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IMMUNIZE AND PROTECT YOUR FAMILY In this issue:

1 XVIII TAG Meeting Conclusions and Recommendations 1 , CRS, and in the Americas 8 Project Launches Three Publications

Volume XXXI, Number 5 October 2009

Rubella, CRS, and XVIII TAG Meeting Measles in the Americas Immunization: Prioritizing Vulnerable Populations The Region of the Americas has made extraordinary progress in rubella The XVIII Meeting of the Technical Advisory Group (TAG) on -preventable Diseases of the Pan Ameri- and congenital rubella syndrome can Health Organization (PAHO) was held from 24-26 August 2009 in San José, . TAG meets every (CRS) elimination, with an estimated two years and functions as the principal forum for providing advice to PAHO Member States on vac­cine 112,500 CRS cases prevented in Latin policies and disease control efforts. The following is a summary of TAG’s technical deliberation and recom- American and the Caribbean over a mendations as presented in the final report. fifteen-year period. Endemic The XVIII TAG meeting focused on the challenges imposed by the current influenza A(H1N1) and circulation has been limited to only the next steps to document and verify the elimination of measles, rubella and congenital rubella syndrome in one country (). The last con- the Americas, while strengthening routine immunization. As he opened the meeting, Dr. Ciro de Quadros, TAG firmed indigenous rubella case was President, highlighted the progress achieved by the Americas and recognized the major challenges the Region reported in epidemiological week 4 of must still face. Dr. Socorro Gross-Galiano, Assistant Director, PAHO, remarked on the technical strengths of 2009. Canada and the United States the Expanded Program on Immunization (EPI) and the political support of Member States, who consider im- have reported 3 and 4 import-associ- munization as a public good. Dr. Daisy Mafubelu, Assistant Director, Family and Community Health, World ated rubella cases (genotype 2B in the Health Organization (WHO), reiterated WHO’s commitment to the strengthening of EPI in all WHO Regions. United States), respectively. In 2008- Dr. María Luisa Ávila, Minister of Health, Costa Rica, declared her country’s commitment to advancing the EPI 2009, the Americas reported a total of in the Region. Gina Tambini, Manager, Family and Community Health, PAHO, referred to the theme of the 40 CRS cases in Argentina (n=3), Bra- meeting, Immunization: Prioritizing Vulnerable Populations, and remarked that the Regional social and eco- zil (n=33), Chile (n=2), Mexico (n=1), 1 nomic conditions must be taken into consideration and primary health care strengthened. and the United States (n=1). In November 2002, D9 virus transmis- Figure 1. Percentage of Municipalities by DTP3 Coverage Levels, sion was interrupted. The last measles Latin America and the Caribbean, 2008* case associated with that outbreak oc- curred in Carabobo, . Since 2003, imported and import-associated measles cases have been reported in historically low numbers in the Ameri- cas: 119 in 2003, 108 in 2004, 85 in 2005, 237 in 2006, 167 in 2007, 207 in 2008,2 and 81 in 2009.3 In the period 2008-2009, 199 secondary cases re- sulted from a total of 69 importations, while for 24 cases the source was un- known.3 Measles cases reported in the Coverage Ranges: Americas have been isolated and/or sporadic and outbreaks have resulted <80% in a limited number of cases second- 80-94% ary to importation, with outbreak size ≥95% ranging from 1 to 52 secondary cases * Venezuela 2007 data in Canada and the United States, re-

1 Data until epidemiological week 31/2009. 2 Preliminary data. Source: PAHO-WHO/UNICEF Joint Reporting Form, 2009 3 Data until epidemiological week 31/2009.

See RUBELLA, CRS, AND MEASLES page 7 2 IMMUNIZATION NEWSLETTER Volume XXXI, Number 5 October 2009 PAN AMERICAN HEALTH ORGANIZATION

