2009. In 2010 a new position paper on Polio and an update on Cholera was issued. All position papers and full reports of SAGE are published in the WHO Weekly Epidemiological Record (WER) in a timely manner.Summarires of the recenent position papers were shared with the participants. Issues of specific interest to EPI Managers such as immunization schedules, the epidemiology of unvaccinated children, the impact of new vaccines introduction on immunization and health systems and strengthening of NITAGs were also summarized. National EPI managers were also informed about subjects for the next meetings.

Global Burden of Disease Estimates for Hib, pneumococcal and rotavirus

Dr. Thomas Cherian, Coordinator, Expanded Programme on Immunization Plus (EPI), IVB, WHO HQs

Burden of disease estimates are a key piece of information required for prioritizing new vaccines for introduction into national immunization programmes besides being of importance to donors and vaccine developers. While surveillance data contribute to defining the burden of disease, this data alone may not be sufficient to capture the full burden of some diseases. Furthermore, the lack of local good quality surveillance data may be an obstacle in some countries and even may be misleading.


To support its member states, WHO develops burden estimates for select diseases, including vaccine preventable diseases. The process of diseases burden estimation include systematic collection of publically available data conforming to set standards and independent expert review and country consultation

The rotavirus mortality estimates were based on the relatively simple model where the proportion of childhood diarrhoea deaths caused by rotavirus was estimated. This was based on the assumption that the proportion of diarrhoea deaths caused by rotavirus is equal to the proportion of severe hospitalized diarrhoea cases caused by rotavirus.

The models for estimating Hib and pneumococcal disease burden estimates are more complex, because these two organisms cause multiple disease syndromes. The estimation is based on three separate models for meningitis, pneumonia and other invasive diseases, respectively. The meningitis and other invasive disease estimates are based on the incidence-based approach, whereas the pneumonia mortality estimates are based on a proportional mortality approach.

The detailed methods and results of these estimates are published(1-3) and also available on the WHO website (http://www.who.int/immunization_monitoring/burden/en/).

Discussion:

This session surged a great deal of discussion particularly around the idea of immunization programmes to be integrated into the other relevant health interventions and programmes. For instance, a question came out whether EPI should be integrated to Integrated Management of Childhood Sickness (IMCS) or vice-versa. The reply was to have a synergistic rather than integration approach. It was correctly mentioned that two relevant programmes should harmonize their activities as much as possible.

The question of integration and specific vertical programmes came up several times during discussions. These two approaches may sometimes have conflicting effects and may confuse health workers at the field level. The scarcity of funds and diversity of priorities should also be taken into account when we plan for integration.


In order to increase funds, it was mentioned that integration also requires bringing other government bodies such as Ministry of Finance to planning session

SESSION 3: PROTECTING MORE PEOPLE IN A CHANGING WORLD: REACHING THE UNREACHED

1. Innovative approaches to improve routine vaccination coverage in low coverage countries

Immunization month in Pakistan: an intervention for raising routine immunization coverage

Dr. Altaf Bosan, EPI Manager Pakistan

The EPI Pakistan decided to conduct a ‘Immunization month’ in the month of October 2009 for 19 working days (excluding 8–16 October for the National Immunization Days (NID) for eradication of poliomyelitis and weekend day). National Immunization Technical Advisory Group (NITAG) endorsed the plan, strategy and the schedule for the activities. Federal Secretary Health issued letters to all provinces requesting appropriate preparation for achieving desired objectives. Therefore, the immunization month was observed in October 2009 in the whole country except in Baluchistan.

The main objective of the immunization month was to raise routine immunization coverage by vaccinating all missed children with appropriate antigens; identifying all drop-outs and vaccinating them with the missed doses; using the opportunity to vaccinate all children with an additional dose of measles vaccine and vaccinating all pregnant women with TT vaccine as per schedule. Target groups were all children up to 2 years of age and all pregnant women. The intervention not only helped immunizing large cohort of children but also centre staged immunization as a key strategy of the government in disease control and prevention.

Strategy was provided to all districts such as one vaccination team will work in one union council over the 19 working days. The team would conduct outreach vaccination session in each and every village/community during this period following a detailed micro-plan. The outreach sessions would be held in already established sites in that village or in an acceptable place to the community. Fixed sites delivered vaccination services daily throughout the month.


The vaccinators would collect required vaccines and related equipment daily from the nearest supply store and would return all unused vaccines to the same supply store and reports were to be submitted to the designated supervisors. Door to door vaccination was strictly NOT allowed.

Social mobilization materials were developed. Selected firms were assigned to print messages and electronic media were involved to:

– broadcast radio spots – televise messages – print materials were distributed – private media channels were involved

Local level community mobilization was completed through mosque announcement and social immobilizers. Leaflets/messages were distributed to the communities through polio teams during polio campaign.

Federal and provincial EPI officials, including partners, monitored the activities; district deployed all their supervisory staff to supervise the activities and one independent monitor hired for each district through WHO for monitoring and evaluation.

The Federal EPI provided vaccines, injection equipment and printed materials and made commitment with the provinces for operational support on the basis of their performance. The indicator was that every district should reach over 85% coverage with MCV1 assessed and approved by monitors hired through WHO.

The salient feature of operational cost is given below:

• Each UC would be provided Pakistan Rupees (Rs.) 500 (US$ 6) daily as operational support. This amount was an addition to their regular support from local government for the same purpose;

• Each district would receive a lump sum amount of Rs. 40,000 (US$ 488) for supervision and monitoring

• Each province would receive a lump sum amount of Rs. 160,000 (US$ 1,951) for supervision and monitoring


a) Achievements

Number of children vaccinated during the immunization month

Province Children up to 2 yrs of age Pregnant

women

BCG

OPV0

OPV& Penta1

OPV& Penta2

OPV& Penta3

Msl1

Msl2

TT1

TT2+

Punjab

422,602

235,583

359,749

289,492

295,690

387,344

439,514

230,500

180,467

Sindh

166,100

56,241

167,248

101,383

97,387

167,963

102,099

167,162

128,502

NWFP

95,361

45,893

103,709

70,768

70,393

94,261

40,691

94,985

58,403

Gt-Btan

5,336

1,505

6,064

4,426

4,477

5,240

4,838

6,771

4,549

Total

689,399

339,222

636,770

466,069

467,947

654,808

587,142

269,149

371,921

Proportion of annual target vaccinated during the immunization month

Province Children up to 2 yrs of age Pregnant

women

BCG

OPV0

OPV& Penta1

OPV& Penta2

OPV& Penta3

Msl1

Msl2

TT1

TT2+

Punjab

14%

8%

12%

9%

9%

12%

14%

6%

5%


Sindh

13%

4%

13%

8%

7%

13%

8%

11%

8%

NWFP

12%

6%

13%

9%

9%

12%

5%

11%

7%

Gt-Btan

15%

4%

17%

12%

13%

15%

14%

16%

11%

Total

12%

6%

11%

8%

8%

11%

10%

4%

6%

Usually on average 8.33% of the annual target is reached in a month

b) Evaluation method • One independent monitor was hired for every district by the WHO provincial PEI

offices to monitor the month’s activities • Beside monitoring the vaccination sessions, every monitor was to do at least one quick

cluster survey to assess immunization coverage daily

Number of monitors

Number of cluster surveyed

Number of children surveyed

Punjab 36 681 7,243

Sindh 40 517 5,068

Assessed coverage

BCG

OPV0 P1 P2 P3

Penta1

Penta2

Penta3

Msl1

Msl2

FIC

Punjab

96%

84% 8% 7% 5%

97%

96%

93%

91%

56%

89%

S 9 8 8 8 7 7 3 7


indh 2% 1% 8% 3% 9% 8% 2% 7% 6% 1% 0%

Number of districts in provinces achieving different benchmark for different antigens

Punjab > 85% > 80% to <85%

>50% to <80%

<50%

Penta 3 32 2 2 0

Measles 1

29 4 3 0

FIC 29 2 5 0

Sindh > 85% > 80% to <85%

>50% to <80%

<50%

Penta 3 13 3 4 3

Measles 1

11 3 6 3

FIC 7 3 10 3

In conclusion: It was a satisfactory exercise which has improved coverage to some extent but the programme did not succeed in transfer of funds from GAVI to WHO EMRO and promised operational funds could not be paid to 36 districts reached 85% MCV1 coverage. However, the next immunization month will be celebrated with more focused intervention to mobilize community and raise immunization coverage to reach 90% for all antigens in all districts.

Community involvement in Lebanon

Ms. Randa Hamada, EPI Manager, Lebanon


Lebanon has adopted innovative approaches in some remote areas in order to increase the vaccination coverage. Those new approaches proved to be effective and made differences. The strategies mainly stressed on initiating an effective communication process with all potential partners starting with people in charge at lowest administrative level and at community levels, to private sector and Ministries of Education and Interior Affairs, to Media People such as actresses who became a main supportive partner.

Reported figures from districts showed improved coverage rate namely in Akkar where some 11 remote villages were targeted and vaccination coverage reached above 90%.

It should be mentioned that Lebanon has met GIVS Strategies (Area 1):

• in applying combined strategies; • in increasing community participation through raising community awareness about the

importance of vaccines • in ensuring to reach the unreached; • in expanding vaccination beyond traditional target group namely in vaccination

against hepatitis B and neonatal

2. Integrated interventions

Global Action Plan for Pneumonia (GAPP) and Enhanced Diarrheal Disease Control

Dr. Thomas Cherian, Coordinator, Expanded Programme on Immunization Plus (EPI), IVB, WHO HQs

Synergistic approaches to prevent, protect and treat children with pneumonia and diarrhoea

Pneumonia and diarrhoea are the leading causes of death in children under 5 years of age. Failure to reduce mortality due to pneumonia and diarrhoea will result in failure to achieve MDG-4.


While simple, inexpensive and effective interventions exist to control pneumonia and diarrhoea, these have not been implemented to large scale in many developing countries, especially those not on track to achieve MDG-4. Vaccines against rotavirus, Hib and pneumococcus are likely to be important contributors to reducing diarrhoea and pneumonia mortality, respectively, but they will not address the entirety of the problem. They need to be complemented by additional strategies to address risk factors for pneumonia and diarrhoea, to provide early treatment facility at community level and to implement preventive strategies for mother to child transmission of HIV and for Pneumocystis jiroveci pneumonia in HIV infected and exposed children.

Two reports on pneumonia and diarrhoea prevention and control have been published by WHO and UNICEF in 2009. The global action plan for the prevention and control of pneumonia was discussed at the WHO Executive Board and the World Health Assembly (WHA) in 2010, leading to a WHA resolution. The next steps are to advocate for the implementation of these strategies, particularly in countries planning to introduce pneumococcal and rotavirus vaccines, to raise resources, and to assist countries in adjusting their national plans to facilitate a more coordinated implementation of the programmes that address diarrhoea and pneumonia.

Reference List

(1) Parashar UD, Burton A, Lanata C, Boschi-Pinto C, Shibuya K, Steele D et al. Global mortality associated with rotavirus disease among children in 2004. J Infect Dis 2009; 200 Suppl 1:S9-S15.

(2) Watt JP, Wolfson LJ, O'Brien KL, Henkle E, Deloria-Knoll M, McCall N et al. Burden of disease caused by Haemophilus influenzae type b in children younger than 5 years: global estimates. Lancet 2009; 374(9693):903-911.

(3) O'Brien KL, Wolfson LJ, Watt JP, Henkle E, Deloria-Knoll M, McCall N et al. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet 2009; 374(9693):893-902.

Child Health Days in Somalia

Dr. Assejid Tessema Kebede, Medical Officer EPI, WHO Somalia


The coverage of child health services has been low in Somalia for long time. As a result, WHO/UNICEF and all partners have agreed to scale up child health services through implementation of Child Health Days (CHD) in which life-saving integrated interventions are delivered. The interventions include: measles vaccine for children 9 – 59 month of age (measles follow up campaign), routine immunization for under 1 year (except BCG), OPV together with vitamin A and de-worming tablets and nutritional screening for under 5 years of age, TT for women of child bearing age (WCBA), distribution of water purifying tablets and health promotion messages for families. CHD campaign is being conducted over 5 days in all villages of Somalia every six month.

Two rounds of CHD were conducted in 2009 all over Somalia except in 1 region and 1 district (Lower Shebelle and Kismayo), where access was denied. The third round is ongoing: completed in North East and North West zones; and is planned in South and Central zones. In each round more than 1 million children have been reached with this approach and average coverage of more than 80% for all the interventions have been achieved except that for the coverage for TT which is still less than 60 per cent.

The CHD delivery strategy has proved to be appropriate for conflict areas like that of Somalia. Success factors include building on and utilizing existing polio program structure, delineation of roles and responsibilities of partners, integration of interventions that has increased acceptance by the community. Challenges include deterioration of security in many districts, unpredictable funding for CHD activities.

Discussion:

Somalia’s achievement in remaining polio free for the last 10 years was commended. Somalia program always take advantage of activities related to vaccination to provide other services. The question of Somalia’s eligibility of receiving more funds from GAVI was brought up. It was also mentioned that GAVI’s eligibility for new vaccines introduction cannot be changed since the coverage of traditional vaccines is still below 70%.

3. Expanding immunization activities beyond infancy

H1N1 vaccination: successes and challenges

Dr. Ezzeddine Mohsni, Coordinator, Disease Surveillance, Eradication and Elimination and coordinator, Polio Eradication Programme, WHO, EMRO


Expanding immunization beyond infancy is one of the key strategies recommended by the WHO/UNICEF Global Immunization Vision and Strategies (GIVS) 2006-2015 as well as vaccines in global epidemic preparedness plans and measures. Implementation of both above-mentioned strategies has been very variable across countries from the Regions, till recently when national immunization programmes were requested to be actively involved into the last H1N1 pandemic preparedness and response.

Well aware about the importance of this activity and the challenges that EPI programmes might have to face mainly because of the emergency context as well as the need to deal with most of them for the first time with different target groups as well as different partners, the Regional office conducted an inter-country training Workshop on Pandemic Influenza Vaccine Deployment Plan in Rabat, Morocco, from 12 to15 July 2009, attended by representatives from all countries of the Region (Communicable Diseases Control Director or his representative), National Focal Points for Pandemic Flue and National EPI Managers).

The main objectives of the Workshop were to:

– Provide country teams with a framework for permitting the deployment of a pandemic influenza vaccine and other ancillary products in seven days

– Encourage each country to conduct exercises to test its deployment and execution capacity and use the "illustrative checklists" to evaluate their existing plan

– Brief country teams on core-management activities that underpin the deployment of pandemic influenza vaccine, including the allocation of the required funds for covering the deployment of the pandemic vaccine when time arrives

– Update them on latest developments on the epidemiology and vaccine development and availability

The workshop focused on a number of key issues, including:

– National policy for the use of a pandemic influenza vaccine should be part of the pandemic preparedness plan;

– An assessment of the investment and resources required to achieve the level of surge capacity necessary to support the deployment needs to be carried out;

– Adequate funds are assigned to support the deployment of a pandemic influenza vaccine;

– Individuals and processes exist at each level of the health system or government structure with clear responsibility and roles for the rapid deployment of the pandemic influenza vaccine in the country;

– The national H1N1 vaccine deployment plan should be clear and built all available vaccine delivery systems within the country (public and private, health and extra-health)


In order to assess the degree of involvement of national EPI programmes in this activity as well as their experience (achievements and constraints), the Regional office developed a questionnaire that was sent to all countries.

The main outcomes from this survey were:

– Some countries did face problems mainly in the area of vaccine handling and regulation issues, coordination with other non-usual partners and monitoring and evaluation.

– AEFI surveillance varied across countries but in general almost all AEFI reported were minor and within the expected limit.

– Low acceptance of the different target populations in almost all countries (except for pilgrims in some countries for which H1N1 vaccination was mandatory)

The main lessons learned according to country reports were the importance of a strong and pro-active communication and social mobilization plan, as well as a perfect and dynamic inter-sectoral collaboration, in addition to the crucial need for a regional mechanism that will secure EMR countries a rapid access to good quality and affordable vaccines on time (pooled vaccine procurement, vaccine production, etc).

In general, the exercise was beneficial to almost all EPI programmes in the Region. The exercise brought to the programmes an excellent opportunity to:

– Assess, and in most countries, upgrade their capacities in terms of vaccine procurement and regulation and vaccine management;

– Go beyond the “classic” EPI duties and tasks and be involved in wider and crucial health issues (country pandemic preparedness plans, national H1N1 committees, etc);

– Show the crucial role of EPI and capacities and gain more trust, confidence and support.

