Coordination of Operation MECACAR Plus

EUR/ICP/CMDS 03 02 04 ENGLISH ONLY UNEDITED E69229

REGIONAL OFFICE FOR EUROPE

______

COORDINATION

OF OPERATION

MECACAR PLUS

Report on the Sixth Meeting

Ankara, Turkey

20–22 October 1999

SCHERFIGSVEJ 8 DK-2100 COPENHAGEN Ø DENMARK

TEL.: +45 39 17 17 17 TELEFAX: +45 39 17 18 18

TELEX: 12000 E-MAIL: [email protected] WEB SITE: HTTP://WWW.WHO.DK 2000 EUROPEAN HEALTH21 TARGET 7

EUROPEAN HEALTH21 TARGET 7

REDUCING COMMUNICABLE DISEASES

By the year 2020, the adverse health effects of communicable diseases should be substantially diminished through systematically applied programmes to eradicate, eliminate or control infectious diseases of public health importance (Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)

ABSTRACT

The sixth meeting on the coordination of Operation MECACAR Plus was attended by representatives of 16 participating countries from the WHO European (EUR) and Eastern Mediterranean (EMR) Regions and of the major partner organizations. Operation MECACAR/MECACAR Plus has led to unprecedented collaboration among 18 countries of EUR and EMR to coordinate implementation of polio eradication strategies. The last case of polio in EUR to date has been reported from Turkey with onset on 26 November 1998. Extraordinary progress toward polio eradication has also been achieved in EMR and reported polio is now at record low levels. Nevertheless, wild poliovirus transmission is still occurring in some MECACAR Plus countries of EMR, including Afghanistan, Iraq and Pakistan. Discussions focused on the results of Operation MECACAR Plus in 1999 and plans of action for 2000, improving surveillance in participating countries, and enriching the polio eradication partnership. Accelerated activities may be necessary in several MECACAR Plus countries to interrupt or prevent poliovirus transmission. Regional plans of action for the containment of wild poliovirus must be prepared as soon as possible to facilitate the certification process.

Keywords

POLIOMYELITIS PREVENTION AND CONTROL IMMUNIZATION PROGRAMS PROGRAM EVALUATION EPIDEMIOLOGIC SURVEILLANCE EUROPE MIDDLE EAST TURKEY COMMONWEALTH OF INDEPENDENT STATES

© World Health Organization – 2000 All rights in this document are reserved by the WHO Regional Office for Europe. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors.

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CONTENTS

Page

Introduction...... 1

Scope and purpose ...... 1

Situation analysis and progress toward poliomyelitis eradication...... 1 Global overview ...... 1 European Region ...... 3 Eastern Mediterranean Region ...... 3

Country reports, European Region ...... 4 Armenia (not presented at the meeting)...... 4 Azerbaijan (not presented at the meeting)...... 5 Georgia (not presented at the meeting)...... 5 Federal Republic of Yugoslavia (not presented at the meeting)...... 5 Kazakhstan (not presented at the meeting)...... 5 Kyrgyzstan (not presented at the meeting) ...... 6 Russian Federation ...... 6 Tajikistan...... 6 Turkey ...... 7 Turkmenistan (not presented at the meeting) ...... 7 Ukraine (not presented at the meeting)...... 8 Uzbekistan (not presented at the meeting) ...... 8

Country reports, Eastern Mediterrranean Region ...... 8 Afghanistan...... 8 Iran (not presented at the meeting)...... 9 Iraq...... 9 Jordan (not presented at the meeting)...... 10 Lebanon (not presented at the meeting) ...... 10 Palestine (not presented at the meeting) ...... 10 Pakistan ...... 11 Syria (not presented at the meeting) ...... 11

Partnership ...... 12 Summary of discussion and suggestions for improvement ...... 12

Conclusions and recommendations...... 13 Recommendations ...... 14

Annex 1 Results of partnership questionnaire...... 17 Annex 2 Programme...... 19 Annex 3 Participants...... 21

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Introduction

The sixth meeting on the coordination of Operation MECACAR Plus took place in Ankara, Turkey from 20 to 22 October 1999. All the ten countries from the World Health Organization (WHO) European Region (EURO) and six out of the eight countries from the Eastern Mediterranean Region (EMRO) that are participating in Operation MECACAR Plus were represented, as well as WHO, the United Nations Children’s Fund (UNICEF), the Centers for Disease Control and Prevention (CDC), Japan International Cooperation Agency (JICA), Rotary International and the United States Agency for International Development (USAID). In addition, Ukraine and the Federal Republic of Yugoslavia were represented.