Several partners, such as the Centers for Disease Recommendation: rated carefully to clearly communicate national Control and Prevention (CDC) of the United • TAG reaffirms the recommendation that all target groups, in essence suppressing the public States, the Canadian Public Health Association countries should achieve ³95% cov- turnout for vaccination. This presents a unique (CPHA), the Global Alliance for and erage with all antigens in every municipality. communication situation in the Region that will Immunization (GAVI), UNICEF, the United States need to be handled carefully. Agency for International Development (USAID), Pandemic Influenza Considering that influenza A(H1N1) vaccine Rotary International, and Sabin Vaccine Institute, supply will be limited, countries will need to 1. Epidemiological Situation: Beginning in mid- reaffirmed their support to PAHO’s immuniza- prioritize risk groups. On 7 July 2009, WHO’s March 2009, surveillance systems in Mexico be- tion program and national programs during an Strategic Advisory Group of Experts in Immu- gan to report a sharp increase in cases of acute Interagency Coordination Committee Meeting. nization (SAGE) recommended that countries respiratory disease, characterized by cases of In the Americas, immunization has been respon- should consider three objectives (and associ- influenza, accompanied by severe pneumonia. ated population groups) when deciding upon sible for nearly one-quarter of the reduction in This increase began when cases of seasonal in- vaccination priorities: protecting essential health mortality in children aged <5 years between fluenza typically started to wane. The number infrastructure (vaccinating health care workers), 1990 and 2002, making a significant contribution of cases continued to increase during the first reducing morbidity and mortality (vaccinating to the achievement of the Millennium Develop- weeks of April when a new influenza A strain individuals with chronic disease), and reducing ment Goals (MDGs) and the goal of the WHO’s (H1N1) was identified. During the same time virus transmission (vaccinating school children). Global Immunization Vision and Strategy (GIVS). period, the United States and Canada also began After considering the current context, SAGE rec- However, the Region still faces substantial epide- to report confirmed cases of influenza A(H1N1). ommended the following population groups miological, demographic, and social challenges. Given the emergence of the new influenza strain New vaccines and new ways of organizing and (edited to reflect age ranges more commonly and its subsequent global spread, WHO moved managed in the Region): Health care workers; delivering services have provided hope for ad- through the pandemic phases, declaring pan- dressing those challenges. PAHO, through the pregnant women; population aged >6 months demic phase six on 11 June 2009. Previously with chronic disease; healthy young adults aged Regional Immunization Vision and Strategy healthy young adults have been a particularly 19-49 years; school children aged 5-18 years; (RIVS), has developed a road map to offer all the affected population group. The majority of in- children aged 6 months to 4 years; and healthy Region’s inhabitants the opportunity to receive fluenza A(H1N1) cases have presented with adults aged >50 years. the vaccines capable of protecting them against mild symptoms, including cough, , sore the greatest possible number of diseases, using throat, malaise, and ; gastrointestinal As with all new vaccines, the detection of events an integrated approach in the context of family symptoms have also been observed. Severe ill- supposedly attributable to vaccine or immuni- and community health, and also based on PA- ness has been characterized by pneumonia and zation (ESAVIs) will be essential. Neurological HO’s principles of equity, quality, universal ac- respiratory insufficiency, whereas bacterial co- ESAVIs are one specific concern. Guillain–Barré cess, solidarity, and Pan Americanism. TAG fully has been infrequent. Risk factors for se- Syndrome (GBS) is a rare condition with an an- endorses the RIVS and the road map. vere illness are emerging and appear to include nual incidence of 10–20 cases per one million , heart disease, diabetes, asthma, adult population and has been associated with Routine Immunization pulmonary emphysema, immunodeficiency, and many respiratory and gastrointestinal illnesses. obesity. During the swine influenza vaccination cam- Routine coverage for BCG, DTP-3, and polio-3 in paigns of 1976 in the United States, the increase 2. PAHO’s Regional Plan for Pandemic Vac- children aged <1 year and measles-containing in the GBS cases above the background rate was cination: As part of PAHO’s technical coopera- vaccines in children aged 1 year remains over approximately one case per 100,000 persons tion activities with Member States in response 90% at the Regional level. Also, all countries in vaccinated. Through the surveillance of acute to the influenza A(H1N1) pandemic, a Regional the Region include measles-rubella containing flaccid paralysis (AFP) from 2000-2008 in the Vaccination Plan for Pandemic Vaccination was vaccines in their routine immunization sched- Americas, approximately 10,500 GBS cases were developed and distributed to Member States in ules. All countries but are using Haemophi- diagnosed, resulting in an average incidence of May 2009. Ensuring equitable access to vac- lus influenzae type b (Hib) and vac- 0.82/100,000 aged <15 years. cine, the two main objectives of this plan are to cines for infants, and 35 countries and territories (a) strengthen seasonal influenza vaccination in 3. Recommendations: Considering the current were using the seasonal target- the Region and (b) assist Member States in their dynamic epidemiological situation of the influen- ing various groups by 2008. preparation for the introduction of influenza za A(H1N1) virus and the current SAGE recom- While the reported coverage at national level is A(H1N1) pandemic vaccine. mendations concerning the use of an influenza high throughout the Region, heterogeneity in A(H1N1) vaccine, TAG makes the following rec- As of 21 August, the majority of country and coverage exists at municipal level, with a signifi- ommendations, which may need to be updated territories had estimated the need to vaccinate cant proportion of municipalities reporting cov- based upon evolving information. approximately 200 million people. As more in- erage <95% (Figure 1). formation becomes available concerning dose • The national objectives for vaccination against Given that equity is a key principle of PAHO’s requirements and finalized target groups, this pandemic influenza should be to reduce technical cooperation, national immunization consolidation will need to be revised. Because morbidity and mortality and keep health ser- programs, with PAHO support, should continue intense public demand for influenza A(H1N1) vices functioning. Therefore, priority groups to focus on reaching every family in these low- vaccine is expected to be coupled with initial vac- for vaccination should be health care work- performing municipalities. cine shortages, messages will have to be elabo- ers, pregnant women, and persons aged >6 PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXXI, Number 5 October 2009 3