Global Study on School-based immunization

Dr. Rudolf Richard Eggers, Medical Officer, Expanded Programme on Immunization Plus (EPI), IVB, WHO HQs

School based immunization is a natural expansion of the traditional EPI when children of school going age are targeted, to countries where school enrollment is high, school based vaccination can be an effective, easy and relatively cheap means to reach adolescents.

The presentation reported a global email survey done by UNICEF and WHO, showing


that 61 of 143 reporting counts indicated that they had some kind of school immunization. In most cases (97%) tetanus toxoid was given, and to a lesser extent measles (52%) and polio vaccines (48%).

In depth case studies were conducted in Malaysia, Indonesia, Sri Lanka, Tunisia and Syria (not completed). In the four completed countries, the school-based immunization were part of a native programme, well integrated in district and local health services. Generally all schools were targeted and school enrollment was high. Vaccines delivered through this means differed country by country, and standard operating procedures were in place to guide health workers. This delivery strategy can become an effective delivery method if planned correctly.

Discussions;

Both presenters reemphasize on the key word of “expansion”. The role of internet and other media in acceptance of vaccines by public was significant in many countries. It was mentioned that in some countries physicians were acting on anecdotal incidences. The importance of taking the opportunity of the H1N1 pandemics to further expand EPI programmes was reemphasized during discussions. The size and the capacity of the vaccine cold chain was one of the issues of concern in relation to storage and distribution of H1N1 vaccine. In some instances the pandemic help expansion and improvement of the logistics and the vaccine cold chain.

SESSION 4: ACHIEVING REGIONAL TARGETS

1. Poliomyelitis Eradication

Global Overview

Dr. Roland Sutter, WHO, HQs

Since the 1988 resolution by the World Health Assembly to eradicate poliomyelitis globally by the year 2000, substantial progress towards this target has been achieved. The incidence of polio cases was reduced by >99%, and the number of polio-endemic countries


decreased from >125 to 4. There were two waves of polio exportation from Nigeria (and to a lesser degree from India) in 2003-2004 and 2008-2009, which affected primarily sub-Saharan countries but long-distance exportation were experienced by Indonesia in 2005 (originating from Nigeria) and Angola multiple importations originating from India.

Since 2005, there has been an unprecedented effort to strengthen the program and integrate many innovations, including the introduction of new vaccines (mOPV1, mOPV3), introduce short-interval rounds, increase the number of supplemental immunization activities (SIAs), improve the monitoring (including reporting within 15 days after completion of an SIAs round of independent monitoring data to regional / global levels), feed-back and supervision of SIAs. Because the monovalent OPVs led in some instances to alternating outbreaks of the strain that was less well targeted, a new bivalent (1+3) OPV (bOPV) was developed in 2008-2009, and licensed in Fall 2009. The enhanced efforts finally paid of by mid-2009, with polio cases dropping precipitously in two major polio-endemic countries (i.e., India and Nigeria). No type 1 polioviruses were detected in Uttar Pradesh and Bihar States in India since November 2009. Similarly, in the first 6 months of 2010, only three wild poliovirus cases were detected in Nigeria. The progress in Afghanistan and Pakistan is less striking because of conflict causing access difficulties. However, there is still polio in India (most likely restricted primarily to migrant populations) and probably in Nigeria (most likely in pockets of under-vaccinated children in Northern States). In addition, a large outbreak in Tajikistan, a country that has been polio-free for many years, highlights the risk for poliomyelitis as a result of importation, should one decrease efforts or vigilance.

Although the program has now a unique opportunity to finish the eradication job, however, further enhanced efforts will be needed that are outlined in the recently published Strategic Plan 2010-2012. A new independent monitoring committee will quarterly assess the progress and suggest, mid-course corrections, if necessary. However, the most immediate threat to the eradication effort is short-falls in funding which will curtail programmatic activities.

Regional Overview

Dr Tahir Pervaz Mir, WHO, EMRO

Presentation was focused on the progress and remaining challenges in the polio endemic countries of the region. It included an update on situation in the countries where there had been polio virus circulation re-established in the recent past and on what should be done by the polio free countries with respect to preparedness to address importation. In the


endemic countries, Pakistan and Afghanistan, poliovirus circulation is localized to thirteen district in Afghanistan and fifteen districts in Pakistan but continued circulation poses risk outside the transmission zones. Insecurity and weak campaign management are the major risks for achieving the strategic milestones. District specific planning and linking payment with performance have resulted in recent improvement in Pakistan which needs to be sustained.

The polio eradication program introduced large number of innovative approaches to address the issue of ‘access’ including SIAD, Focused District strategy and HRC approach, working through NGOs and CDCs, negotiating access and tranquility with ISAF/NATO, Letter of support from Anti Government Elements through ICRC, engaging access negotiators locally, negotiations with local and religious leaders /Jirgas, vaccinating IDPs on exit points and established transit vaccination posts in inaccessible districts.

In response to situation in Tajikistan, Afghanistan program established vaccination posts at the border crossing points, enhanced surveillance, risk prediction analysis for action by district and conducted mOPV1 vaccination round in synchronization with Tajikistan and Uzbekistan.

The outbreak in South Sudan came to an end with the last polio case in June 2009. Program major focus is on the AFP surveillance in order to ensure not missing any circulation. Actions taken to improve case detection are increasing field visits, active case search, strengthening ‘0’ Reporting, enhancing Logistic support (7 vehicles, 13 motorbikes and 300 bicycles) and taking additional stool samples from the community children particularly from the counties not reporting AFP case and there is positive impact and reporting of AFP cases have improved.

The EMR is making good progress in the Certification process. Basic National Documentation has been accepted from nineteen countries (BAH, DJI, EGY, IRA, IRQ, JOR, KUW, LEB, LIB, MOR, OMA, PAL, QAT, SAA, SOM, SYR, TUN, UAE and YEM). Final National Documentation has been accepted from 17 countries that have been polio free for 5 years or more and have completed Phase I Laboratory Containment (BAH, DJI, EGY, IRA, IRQ, JOR, KUW, LEB, LIB, MOR, OMA, PAL, QAT, SAA, SYR, TUN and UAE). Regular (Annual and Abridged) Updates were submitted by all countries who submitted the Basic National Documentation. Lab Containment process in the region is progressing satisfactory.


Regional priorities and plans are to interrupt virus transmission in Pakistan and Afghanistan block at the earliest possible, consolidate achievements in Sudan, sustain polio-free status of other countries by avoiding large immunity gaps in polio-free countries while maintaining certification-standard surveillance, aadequate preparedness to detect and respond to importation, ooptimize PEI / EPI collaboration, maintain and further strengthen coordination activities inter-regional, continue with containment and certification activities, and avail the financial resources required to implement the regional plan for eradication.

Discussions on the Global and Regional overview:

The following points were raised:

• Regarding the outbreak of wild poliovirus type 1 (WPV) in Tajikistan it was indicated that the European RCC in their meeting labeled Tajikistan as high risk country well before outbreak, but there was no parallel response from the authorities. In response to the SIA were conducted in Tajikistan and also in some neighboring countries. This will help to boost the immunity status of central Asian States of European region. On Afghanistan side of Tajikistan, routine and SIA activities were carried out and vaccination posts were put in place to vaccinate children entering into and going out of border areas, and at the same time AFP surveillance is enhanced. O6 cases have been reported from Russia and all these cases have history of travel to Tajikistan.

• Situation in countries with reestablished WPV infection; out of the 04 countries in this category, 02 are already polio free (DRC and Sudan). Vulnerable populations (with no immunity or partial unprotective immunity against poliovirus) are in many countries, and it poses the risk of spread following importation.

• The bOPV is produced by four manufacturers and it is prequalified by WHO, however, its registration should be the job of ministry of health. Polio free countries at risk of importation and should act in advance to initiate registration of bOPV in their countries.

• The risk of importation to polio free countries remains high up till the time all countries are polio free, and this highlights that all EPI managers should take all measure to alert and response to any WPV importation.

• In Pakistan and Afghanistan three quarter of population are living in polio free areas.


Monitoring Eradication Activities and Progress

Monitoring Immunization Activities

Dr A. Elkasabany, WHO,EMRO

Monitoring immunization activities involve monitoring routine immunization, monitoring SIAs and using surveillance data to monitor immunity outcome. The approaches for monitoring SIAs include administrative coverage, field visits by national supervisors or international observers and independent monitoring. Independent monitoring is the gold standard since it avoids the possible shortcomings in other methods.

The data obtained from independent monitors can be analyzed to help direct the corrective actions. Examples of this data include the reason for missing children, the source of information about the round. Another source of data that can evaluate the immunity outcome is the AFP surveillance data. It can provide information about the immunity profile of NPAFP, the distribution of zero dose children and the immunization coverage as evaluated for children who live around AFP cases. The regional office is working on regional guidelines for independent monitoring. The highlights of the guidelines were shared stressing the important areas of the different types of independent monitoring, the independence of the process, and the selection of districts and the timeliness of the reporting.

Monitoring Surveillance Quality

Dr F. Kamel, WHO/EMRO

Different approaches are available to monitor and discover gaps in AFP surveillance including

• Regular analysis of surveillance data which is done at Global (weekly and monthly update), regional (Regional weekly polio-fax, RCC documentations ) and country (review meetings, weekly presentation and monthly bulletin) levels. It is mostly based on performance indicators (sensitivity, quality, process and timeliness). It represents a quick way for highlighting problems and initiating actions

• Supervisory field visits (should be regular, based on standard checklist with written report and follow-up)

• Desk reviews are done by independent evaluators. These look at all aspects of the surveillance system not only the indicators e.g. structure and guidelines, staffing and


logistics, data and communications, review central unit and files and Interview field staff at capital. These reviews can be followed by field review (sub-national) if needed and can be done jointly for a group of countries

• Field reviews: Independent evaluation through an external reviewer, it supersedes any other evaluation, can be National or international. It is done according to standard guidelines by combination of nationals and internationals in every team. It covers all aspects of the programme: structure, system, personnel , communication, coordination, feedback, supervision, AFP case management , stool specimen collection, data analysis/data validation, active surveillance, quality of active visits, zero reporting, awareness among clinicians and hospital staff and importation preparedness.

The above approaches are complementary and provide different kinds of insight. They should be implemented properly with care to avoid their pitfalls.

Dr H. Asghar

The Global Polio Laboratory Network (GPLN) comprises of 3 tiers, each is performing its specific functions: Global Specialized Laboratory, mainly responsible for genomic sequencing, training, and development of methods; Regional Reference Laboratory (RRL), responsible for virus isolation and Intratypic Differentiation (ITD), and; National Polio Laboratory (NPL) is responsible for virus isolation.

The performance of the Polio Laboratory Network (PLN) is monitored and assessed by measuring a set of laboratory performance indicators, which are mainly addressing timeliness of results reporting for various stages of testing: virus isolation, ITD etc. The PLN are annually accredited by WHO through on-site visits and by testing of proficiency testing panel of unknown viruses for isolation and ITD methods, and cell sensitivity data is also monitored regularly. The AFP surveillance is supplemented with environmental surveillance in only two countries of Region (Egypt and Pakistan). It can help to detect wild poliovirus circulation in the absence of paralytic cases. The nucleotide sequencing of poliovirus is helping to detect epidemiologic links between polio cases, identify local reservoirs sustaining poliovirus circulation, gaps in surveillance (Orphan viruses) and importations, and detection of vaccine derived polioviruses (VDPVs).

The Phase 1 of laboratory containment of polioviruses and other potential infectious material (developing list of laboratories, surveying laboratories, collecting and collating data, identifying laboratories storing WPV material/potential infectious material, developing a National inventory of laboratories storing WPV, and instructing these laboratories to implement BSL-2/ polio) has been completed in nineteen countries of the Region (Bahrain,


Djibouti, Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Syrian Arab Republic, Sudan, Tunisia, United Arab Emirates and Yemen), remaining countries are Afghanistan, Pakistan, and Somalia. At the end of completion Phase 1 activities a comprehensive self-assessment report of containment activities including tables of relevant data is submitted. The Global Action Plan of containment activities, 3rd edition, is addressing to minimize the post eradication risk of reintroducing wild polioviruses or Sabin strains from the laboratory to the community, at a time when OPV use has stopped. It is in draft awaiting endorsement by World Health Assembly.

It is expected from the national EPI to support and assist laboratories to resolve their problems when and where required, and also make on-site visits and data verifications. It is also important to invite them to meetings related to polio eradication activities.

Discussion on Monitoring Eradication Activities:

During this discussion the following points were raised:

• The atmosphere of fear can cause multiple problems like faking data and false reporting, which will affect the quality of data and it will lead to inaccurate information and mislead the programme.

• Concerns were shown about the situation in Pakistan and it was reiterated that solution should be sought to resolve the management issues and security/access problems. The EPI manager of Pakistan stated that they are taking all innovative measure through specific plans (Prime Minister Polio Action Plan) and progress is reviewed quarterly at federal level. They are faced with district management issues and these are mainly responsible for poor performance in these districts. Payments to vaccinators and supervisors have been linked to their performance during SIA, and more accountability has been added by taking actions against the poor performance staff.

• The process of independent monitoring (IM) should be finalized and shared with the countries.

• Other methods of IM like cluster lot quality assurance (CLQA) method can be used in which 06 clusters of 10 children are randomly selected. It can be carried out by two persons after the campaign in one day. This has been pilot tested in Nigeria and now implement in Nigeria and in other countries of Africa Region.

• The problem of denominator and numerator should be given very special attention to seek proper figures..

• It is important to collect accurate Independent monitoring data and it should be presented and shared at WHO website.

• NGOs should be involved in the process of independent monitoring especially in conflict and inaccessible areas.


• There is advantage of using international observers that they can share their experience of other countries and they can criticize the system. They are not part of implementation, so they can correlate the process with system and come up with solution for bottle neck areas.

Monitoring Risk

Monitoring Risk of Outbreak after Wild Poliovirus Importation

Dr H. Safwat, WHO, EMRO

EMRO undertook a quantitative analysis in the region based on EURO experience and tailored to EMRO situation to assess risk of transmission of wild polio virus after an importation. The assessment was based on surveillance performance indicators, population immunity, performance of health systems, and environmental factors.

Countries were classified using a cumulative score of low, medium and high risk groups. Besides determining the risk of wild polio virus outbreak after importation, this assessment will help identifying weak areas on which to focus improvement efforts by prioritizing technical assistance, immunization and surveillance activities.

Assessment tool identified Sudan, Djibouti, Somalia, Yemen, Iraq, Syria and Lebanon to be at high risk of outbreak after an importation. It was noted that countries of highest risk had a population immunity gap.

The assessment tool is a work in progress that is not finalized. It is re commended to undergo similar assessment at country/ sub-national levels.

Discussion on the monitoring risk:

� Draft risk assessment model is in the process of development and it should be modified/revised taking into consideration variables and redefining some of those, calculation criteria, and scoring. The criteria may not be the same for countries in different stages of polio eradication or status. There is no fix cut off point for variables and it can be tailored to the needs of the country. The purpose is to know the gap and


address those. Once it is modified should be shared with countries and all concerned and their comments should be addressed, before final approval.

� Risk assessment exercises have been carried out earlier in Pakistan/Afghanistan and Somalia taking into consideration more variables. This experience can be combined with risk assessment model and it can help to refine the model.

Outbreak Preparedness and Response

Guidelines and Regional Experience

Dr F. Kamel, WHO, EMRO

Isolation of wild poliovirus in polio-free area is a public health emergency. Importation of wild poliovirus cannot be prevented until global polio eradication is achieved, but its spread within the country can be controlled.

Between 2003-2009 EMR experienced 12 wild virus importation events in 6 countries including 4 outbreaks with a total of 910 cases and 2 isolates, all except two are P1.

Pillars for importation preparedness include High quality surveillance which is essential for early detection and High general population immunity, achieved by routine immunization and SIAs to guard against virus spread. Countries should monitor population immunity (coverage, vaccination status of AFP cases). In addition, special attention should be given to high risk areas/populations.

Proper response include rapid Notification and investigation, enhancing surveillance for AFP and wild poliovirus, Immediate and appropriate immunization response with at least 3 large scale house to house rounds using type specific monovalent vaccine, 1st campaign within 4 weeks of confirmation with potential target ( 2 to 5 million). In small populations entire country and bordering areas may be included. Documenting cessation of transmission should also be done. The lessons learned from regional experience were shared

Risk factors for emergence of Circulating Vaccine Derived Poliovirus (cVDPV) are


similar to factors facilitating wild virus circulation and warrant similar response.