The meeting was opened by Dr Osman Durmus, Minister of Health, Turkey, Dr Serguei Litvinov who brought greetings and a message from Dr Asvall, the then WHO Regional Director for Europe, and Dr Rafi Aslenian who brought greetings and a message from Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean. Dr Tarantola brought greetings and a message from Dr Gro Brundtland, Director-General of WHO. The meeting was chaired by Dr Norman Begg, Drs Serguei Deshevoi, Hamid Jafari and Roland Sutter served as co-rapporteurs and Drs George Oblapenko and Rafi Aslanian served as secretaries. The programme of the meeting and the list of participants are attached as Annex 2 and Annex 3, respectively.

Scope and purpose

The main objectives of the meeting were: · to evaluate and discuss the final results of Operation MECACAR and Operation MECACAR Plus 1999; · to coordinate the plan of action for polio eradication in EMRO and EURO Member States in 2000, including dates for national immunization days (NIDs) and mopping-up activities; · to assess the results achieved in improvement of surveillance in the participating countries and to discuss future action; · to brief the main partners on the efficacy and the development of Operation MECACAR Plus; · to finalize the strategic plan for Operation MECACAR Plus in 2000.

Situation analysis and progress toward poliomyelitis eradication

Global overview

The eradication of poliomyelitis depends on implementation of the following four strategies in every polio-endemic country: 1. achieving and maintaining high routine coverage of all children by one year of age with at least three doses of oral poliovirus vaccine (OPV) through routine vaccination services;

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2. providing supplemental OPV doses through NIDs1 to interrupt widespread circulation of poliovirus; 3. establishing sensitive epidemiological and virological surveillance systems for acute flaccid paralysis (AFP) and poliovirus; and 4. conducting mopping-up operations2 to eliminate the last remaining foci of poliovirus transmission.

Routine coverage with three doses of OPV has remained relatively stable globally at 80–84% during the 1990s. In 1999, for the first time all polio-endemic countries conducted NIDs, including the Democratic Republic of Congo which managed to carry out three NID rounds between September and November. In addition to expansion to include all polio-endemic countries, supplemental immunization activities were intensified in all priority countries (global reservoir or war-torn countries). For example, India carried out four rounds of NIDs between October 1999 and January 2000 with an interval of four weeks each. In addition, eight priority states of Northern India will conduct two rounds of mopping-up operations during February and March 2000 with the objective of eliminating the last remaining foci of poliovirus transmission or at least to greatly reduce transmission to a few foci by summer 2000.

Surveillance for AFP improved substantially during 1999. All polio-endemic countries are now conducting AFP surveillance. The rate of non-polio AFP (an indicator of the sensitivity of AFP surveillance) increased from 0.72 in 1998 to 1–3 in 1999. The proportion of AFP cases from whom two adequate stool specimens were collected (an indicator of the quality of AFP surveillance) was 68% in both 1998 and 1999. However, these global rates hide significant variations between WHO regions, individual countries and areas within countries. For example, the African Region continues to lag behind the other WHO regions both in terms of non-polio AFP rate (0.3 in 1998 and 0.7 in 1999) and proportion of AFP cases with two adequate stool specimens (36% in 1998 and 31% in 1999). Nevertheless, the AFP surveillance system in Afghanistan, and improving surveillance in Southern Sudan and Somalia, indicate that surveillance can be implemented even under the most challenging circumstances.

The global laboratory network for poliomyelitis eradication has gradually expanded and now includes a total of 148 laboratories (including 126 national or sub-national laboratories, 16 regional reference laboratories, and 6 global specialized laboratories). All polio-endemic countries (except the Democratic People’s Republic of Korea) have access to WHO-accredited laboratories to ensure that all stool specimens from AFP cases are examined under high-quality conditions.

National committees, regional commissions and a global certification commission have been formed for the eventual certification of countries, WHO regions and the entire world as polio- free. Following the certification of the western hemisphere in 1994, the Western Pacific Region may complete the certification process in 2000, and the European Region may follow in 2002.

1 Mass campaigns over a short period (days to weeks) in which two doses of OPV are administered to all children in the target group (usually those <5 years of age), regardless of previous vaccination history, with an interval of 4–6 weeks between doses. 2 Focal mass campaigns in high-risk areas over a short period (days to weeks) in which two doses of OPV are administered during house-to-house visits to all children in the target age group (usually those <5 years of age), regardless of previous vaccination history, with an interval of 4–6 weeks between doses.

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The major focus of activities in 1999 was containment of wild-type poliovirus. Once poliomyelitis has been eradicated, the only wild-type poliovirus will be in laboratories either as preserved isolates or in samples known or suspected to contain wild-type poliovirus. A global plan and guidelines for implementation have been drafted and three regions are gaining experience with implementation. Nevertheless, global certification of polio eradication will depend on containment of wild-type poliovirus.