months with chronic diseases (heart disease, laboratories by allocating more resources. Recommendations: diabetes, respiratory conditions, immunodefi- • Countries should conduct retrospective hos- • While there is poliovirus circulating in the ciency, obesity). Depending on the epidemio- pital-based studies to more accurately de- world and the danger of importations con- logical situation, availability of resources, and termine morbidity and mortality of influenza tinues, TAG recommends that the vaccine of EPI capacity, TAG suggests the following ad- A(H1N1). choice remain OPV as stated in previous TAG ditional risk groups to be prioritized: children • To promote dose-sparing and ensure equi- reports and as recommended by WHO. This aged 6 months to 4 years, healthy children table access to the limited pandemic vaccine recommendation will continue to be reviewed aged 5-18 years, and healthy adults aged 19- supply, adjuvanted vaccine should be used as the global situation evolves. 49 years. whenever possible. • To reduce the risk of importations and to pre- • Due to the annual high morbidity and mor- • Industrialized countries in the Region of the vent another outbreak caused by a Sabin-de- tality caused by seasonal influenza , Americas with abundant pandemic vaccine rived poliovirus, countries that do not achieve vaccination with the seasonal vaccine should access are encouraged to contribute vac- OPV coverage >95% in every municipal- be continued. Technical recommendations cine supplies to countries with considerable ity should conduct annual OPV immunization regarding the simultaneous administration of less access. To do this, they should consider campaigns for children aged <5 years, regard- both influenza vaccines should be followed, limiting their vaccine interventions to priority less of their vaccination status. when applicable. Continued epidemiological groups, as seconded by SAGE and TAG. • Countries should maintain certification stan- monitoring of the circulating influenza strains • Recognizing that and Mexico are em- dards of AFP surveillance (compliance with should be continued to inform decisions re- barking on influenza vaccine production, TAG surveillance indicators). garding the future composition of influenza encourages PAHO to develop a Regional stra- • To prevent reintroduction of wild poliovirus vaccines. tegic plan that will ultimately lead to Regional into their communities, all American countries • Countries should conduct retrospective stud- vaccine self-sufficiency. should conclude phase I of wild poliovirus ies to calculate baseline rates of GBS in differ- • PAHO should revitalize the supply chain al- containment in the laboratories as requested ent populations so that potential changes in liance that in the past successfully identified by the Regional Commission on Containment. the incidence of GBS associated with influenza unused oversupply of vaccine in some coun- A(H1N1) virus circulation, and potentially with tries that could be used in other resource-poor Pertussis influenza A(H1N1) vaccines can be detected. countries. • Countries should monitor the following events TAG considers that the of pertus- during the introduction of the vaccine: (1) seri- • To assure equitable access to an influenza sis must be properly studied in Latin America ous events (require hospitalization, life-threat- A(H1N1) vaccine, countries should use the to guide the decision-making process, and that ening, cause disability, fatal), (2) new events, PAHO Revolving Fund for Vaccine Procure- PAHO must support countries in this initiative. (3) rumors, (4) events that occur in groups of ment to buy vaccine. In that respect, TAG welcomes the joint CDC/ people, and (5) programmatic errors. Sabin Vaccine Institute/PAHO project aimed at • Countries should prepare social communi- Poliomyelitis and Containment of strengthening the surveillance system in 3 coun- cation strategies to maintain public trust by Wild Poliovirus in Laboratories tries in the American Region as a way of creating informing in a clear and transparent fashion; evidence that can facilitate the decision-making ensure that individuals and their families are TAG supports the need to minimize the poten- process in pertussis control. using mitigating interventions for prevention; tial for reintroduction of wild polioviruses into Recommendations: ensure that the public fully understands the communities through containment of poliovi- rus strains in the laboratories. Most countries recommendations and the reasons for vacci- • Countries must consider pertussis control as a of the Region of the Americas have concluded nation of priority groups; and understand the priority and strengthen their surveillance sys- Phase 1 of the Plan of Action for Containment, general benefits and risks of events associated tem and control measures. corresponding to the conduction of a survey and with vaccination when they occur. • Changes in immunization policies and con- the elaboration of a national inventory of labo- • PAHO and WHO should continue to strength- trol measures should only be justified with ratories that may have stored wild poliovirus or en and prioritize the global regulatory net- adequate documentation and analysis of the potential infectious material. TAG received a re- work and national regulatory bodies that basic causes of outbreaks. port on containment and notes the progress that comply with WHO policy. • Before shifting from the whole-cell vaccine has been made in containment activities in the • In unique emergency situations, TAG endorses (wP) to the acellular vaccine (aP), countries Region and looks forward to the final report that the SAGE recommendation which allows for should take into consideration the impact of the Regional Commission on Containment will the change on the immunization schedule, countries to buy unlicensed vaccine. In these send to the Global Commission. situations TAG also recommends that national delivery issues, and affordability. regulatory authorities fast track their licensing Acute flaccid paralysis (AFP) surveillance re- • Since adding boosters to the primary three- procedures. mains in place in the American Region and the dose schedule will extend the duration of the th • In order to ensure comparability, countries polio laboratory network continues to conduct immunity, countries should apply a 4 DTP should follow PAHO/WHO guidelines to timely analysis of specimens of AFP cases. dose as part of the regular vaccination sched- th strengthen and standardize surveillance sys- As long as global eradication and containment in ule. The coverage of the 4 DTP dose must tems. the laboratories are not achieved, the risk of re- be monitored and must become part of the • Ministries of Health should continue strength- introduction of wild polio virus into the American reporting system. ening national influenza centers and influenza Region remains a real threat. • During outbreaks, immunization of newborns 4 IMMUNIZATION NEWSLETTER Volume XXXI, Number 5 October 2009 PAN AMERICAN HEALTH ORGANIZATION