Simulation of Preparedness Plan in Oman

Dr S. Awaidy, EPI Manager, Sultanate of Oman

The purpose of the simulation was to test the capacity of system to know the strength and weaknesses and any need for further improvement of different component of the preparedness plan. Most important components looked at, were planning, resources, organizational coordination, roles and responsibilities, and individual performance etc. In this regard, wild poliovirus importation and containment measures to control spread were simulated in Dofar, Oman. This exercise provided a good opportunity of training and understanding of the process. It helped to improve the emergency management system. Such exercises should be conducted involving the national and sub-national levels. This exercise can be monitored by the national certification and/or expert committee.

Discussion on the Outbreak Preparedness and Response:

� Before simulation exercise, public, political and community leaders and media should be involved and well informed to avoid any public panic

SESSION 4: ACHIEVING REGIONAL TARGETS (CONT’D)

2. Measles Elimination

Regional Situation:

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Dr. Boubker Naouri

Medical Officer, Vaccine Preventable Diseases and Immunization, WHO/EMRO


Remarkable progress has been made since 1997 when the Regional Committee passed the resolution of measles elimination by 2010. Regional routine coverage with the first dose of measles-containing vaccine (MCV1) reached 84% in 2009, compared to 75% in 1995 (64% increase). However, the regional MCV1 is still below the 95% coverage target. The number of reported measles cases dropped dramatically especially during last three years, with around 15,800 measles confirmed cases recorded in 2009. This was an epidemic year. In 2008-09 the reported outbreaks were small outbreak by historical standards. Comparing this epidemic year with the previous ones one can notice that the size of the epidemic decreases over time. Another great achievement is that countries in the EMR reduced the number of measles-related deaths by approximately 90% from 2000 to 2007. This is a great public health success. Goal reached three years before the year target of 2010. The largest regional percent reduction in estimated measles mortality during this period and accounting for 16% the global reduction in measles deaths, in 2008, this reduction was around 93%. MCV1 is still provided at 9 months in 7 countries (Afghanistan, Sudan, Somalia, Iraq, Djibouti, Morocco. Nineteen countries have 2 routine measles doses. MCV1 reached a coverage over 90% in16 countries and 95% in 14 countries. MCV2 reached 90% in 13 countries over 90% and 95% in 12 countries. Three countries reported that all districts reached more than 95% (Bahrain, Oman, Palestine). All countries have now completed a catch-up SIA. Between 1994-2009, 154 SIA were conducted and approximately 384 million children were vaccinated.

National measles case-based surveillance is established in 19 countries. However, performance indicators need to be improved in most of the countries, even those that are close to elimination. Both epidemiology and laboratory together must provide the needed sensitivity and specificity to ensure the detection of measles virus. The performance indicators and targets should be monitored by countries with elimination goals to assess the quality of the surveillance system.

Countries within the Region are at different stages of, and have variable capacity of measles elimination. Fifteen countries are very close or are at the phase to interrupt measles virus transmission. These countries are scaling up and intensifying surveillance measles requirement monitoring indicators and programme performance, with these continued activities they may be able to validate measles elimination by the year 2012. Seven countries are making efforts to strengthen their measles routine vaccination coverage and surveillance and some of these countries still need to conduct regular supplemental Immunization Activities (SIA) and strengthen routine immunization services to sustain the gain of the high immunity reached through the catch-up and follow-up campaigns. By the end of 2013, these countries can interrupt measles transmission and be able to validate measles elimination by 2015.


During the discussion it was mentioned that the reason for the recent outbreaks of measles might have been combination of technical and financial problems. Some campaigns were postponed due to lack of funds.

Group work: reviewing situation of measles elimination in the region

Objectives

The objective of the group work was to assess the status of measles elimination in EMR countries and to propose a new elimination target date. For this purpose, indicators for monitoring achievement of measles elimination in different countries were reviewed and used during this group work session. Countries were categorized in three groups: countries at elimination phase, countries near elimination phase and countries with high burden of disease.

procedure of the group work:

After explaining the objective and the process of the group work, each country had 5-10 minutes to go through the matrix that they filled out prior to the meeting. These matrices contain markers and criteria to monitor progress toward measles elimination. For the targets that are not reached, the country are asked to firstly provide an explanation, secondly the action needed to achieve the target and thirdly the timeline to achieve the specified target.

Outcome

The three groups agreed that they would achieve measles elimination by 2015. In addition, each group made some specific recommendations. In countries at elimination phase, main recommendations were to have measles elimination programs up to the elimination standards focusing on reaching high measles immunity, validation of administrative coverage and having a well performing measles case-based surveillance and epidemiological virologic surveillance. The Gulf Countries brought the issues of the risk of importation due to high number of foreign workers.

GAVI supported countries will need to conduct follow-up measles campaigns until reaching over 95% coverage for MCV1 and MCV2 (routine or campaign). Resources mobilization needs to be conducted at the Regional level to bridge the funding gaps supporting the countries in need.


SESSION 4: ACHIEVING REGIONAL TARGETS (CONT’D)

3. Hepatitis B Control

Briefing on Global Activities and Initiatives on Hepatitis Control and Resolution on WHA 2010

Dr. Rudolf Richard Eggers, Medical Officer, Expanded Programme on Immunization Plus (EPI Plus), IVB, WHO HQs

Hepatitis B remains a serious disease with an estimated 2.7% of all deaths being due to acute hepatitis B/C, cancer/cirrhosis of liver with increasing trend over time. In total, about 2,000 million persons have been infected with HBV worldwide and more than 350 million are chronically HBV infected.

Recently, the World Hepatitis Alliance conducted a survey and subsequently published a Global Policy Report, to better understand the global hepatitis policy environment and the need for technical assistance. This report indicates that viral hepatitis clearly is now on the policy agenda - the vast majority of governments consider it an urgent public health issue. The majority of countries report having a policy and goals in place (70%) but many ‘policies’ are really a handful of unconnected programmes. 60% of countries with hepatitis control goals want assistance from WHO in this area. In terms of surveillance, 82% of countries report having surveillance in place, but one third of the countries have no prevalence data available. On questions relating to hepatitis prevention, 95% of countries have a hepatitis B immunisation policy in place but it’s mostly for infants and only half have an immunisation policy for other "at-risk groups". While 82% of countries report having a strategy in place to prevent infection in healthcare settings, they still estimate 6.7 billion unsafe injections (40%) being given per year, resulting in 23 million new viral hepatitis infections. In addition, an estimated 6 million units of blood not screened each year. Availability of testing varies substantially across the world, and just 40% of people live in countries where testing is accessible to more than half of the population.

Within WHO, Brazil requested WHA action of viral hepatitis in the Executive Board meeting in January 2009, ultimately resulting in a hepatitis resolution being adopted in the World Health Assembly in May 2010. The WHA Resolution 63.18: (Viral Hepatitis) establishes 28 July as World Hepatitis Day, and urges both member States and the WHO agency and director-general to a broad range of activities to control hepatitis.

Hepatitis B Regional Control Targets: Resolution of RC 2009 and proposed Regional Strategy for achieving the target

Dr. Ezzeddine Mohsni, Coordinator, Disease Surveillance, Eradication and Elimination and Polio Eradication Programme, WHO, EMRO


On October 2009, in Fez, Morocco, the 56th Regional Committee for the WHO EMR adopted a resolution (EM/RC 56/R.5) on speeding-up prevention and control of hepatitis B and C in the WHO Eastern Mediterranean Region and endorsed a regional target on “reducing the chronic hepatitis B viral (HBV) infections to less than 1% in less than five years children by 2015. In order to assist member states develop and implement adequate action plans to reach this target, EMRO drafted a regional strategy focusing on 6 core components:

1. Provision of a birth dose of hepatitis B vaccine to all newborns within the first 24 hours of life;

2. Routine infant hepatitis B immunization with high coverage in the first 6 months of life;

3. Catch-up vaccination of children under 5 years of age, if needed; 4. Ensure vaccine effectiveness; 5. Advocacy and social mobilization and 6. Monitoring & evaluation

Prevention of prenatal transmission: Vertical transmission is important in intermediate to high endemic countries (all EMR countries), and the best way to prevent it is to provide hepatitis B vaccines as soon as possible after birth (not later than the first 24 hours).

The importance of this intervention was very well highlighted in the WHO position paper on hepatitis B vaccine (WER No.40, 2009, 84) stating clearly that “since prenatal or early postnatal transmission is an important cause of chronic infections globally, the first dose of hepatitis B vaccine should be given as soon as possible (<24 hours) after birth even in low-endemic countries” and that “the timely delivery of birth dose of hepatitis B vaccine (that is, within 24 hours of birth) should be a performance measure for all immunization programmes”.

However, the birth dose may be still of value (but much less) in preventing prenatal and early postnatal infections even if given later, and should be given on first possible contact, if missed at birth (WPRO plan for HBV control through immunization, Dec 2007).

So far, 14 countries in the Region have adopted the birth dose strategy, however, most of them do not focus on the importance of administering it during the first 24 hours after birth, and very few of them adequately monitor the related coverage.

The regional strategy recommend clearly to:


Countries already using a birth dose of vaccine, to:

– Make sure all private and public delivery institutions have system in place to provide the hepatitis B vaccine within the first 24 hours of life (staff well trained; regular supply with required quantity of vaccines as well as injection equipment, safety boxes and documents, reporting forms, vaccination cards, etc).

– Explore other opportunities and innovative approaches to provide hepatitis B vaccine birth dose (24 hours) to home births as well

– Ensure accurate understanding among all providers of the timing of the birth dose (24 hours after the birth) as well as a close monitoring of the real provision of a birth dose

– Ensuring a high coverage of birth dose of hepatitis B vaccine at all levels

Countries not yet implementing the birth dose strategy, to:

– Work in collaboration with NITAGs on convincing Ministries of Health and Ministries of Finance to introduce the birth dose (WHO global recommendation, RC 56 resolution, disease burden data, low incremental cost, etc)

– Revise their vaccination policy and MYP accordingly – Start with maximizing the utilization of existing opportunities (all public and

private delivery facilities even if institutional delivery rate is low) as well as all trained health staff and traditional birth attendants

– Collaborate with maternal health programs, communities, mother associations, etc.

– Intensify health education and social mobilization – Use new technologies (Uniject, vaccines out of cold chain vaccine, etc.)

whenever possible – Monitor hepatitis B birth dose coverage (24hours)

7. Routine HepB Immunization: The core strategy for hepatitis B disease reduction is reaching very high coverage during the first six months of life with 3 doses of hepatitis B vaccine (with first dose administered during the first 24 hours after birth).

So far, all EMR member states except Somalia have introduced hepatitis B vaccine into their routine immunization programmes. Fifteen of them were able to achieve very high national coverage rates with the third dose. However, because of the variability of the disease prevalence within the same country, national immunization programmes should aim at reaching very high coverage figures in all districts.

8. Catch-up vaccination campaigns: Because of the risk of developing a chronic disease, the priority should be given to younger age groups. Accordingly, countries that did not


ensure yet high immunity among under-five children are encouraged to conduct catch-up activities for this age group to reach the target on time.

9. Ensuring vaccine effectiveness through proper vaccine handling (hepatitis B vaccine is freeze-sensitive) and administration (IM injection into the anterolateral aspect of the thigh (for children < 2 years) or into the deltoid muscle (for older children and adults), as well as early provision of the birth dose (first 24 hours of life)

10. Advocacy and Social Mobilization aiming at raising awareness among decision makers and service providers in order to ensure high coverage and secure quality of the hepatitis B vaccination as well as at educating parents (to increase demand, in particular for the birth dose

11. Monitoring and evaluation: All components of the HepB vaccination programme should be closely monitored and resulting information should be used in a timely manner to address any detected issue, at all administrative levels, with a particular focus on:

– Vaccine management, injection safety, social mobilization and health education, etc.

– Quality of the vaccination program: vaccine administration, respect for the schedule, staff knowledge and behaviour, etc

– Vaccine coverage at different administrative levels: – Birth dose administered within the first 24 hours of life – HepB 3 (2nd pentavalent vaccine for countries using only pentavalent

vaccine and providing a birth dose) – Drop-out rates

Unlike the other vaccine preventable diseases, surveillance does not constitute an adequate tool to monitor the impact of the vaccination programme. Special studies are therefore needed such as the use of the hepatitis B disease burden model, sero-surveys (5 years after vaccine introduction), LQAS, etc.

In conclusion, WHO Eastern Mediterranean Region has been so far the second Region amongst WHO regions to adopt a chronic HBV infection reduction target. In order to reach this target, all national EPI managers are highly requested to:

– Use the regional strategy to develop, implement and monitor national detailed action plans to reach the < 5 target

– Actively contribute to the wider national strategy and action plan on scaling up prevention & control of hepatitis B and C, in particular through expanding hepatitis B vaccination to HCW and high risk groups, and ensuring injection safety.


Hepatitis B monitoring and evaluation tool

Dr. Eric Mass, CDC Atalnta

Hepatitis B Monitoring and Evaluation Tool for use at country level is being developed by EMRO VPI in collaboration with CDC. The objectives of the tool are to assist with monitoring implementation of hepatitis B immunization programs; evaluating progress towards hepatitis B control goals; and to assess potential impact of vaccination strategies to reach hepatitis B control goals The tool is based on a disease burden model that was developed to assist countries with hepatitis B vaccine introduction. The methods of this model have been published (Goldstein et al. A mathematical model to estimate global hepatitis B disease burden and vaccination impact. Int J Epidemiol 2005;34:1329-39). It uses EXCEL software, has a user-friendly interface, and a user’s manual, and is available online at http://aim.path.org/en/vaccines/hepb/assessBurden/model/1.html. Major inputs for the disease burden model are hepatitis B prevalence before the vaccination program began, including HBsAg/HBeAg prevalence among women of child bearing age, anti-HBc prevalence at age 5 years, and national HepB3/birth dose coverage. Based on these inputs, the model provides estimated lifetime hepatitis B burden in a birth cohort with and without vaccination, including HBV infections (total, chronic), HBV-related deaths (acute, chronic).

Three revisions of the disease burden model are planned to meet the objectives of the Hepatitis B Monitoring and Evaluation Tool. To assist in monitoring implementation of hepatitis B immunization programs, the tool will input district-level HepB3/birth dose coverage; outputs will include a district-level coverage table, and the % of districts meeting coverage targets. To assist in evaluating progress towards hepatitis B control goals the tool will input national and district-level HepB3/birth dose coverage; output will be estimated HBsAg prevalence among 5 year olds. To assist in assessing potential impact of vaccination strategies to reach hepatitis B control goals, the model will input projections and targets for HepB3/birth dose coverage; outputs will include estimated HBsAg prevalence among 5 year olds, and estimated hepatitis B disease burden averted with increased HepB3 and birth dose coverage.

Limitations of the Hepatitis B Monitoring and Evaluation Tool are: 1) it relies on reported birth dose coverage which often does not differentiate timing of administration -- thus, methods are needed to report administration at <24 hrs vs. ≥24 hrs; 2) it relies on reported HepB3 coverage – thus, methods are needed to validate reported coverage at district level; and 3) estimates of HBsAg prevalence at age 5 yrs need to be validated with seroprevalence studies.

Training and feedback on the test version of the tool is planned for the EMR Monitoring and Evaluation Workshop in December 2010.


Group work: Hepatitis B control target

Objective of the session:

• To develop a clear understanding among the EPI managers and the chairperson of the NITAGs about:

o The proposed strategy to reach the target and the important role of hepatitis B vaccine birth-dose

o The importance of monitoring the vaccination programme and the impact on the disease burden

o The importance of detailed and accurate country information to develop and implement adequate strategies

• To obtain from country teams the key information for developing detailed action plans to reach the target

Working group procedures:

• Participants divided into three groups based on the implementation status of birth-dose reported by the member states in the Joint Report Form (JRF) 2009.

o Group 1: Countries providing hepatitis B birth-dose (Bahrain, Iraq, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates)

o Group 2: Countries providing hepatitis B birth-dose (Iran, Libya, Lebanon, Morocco, Palestine, Syria and Tunisia)

o Group 3: Countries do not provide hepatitis B birth-dose (Afghanistan, Egypt, Djibouti, Jordan, Pakistan, Somalia, Sudan and Yemen)

• The group work reviewed the country situation (country by country), identifying main achievements, major constraints, as well as existing opportunities for improving and implementing recommended strategies to reach the regional hepatitis B target with special focus on the birth-dose strategy. In addition, to identify main country needs in terms of technical and logistical assistance to speed-up and initiate implementation of recommended strategies

Outcome:

• Country profile vis-à-vis the hepatitis B reduction target was drafted • Required support was identified. Most of program mangers requested for the

following: 1. Technical assistance to review the current program and assist with the development

of a detailed country plan 2. Training on the HBV monitoring tool


3. Technical and financial assistance to conduct sero-surveys to evaluate the impact of the national hepatitis B vaccination programme and monitor the progress towards the regional target

SESSION 5: INTRODUCTION TO NEW VACCINES AND TECHNOLOGY

Introduction of new vaccines is one of the four strategic areas of the Global Immunization Vision and Strategies (GIVS). This session fell under strategy 2 of the GIVS and was organized to update the participants on availability of new vaccines , changes in GAVI policy , pooled vaccine procurement and sharing of country experiences for introduction of new vaccines. With regards to introduction of new vaccines, EMR countries still faces a huge challenge. 16 out of 22 countries of the region have already introduced Hib vaccine to their routine immunization services.These 16 countries are from the t high and upper-middle income countries and the low income countries supported by GAVI. Most of middle-income countries are struggling to finance introduction of Hib vaccines. Introduction of pneumococcal and rotavirus is still slower. Among the EMR countries only seven have already managed to include pneumococcal vaccine and three introduced rotavirus vaccines in their immunization programmes. It is appears that there is a gap in decision making process for introduction of new vaccines which have great potential for decreasing morbidity and mortality associated with VPDs in some of the middle income countries . Decision makers need strong advocacy to allocate more funding to EPI programmes. There is no doubt that new vaccines are effective and safe but they are still very costly.