Although there has been considerable progress towards implementation of the essential polio eradication strategies, further acceleration is inevitable to reach the goal of polio eradication by the end of 2000 or shortly thereafter.

European Region

The last case of poliomyelitis associated with wild-type poliovirus isolation had onset on 26 November 1998 in south-eastern Turkey. Since then, all stool specimens from >1500 AFP cases in the Region have all tested negative for wild-type poliovirus. Thus, for the first time in modern history, the WHO European Region has passed nearly a year without reported cases of poliomyelitis associated with wild-type poliovirus isolation.

Routine coverage with OPV was ~92% and Turkey was the only country with a level of <80% (79%). Coordinated NIDs were carried out in seven countries during 1999 (Armenia, Azerbaijan, Russian Federation, Tajikistan, Turkey, Turkmenistan and Uzbekistan) providing supplemental immunization with OPV to ~16 616 000 children. Large-scale mopping-up was conducted in eight countries (Armenia, Azerbaijan, Kyrgyzstan, Russian Federation, Tajikistan, Turkey, Turkmenistan and Uzbekistan).

AFP surveillance continues to mature; in endemic or recently endemic countries (n=17) the non- polio AFP rate was 1.51 in 1997 (but included facial paralysis in the Russian Federation and Ukraine), 1.13 in 1998 and 1.52 in 1999 (provisional data from October 1999), while the proportion of AFP cases with two stool specimens increased from 70% in 1997 to 85% in 1999. Nevertheless, the non-polio AFP rate in non-endemic countries is much lower, as is the timeliness and quality of AFP case investigations. In addition, there are substantial variations in non-polio AFP rates between countries which will need to be addressed in 2000. Increased attention will also be placed on sub-national AFP performance in 2000. Reporting to the Regional Office has improved by use of electronic data transfer (internet entry or e-mail) which 28 countries have adopted, but the completeness of AFP reporting is only 68%.

The laboratory accreditation process is nearly complete. Thirty-six national laboratories have been visited and 33 have already been accredited. This process will be completed shortly.

Eastern Mediterranean Region

As at 31 October 1999, 466 cases of poliomyelitis had been reported during 1999 from eight countries in the Region: Pakistan (267), Afghanistan (75), Iraq (55), Sudan (37), Somalia (11), Egypt (7), Republic of Yemen (11) and the Islamic Republic of Iran (3). Of the 23 countries in the Region, 15 reported zero cases, and 11 of them had reported zero cases for three years or more. It was expected that, notwithstanding the significantly improved surveillance, the total number of reported poliomyelitis cases reported in 1999 would not exceed the number reported

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in 1998 (553). The declining trend in the reported number of poliomyelitis cases is a reflection of the successful implementation of all critical eradication strategies.

In 1999, NIDs were conducted with high coverage in all countries where they were relevant. Most significantly, in 1999 they were conducted in all parts of Somalia for the first time and for the second time throughout all of Sudan, including the war-torn areas of the south. After a gap of two years, they have also been conducted in the northern areas of Afghanistan, where intense fighting and security concerns have prevented access previously. Plans are advanced with respect to many NIDs planned for the remaining months of 1999 and 2000.

Routine OPV3 coverage of above 90% has been maintained in 16 countries of the Region.

Coordinated NIDs and mopping-up campaigns continued to prevent cross-border wild poliovirus transmission between Afghanistan, the Islamic Republic of Iran and Pakistan, and between the Islamic Republic of Iran, Iraq, the Syrian Arab Republic and Turkey. In addition to these activities supported by Operation MECACAR, different regional and interregional epidemiological blocs also coordinated immunization and surveillance activities under the auspices of the Gulf Cooperation Council, the Maghrebian Union and the South Asian Association for Regional Cooperation. Attention is currently focused on coordination between the countries in the Horn of Africa, especially Djibouti, Eritrea, Ethiopia, Somalia and Sudan.

During 1999, AFP surveillance continued to improve all over the Region. Its sensitivity, indicated by the regional average of the non-poliomyelitis AFP rate, improved from 0.49 in 1994 to around the expected level of ³1 per 100 000 children under 15 years of age in 1999. The laboratory network continues to improve. The laboratories in Iraq and Sudan have recently been accredited, completing the regional network of good performance laboratories. The genetic diversity of viruses circulating in the Region are decreasing. No type 2 cases were reported in 1999. Wild polioviruses (type 1) were isolated in six countries (Afghanistan, Egypt, Pakistan, Sudan, Islamic Republic of Iran and Iraq), in the first four of which type 3 was also recorded.