can begin at 6 weeks of age, especially if that gration originates. vaccinated over 10 mil- in the Region, a comprehensive age group is being affected. Death prevention lion people in the period 2004-2007; Brazil, 90 approach should be adopted that highlights in neonates will rest in community awareness million over the past 10 years; and con- vector control of Aedes aegypti in urban cen- and medical protocols. The importance of ducted a national campaign, vaccinating approx- ters bordering enzootic areas. Elimination of obtaining specimens for culture, especially in imately 5 million people in 2007. In response to breeding sites should be undertaken and, neonates, should be underscored. the 2008 outbreaks, Brazil administered over insofar as possible, environmental conditions • The current emphasis on PCR for pertus- 18 million doses; Argentina, 1.5 million; and should be improved so that they don’t foster sis diagnostics in the field makes obtaining over 3.5 million. Concerning ESAVIs, in mosquito reproduction. a culture appear to be less important. How- 2007, Peru reported a cluster of 5 cases of vis- • Countries should have a risk communication ever, since PCR can result in false positives, it cerotropic disease, and in 2008, Brazil reported plan in order to avoid crisis situations due to should be stressed that obtaining specimens 6 cases, Argentina 1 case, and Paraguay 1 case. yellow fever outbreaks and ESAVIs related to for culture is still essential for confirming the TAG acknowledges the progress countries have the vaccine. diagnosis, especially in neonates. made in vaccinating populations in enzootic • Countries should consider adequate screen- areas through the implementation of plans for ing mechanisms to identify vaccine contrain- Yellow Fever yellow fever control and the inclusion of the dications and precautions before vaccination. in the routine schedule in Yellow fever is a zoonosis found in extensive Rotavirus and Pneumococcus areas of subtropical and tropical Africa and the most countries. However, the recent yellow fe- Americas. In the past 30 years, yellow fever vi- ver dynamic observed makes it necessary to re- 1. Rotavirus: Two rotavirus vaccines are avail- rus activity in the Americas was confined to the assess the risk areas, considering the changing able on the market and prequalified by WHO. enzootic area shared by Bolivia, Brazil, Colom- ecological and environmental conditions that Since 2006, 14 countries and one territory have bia, , , , , favor yellow fever transmission. This will permit introduced this vaccine in their national vac- Peru, , , and Ven- better definition of the areas and populations to cination schedule: in 2006, Brazil, , ezuela; however, since late 2007, the Region has vaccinate. Mexico, Panama, , the United States, witnessed intense circulation of the yellow fever 2. Recommendations: and Venezuela; in 2007, Ecuador; in 2008, Boliv- virus, with extensive epizootics and outbreaks ia; in 2009, , Guyana, , Peru, of human cases, expanding the enzootic area to • Countries with enzootic areas should consider and the British territory of Cayman Islands. The Paraguay and northern Argentina. completing their plans for yellow fever control countries of the Region of the Americas were the vaccinating all residents in these areas aged In late 2007, Paraguay reported its first yellow first to introduce this vaccine into their vaccina- >1 year. Travelers to these enzootic areas tion programs, and for the first time ever, a new fever case in 34 years, as part of a large epizo- should also be vaccinated. otic wave which began in Brazil. The first case vaccine is being introduced in developing and • Countries should assess vaccination coverage developed countries at the same time. in Paraguay was reported from the north of the through rapid monitoring or other method- country; the disease subsequently spread south- ologies to ensure that the entire population Many lessons were learned from the introduc- ward, with 28 confirmed yellow fever cases, in- living in risk areas is vaccinated. tion of the in the Region of the cluding a cluster of 9 cases of urban transmis- • The four remaining countries with enzootic Americas: for example, the need for adequate sion of yellow fever detected in the metropolitan areas that have not yet introduced the yellow evaluation of the cold chain and the logistics area of Asunción. Prior to this, the last confirmed fever vaccine in their routine program should of the immunization program prior to intro- outbreak of urban yellow fever in the Americas target children aged one year in order to have ducing a new vaccine, the need for training at had been in Brazil in 1942. In Argentina, epizoot- protected cohorts in the long term. Vaccina- all levels, the importance of strengthening the ics and monkey deaths were reported from the tion coverage should be maintained at over network for ESAVI reporting and investigating, Misiones and Corrientes Provinces in January 95% in routine vaccination programs for the the importance of ensuring the sustainability of 2008. An outbreak of eight yellow fever cases in first year of life. the EPI vaccine in the national budget, and the humans was reported from the Misiones Prov- • Epidemiological information and careful yel- establishment of rotavirus diarrhea surveillance ince in February. Prior to this outbreak, Argen- low fever risk assessment, considering eco- prior to the introduction of the vaccine and the tina had not reported any human cases of yellow logical, environmental, and cultural factors subsequent maintenance of that surveillance as fever in 40 years. that favor disease transmission, should guide fundamental to decision-making. 1. Yellow Fever Vaccination: Yellow fever can vaccination activities. Therefore it is important 2. Pneumococcus: Two conjugate pneumococ- be prevented with live attenuated yellow fever that countries maintain and improve their epi- cal vaccines are currently on the market: the vaccine 17D. Over 500 million doses have been demiological surveillance systems. heptavalent and the decavalent. The heptava- administered worldwide since its development • In light of outbreaks in Brazil, Paraguay, and lent vaccine is recommended by WHO, and in 1937. The yellow fever vaccine has been con- Argentina in 2008, Regional and Global Emer- the decavalent vaccine is in the prequalifica- sidered safe and effective. gency vaccine supplies were consumed in their tion process. The United States (2001), Canada Mass vaccination activities vary from country entirety in January and February 2008. Given (2002), Bermuda (2008), Mexico (2008), Uru- to country, from reactive campaigns to control the limited availability of yellow fever vaccines, guay (2008), Costa Rica (2009), and Peru (2009) outbreaks to preventive campaigns conducted in priority should be given to primary vaccination have introduced this vaccine in their vaccination stages, targeting the resident population in en- and re-vaccination should be avoided. schedule for children aged <1 year. A 13-valent zootic areas, border areas, and areas where mi- • Given the current risk of the reurbanization of vaccine was recently licensed in some countries. PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXXI, Number 5 October 2009 5