Update on New Vaccine Introduction, Global Availability of the new vaccines and the Vaccines Pipeline

Dr. Carsten Mantel, Medical Officer, Expanded Programme on Immunization Plus (EPI), IVB, WHO HQs

Hib vaccine

This vaccine is now introduced in 165 countries and available to 48% of the world's 2010 birth cohort. India has now decided to introduce the vaccine in 5 states following an extended decision-making process. Key challenges remain with other large countries not yet introduced Hib in their program such as Nigeria, Indonesia and China. In the Eastern Mediterranean Region countries like Egypt, Iran, Iraq, Somalia, and Southern Sudan are still to introduce the vaccine while Tunisia is planning to re-introduce the vaccine. The overall price reduction of pentavalent vaccines was less than expected over the past years and the


recent recall of pentavalent vaccine of one manufacturer leads to additional challenges and will have repercussions on shaping the vaccine market.

Pneumococcal Conjugate vaccine

The first procurement under the Advance Market Commitment (AMC) was concluded with first contracts signed with two manufacturers for 60 Million doses annually for 10 years as of 2012/13. Both PCV10 and PCV13 will be potentially available for GAVI supported countries by the fourth quarter of 2010. Key challenges are the revision of the demand forecast following the GAVI Board and Executive Committee decisions in June - July 2010 as well as the management of the suggested continued AMC eligibility of all 72 presently GAVI supported countries. Initial supply constraints for 2010/2011 necessitated a new supply allocation policy. Thanks to additional doses which have been made available to date, all already approved countries will be supplied with the vaccines in the years 2010/2011. Streptococcus Pneumoniae (Spn) strain replacement has emerged as an issue of concern and will be discussed in further detail at a meeting on the changing Spn epidemiology in Geneva in early July. Further research and communication on this issue is required.

Rotavirus Vaccine

The WHO position paper on rotavirus vaccine was updated in December 2009 and now contains a global recommendation for use with prioritization of vaccine introduction in countries where diarrhoea is responsible for 10 percent or more of deaths among children under five years of age. Cold chain requirements for the vaccines have substantially improved with new squeeze tube presentations. Eight African countries have put forward GAVI applications for introduction of rotavirus vaccine. A major challenge is the lower efficacy of these oral vaccines in countries with high mortality rates. However, given that incidence of severe rotavirus gastroenteritis exceeds that of low mortality countries, the absolute number of severe episodes prevented is higher there than in those countries where the vaccines show a higher efficacy. There is an imminent risk for the vaccine to be down-prioritized versus pneumococcal vaccines in low-income countries as simultaneous introductions of two vaccines will no longer be supported by GAVI.

Human Papillomavirus Vaccine (HPV)

A WHO position paper with global recommendation was published in April 2009 and both licensed vaccines were prequalified by WHO in 2009. High-level advocacy for these vaccines is ongoing in many countries. The high price of HPV is the major obstacle for introduction of HPV. Vaccine introduction will only be cost-effective in most developing countries if the price will come down to the lower single digit USD per dose range.


Moreover, new delivery systems are needed for these vaccines with additional delivery costs of 1.5 – 5.0 USD per targeted girl. New approaches for vaccine coverage and impact monitoring are under pilot testing.

Integrated Approaches to Disease Control

Major activities have been undertaken to stimulate integrated approaches to disease control in the field of vaccine preventable diseases. A World Health Assembly resolution on pneumonia prevention and treatment was passed in May 2010 and the Global Action Plan for Prevention and Control of Pneumonia was launched in Dec 2009 and a Global Pneumonia Summit was held in Nov 2009. In November, a comprehensive WHO/UNICEF Diarrhoea Control Strategy was launched. At the same time the comprehensive Cervical Cancer Control Strategy is being updated and will include immunization, reproductive health, cancer screening and control programmes as well as adolescent health services.

Epidemic Meningitis Vaccine

The new meningitis A conjugate vaccine for 1 - 29 year olds (MenAfriVac™) has been granted an export licensure in India in January 2010 and has been WHO prequalified in June 2010. First vaccine introduction will take place in the fourth quarter of 2010 to Burkina Faso, Mali and Niger. The uncertain funding situation for the MenA vaccine is the main challenge together with funds for further introduction of meningitis belt countries running low. The immunization strategy to induce rapid protection and herd immunity will be single dose mass campaigns targeted at 1- 29 year olds accompanied by introduction into the EPI schedule and follow-up campaigns in 1 - 4 year old children. Evaluations of the effect on transmission as well as monitoring of AEFIs are pertinent.

Typhoid Vaccines

Two new generation typhoid vaccines; the injectable Vi polysaccharide and the oral live-attenuated Ty21a are presently available. There are large scale projects across Asian countries which demonstrated the feasibility of introducing typhoid vaccine and a significant impact on reducing disease burden. Key challenges related to these vaccines are the limited duration of protection and the definition of target high risk populations (e.g. slum dwellers) as well as the strategies to reach them.

NUVI Plan of Action


The New and Underutilized Vaccine Introduction Plan of Action is a dynamic document, updated annually, and outlining the collaborative efforts of all immunization partners in the following work areas:

• Norms and Standards (Benchmarking); • Country Decision Making (Prioritization); • Planning, Financing & Procurement (Planning); • Vaccine Delivery (Implementation); • Integration with other Health Interventions; and • Monitoring and Surveillance (Evaluation).

Strengthening decision making process for New Vaccines

Regional Surveillance network: Data for action

Dr. Nadia Teleb, Regional Advisor, EMRO

Invasive bacterial diseases caused by Hib and the pneumococcus as well as rotavirus

gastroenteritis are among the leading causes of child mortality all over the world, including the Eastern Mediterranean Region. Effective vaccines against these agents are available and should be introduced in immunization programmes on priority for saving the children and supporting achieving MDG4.

The regional surveillance networks on invasive bacterial diseases and rotavirus gastroenteritis were established by WHO/EMRO to support the member states generate reliable local data to support evidence-based decision on introduction of new vaccines and studying impact of the new vaccines on disease occurrence after their introduction.

Bacterial meningitis surveillance network, launched in early 2004, is now covering several countries of the region. 18 out of the 22 countries have ongoing surveillance activities, either nation-wide or sentinel surveillance system. Surveillance of other invasive bacterial diseases (pneumonia and bacteraemic fever) in addition to meningitis started in 5 countries and 3 more countries received the necessary training and field work is expected soon. Rotavirus gastroenteritis surveillance network, started early 2006, covers 60 sites in 13 countries. Reported data denotes that rotavirus is behind the occurrence of substantial proportion of hospitalization due to gastroenteritis among children <5 years of age, with a proportion ranging from 25% in Tunisia to 58% in Afghanistan and a regional average of 40%.

The regional surveillance networks generated valuable specific data regarding the organisms targeted by new vaccines. Based on this locally generated data, several countries have taken the decision-based on evidence, on introduction of pneumococcal and rotavirus vaccines, including Morocco, Libya, Afghanistan, Sudan, Iraq and Oman. However, limitation of the data generated through sentinel hospital based surveillance should be taken


into consideration while interpreting the surveillance data viz a viz disease burden ?. Identification of bacterial pathogens by culture, specially the fastidious organisms like Hib and the pneumococcus, is not easy and many of the true positive specimens yield negative culture results (Prior use of antibiotics before specimens collection, specimens transfer and handling procedures, lab capacity, adherence to SOPs in performing culture). As well, hospital based surveillance of rotavirus gastroenteritis is not suitable to study mortality as most of the diarrheal deaths occur outside the hospitals. These facts should be taken into consideration to avoid underestimating the true burden of the diseases

Experience of Sudan with decision making on New Vaccines introduction

, Prof Mabyou Mustafa , chairman NITAG Sudan

Before the establishment of disease surveillance system , the decision to introduce new vaccines (HepB, Hib, vaccines) was depending on the EPI by using Regional data, limited national data , national personal studies and consensus with the Pediatricians. Later it was felt that stronger evidence for decision making process for introduction of new vaccines and involvement of a technical advisory body is crucial. Following the receipt of WHO/EMRO guidelines, the Sudan National Immunization Technical Advisory Group (NITAG) was established in 2009 by a ministerial decree . The NITAG facilitates and provide technical advice on policy analysis and strategy formulation for all vaccine-preventable diseases, and guides the national authorities on identifying and monitoring important data on the latest scientific recommendations and development.

Series of meetings were held for decision making regarding the introduction of Rota and Pneumococcal vaccines as follows:

• External meetings at Regional (WHO) level attended by FMOH/ EPI & Planning personnel and NITAG members, supported and guided the country for the steps to be followed to facilitate introduction approval and process.

• EPI facilitated the communications of information to the authorities and facilitated the NITAG meetings.

• NITAG meetings discussed the burden of the disease and the magnitude of the problem in Sudan.They revised the available regional and local surveillance data on the burden of Rotavirus. Sudan had joined the WHO network of rotavirus gastroenteritis surveillance in April 2007.In this regard 8 sentinel sites were selected which are reporting and collecting samples from the suspected cases of rotavirus gastroenteritis. These data along with the available Pneumococcal disease data were


shared and revised by the technical persons representing different specialities. Beside that the WHO Weekly Epidemiological Record and the new vaccines position papers, vaccine trials studies data were revised and discussed too.

• Recommendations were made and raised to the H/E National Minister of health for the importance of the introduction of the Rota and Pneumococcal vaccine into the routine immunization services taking into consideration the financial and logistical issues related to these introductions.

As the FMOH is aiming at making progress towards the MDG4, the introduction of new vaccines and technologies into the routine immunization services and optimizing the benefits of current immunization is one of the main National objectives of the strategic plan and the immunization multiyear-plans for the period 2006-2015. The National Minister of Health supported the recommendation, discussed the financial implications and the country co- finance system by GAVI with the National Minister of Finance. A correpondance was issued by the EPI programme to complete the process of application in the specified period with support of the ICC members.

Conclusion and lessons learned:

• For the first time in Sudan the decision to introduce new vaccine is taken by the NITAG using scientific evidence.

• NITAG gave a strong back-up to EPI programme by giving technical & scientific support.

• Investment on disease surveillance for making a decision is worthy. • The NITAG was utilized not only for childhood vaccines, but also to introduce other

vaccines such as H1N1. • The NITAG became an important resource group in the FMOH.

Recommendations:

• To maintain the current strong ties between the EPI and NITAG for better utilization of its technical capacity.

• Strengthening and maintaining the Rotavirus surveillance to evaluate the impact of the introduction of the new Rotavirus vaccine.

• Expanding the surveillance network to include other diseases targeted by the EPI.


Challenges Facing New Vaccines Introduction in Low-income Countries –

New vaccines introduction in GAVI supported countries in view of the financial crises and need for prioritization

Dr. Raj Kumar, Senior Programme Officer, Country Support, Global Alliance for Vaccines and Immunization (GAVI)

In June 2010 the GAVI Board approved, in principle, to fund the applications reviewed and recommended for approval by the IRC in October 2009. Countries with multiple vaccine approvals were asked to indicate their priority vaccine as due to a new prioritization policy only one country vaccine application will be funded per round. The Board also endorsed calling for a new round of applications for which date will be determined by the Executive Committee before end of July 2010. The Executive Committee will also decide if the new eligibility policy will be applied if new call for application is launched in 2011. For the new round, the following decisions will be incorporated:

‐ Countries will apply for Men A (routine and catch-up) and Yellow fever preventative campaigns through an NVS application process.

‐ One vaccine per round will be funded (incl. Men A and YF); unfunded proposals will go into the pool for the next round. If still unfunded in the second round, countries will be asked to reapply.

‐ Cash-based programmes will account for 15-25% of resource available in each funding round. In case, the funding falls short of the needs, the applications will be ranked according to the need and financial sustainability, as required by prioritization policy..

‐ For new vaccines, the prioritisation mechanism will be applied, using weighted index to rank proposals.

Additional Board’s decisions:

‐ Funding for HPV, rubella, typhoid and JE was endorsed; however, opening of funding window will be determined later.

‐ Countries which were eligible for GAVI funding from 2003 will have access to pneumococcal vaccines through the AMC if they agree to pay for tail of the vaccine at USD 3.50 per dose. The threshold needed to purchase under the AMC agreements a coverage of DTP3 >70%.


‐ HSS Allocation calculation will be based on an eligible country’s total population and weighted against a graded GNI scale, but with an amount no less than US$ 3 million per country

GAVI remains committed to supporting introduction of new vaccines in world`s poorest countries, however, currently there is a funding challenge of US$ 2.6 billion. There is a strong call for new donors, and a new resource mobilization meeting will be held on 6 October 2010.

Cost effectiveness analysis for New Vaccines Initiative

Dr. Altaf Bosan, EPI Manger, Pakistan

The World Bank in collaboration with London School of Hygiene and Tropical Medicine conducted a cost-effectiveness analysis for hemophilos influenza type B (Hib), pneumococcal and Rotavirus vaccine in 2009 in Pakistan. A computer based decision support model was used. Fifteen successive cohorts of under 5 years of age children were targeted . Disease burden attributable to Hib, SP and Rotavirus,t vaccine program cost based on scenarios were analyzed under different assumptions. Objectives of the study were:

• To Undertake a comparative cost-effectiveness analysis • To Conduct a fiscal impact and affordability analysis

All three vaccines were found cost-effective according to WHO definition. Hib vaccine was found to be most cost-effective. However, pneumococcal vaccine had the potential to have most health benefit in terms of avoiding death and DALY though this vaccine is the most expensive one.

Fiscal impact in adding these vaccines was found to be as follows:

• Cost of new vaccines and cold chain starts from more than $ 5 million in 2010 with an potential increase of more than $185 million per year in 2020

• Adding both pneumococcal and rotavirus vaccines will account for 11% of Government health budget and 46% of EPI budget per annum


• If health spending continues to grow at 7 to 8% per annum, this new growth could only fully finance introduction of pneumococcal and rotavirus vaccines.

Challenges of new vaccines introduction in middle-income countries

Morocco: Decision taken on New Vaccines Introduction

Dr. Mohammed Charradi, Head of the MCH Division, Ministry of Health, Morocco

Morocco with a population of 31 million, has an annual birth cohort of 650,000 with an immunization coverage of more than 95%. Currently National Immunization Programme is delivering 9 antigens to the children and all vaccines are procured from government budget. In Morocco there are approximately an annual deaths of 28,000 children before they reach five years of age. Half of these deaths are due to communicable diseases mainly pneumonia and diarrhoeal diseases. Therefore, in order to reach MDG 4, the action plan 2008-2012 of the Ministry of Health considers reduction of infant mortality as a priority. After weighing all technical and scientific issues related to introduction of new vaccines, the Ministry of Health in collaboration with the NITAG and the partners took the decision to introduce pneumococcal conjugate and rotavirus vaccines into the routine immunization services. This has not been possible without the personal engagement of HE the Minister of Health of Morocco who convinced the Minister of Finance to fund these costly but safe and cost effective new vaccines. To introduce these two new vaccines, The budget related to vaccines has been multiplied by four. The tendering process has been launched and the Ministry of Health selected the acquisition of Prevenar 13 and Rotarix. With the introduction of new vaccines, in addition to the other already existing activities of the National Immunization Programme, there is a need for restructuring the immunization programme in order to ensure a better management of the vaccine delivery, logistical support, research development and training needs.

Iran: Functional National Regulatory Authority (NRA) and future plan for New Vaccines Initiative

Dr. Seyed Mohsen Zahraei, EPI Manager, Ministry of Health and Medical Educaiton, Islamic Republic of Iran

Islamic Republic of Iran has a long history of vaccine production. OPV, DTP, BCG,


MMR and hepatitis B vaccines are all locally produced. Two Iranian manufacturers (Razi and Pasteur Institutes) are working in line with WHO recommendations to improve quality of vaccines and to comply with good manufacturing practices (GMP) aiming at possibilities of exporting vaccines.

A certified National Regulatory Authority (NRA) was the prerequisite for WHO prequalification of locally produced vaccines. The Iranian vaccine regulatory system has been reviewed by WHO teams six times in the past (1997, 1998 2000, 2002, 2004 and 2006). Different WHO NRA assessments since 1997 to 2002 resulted in number of shortfalls for each of the regulatory functions and criteria. On the basis of those assessments, a project named “Improving the Quality of Vaccine Production in the Islamic Republic of Iran” was formulated aiming at strengthening the NRA functions. The project started officially on 29 July 2004.

All assessments identified that the staff need training and the priority areas for training were also identified. The training requirements encompassed all six critical functions for vaccine regulation. Training was offered to all NRA, CDC and manufacturing staff with the aim to ensure quality, safety and efficacy of vaccines imported and produced in Iran.

The latest WHO NRA assessment in June 2010 findings showed that all requirements are now implemented and all critical indicators for the WHO vaccine prequalification are met as of May 2010. Most of the regulatory functions achieved a score that ranged from 83% to 97% and sub indicators achieved 100% scores. The WHO NRA assessment team indicated in their official report that the national vaccine regulatory system has achieved a general score of 84%.

Persisting challenges facing new vaccines introduction:

Dr. Ibrahim Moussa, EPI Manager, Ministry of Health, Egypt

Egypt is one of the biggest countries in the region with an annual birth cohort of more than 2 million. Mandatory vaccination includes 10 antigens provided to cohorts of under 2 years of age and to school children. The government of Egypt covers the costs of all vaccines.


The total vaccines related financing by Government of Egypt for 2009 was approximately US$ 76 million

Egypt depends on several factors and issues in decision making process for introduction of new vaccines which mainly include :

1. Burden of disease 2. Financial resource availability 3. Cost effectiveness of available vaccines

The selection of manufacturer/supplier of vaccines depends on ; WHO prequalification, registration of the vaccine in Egypt , price of the vaccine and delivery conditions.

The new vaccines under consideration for introduction by MOH are :

1. Hib vaccine 2. Pneumococcal vaccine 3. Rota Virus Vaccine

Introduction of Hib vaccine was contemplated by the Ministry of Health since 2006. However, due to financial constraints the inclusion of this new vaccine in the Immunization programme was postponed. Egypt plans to introduce this vaccine in 2011 provided WHO supports EPI programme to obtain vaccines at the level of GAVI eligible in GAVI price.

Pneumococcal vaccine is the second vaccine to be introduced in the near future. Egypt requests the support of WHO to establish the surveillance system for streptococcal pneumonia in order to know the magnitude of the problem, the burden of the disease and help to generate the political support necessary for the inclusion of this vaccine.

Rota virus vaccine will be the third one in the list. Ministry of health of Egypt has been evaluating the burden of the disease and is fully aware of the magnitude of the problem. However, due to financial constraints this vaccine will be the third one in the priority list.


MOH Egypt requests support for ; reliable information on vaccine price, source and sustainability, mechanism to get new vaccines at affordable price ; a global initiative to support lower middile income countrires.

Establishing pooled vaccine procurement system in the EMR: progress and the next step

Dr. Irtaza Ahmad Chaudhri, Technical Officer (FSP), EMRO, WHO

WHO EMRO in collaboration with the key partners particularly WHO HQ, UNICEF MENA, UNICEF Supply Division (SD) and Centre for Disease Control (CDC) Atlanta is in process of establishment of a Pooled Vaccine Procurement (PVP) System as per request of the member states. PVP is likely to facilitate introduction of new vaccines in the Middle income countries which are lagging behind in this area compared to high income countries and the low income countries mainly supported by GAVI. New vaccines introduction in all the countries are important intervention to reduce under-five morbidity and mortality.

A Coordination Committee has been constituted by the Regional Director of EMRO to guide the process of establishing PVP in EMR. The Coordination Committee is composed of the members from low, middle and high income countries of EMR, representative from RTAG and representatives of main above mentioned partners. The Coordination committee recommended to undertake a feasibility study for establishment of PVP under two phases. Phase 1 of the study has been concluded and its finding shared with the Ministers of Health and head of delegations from EMR countries during the side meeting at the time of 61 World Health Assembly in May 2009. The consensus of the side meeting was to start the process with option 1 i.e. UNICEF as the procurement agent for member countries with the ultimate aim of reaching the option 3 i.e. having WHO Central Procurement Unit (CPU) modeled on the PAHO Revolving Fund.

UNICEF Supply Division agreed to provide the necessary support to put the option 1 to operation. Tunisia, Morocco and Egypt have officially requested UNICEF SD assistance for this purpose while Syria, Jordan and Lebanon have expressed their interest to join the PVP. The phase 2 of the feasibility study is in process. A concept paper by UNICEF SD outlining the mechanism of availing UNICEF SD support for PVP has been prepared. A joint letter to ministers of Health from the Regional Directors of WHO and UNICEF MENA for their official concurrence for joining PVP will be dispatched soon.


A Technical letter from WHO EMRO to related WHO country staff and UNICEF MENA for sharing with related UNICEF country staff along with the background documents to assist the countries in preparing for joining PVP has been dispatched. With the support of CDC, WHO EMRO has begun the process of establishing a CPU in EMRO. A road map for action for 2010 has been prepared by the working group of the Coordination Committee.

Role of UNICEF in assisting establishing pooled vaccines procurement system in EMR

Dr. Mahendra Sheth, Regional Health Advisor, UNICEF MENARO

The presentation basically offered an outline for discussion as follows:

Support from UNICEF as requested by WHO EMRO:

1. Procurement for vaccines on behalf of EMR Middle Income Countries

2. Provision of Technical assistance to WHO EMRO to build the CU Capacity

3. Contribute to improving/adapting MIC capacities relating to vaccine procurement system (rules & regulations, mechanisms, etc)

Within the framework of the Three Stage approach

1. Procurement for vaccines on behalf of EMR Middle Income Countries – with specific reference to Stage 1 of the PVP initiative

While the initial discussions of UNICEF Supply Division (SD) involvement in vaccine procurement for Middle Income Countries MICs in the EMR were focused on the procurement of new vaccines and not the full scope of routine vaccines, SD may consider procuring all requested vaccine procurement for this group of countries under the first phase of the pooled procurement to enable the pooled mechanism to be established should this be requested by countries, based on the following requirements


and framework.

Context

· Formal request from the Country via the UNICEF Country Office

· UNICEF Country Office and Regional Office support of Country Ministry of Health requests for participation in such an initiative

· UNICEF SD should definitely not be replacing government capacity but be enabling so that a sustainable system can be created in future.

Legal Structure

· Standard UNICEF Procurement Services MOUs to be signed with individual countries, including standard terms of advanced payment in USD, Handling fees (between 3.5 – 4.5% for vaccines) and a 10 percent Buffer. Additional information is available at http://www.unicef.org/supply/index_procurement_services.html

· Coordination via the region – agreement with countries individually. Potential conflicts as contracting parties are the Country and UNICEF, not the WHO Regional office, therefore individual country approval for EMRO involvement would be required.

Forecasting and Planning

· Participating countries complete and submit forecasts to UNICEF Supply Division as part of the annual vaccine forecast exercise

· Participating countries provide a historical overview of the actual quantity of the various vaccines included in their immunization schedules procured over the past 5 years

Budget and Finance

· Advanced payment is required in USD prior to order placement, in line with the Cost estimate requirements, including a handling fee1 and 10% buffer (on product cost)

1 See internet page http://www.unicef.org/supply/index_faq.html#What%20does%20it%20cost for reference on handling fees


· MOUs must be finalised and Funds should be received in Supply Division 3 months before the requested delivery date.

Quality Assurance

· WHO prequalification forms the quality criteria; non WHO prequalified vaccines will not be considered for procurement

· Individual countries may not impose further restrictions on acceptable suppliers and or products, with the exception of in country product registration

· Should vaccines be required to be registered in countries, this is required to be highlighted and adequate lead time provided to enable vaccine registration in the recipient country.

· Recipient countries must facilitate the registration of any WHO pre-qualified product, irrespective of source country or manufacturer.

Procurement Process

· Procurement is to be undertaken in line with UNICEF Vaccine Procurement Principles in support of Vaccine security, conforming to all UNICEF financial rules and regulations, procurement principles and procedures

· Following a forecast of the regional demand requirement, and identification of the procurement volumes to be procured through UNICEF on behalf of the region, a separate tender activity be undertaken by UNICEF SD for this demand

· UNICEF would undertake the procurement on its terms and provide the opportunity for representatives from the pool of countries to be involved and monitor the process, although final decision making would lie with UNICEF – in a manner similar to the GAVI based Procurement Reference Groups.

· UNICEF does not participate in any form of Tender activity. Therefore if a country has requested procurement through UNICEF, it is anticipated that the country will procure through UNICEF and not independently or through another third party.

Supply Management

· UNICEF Supply Division will follow up on forecast demand requirements through their standard operating procedures.

Vaccine Expediting, Delivery & Logistics

· A 6 month lead time from the finalisation of the forecast demand to the first scheduled delivery must be provided to allow for the tendering activity to be


completed and provide for adequate order lead time.

· Any large volumes or campaign requirements may require additional lead times.

Invoicing and Payments

· Advanced payment is required prior to order placement. This is based on the Cost Estimate issued by SD and includes the product cost

· A Handling Fee (based on the cost of the product) and is available at http://www.unicef.org/supply/index_faq.html#What%20does%20it%20cost

· A 10 per cent buffer to cover market and foreign exchange fluctuations is added to the cost estimate when non-stock items are purchased. Any unused balance is returned to the customer after the accounts are finalised.

· Freight and insurance is charged at cost price, using UNICEF-contracted freight forwarders

Monitoring and Reporting

· Monthly monitoring on changes in forecast quantities and timing are undertaken, with monthly reporting back to suppliers and quarterly reporting back to countries

· Procurement Services Transactions overview

2. Provision of Technical assistance to WHO EMRO to build the Central Unit Capacity

· Determination of the level of need of Technical support is required to be defined

· Procurement Reference Group Approach

· Technical Support & Information Sharing

a. Forecast Documentation2

2 Requires country agreement for sharing data


b. Participation in the forecast review

c. Procurement Process and Framework

d. Country Performance reporting3

3. Contribute to improving/adapting MIC capacities relating to vaccine procurement system (rules & regulations, mechanisms, etc)

Determination of the level of need of Technical support is required to be defined

Discussions:

It was noted that price of the new vaccine are decreasing but not enough for middle-income countries for which no external financial support is available. There are some emerging and potential manufacturers and their number depends on demand from the programmes.

It was mentioned that Bill and Melinda Gates is supporting studies and procedures which may result in bringing the price of vaccine down.

SESSION 6: STRENGTHENING EPI LOGISTICS SYSTEMS

Overview on:

Cold chain and logistics tools

Cold chain capacity estimation for new vaccine introduction

Dr. Nasrin Musa, Technical Officer, VPI

3 Requires country agreement for sharing data


One of the GIVS strategies 2006 to 2015 was introduction of new vaccines and technologies into immunization programmes. Since then, several new vaccines were introduced to the programmes globally.

The vaccine cold chain, logistics and vaccine management situation in the Region facing some challenges:

o There are poor vaccine management and supply chain practices in several countries;

o Many countries have ageing cold chain equipment; o No major reviews of cold chain carried out in the recent past in some

countries; o The EPI managers’ challenge is how to chose the suitable vaccine in term of

formulation, presentation and the rate of vaccine wastage; o How and when to upgrade the cold chain equipment and o Shortage of funds, with competing priorities at national level,

There have been global efforts to address these challenges;

• The Vaccine Presentation and Packaging Advisory Group (VPPAG) was established to advise on recommended presentation and packaging of vaccines;

• Intensified the development and updating of Cold Chain Logistics (CCL) tools to provide more comprehensive and updated instruments for country decision-making, planning, implementing and monitoring.

• Rejuvenating Effective Vaccine Management (EVM) efforts by rising expectations or requirements and combining Effective Vaccine Store Management (EVSM) and Vaccine Management Assessment (VMA) tools

Vaccine and Cold Chain Logistics (CCL) management available tools:

• Vaccine presentation assessment tool , • Vaccine Volume Calculator

(http://www.who.int/immunization_delivery/Vaccine_Volume_Calculator.2009_xls)

Forecasting and Planning tool:

• Logistics Planning http://www.who.int/immunization_delivery/systems_policy/Logistics_Planning_Tool_2009.xls

• EPI Logistics Forecasting:

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Vaccination Supplies Stock Management (VSSM)

Mojtaba Haghgou, Temporary Advisor, EMRO, WHO

VSSM is a computer tool to assist vaccination program managers and store-keepers to organize and manage the stock of vaccines and other related supplies was initially developed by EMRO. VSSM focuses on vaccines and diluents however it also caters for all other supplies particularly those related to PHC components. VSSM is open source software based on Microsoft Access and all sources and codes are provided to users. Anyone familiar with MS Access can modify VSSM, add new fields and manipulate reports.

VSSM is a multilingual tool and supports switching from English to French, Arabic, Russian and Spanish without affecting data. VSSM can be translated into any other languages in less than 6 hours. It has already been translated into Mongolian, Persian (Farsi), Laotian and Vietnamese languages.

VSSM is a fully customizable tool and all coding is left to users and they can select the language of their choice for coding. VSSM design is mainly based on WHO/UNICEF training principles on vaccine management in developing countries and with consideration for common field practices.

VSSM has developed in several stages and has gone through gradual changes and development based on extensive and real time field tests.

VSSM is used in 12 countries in different regions:

1. Sudan (since 2008) 2. Egypt

7. Lao PDR 8. Mongolia

Primary cold storage capacity to date, cm3/child Primary cold storage capacity in futur, cm3/childVaccine volume to date, cm3/child Vaccine volume in futur, cm3/child


3. Syria 4. Pakistan 5. Iran 6. Uzbekistan

9. Somalia 10. Nicaragua 11. Bolivia 12. Paraguay

Vietnam, Philippines and Honduras will join the other 12 countries in using VSSM version 4.6 in August and September 2010.

VSSM web-based version with barcode support is planned to be developed in 2011. VSSM Installation program with helps in English and Spanish are available on request and soon will be available for download on EMRO (with helps in Arabic) and on TECHNET web-sites.

The presenter iterated that all computer programmes should be taken as tools in the hand of the EPI managers and no computer application can replace effective, dedicated, trained and experienced manager.

Experience of Egypt in using VSSM

Dr. Ibrahim Musa, EPI Manager, Ministry of Health, Egypt

Egypt is using VSSM versions 2.4 and later on 2.5 at the national vaccine store for the entire country (VACSERA) since 2008. This store serves over 80 million total population and receives and dispatches all vaccine to 29 provinces. There is close collaboration between the Ministry of Health and VACSERA.

A monthly VSSM report of the current stock is sent from the national store to the communicable disease department in Ministry of Health to help decision making at the suitable time. The advantages of using VSSM have been:

• VSSM provides more simple, convenient and instant reporting system on the current stock situation

• Provides instant current stock reports that helps giving an alarm for the vaccines closing to expiry or those outside of the minimum or maximum defined stock level

• It provides the accurate remaining capacity of store in general and for every individual cold room and freezer room


• It facilitates the identification of items close to expiry with details such as batch numbers, vial size and manufacturers

• Minimizes human error such as typographic errors • Using VSSM saves staff time and in a long run may reduce number of staff

requirement However, there are a few problems inherent in VSSM such as:

• Difficulties in error adjustment • Basic data entry is long and cumbersome • There are several unnecessary must enter information that makes VSSM not

very flexible

Immunization program in Egypt is planning to upgrade the data file to the latest version of VSSM and to install VSSM at provincial level. In general use of VSSM is helpful since it increases the efficiency and the effectiveness of the vaccine management system and prevents several errors and mishandling of vaccines.

Discussion:

Almost all the problems summarized by Egyptian Program Manager have already been removed in later versions of VSSM.

Program mangers of Sudan and Pakistan, two countries amongst others use VSSM, also expressed satisfaction with VSSM. Pakistan is planning to install VSSM to 6 provincial levels. Sudan program manager expressed concern about frequent new version and editions of VSSM and suggested to reduce development of new version of VSSM and give time to store staff to digest the existing version.