Financial Sustainability: The PAHO Revolving Fund for Vaccine Procurement Currently, the RF offers 28 antigens, in addition to syringes, needles, and cold chain equipment. Figure 1. PAHO Revolving Fund: Vaccine Doses Purchased and Total Cost, 2000-2010 In 2008, 41 countries and territories bought $600.00 300.00 vaccines through the RF for a total amount of US $271.7 million. Demand forecast for 2009 is $500.00 250.00 approximately $369.5 million. ) ) During its 30 years of existence, the RF has s s $400.00 200.00 n n o i l

faced many challenges and risks. Current chal- o l i i l l i

lenges include the introduction of new vaccines M ( M

( $300.00 150.00

at high prices and with a single provider, the s $ e s participation of new actors in the field of immu- S o U nization, and the development of new market $200.00 100.00 D mechanisms. Member States have manifested their desire to see the RF adapt to those new $100.00 50.00 conditions while maintaining the principles of Pan Americanism, equity, solidarity, and uni- $0.00 0.00 versal access. 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010* Recommendations: Total US$ FOB** Quantity of Doses • TAG recommends the continued and strengthened participation of Member States 2001: Increase BCG and Hepatitis B 2004: Reduction Measles, MR, MMR, and Polio in the Revolving Fund, in order to benefit 2006: Increase polio (Brazil) 2008: Increase MR (Brazil) * 2010: Estimated and includes H1N1 vaccine ** Free on Board from the consolidated purchase of vaccines, syringes, and other supplies, and to maintain Source: PAHO Revolving Fund for Vaccine Procurement. the Revolving Fund as a mechanism of col- laboration and solidarity. response to the needs of Member States. • In view of current challenges, the PAHO Re- • PAHO must continue to find ways to increase • PAHO must work internally with all parties volving Fund for vaccine procurement must the level of capitalization of the Revolving involved in the management of the Revolving remain faithful to its principles of Pan Ameri- Fund in order to maintain the line of credit Fund in order to improve its operational ef- canism, equity, universal access, and solidarity. at levels allowing for an adequate and timely ficiency.