It was also mentioned that time is ripped for development of VSSM web-based, VSSM multi-user and combining barcode reader to VSSM. EMRO informed the participants that they are about to release the VSSM version 4.7 Users Manual in Arabic.


SESSION 7: INITIATIVE FOR STRENGTHENING EPI VACCINATION WEEK IN THE EMR

Vaccination Week in the Eastern Mediterranean Region: an opportunity to protect more people

Summary of country activities during Vaccination Week in 2010 in EMR

Mr. Nahad Sadr-Azodi, Technical Officer, Measles, EMRO, WHO

Despite substantial progress in immunizing more people over the past two decades, the Region continues to face major challenges. Every day, more than 5500 miss their third dose of DPT vaccines amounting to around 2 million children not receiving DTP3 vaccine in 2009. Moreover, 25% of under-five deaths are attributed to vaccine-preventable diseases each year. A large number of child deaths due to pneumococcal disease and rotavirus diarrhoea can be prevented through vaccination with newly available vaccines. But introducing these vaccines into national immunization programmes will require additional financial commitment from countries and donors.

Recent studies have demonstrated that the structural determinants and conditions of daily life responsible for unvaccinated and under-vaccinated children are primarily related to: parental attitudes and knowledge, such as perceived benefits and threats, and group pressures for or against vaccination; and family characteristics, such as education level, family size, income and occupation. Other contributing factors include communication, information and immunization system, such as health worker knowledge.

Accordingly, in response to both the opportunities and daunting challenges, in 2010 the WHO Regional Office, partners and countries implemented the first Vaccination Week in the Eastern Mediterranean Region (VWEM) during the week 24-30 April 2010, which coincided with the Vaccination Week in the Americas and the European regions. The goals and objectives of the initiative were in line with those set out in the Global Immunization Vision and Strategy 2006–2015, developed jointly with UNICEF, which calls for countries to improve communication and dissemination of information; increase community demand for immunization; and use of a combination of innovative approaches and solutions to protect all people, at risk, against vaccine-preventable diseases.

Outcome, constraints, challenges of the vaccination week 2010 and suggestion for 2011 Discussion moderated by Dr Hyam Bshour, RTAG member


Dr. Hyam Bashour, guided the discussion by posing the following questions to the participants:

· Most of you suggested that Vaccination Week added value to your immunization program. How did it so?

· Given your time constraints, human and financial resources, how would you evaluate your efforts? Like most? Like least? What to change?

· How can we top 100% country participation and impressive media coverage in 2011?

· What regional/ sub-regional themes should we consider?

· How do we ensure availability of resources, including financial, for the 2011 Vaccination Week initiative?

In terms of the initiative’s added value to the immunization program, participants mentioned that Vaccination Week provided a framework for recognizing, motivating, mobilizing resources and expanding partnerships with private and public sectors, civil societies, NGOs, NITAGs, media. It also created a forum to involve the policy makers, while enhancing the profile of immunization program; raising awareness of community and health workers; increasing coverage; and setting and reaching specific special population groups. Some of key challenges included lack of time, human resources, and finances. In addition, some countries described that maintaining the momentum and good will may be difficult. There were also concerns regarding the programmatic and logistical aspects of planning numerous global days (e.g. TB, HIV/AIDS, etc).

In terms of lessons learned, future planning and activities, countries specified the following: partnering or integrating with ongoing activities (e.g. Pakistan NIDs); ensuring consistency in the promotional or advocacy messaging, especially in the Arab countries; engaging with the provincial level authorities and communities; planning cross border or sub-regional activities, including provision of vaccination services; advance planning, political and financial commitment, and designing proper assessment tools. Also, an important point was made regarding the timing of the initiative, as it should not compete with existing or planned events (e.g. mother and child weeks). Moreover, it was mentioned that the initiative should not be perceived as externally driven. Finally, regarding future activities, Pakistan discussed the Regional launching ceremony, and proposed that the Regional Office, partners and countries consider the invitation of holding this event there. The possibility of a regional theme to unify the effort, yet maintaining country autonomy and flexibility was also discussed. The theme of “partnership for immunization” was proposed and it generated some discussion and energy. However, there was no consensus on this matter.


Role of NITAGs in strengthening EPI

Mr. Nahad Sadr-Azodi, Technical Officer, Measles, EMRO, WHO

In recent years, the WHO Regional Office for the Eastern Mediterranean and the EMR countries have intensified their efforts in improving evidence-based decision making process through establishment or strengthening of National Immunization Technical Advisory Groups (NITAGs). In 2008, the Regional Office gained great insight into the existence of NITAGs in the Region following a global survey. Although 59% of the countries claimed to have national technical bodies, the status of these NITAGs and their level of functionality for the most part were still unknown. In addition, a number of countries stated the necessity for regional Framework and Guidelines, common language, information sharing and advocacy. The results of the survey helped inform the regional plan of action for 2008 to 2010.

The Regional plan of action consisted of three core strategic areas: assessment and standardization, technical support and information sharing, and advocacy and partnership. In terms of assessment and standardization, the Regional Office has ensured transparency and accountability by developing and updating an action plan, guide, tools and templates for various standard operating procedures. As for technical support and information sharing, in 2009, the Regional Office organized the first briefing for the NITAG chair persons to update them on the latest immunization policies and strategies. In 2010, for the first time and by the request of the countries, the Regional Office invited and supported all the NITAG chairs to the annual EPI managers meeting. Furthermore, a regional webpage (www.emro.who.int/vpi/nitag) which hosts NITAG information and resources has been developed. Finally, regarding advocacy and partnership, EMRO initiated and continued communication with the member states to ensure establishing and strengthening the NITAGs according to the set criteria. In partnership with Agence de Médecine Préventive (AMP), more support is provided to Lebanon and Tunisia.

Remarkable progress has been made since 2008. As of July 2010, 21 countries have established NITAGs, an increase of 60% compared to 2008 baseline. In addition, almost all countries are taking the necessary measures to strengthen their NITAGs by issuing ministerial decrees, developing terms of reference and standard operating procedures, completing declaration of interest, appointing independent chairpersons and ensuring multidisciplinary composition.


Enhancing role of NITAGs in strengthening EPI in the EMR Discussion moderated by Dr. Philippe Duclos, WHO HQ

The discussion went around 5 key questions:

• Given the discussion from the last few days, how can an NITAG (and its chair) support and strengthen an immunization program?

• What is the role of the NITAG chair and expected qualities? • What are some of key challenges in supporting an NITAG? • What are the expectations from the NITAG secretariat/ Ministry of Health? How

WHO and countries facilitate the work of NITAGs? • How can the achievements/contributions of an NITAG be determined or measured?

In terms of support to the immunization programmes, the NITAG chairs mentioned that they can serve as a resource, such as providing expertise, facilitating dialogue, motivating and generating interest, empowering, disseminating and communicating credible and impartial information. NITAGs and their chairs can also serve as a bridge between the private and public sectors. One chairperson stated that in order to know how to help, he first needs to know the problem. Some of the key challenges in supporting an NITAG included access to background materials (e.g. reliable and accurate country-level data), clear role description, knowledge of the immunization program, logistics and administration support, time commitment, true independence from the ministry of health, and different particular expertise (e.g. health economist) on the group. NITAG chairpersons further discussed their expectations of the secretariat and WHO, mentioning that secretarial and administrative support in terms of preparations (data, literature, etc), recording and reporting of the meetings would be critical. Furthermore, specific briefing or training on group dynamics and facilitation would be highly useful.

Finally, on the issue of assessing the achievements of an NITAG, one chairperson mentioned that perhaps the implementation or uptake of NITAG recommendations by the ministry of health can be considered an indicator of success. On this point, the moderator mentioned there are ongoing global discussions on how to measure the NITAG success based on varying stakeholder perspectives.


RECOMMENDATIONS

Preamble:

The Regional Technical Advisory Group (RTAG) noted with satisfaction the substantial progress made by several countries of the Eastern Mediterranean Region in several areas of the Expanded Programme on Immunization (EPI). The RTAG noted also the successful implementation of the first vaccination week in the EMR, the achievement of the measles mortality reduction target and the progress made in the process of establishing pooled vaccine procurement mechanism. Never-the-less, the RTAG raised concern about the continuous transmission of wild polio virus in Pakistan and Afghanistan as well as the low likelihood of achieving measles elimination target in the region. The RTAG underlined the need for accelerating the efforts to meet the regional and national targets of eradication, elimination and control of vaccine-preventable diseases. The RTAG reiterated the importance of completing and accelerating the implementation of the recommendations of the previous EPI meetings. In addition, the followings are recommended:

1. General recommendations

1.1. Countries that did not achieve yet routine immunization coverage target figures (at least 90% DPT3 coverage at national level and 80% in all districts) should use innovative approaches, adapt recommended global strategies and tools to the country specificities and widen partnership to include other sectors (such as Ministry of Interior, Minister of Education, community, private sector, etc) in order to achieve the target

1.2. EPI Managers, with the assistance of NITAG, should explore all possible ways to mobilize sustainable resources needed to improve their delivery capacity, match the new responsibilities of the EPI programme and advocate for EPI needs at the highest level of the country in order to mobilize more government resources.

1.3. EMRO to continue advocating for strengthening capacity of national EPI team in terms of number, quality and status of the team members, empowering EPI programme, allocate more funds which enable the EPI structure to respond to the evolving needs, responsibilities but also to the national and global community expectations and solicitations.

1.4. EPI managers should look more critically to reported coverage figures (national, district and sub-district levels), triangulate data from other different sources (vaccine stock-outs, incidence of VPDs, etc) and use WHO recommended tools (DQS, etc) to assess and improve data quality.

1.5. EMRO is to provide the necessary technical support for building national capacity for improving the accuracy and quality of the EPI reporting system and improving quality and coverage calculation/estimate methodology, helping the country to generate the most accurate coverage figures

1.6. EMRO to ensure timely sharing electronically of all relevant documents and information, including SAGE meetings outputs (WHO position papers, SAGE


reports, recommendations, etc), with national EPI managers, NITAG chairpersons and partners agencies .

1.7. Countries are requested to seriously consider integrating all immunization activities taking place at country level within the national EPI programme, but also ensuring coordination, collaboration and synergy with other concerned departments and ministries.

1.8. National EPI managers should build on lessons learned from H1N1 experience and develop strong social mobilization and communication plans in order to prevent possible rumors that could interrupt the smooth implementation of the EPI programme.

2. Polio eradication:

2.1. RTAG raised concern about the lack of progress in Pakistan in comparison with what happened in other endemic countries and would like to stress on the urgent need to see the Government of Pakistan taking more responsibility and stronger ownership of the polio eradication activities.

2.2. National EPI managers should build on lessons learned from the polio outbreak in Tajikistan to review the quality of their population immunity as well as surveillance and address potential gaps. The different approaches, presented in the meeting, on monitoring both immunization and surveillance activities and outcome can be very instrumental in this regards

2.3. RTAG stressed the importance of inter-regional and inter-country coordination and is calling for re-activation of MECACAR operation between EMR and EUR Countries.

2.4. The draft regional guideline for independent monitoring should be finalized and shared with countries. Countries conducting supplementary immunization activities should implement independent monitoring as per the guidelines. Results should be shared with regional and global levels within 15 days of SIA implementation.

2.5. EMRO to share the outbreak risk analysis methodology and results with concerned countries. National EPI managers to assess the risk profile of their respective countries, to implement similar analysis at sub-national level, and to use the analysis as the basis for addressing the identified gaps and report back to EMRO.

2.6. RTAG recommends to the secretariat to ensure stronger and effective integration of EPI/PEI activities at both regional and operational levels.

2.7. As the bOPV is now a WHO prequalified product and it is manufactured by 04 companies, it recommended that countries should register bOPV from one or more of these companies to be possible to use in case of importation of wild poliovirus.

3. Measles Elimination

3.1. As 7 countries of the EMR are close to achieving elimination target, the participants recommended the following:


3.1.1. EMRO to Undertake validation of measles elimination in any country ready for that exercise

3.1.2. all other countries should strive for achieving elimination soonest possible

3.1.3. Postponing the target date of regional measles elimination to 2015.

3.1.4. EMRO to submit technical information of the current situation, including the proposed new regional target date, to the Regional Committee for consideration

3.2. EMRO to organize a group work during the next inter country meeting on measles elimination, November 2010, in order to discuss the problems of the low immunity against measles among the immigrant population faced by some countries and develop suitable recommendations to the concerned Health Authorities

4. Hepatitis B disease reduction target: 4.1. All countries are requested to form a suitable structure to follow up on

implementation of the Regional Committee resolution concerning speeding up prevention and control of hepatitis B and C (EM/RC56/R.5), involving all concerned departments, sectors and stakeholders.

4.2. EMRO to urgently share with national EPI managers the recommended strategy for achieving the chronic HBV infection reduction target.

4.3. Countries are requested to use above-mentioned strategy to develop practical action plans to reach this target and share it with the secretariat latest by end of 2010.

4.4. All countries should plan to achieve high coverage (at least 90%) for the HepB birth dose during the first 24 hours. In order to do that:

4.4.1. National plan of action for achieving the regional target should use all possible means to implement this strategy, including administration of HepB vaccine in all maternity care institutions, public and private, innovative approaches should be indentified for the expansion of the birth dose beyond the health care institutions.

4.4.2. National EPI managers should coordinate with MCH and other involved departments and concerned partners to improve access to HepB vaccine during the first 24 hours of life

5. New vaccine introduction:

5.1. In order to save children’s lives and assist achieving MDG4, countries should take the necessary action for making evidence-based decision on introducing the new highly effective and life saving vaccines such as Hib, Pneumococcal and rotavirus. RTAG noted the good experience of NITAG/Sudan in using local surveillance data for decision making on rotavirus vaccine introduction and is encouraging other countries to learn from this experience for improving their decision making process


5.2. In view of the value of the data generated by the surveillance network of diseases preventable by new vaccines in making evidence-based decision on new vaccines introduction, countries should strengthen and sustain the ongoing surveillance system and ensure timely sharing of the data with NITAG and other relevant authorities for evidence based decision.

5.3. EMRO to continue providing the necessary technical support for strengthening the regional surveillance network for diseases preventable by new vaccines as well as to advocate for decision making on new vaccines introduction

5.4. Countries should make use of the WHO-endorsed disease burden estimates like the new disease burden estimates on Hib, Pneumococcal and rotavirus diseases in order to supplement the locally available surveillance data for adequate evidence-based decision on introduction of new vaccines.

5.5. EPI managers should take the necessary steps for implementation of the WHA resolution on pneumonia and coordinate with other concerned national counterparts and partner agencies to develop, implement and monitor adequate action plan to implement the resolution in an integrated and synergistic way.

5.6. RTAG congratulates Iran for the recent WHO recognition of the Iran NRA as functional NRA. RTAG expressed also satisfaction with the progress made by the secretariat in the preparation for establishing pooled vaccine procurement. RTAG strongly recommend LMIC to join as soon as possible the phase one of the system and work in close collaboration with WHO & UNICEF to materialize phase two of the feasibility study.

6. EPI logistics system

6.1. With the high cost of the new vaccines, the complexity of the vaccine handling and in order to ensure proper vaccine and logistic management system, national EPI team are encouraged to use computer tools such as Vaccine Supplies Stock Management (VSSM).

6.2. WHO and the partners are to extend the required technical support to the Member States for installing the VSSM and conducting the related training activities.