3. Recommendations: of the ESAVI network. control of cervical cancer. The plan calls for in- • Countries should improve or begin sentinel • PAHO should continue to support the coun- creased action to strengthen programs through surveillance of rotavirus diarrhea, pneumo- tries and encourage them to conduct special an integrated package of services: health infor- nia, and bacterial meningitis in children aged studies on the introduction of a new vaccine mation and education, screening and pre-cancer <5 years, so that the impact of vaccine intro- when necessary. treatment, invasive cancer treatment and pal- duction can be adequately assessed and the • Rotavirus and pneumococcus vaccines should liative care, and evidence-based decisions on prevalence of circulating strains and changes be universally introduced in the immunization whether and how to introduce HPV vaccines. The in the epidemiological profile of the disease schedule, using vaccination regimens with greatest barriers to providing equity and access to monitored. evidence of efficacy in developing countries. HPV vaccines and new screening technologies for • All countries should systematically report their Introducing those vaccines in priority areas HPV virus detection are the prices of the products. surveillance data for rotavirus diarrhea, pneu- (i.e., only in certain municipalities/towns or provinces) makes it more difficult to assess Recommendations: monia, and bacterial meningitis to facilitate the the impact of the intervention and might cre- development of an epidemiological profile for • HPV vaccine should be delivered as part of an ate logistical and programming problems for the diseases in the Region, compare the pro- integrated package including screening, health the EPI. Therefore, these vaccines should be files of different countries, geographical areas, promotion, pre-cancer and cancer treatment, introduced nationwide whenever feasible. If and seasonality, and evaluate the epidemio- and palliative care. a country can only introduce them to prior- logical changes in these diseases that could • Countries should conduct cost-effectiveness ity groups, this should be done as a first step occur with the introduction of the vaccine. studies to make evidence-based decisions toward universal introduction. • Before introducing any new vaccine, coun- regarding HPV vaccine introduction into the regular program. PAHO should continue to tries should develop a plan of action, based Human Papillomavirus on PAHO guidelines, that includes basic activi- provide technical cooperation to conduct ties such as the evaluation of the cold chain at In 2008, PAHO’s Directing Council approved these studies and gather the framework of all levels, logistics, training, and strengthening the regional plan for integrated prevention and evidence needed to make informed decisions. 6 IMMUNIZATION NEWSLETTER Volume XXXI, Number 5 October 2009 PAN AMERICAN HEALTH ORGANIZATION

• The PAHO Secretariat should report back to portunity for countries to evaluate the impact with the development of impact studies for the next TAG on the progress of the imple- of pandemic vaccine. influenza and other vaccines and assist them mentation of the Regional Plan for integrated • Strengthen disease e-learning tools for evi- with reporting results at the next TAG. prevention and control of cervical cancer, in- dence-based decision making. • ProVac should continue its efforts to standard- cluding studies being conducted in • Conduct country-specific economic studies in ize approaches, to the extent possible, when and elsewhere on disease burden, surveil- Jamaica, Trinidad & Tobago, and Honduras conducting economic studies. lance implementation, and economic analy- on HPV vaccination program costs. ses. • Convene first meeting of an ad-hoc scientific Coverage Data Quality panel of experts to review the scientific basis Evidence-based Decisions of the economic tools being developed. • TAG reaffirms the recommendation that sys- Examples of work were presented from Bolivia tematic and periodic assessment of coverage PAHO’s ProVac Initiative is working to enhance and Ecuador. The cost-effectiveness of rotavi- data accuracy, consistency, completeness, and national capacity to make informative evidence- rus and introduction, timeliness should become a regular activity based decisions regarding new vaccine introduc- respectively, were analyzed using data on the within national immunization programs. This tion. Next year’s work plan includes the follow- incidence of the disease, health services utiliza- assessment should be conducted within the ing tasks: tion and costs, vaccination program costs, and context of regular on-going evaluation and • Complete modifications of the pneumococcal vaccine coverage and efficacy rates. In Bolivia supervisory activities. model. the data were collected from sentinel sites over • Monitoring numerator trends by month and • Hold the first meeting of Economic Centers of a one-year period and were analyzed from the year and calculating drop-out rates between Excellence. perspective of the . Using US $19 all doses, including DTP2, and monitoring de- • Continue to develop the OLIVES1 on-line da- to fully vaccinate a child, they estimated that nominator variations should be done system- tabase of the ProVac website which will serve with rotavirus vaccination the cost of averting atically at all levels. as a repository of data for developing country a DALY to be $213. In Ecuador, data were ana- • Immunization programs should be aware of use when conducting economic analyses. lyzed from the perspective of the society. Using the conduction of surveys that, among other • Strengthen influenza tools to provide an op- $79.05 to fully vaccinate a child, Ecuador deter- health indicators, calculate vaccination cover- mined the cost of averting a DALY to be $2,640. age in order to ensure that questionnaires are 1 OLIVES (On-Line International Vaccine Economics and Statistics) is adequate and interviewers properly trained to a website presenting country-specific statistical parameters used Recommendations: TAG fully supports the im- assess vaccination status, and that the results in economic evaluations, bringing together internationally com- plementation of the ProVac initiative. parable statistics from a variety of data sources (WHO, UNICEF, are internally consistent between biologicals. UN, Demographic and Health Surveys, World Bank). Available at • The ProVac initiative should assist countries • PAHO’s immunization program should devel- http://gcpsys.com/. op guidelines regarding coverage monitoring and data quality, and establish strategic alli- ances with entities specializing in vital statistics Integrated Surveillance and demography to promote the generation In 2007, the World Health Organization issued a document entitled Global Framework for Immu- and availability of accurate denominators fig- nization Monitoring and Surveillance,* with the object of recommending actions to improve the ures to calculate vaccination coverage. surveillance of vaccine-preventable diseases, primarily taking advantage of the strengths of the ex- • PAHO should continue supporting countries isting surveillance systems. In the Region of the Americas, Costa Rica was selected for the project’s to improve their immunization data quality pilot study, with the endorsement of the country’s national authorities and the collaboration of the by promoting the evaluation of the quality of Pan American Health Organization and U.S. Centers for Disease Control and Prevention. their immunization data and information sys- tems.2 PAHO should also support the imple- The objectives of the integrated surveillance are basically geared to ensuring better use of hu- mentation follow-up of the recommendations man and financial resources, improving the effectiveness of activities, and maintaining the quality resulting from such assessments. of services and information. Although the ability of health services to monitor existing vaccine- • Countries using national computerized nomi- preventable diseases is the ideal, it is difficult to operationalize, demanding teamwork and coor- nal immunization registries should document dination of functions. their experiences, successes, and lessons The pilot project will be a way to identify strengths and weaknesses of the integrated surveillance learned in order to share them with other process, document its progress, and recognize advances, disadvantages, advantages, and lessons countries. learned. The information can be shared with all countries interested in adapting the methodology and contributing to the implementation of integrated surveillance in the Region and other regions Note: For a complete copy of the report, please contact the Comprehensive Family Immunization Project at fch-im@ as well. paho.org or see the project’s webpage at www.paho.org/ immunization. Recommendation: • The different phases of the pilot project for integrating the surveillance of vaccine-preventable diseases in Costa Rica should be strengthened, monitored, and evaluated to identify obstacles to project implementation so that it serves as an example for other countries. 2 These systems are defined as the people involved in data collec- * Global framework for immunization monitoring and surveillance. Available at: http://www.who.int/ immunization/docu- tion and processing, data recording practices, and activities that ments/WHO_IVB_07.06/en/. process and aggregate the data and information, including soft- ware if available, in a given country. PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXXI, Number 5 October 2009 7