6.3. WHO and the partners are requested to review the available cold chain and logistics tools, ensure validity and simplify/unify them in one unified user friendly tool

7. Implementation of the vaccination week in the EMR

7.1. RTAG congratulate all countries for the successful implementation of the first vaccination week in the EMR and commends the activities conducted. RTAG urge the countries to take the necessary steps to ensure improving and expanding the achievement and ensuring contribution of this activities for protecting more people against vaccine preventable diseases


7.2. RTAG requests WHO to continue supporting the countries in planning and implementing the vaccination week

8. Strengthening National Immunization Technical Advisory Groups

8.1. RTAG commends the remarkable progress in establishing NITAGs in the region over a short time span. RTAG requests WHO and partners to continue providing the technical support and follow up on establishing and strengthening the NITAGs to meet all required criteria

8.2. RTAG encourages NITAG to play a more central role in advocacy for the strengthening of immunization programmes and react to prevent any possible damage to immunization programmes resulting from rumors and from anti vaccine groups


ANNEX 1

Programme

Sunday, 4 July,2010 08:00-09:00 Registration

09:00-09:45 Session 1: Opening

Address by Dr Hussein A. Gezairy, Regional Director, WHO/EMRO

Introduction of participants Election of officers Adoption of the Agenda Celebration of the 1st vaccination week in the

EMR

Moderated by: Dr J. Mahjour, DCD/EMRO

Session 2: Global & Regional briefings

09:45-10:05 EPI Global Overview Dr T. Cherian, WHO/HQ

10:05-10:30 • EPI regional overview • Follow-up on implementation of the recommendations of the 25th EPI manager’s meeting

Dr N. Teleb, WHO/EMRO

10:30-10:45 Discussion

10:45-11:15 Coffee Break

11:15-11:45 Briefing on SAGE sessions 2009-2010 • Conclusion and main recommendations • Revised WHO position papers

Dr H. Bashour, SAGE & RTAG Member



12:00-12:20 WHO burden of disease estimates Dr T. Cherian, WHO/HQ

12:20-12:35

Discussion

Session 3: Protecting more people in a changing world: reaching the unreached

12:35-12:45 Introduction to the session

Dr N. Teleb, WHO/EMRO

12:45-13:15 Innovative approaches for improving routine vaccination coverage in lower coverage countries: – Immunization month in Pakistan – Community involvement in Lebanon

EPI Manager/ Pakistan EPI Manager/Lebanon



14:30-14:50 14:50-15:10 15:10-15:30

Integrated intervention: – Global Action Plan for Pneumonia (GAPP)

and Enhanced diarrheal disease control

– Integrated child health intervention in Yemen

– CHDs in Somalia: achievement and challenges

Dr T. Cherian, WHO/HQ

EPI Manager/Yemen

Dr A. Kebede, WHO/Somalia



16:15-16:30 16:30-16:45 16:45-17:15

Expanding immunization activities beyond infancy – H1N1 vaccination: successes and challenges – Global study on school- based immunization Discussion: streamlining immunization programmes beyond infancy

Dr E. Mohsni, WHO/EMRO Dr R. Eggers, WHO/HQ

17:30-18:30 RTAG meeting


Monday, 5 July 2010

Session 4: Achieving the Regional targets

Poliomyelitis Eradication 08:30-08:50

Global overview Dr R. Sutter, HO/HQ

08:50-09:20 Regional overview Dr T. Mir, WHO/EMRO


Monitoring Eradication Activities and Progress:

09:50-10:10 Monitoring Immunization Activities Dr A. El Kasabany, WHO/EMRO

10:10-10:40 Coffee break

10:40-11:10

Monitoring Surveillance Quality

Dr F. Kamel/ Dr H. Asghar, WHO/EMRO


Monitoring Risk:

11:40-12:00 Monitoring Risk of Virus Spread Dr H. Safwat, WHO/EMRO

Outbreak preparedness & response

12:00-12:20 • Guidelines and regional experience

Dr F. Kamel, WHO/EMRO

12:20-12:35 • Simulation of preparedness plan in Oman

Dr S. Awaidy, EPI Manager, Oman



Session 4: Achieving the Regional Targets (cont’d)

Measles Elimination

14:00-14:20 Current situation: – Achieving the target of mortality reduction

and progress towards elimination – Milestones towards global eradication

of measles – Elimination validation process – Proposed new elimination target date

Dr B. Naouri, WHO/EMRO

14:20-14:30 Introduction to the group work

Dr H. Ahmed, WHO/EMRO


14:30-16:00 Group work: reviewing the target date: where are we, when can we achieve elimination: 3 groups: – Elimination group – Near elimination group – High burden group Discussion points: – Current situation – New target date – Challenges – Current opportunities and additional needs – How to use the opportunities to overcome the

challenges


16:15-17:30 Group work presentation (10- Minute presentation and 15 minutes discussion each)


Tuesday, 6 July 2010

Session 4: Achieving the Regional targets (continued)

Hepatitis B control

08:30-09:30 09:30-09:35

Briefing on: • Global activities and initiatives on

hepatitis control and Resolution of WHA 2010 • Hepatitis B Regional control target: Resolution of RC

2009 and proposed regional strategy for achieving the target

• Hepatitis B monitoring and evaluation tool Introduction to the group work

Dr R. Eggers, WHO/HQ Dr E. Mohsni, WHO/EMRO Dr Eric Mast, CDC Atlanta Dr E. Mohsni, WHO/EMRO


Tuesday, 6 July 2010 (cont’d)

09:35-10:30 Group work: 3 groups: • Countries with birth dose in national schedule (2 groups) • Countries without birth dose in national schedule

Discussion points: how to achieve the target • Current situation • Challenges • Current opportunities and additional needs to implement the regional strategy • How to use the opportunities to overcome the challenges


11:00-12:00 Continuing the group work

12:00-13:00 Presentation of the group work on Hepatitis B control (10 minutes presentation and 10 minutes discussion each)


Session 5: Introduction of New Vaccines and Technology

14:00-14:10 Introduction to the session

Dr D. Aden, WHO/EMRO

14:10-14:30 Update on New Vaccine Introduction, Global availability of new vaccines and the Vaccine Pipeline

Dr C. Mantel, WHO/HQ

14:30-14:55 14:55-15:10

• Strengthening decision making process for NVI • Regional surveillance networks: Data for action • Experience of Sudan with decision-making on NVI

Dr N. Teleb, WHO/EMRO EPI manager/Sudan



15:25-16:40 15:40-16:00

Challenges in NVI in low income countries: • New vaccines introduction in

GAVI-supported countries in view of the financial crises and need for prioritization

• Cost effectiveness analysis for NVI

Dr R. Kumar, GAVI EPI Manager/Pakistan


16:15-16:30

Coffee break

16:30-16:45 16:45-17:00 17:00-17:15

Challenges of new vaccines introduction in the MICs • Morocco: Decision taken on NVI • Iran: functional NRA, future plans for NVI • Egypt: how to overcome the persisting challenge

EPI Manager/Morocco EPI Manager/Iran EPI Manager/Egypt

17:15- 17:30 Discussion

17:30- 17:45 Establishing pooled vaccines procurement system in the EMR: progress and next steps

Dr I. Chaudhry, WHO/EMRO

17:45- 18:00 Role of UNICEF in assisting establishing pooled vaccines procurement system in the EMR

Dr M. Sheth, UNICEF/MENARO

18:00- 18:15 Discussion


Wednesday 7 July 2010

Session 6: Strengthening EPI logistics system 08:30-08:45 08:45-09:00

Overview on: • Cold chain and logistic tools • Cold chain capacity estimation for new vaccine introduction

Dr N. Musa, WHO/EMRO



09:15-09:30 09:30-09:45

• VSSM

• Experience of Egypt in using VSSM

Mr M. Haghgou, Temporary Adivser EPI/Egypt



Session 7: Initiatives for strengthening EPI

Vaccination Week in the EMR 10:30-12:30 Vaccination week in the Eastern Mediterranean

Region: an opportunity for protecting more people: – Summary of country activities during

VWEM 2010 – Summary evaluation of VWEM 2010-05-28

• Kuwait presentation on Vaccination Week • Iraq presentation on Vaccination Week • Sudan presentation on Vaccination Week Discussion: outcome, constraints, challenges and suggestion for 2011

Mr N. Sadr-Azodi, WHO/EMRO EPI Manager/Kuwait EPI Manager/Iraq EPI Manager/Sudan Moderated by Dr H. Bachour


Role of NITAG in strengthening EPI

13:30-14:45 Role of NITAG Discussion: enhancing role of NITAGs in strengthening EPI in the EMR

Mr N. Sadr-Azodi, WHO/EMRO Moderated by Dr P. Duclos


Session 8: Closing

15:00-15:30 • Conclusion and recommendations • Closing


ANNEX 2

List of PARTICIPANTS

AFGHANISTAN, ISLAMIC REPUBLIC OF Dr Agha Gul Dost National Manager, Expanded Programme on Immunization Ministry of Public Health Kabul Tel: +937 99814812 E-mail: [email protected] ; [email protected]

Dr Ghulam Haider Rafiqi

Programme Manager, Capacity Building of MOPH

Management Science for Health (MSH)

Kabul

Mobile: +93(0)706155628

E-mail: [email protected]

BAHRAIN Dr Jaleela S. Jawad Manager, Expanded Programme on Immunization Head of Immunization Group Public Health Directorate Ministry of Health P.O.Box: 42 Manama Tel : +973 17279295 E-mail : [email protected] DJIBOUTI Mr Abdallah Ahmed Hade Manager, Expanded Programme on Immunization Coordinator, national DUPEV Ministry of Health B.P 1974 – Ministry of Health Djibouti Tel: +253351491 Mobile: +253 825900 Fax: +253 350647



Dr Ahmed Hassan Boulaleh

Directeur du Service de Sante des armees

Chairperson of the NITAG

Ministry of Health P.O.Box: 1905 Djibouti Tel: +253 817506 E-mail: [email protected] EGYPT Dr Mohamed Abdel Hamid Genedy Director, Communicable Disease Department Ministry of Health Cairo Dr Ibrahim Fahmy Moussa Manager, Expanded Programme on Immunization Ministry of Health Address: 39 Kasr Alaini Street Cairo Tel : +2 02 25313756 E-mail: [email protected]

Dr Amira Abdel Fattah Edris

NITAG Chairperson

Professor of Pediatrics

Pediatric Department

Cairo University

Address: 1125 Maspero Street

Cairo

Tel : +20122114366

E-mail : [email protected]


Dr Heba Abdel Aziz Pharmacist

VACSCERA

Ministry of Health Cairo ISLAMIC REPULBIC OF IRAN Dr Sayed Mohsen Zahraei Manager, Expanded Programme on Immunization Iranian Center of Disease Control Ministry of Health and Medical Education Hafez-Jomhoori Cross Roads Teheran Tel: +9821 66 705031 Fax:+9821 66 700143 E-mail: [email protected] ISLAMIC REPULBIC OF IRAN (cont’d)

Dr Mahmood Nabavi

Deputy, Iranian Center of Communicable Disease Control Ministry of Health and Medical Education Hafez-Jomhoori Cross Roads

Teheran

Tel: +982166707377


IRAQ Dr Yosra Hafidh Khalaf Deputy Manager, Expanded Programme on Immunization & National Surveillance Officer AFD Ministry of Health Baghdad Mobile 00964 790233 8189 E-mail: [email protected] Dr Sundus Jamal Patrous Habboush Data Management, Expanded Programme on Immunization Ministry of Health Baghdad


Tel: 00964 7902862817 E-mail: [email protected], [email protected] Dr Salim Rahma Shaanon Pediatrician, College of Medicine Al Nahrain University Baghdad Tel: 07701451971 E-mail: [email protected] JORDAN Dr Mohammad Ratib Surour

EPI Manager

Vaccine Preventable Diseases Department

Ministry of Health Amman Tel: +96277741620 Fax: +96265058671 E-mail: [email protected] Dr Najwa Khoury-Bulos Chairman of NITAG Professor, Jordan University Hospital Amman Tel: +962795547611 Fax: +9625353388 E-mail: [email protected] KUWAIT Dr Najlaa Alayyadhi Head of Communicable Disease Unit Ministry of Health Kuwait Tel: +96522459528 Fax: +96522467240 Email : [email protected] Dr Rashed Al Owaish Director, Public Health Department Ministry of Health Address: P.O.Box: 12227 Alshamieh 71653 Kuwait Tel: +965 99156490 Fax: +965 22425308


Email : [email protected] LEBANON

Mrs Randa Sami Hamadeh EPI Manager Ministry of Health Beirut Tel: +961 1 611173-4-5

Fax: +961 1615761


Dr Salman Mahmoud Mroueh Professor of Clinical Pediatrics American University of Beirut Address: P.O.Box: 11-0236/49B Beirut Tel: +913689995 Fax: +9611370781 E-mail: [email protected] LIBYAN ARAB JAMAHIRIYA Dr Mohamed Najib Smeo National Coordinator of EPI and Surveillance Director, Communicable Disease Department National Center for Infectious Diseases, Prevention and Control General People's Committee of Health and Environment Tripoli Tel: +218 514 626022 / +218 514 626202 Mobile: +218 912190442 / +218 925419319 Fax: +218 514 626061 E-mail: [email protected] ; [email protected] MOROCCO Dr Mohammed Charradi Head of Division of Maternel and Child Health Directorate of Population Ministry of Health Rabat OMAN Dr Salah Thabit Al Awaidy Director, Department of Communicable Diseases Surveillance & Control Ministry of Health P.O. Box: 393 PC 113 Muscat


Tel.: +968 99315863 E-mail: [email protected] , [email protected] Dr Saleh Mohamed Al Khusaiby Dean, Oman Medical College Chairman, National Technical Advisory Group Ministry of Health Muscat Tel : +96826844004 Mobile : +96899331795 E-mail : [email protected] PAKISTAN

Dr Altaf Hussain Bosan

National EPI Manager

National Institute of Health

Ministry of Health

Islamabad

Tel: +925 1 9255101 Fax: +925 1 9255086 / 9255460


Professor Tariq Iqbal Bhutta

Department of Pediatrics

King Edward Medical Collage &

Mayo Hospital Lahore

Chairman of the National Immunization Advisory Group 240-W DHA

Lahore

Tel: +924 2 572010

Fax: +924 2 5720457



Arshad Iqbal Dar

Director, EPI

Office of Director General Health Services

Punjab

Lahore

Tel: 042 99201143

Fax: 04299201139


PALESTINE Dr Iyad Monir Arafeh

Director of Preventive Medicine

Manager, Expanded Programme on Immunization

Ministry of Health

Ramallah

West Bank

Tel: +9720 2409052 / 3

Fax : +9720 2409052 / 3

E-mail: [email protected] , [email protected]


Mr Jehad Awad Ahmed

Manager, Expanded Programme on Immunization

Ministry of Health

Gaza

Tel: +972 82833460

Fax: +828 33460


QATAR Dr Asma Ali Al-Nuaimi Community Medicine Specialist Acting Head of EPI Section Health Protection and Communicable Disease Control Department of Public Health Supreme Council of Health Doha Tel: +9745859053 E- mail : [email protected] , [email protected] SAUDI ARABIA Dr Abu Hassan Muslim Younis National EPI Manager Ministry of Health Riyadh Tel: +966504858325 E-mail: [email protected] Dr Ziad Memish Assist Deputy Ministry of Health Riyadh SAUDI ARABIA Tel: +9661-212-4052 Fax: +9661-212-5052 Email: [email protected] SOMALIA Mr Mohamed Abdulahi Omar EPI focal point GAVI Sub-national Advisor


Ministry of Health Mogadishu Tel: +252615549353 E-mail: [email protected]

SUDAN Dr Amani Abdelmonaim

National Manager

Expanded Programme on Immunization

Federal Ministry of Health Khartoum E-mail: [email protected]

Dr Mabyou Mustafa Abdelwahab


NITAG Chairperson

Faculty of Medicine and Health Sciences

International University of Africa (I.U.A)

Khartoum

Tel : +249-0912344490

Fax : +249-0153998991

E-mail : [email protected]

Dr Angok Gordon Kuol Director General, Primary Health Care Ministry of Health Government of Southern Sudan Juba Tel: +249-911-579-446 E-mail: [email protected] Mr Taban Musa Lomayat EPI Deputy Director Ministry of Health


Government of Southern Sudan Juba Tel: 0915650347/0129322195 Email: [email protected] Dr William Mbabazi EPI Technical Advisor Management Sciences for Health Ministry of Health Government of Southern Sudan Juba Tel: 256-772-855-462 Email: [email protected] SYRIAN ARAB REPUBLIC Dr Khaled Baradie Manager Expanded Programme on Immunization Ministry of Health Damascus Tel: +963 11 2758143 Mobile: +963 933 326893 Fax: +963 11 2758123 E-mail: [email protected] SYRIAN ARAB REPUBLIC (cont’d) Dr Sahar Idlbi Pediatric Consultant NITAG Damascus University, Faculty of Medicine Damascus Tel: 00963113731200 E-mail: [email protected] TUNISIA Dr Mohamed Ben Ghorbal Major Physician of Public Health and EPI Manager Primary Health Care Department Ministry of Public Health Tunis Tel : +216 71 790483 (Office) Mobile: +216 98 359441 Fax : +216 71 789679 E-mail: [email protected] Dr Souad Bousnina



Hopital D’enfants de Tunis

Tunis

Tel: 00216-98325232 / 0021671563736

Fax: 0021671563736


REPUBLIC OF YEMEN Dr Essa Mohammed Essa National Manager for EPI Ministry of Public Health and Population Sana’a Tel : +967 1626046 Fax : + 967 1619805 E-mail : [email protected] Dr Thabet Nasher Al-Hammadi Head of NITAG Ministry of Public Health and Population Address: P.O.Box: 1352 Sana’a Tel: +967 1-220489 Fax: +967 1-238083 E-mail: [email protected]


EPI REGIONAL TECHNICAL ADVISORY GROUP

Dr Ali Jaffer Mohammed

Advisor, Health Affairs, Supervising

the Directorate General of Health Affairs

and Member of the Executive Board, Health Ministers’

Council for the Cooperation Council States

Ministry of Health

P.O. Box 393

Muscat

OMAN

Tel : +968 24 600808 Fax : +968 24 696099 E-mail : [email protected]

Dr Amr Kandeel Apologized

Under Secretary for Preventive Affairs

Ministry of Health

Cairo

EGYPT


Dr Francis Mahoney Apologized

Medical Epidemiologist

Indonesian Ministry of Health


Jakarta

INDONESIA

Mob: +62 812 10 89 231


Dr Hyam Bashour

Professor and Chair

Department of Epidemiology and Community Health

Faculty of Medicine

Damascus University

P.O. Box 9241

Damascus

SYRIAN ARAB REPUBLIC

Tel: +963 11 6618328/2134081 Fax: +963 11 6116953 E-mail: [email protected]

Dr Majid El Joneid

Deputy Minister for Primary Health Care

Ministry of Public Health & Population

Address: P.O.Box: 299

Sana'a

REPUBLIC OF YEMEN

Tel: +967 1 252217


Fax: +967 1 252 234


Dr Moncef Sidhom Apologized

Mayor of Nabeul- Town Hall of Nabeul

Monoi Slim St.