RUBELLA, CRS, AND MEASLES from page 1 two routine MMR doses is guaranteed for all classified only after the laboratory and epide- municipalities can the follow-up campaigns miologic teams have reviewed all laboratory spectively, and from 1 to 2 secondary cases in be waived and, before introduction of routine results and epidemiologic data. Latin America and the Caribbean. Sixty percent MMR2, countries should determine a suitable • Laboratories should attempt to establish a ge- of measles importations to the Americas for the age for administration of this dose, define an netic baseline of rubella and measles viruses same period have come from Europe; these accurate denominator, implement a nominal through characterization of endemic cases or outbreaks occurred in Argentina, Canada, Chile, registry, monitor coverage, and track default- archival samples (serum, oral fluid, nasopha- Ecuador, Jamaica, Peru, and the United States. ers. ryngeal swab, and tissue), starting with the year 2000. Following the interruption of indigenous measles Surveillance: • Laboratories/countries should establish the virus circulation in 2002 in the Americas and in • Countries should achieve an adequate level light of the achievements in the implementation means to support CRS case confirmation and of preparedness by developing national plans monitoring of virus shedding by CRS cases. of immunization strategies and the accelerated for preparation and rapid response to an im- reduction in the number of rubella cases, Resolu- portation and potential outbreaks. Regional Plan of Action for Documenting and tion CSP27.R2 was adopted during the 27th Pan • Countries should actively involve the private Verifying Elimination: TAG endorses the re- American Sanitary Conference in October 2007. sector in measles, rubella, and CRS surveil- gional plan of action for the documentation and The resolution authorized the formation of an lance to support the rapid detection of im- verification of measles, rubella, and CRS elimina- international Expert Committee and urged PAHO portations and response to outbreaks and to tion in the Region of the Americas. The plan of Member States to establish national commissions strengthen immunization activities. action provides an opportunity to place immu- to document and verify elimination in each coun- • Countries should guarantee the full integration nization programs as a high-ranking priority on try of the Region. This decision marked the begin- of measles and rubella surveillance systems the political agenda of countries and strengthen ning of the process for the documentation and and ensure the completion and continuous vaccination activities and surveillance systems. verification of the interruption of endemic mea- monitoring of the recommended standard- • In accordance with PAHO Resolution CSP27. sles and rubella transmission in the Americas. ized measles/rubella surveillance indicators to R2, countries should establish a national com- attain high-quality surveillance, emphasizing mission and develop a plan of action for the Recommendations high-risk and “silent” areas. documentation and verification of measles, rubella, and CRS elimination, which includes a TAG congratulated Member States and their • Countries that have reported the last rubella realistic timetable for goal completion. health workers for the tremendous efforts made and CRS cases should implement activities, • Countries should complete the analysis and toward achieving and maintaining measles, such as active case searches and monitoring evaluation of the following key components rubella, and CRS elimination and for the rapid of virus excretion of identified CRS cases, in of the documentation process as described in response to importations to the Americas. TAG order to document and verify the interruption the regional plan of action: also urges other regions to eliminate measles of endemic virus transmission. ——Analysis of coverage with the measles- and rubella as a step towards eradication. In ad- • TAG reiterates the previous recommendation in population cohorts aged dition to the following recommendations, TAG to increase sensitivity and quality of the CRS <40 years. encourages countries to continue to adhere to surveillance system by strengthening sentinel ——Epidemiology of measles, rubella, and CRS previous TAG recommendations regarding mea- site reporting. and the impact of vaccination strategies. sles, rubella, and CRS surveillance, vaccination Laboratory: Documentation that elimination of ——Quality and efficiency of integrated mea- strategies, and laboratory issues. measles and rubella has been achieved requires sles, rubella, and CRS surveillance. that each national laboratory produces the high- ——Analysis of virologic epidemiology and veri- Immunization Strategies: est quality surveillance data possible. The final fication of the absence of endemic measles • Countries should routinely maintain high, ho- report and recommendations of the Measles/Ru- and rubella virus strains (through viral de- mogenous coverage (>95%) by municipality bella Laboratory Network Meeting are endorsed st tection) in all countries of the Americas. through the administration of the 1 routine by TAG. dose, monitor the accumulation of suscep- ——Sustainability of national immunization • Laboratories must be fully certified according programs to maintain measles and rubella tibles, and continue the implementation of to the current WHO and PAHO LabNet stan- high quality nationwide follow-up campaigns elimination. dards. • Countries should prepare and implement a to ensure the vaccination of the entire cohort • Countries should establish priorities for ob- as a second opportunity to give the first dose national plan of action for the verification of taining viral samples with emphasis on, for measles, rubella, and CRS elimination, with to those children that were missed by the rou- example, border areas, industrial areas, areas tine program. technical cooperation from PAHO and the in- with frequent foreign travel, and contacts with ternational Expert Committee. • In accordance with previous TAG recommen- a high likelihood of exposure. dations, any resident of the Americas travel- • Laboratory and epidemiologic teams from ing to areas with reported measles or rubella each country should use the specific PAHO cases should be immune to measles and ru- laboratory testing guidelines for classification bella and provide proof of vaccination before of sporadic measles and rubella cases accord- departure. ing to their needs. • Only where coverage >95% with each of the • Measles, rubella, and CRS cases should be 8 IMMUNIZATION NEWSLETTER Volume XXXI, Number 5 October 2009 PAN AMERICAN HEALTH ORGANIZATION

Immunization Project Launches Three Publications A special event took place during the XVIII meet- ing of the Technical Advisory Group on Vaccine- preventable Diseases to celebrate the launching of three books by PAHO’s Immunization Project. Images that inspire (The Mobilization of the Americas to Eliminate Measles and Rubella), presented by María Elena Carballo, Minister of Culture, Costa Rica, is a book dedicated to the health workers and the people of the Americas that made the elimination of measles and ru- bella possible in the Region. The Compendium of Measles Articles and the Compendium of Ru- bella and Congenital Rubella Syndrome Articles, presented by Dr. de Quadros, are compilations of Immunization Newsletter articles. Dr. Oscar Arias, President of Costa Rica, also attended the event and highlighted the progress accomplished by the Region. He remarked that while technical From left to right, Dr. María Luisa Ávila, Minister of Health, Costa Rica, Dr. Oscar Arias, President, Costa Rica, María Elena expertise was required to support health activi- Carballo, Minister of Culture, Costa Rica, and Dr. Ciro de Quadros, TAG Chairman. ties, political support and commitment from all countries were also required. He emphasized ment of the Pan American Health Organization, to health and that those three components are that thanks to the Expanded Program on Immu- and the TAG, the Americas have made consider- essential for the advancement of populations in nization, the Revolving Fund for Vaccine Procure- able progress, within the framework of the right this Region.

The Immunization Newsletter is published every two months, in English, Spanish, and French by the Immunization Unit of the Pan American Health Organization (PAHO), Regional Office for the Americas of the World Health Organization (WHO). The purpose of the Immunization Newsletter is to facilitate the exchange of ideas and information concerning immunization programs in the Region, in order to promote greater knowledge of the problems faced and possible solutions to those problems.

References to commercial products and the publication of signed articles in this Newsletter do not constitute endorsement by PAHO/WHO, nor do they necessarily represent the policy of the Organization.

ISSN 1814-6244

Volume XXXI, Number 5 • October 2009

Editor: Jon Andrus Associate Editors: Béatrice Carpano and Carolina Danovaro

Immunization Unit 525 Twenty-third Street, N.W. Washington, D.C. 20037 U.S.A. http://www.paho.org/immunization