Nabeul 8000

TUNISIA

Tel: + 216 72 271822 / 98628242

Fax : +2167 22 71482 E-mail : [email protected]

Professor Naima El Mdaghri

Faculty of Medicine & Pharmacy

University Hospital

Casablanca

MOROCCO

Tel: 00212663613120


Dr Rana Hajjeh

Director, Division of Bacterial Diseases

National Immunization Programme

Centre for Disease Control and Prevention (CDC)


Atlanta

UNITED STATES OF AMERICA

Tel: 404-639-2819


Dr Stephen Lee Cochi Apologized

Senior Advisor

Global Immunization Division

National Immunization Programme

Centre for Disease Control and Prevention (CDC)

Atlanta 30333

UNITED STATES OF AMERICA

Tel : +1 404 6398723 E-mail : [email protected] , [email protected]

Professor Tahir Masood Ahmad

Dean, The Children’s Hospital and the Institute of Child Health

18-C, Model Town

Lahore

PAKISTAN

Tel: +9242 35869567 / +923008408698

Fax: +9242 9230358



Dr Ziad Memish Assist Deputy Ministry of Health Riyadh SAUDI ARABIA Tel: +9661-212-4052 Fax: +9661-212-5052 Email: [email protected]

OTHER ORGANIZATIONS Centers for Disease Control and Prevention (CDC Atlanta)

Dr Eric Mast

Chief Branch

VPD Eradication and Elimination Branch (DEEB)

Global Immunization Division/NCIRD/CDC Atlanta UNITED STATES OF AMERICA Tel: 404-639-8762


Centers for Disease Control and Prevention (CDC Atlanta) (cont’d) Ms Kristina Tove Ryman Field Support Officer US Centers for Disease Control and Prevention 1600 Clifton Road, NE MS-E05 Atlanta GA 30333 UNITED STATES OF AMERICA Tel: +404 639 6283 Fax: +404 639 8573 E-mail: [email protected] Ms Kathy Cavallaro

Health Scientist

Surveillance and Vaccine Introduction Team

NCIRD/GID/Strengthening Immunization Systems Branch

Global Immunization Division


Centers for Disease Control and Prevention

1600 Clifton Road, NE, Mailstop E-05

Atlanta, Georgia 30333

UNITED STATES OF AMERICA Tel: 404 639 8475

Fax: 404 639 8676


Bill and Melinda Gates Foundation Dr Robin Biellik

Consultant to the Bill & Melinda Gates Foundation

Tel: +41 22 367 20 02

Mobile: +41 78 890 45 77


Global Alliance for Vaccine and Immunization (GAVI) Dr Raj Kumar Senior Programme Manager, Country Support GAVI Alliance Secretariat Palais des Nations CH-1211 Geneva 10 SWITZERLAND Tel: +41 22 909 7163 Fax: +41 22907 6554 E-mail: [email protected] Global Alliance for Vaccine and Immunization (GAVI) (cont’d) Ms Sonia Varunavi Klabnikova Senior Programme Assistant, Programme Delivery Team GAVI Alliance Secretariat Palais des Nations CH-1211 Geneva 10 SWITZERLAND Tel: +41 22 909 6543 E-mail: [email protected] Network for Education and Support in Immunization (NESI)

Professor André Meheus


Head of NESI

Universiteit Antwerpen, Campus Drie Eiken

Universiteitsplein 1

B-2610 Antwerpen

BELGIUM

Tel: +32 3 265 2528

Fax: + 32 3 265 2875

E-mail: [email protected] Ms Katrin Verboven

Project Assistant, NESI

Universiteit Antwerpen, Campus Drie Eiken

Universiteitsplein 1

B-2610 Antwerpen

BELGIUM

Tel: +3232652524

Fax: +3232652875

E-mail: [email protected] Supporting Independent Immunization and Vaccines Advisory Committee (SIVAC) Dr Kamel Senouci, Director, SIVAC Initiative Supporting Independent Immunization and Vaccines Advisory Committees Agence de Médecine Préventive Institut Pasteur – 25-28 rue du Docteur Roux Cedex 15 -75724 Paris FRANCE Tel: + 33 1 53 86 89 20 Fax. : +33 1 53 86 89 39 Email: [email protected] Canadian International Immunization Initiative (CIII)

Dr Gaby Jabbour


Program Director, Canadian International Immunization Initiative Canadian Public Health Association 400-1565 Carling Avenue Ottawa, ON K1Z 8R1 UNITED STATES OF AMERICA Tel: 613-725-3769, Ext: 157 Fax: 613-725-9826 E-mail: [email protected]

SECRETARIAT OF THE MEETING

United Nations Children's Fund (UNICEF)

Dr Mahendra Sheth, Regional Health Advisor, UNICEF/MENARO. Tel: +96265502409. E mail: [email protected]

Dr Fouzia Shafique, Immunization Specialist (MNTE), Health Section, Programme Division, UNICEF/NYHQ, Tel: (212) 326-7157. Fax: (212) 824-6460. E-mail: [email protected].

Dr Zahra Mohammed Seid, Health Specialist, UNICEF Afghanistan Country Office, United Nations Operations Centre for Afghanistan, Jalalabad Road, Kabul, Afghanistan. Tel: +93 (0) 790 507602. Mobile: +93 (0) 798 507602. Email: [email protected] Dr Saboor Bahrami, Health Specialist EPI, UNICEF Afghanistan Country Office. Tel: +93798507605. E-mail: [email protected] Dr Mohamadou Bachir Mbodj, Chief, Child Survival and Development, UNICEF Djibouti. Lot No 155, Lotissement du Héron, B.P. 583, Djibouti. Tel: (253) 31.41.13, (253)31.41.11. Mobile: (253)602755. Fax: (253) 35.63.46, Email: [email protected] Dr Essam Allam, Health Officer, Child Survival and Development, UNICEF Egypt Country Office. Tel: 25265083~9, Ext:401 Fax: 25264218. Mobile: +20165505040 E-mail: [email protected] Mr Taha Al-Mulla, Health &Nutrition Specialist, UNICEF-Iraq, Fax: +962 65513745; P.O.Box 1551, Mobile: +962 796 400563, E-mail: [email protected]

Dr Mohammad Mushtaq Hussain Rana, Immunization Officer, UNICEF Punjab office, PAKISTAN.

Tel: 03334152500 E-mail: [email protected]


Dr Awadallah Younis Rammadan, Health Specialist, UNICEF/PALESTINE. Tel: +97282862400,

+97282820018 Fax: +97282862800 E-mail: [email protected]

Dr Maha Mehanni, Health Specialist (Immunization), Health and Nutrition Section, UNICEF Sudan Country Office, Gereif West (Manshiya), Block # First District H, Plot No. 6/3, P.O. Box 1358, Khartoum, Sudan. Tel: +249 183 471837. Mob: +249 (0) 912 299 302, E-mail: [email protected] Dr Kamel Ben Abdallah, Chief, Young Child Survival and Development, UNICEF/Yemen. Tel: 00967 1 211400, Ext 165. Fax: 00967 1 206092. Cell: +967 733195402. E-mail: [email protected]

Dr Gamila Hibatulla Ali Ismail, Health Officer, UNICEF Aden Sub-office, Yemen.

Tel: +967712223019 Fax: +02-235356 Email: [email protected] ,

[email protected]

World Health Organization, HQ

Dr Thomas Cherian, Coordinator, Expanded Programme on Immunization Plus (EPI), IVB, WHO/HQ. 20 Avenue Appia, Room M334, CH 1211 Geneva 27, SWITZERLAND. Tel: +4122 79 14460. Mobile: +41792173448 E-mail: [email protected]

Dr Roland Walter Sutter, Coordinator, POL, RAP, WHO/HQ. CH 1211 Geneva 27, SWITZERLAND. Tel: +41 22 79 14682. E-mail: [email protected]

Dr Philippe Duclos, Senior Health Adviser, Immunization, Vaccines and Biologicals, IVB, WHO/HQ. 20 Avenue Appia, Room M334, CH 1211 Geneva 27, SWITZERLAND. Tel: +41 79 244 6022, E-mail: [email protected]

Dr Rudolf Richard Eggers, Medical Officer, Expanded Programme on Immunization Plus (EPI), IVB, WHO/HQ. 20 Avenue Appia, Room M334, CH 1211 Geneva 27, SWITZERLAND. Tel: +41 22 79 15051. E-mail: [email protected].


Dr Carsten F. Mantel, Group Leader, New Vaccines Introduction, IVB, WHO/HQ. 20

Avenue Appia, Room M334, CH 1211 Geneva 27, SWITZERLAND. Tel: +41 22 79 13830.

E-mail: [email protected].

Ms Liliane Boualam, Technical Officer, POL, HSE, WHO/HQ. CH 1211 Geneva 27, SWITZERLAND. Tel: +41 22 79 13074. E-mail: [email protected] Ms Sarah Schmitt, WHO/Consultant.

World Health Organization, EMRO

Dr Hussein A. Gezairy, Regional Director, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765000. Fax: +202 26702492. E-mail: [email protected] Dr M. Helmy Wahdan, Special Advisor for RD/Polio Eradication Programme, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765000. Fax: +202 22765445. E-mail: [email protected]

Dr Jaouad Mahjour, Director, Communicable Disease Control, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765000. Fax: +202 22765414. E-mail: [email protected]

Dr Ezzeddine Mohsni, Coordinator, Disease Surveillance, Eradication and Elimination and Polio Eradication Programme, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765000. Fax: +202 22765445. E-mail: [email protected]

Dr Nadia Teleb, Regional Adviser, Vaccine Preventable Diseases and Immunization, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765000. Fax: +202 22765445. E-mail: [email protected]

Dr Tahir Pervaiz Mir, Regional Adviser, Polio Eradication Programme, WHO/EMRO, Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765000. Fax: +202 2765413. E-mail: [email protected]


Dr Faten Kamel, Medical Officer, Poliomyelitis Eradication Programme, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765000. Fax: +202 22765413. E-mail: [email protected]

Dr Daher Aden, Medical Officer, Vaccine Preventable Diseases and Immunization, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765552. Fax: +202 22765445. E-mail: [email protected]

Dr Humayun Asghar, Virologist, Polio, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 2765000. Fax: +202 2765413. E-mail: [email protected]

Dr Boubker Naouri, Medical Officer/Measles, Vaccine Preventable Diseases and Immunization, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765000. Fax: +202 22765445. E-mail: [email protected]

Dr Hinda Jama Ahmed, Technical Officer (LAB), Vaccine Preventable Diseases and Immunization, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.:+202 22765000. Fax: +202 22765445. E-mail: [email protected]

Dr Irtaza Ahmad Chaudhri, Technical Officer (FSP), Vaccine Preventable Diseases & Immunization, WHO/EMRO. Abdul Razzak Al Sanhouri St., Cairo, EGYPT. Tel.: +202 22765541. Fax: +202 227656445. E-mail: [email protected]

Dr Hala Safwat, Technical Officer – POL, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 2765000. Fax: +202 2765413. E-mail: [email protected]

Dr Nasrin Musa, Technical Officer (Cold Chain), Vaccine Preventable Diseases and Immunization, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.:+202 22765000. Fax: +202 22765445. E-mail: [email protected]

Dr Abdalla Mohammed Elkasabany, Technical Officer, Polio, WHO/EMRO, Abdul

Razzak Al Sanhouri St., Nasr City, Cairo, EGYPT. Tel.: +202 2765000. Fax: +202 2765413. E-mail: [email protected]


Mr Nahad Sadr-Azodi, Technical Officer, Measles, Vaccine Preventable Diseases and Immunization, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.:+202 22765000. Fax: +202 22765445. E-mail: [email protected]

Mr Hossam El-Din Abdel Rahman Ashmony, Technical Officer, Data Management, Vaccine Preventable Diseases and Immunization WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765571. Fax: +202 227656445. E-mail: [email protected]

Mr Raef Bekhit, Technical Assistant, Data Management Vaccine Preventable Diseases and Immunization, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 22765249. Fax: +202 22765445. E-mail: [email protected] Mr Mujtaba Hajou, WHO Temporary Adviser, (Rapporteur), WHO/EMRO. Tel: +98212292137398740 E-mail: [email protected]

Mr Kareem El Hadary, Help Desk Assistant, Information Technology & Tele-communication. WHO/EMRO, Abdul Razzak Al Sanhouri St., Nasr City, Cairo, EGYPT. Tel.: +202 22765238. E-mail: [email protected]

Mr Adam Abou Bakr, Office Equipment Technician, Division of General Management, WHO/EMRO, Abdul Razzak Al Sanhouri St., Nasr City, Cairo, EGYPT. Tel.: +202 22765114. E-mail: [email protected]

Mrs Zeinab Aboul Fadl, Senior Secretary, Division of Communicable Disease Control, WHO/EMRO. Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel: +202 22765273. Fax: +202 22765414. E-mail: [email protected]

Ms Nahla Ibrahim, Senior Secretary, Division of Communicable Disease Control, WHO/EMRO. Abdul Razzak Al Sanhouri St., Nasr City, Cairo, EGYPT. Tel.: +202 22765283. Fax: +202 22765414. E-mail: [email protected]

Ms Sara Warda, Secretary, Division of Communicable Diseases, WHO/EMRO, Abdul Razak El Sanhouri St., Cairo, EGYPT. Tel.: +202 2765000. Fax: +202 2765445. E-mail: [email protected]

World Health Organization, EMR Country Offices


Dr Omer Mekki Ahmed, Medical Officer/Polio, WHO Office IRAQ. Amman, JORDAN.

Tel.: +962 796517651 Mobile: +962 6 6517651. E-mail: [email protected]

Dr Ahmed Ali Darwish, Team Leader, Polio/EPI, Punjab, WHO Office, PAKISTAN. Tel; +92 300 8449124, Mobile(Egypt): +20120852003 E-mail: [email protected], [email protected]

Dr Salah Salem Haithami, Medical Officer/Polio, WHO Office Sudan. Grief West, Khartoum, SUDAN. Mobile: +249 912308734. E-mail: [email protected]

Dr Mulugeta Abraham Debesay, Medical Officer & Team leader/Polio, WHO Office, SOMALIA. Tel: +254 724259813. E-mail: [email protected]

Dr Mohammed Osama Mere, Medical Officer, EPI, WHO Office, YEMEN. Tel.: +967 711 994099. Fax: +967 1 251612. E-mail: [email protected] , [email protected]

Dr Abdul Baten Quamrul Hasan, Medical Officer, EPI. WHO Office, Chak Shehjad, Islamabad, PAKISTAN. Tel: +923008504178. E-mail: [email protected] Dr Assegid Tessema Kibede, Medical Officer/`EPI, WHO Somalia, SOMALIA. Tel: 245-734-600608 E-mail: [email protected]

Dr Yehia Mostafa Ahmed Hassan, Team Leader, Polio, WHO Office, Juba, SUDAN. E-mail: [email protected]

Dr Abdul Shakoor Waciqi, National EPI Officer and GAVI Advisor, UN Compound, main Jalalabad Road Kabul. AFGHANISTAN. Tel +0093 70025888. E-mail: [email protected]

Dr Ziad Mansour, Programme Coordinator, WHO Office, LEBANON. Tel: +961 1612970. E-mail: [email protected]

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