In spite of the significant developments and achievements, there are some constraints that must be overcome in order to eradicate poliomyelitis from the Region. These include problems in war- torn countries, which are not only obstructing routine immunization efforts, but are also affecting supplementary immunization efforts and surveillance. Low routine immunization coverage and inadequate AFP surveillance in some other countries, particularly in subpopulations which are difficult to reach, are another major constraint.

Country reports, European Region

Armenia (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 98% in 1999 compared to 98% in 1998 and 97% in 1997. No cases of poliomyelitis have been reported since 1995. The 1999 NIDs targeted children aged 3 months to 3 years, and high coverage was reported for each round (94% and 99%). Mopping-up was carried out in the autumn of 1998 in 26 territories and coverage was 94% and 96% for each round, respectively. Mopping-up is planned again for the autumn of 1999 in 28 districts. AFP surveillance continues to improve with a non-polio AFP rate of 1.4 in 1997, 2.3 in 1998 and 1.7 in 1999. Similarly, the proportion of AFP cases with two adequate stool specimens was 87% in 1997, 80% in 1998 and

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84% in 1999. Challenges for 2000 include: (i) maintaining high-quality surveillance; (ii) preparing for certification of polio-free status; and (iii) mopping-up operations in the spring.

Azerbaijan (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 99% in 1999 compared to 98% in 1998 and 98% in 1997. No cases of poliomyelitis have been reported since 1995. The 1999 NIDs targeted children aged 0–4 years, and high coverage was reported for each round (99% and 99%). Mopping-up was carried out in the autumn of 1998 in 10 districts and coverage was 99% in each of the two rounds. It is planned for the autumn of 1999 in 12 districts. AFP surveillance continues to improve with a non-polio AFP rate of 0.8 in 1997, 0.6 in 1998 and 0.6 in 1999, but has not yet reached the standards for completeness of reporting (>1.0 non-polio AFP per 100 000 children <15 years of age). The proportion of AFP cases with two adequate stool specimens was 53% in 1997, 87% in 1998 and 93% in 1999. Challenges for 2000 include: (i) improving AFP surveillance to meet certification standards; (ii) preparing for certification of polio-free status; and (iii) conducting sub-national immunization days (SNIDs) in the spring.

Georgia (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 61% (for the first eight months of the year) in 1999 compared to 92% in 1998 and 98% in 1997. No cases of poliomyelitis have been reported since 1991. The 1999 NIDs targeted children aged 0–3 years, and high coverage was reported for each round (94% and 96%). Mopping-up was carried out in the autumn of 1998 and reached >150 000 children in each round for a coverage of 95% in each of the two rounds. It is planned for the autumn of 1999. AFP surveillance continues to improve with a non-polio AFP rate of 0.5 in 1997, 1.3 in 1998 and 0.3 in 1999 (first eight months only). The proportion of AFP cases with two adequate stool specimens was 86% in 1997, 81% in 1998 and 100% in 1999. Challenges for 2000 include: (i) improving AFP surveillance to meet certification standards; (ii) preparing for certification of polio-free status; and (iii) conducting mopping-up operations.

Federal Republic of Yugoslavia (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 95% in 1999 compared to 89% and 94% in 1998 and 1997 eight months. No cases of poliomyelitis have been reported since the outbreak of poliomyelitis in Kosovo in 1996. The 1999 SNIDs targeted children in high-risk territories only, and coverage was reported for each round (87% and 77%). Mopping-up was planned for the autumn of 1999 but was not carried out because of the war. AFP surveillance continues to improve with a non-polio AFP rate of 0.6 in 1997, 1.7 in 1998 and 0.4 in 1999 (non-annualized first eight months only). Similarly, the proportion of AFP cases with two adequate stool specimens was 71% in 1997, 79% in 1998 and 80% in 1999. Challenges for 2000 include: (i) maintaining high-quality AFP surveillance; and (ii) preparing for certification of polio-free status.

Kazakhstan (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 67% in 1999 (first eight months only) compared to 99% and 99% in 1998 and 1997 eight months. No

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cases of poliomyelitis have been reported since 1995. Mopping-up was carried out in the spring of 1999 in five high-risk districts and coverage was 98% and 99% for each round, respectively. No mopping-up operations are planned for the autumn of 1999. AFP surveillance continues to improve with a non-polio AFP rate of 0.8 in 1997, 1.2 in 1998 and 0.8 in 1999. Similarly, the proportion of AFP cases with two adequate stool specimens was 86% in 1997, 85% in 1998 and 96% in 1999. Challenges for 2000 include: (i) maintaining high-quality AFP surveillance; and (ii) preparing for certification of polio-free status.

Kyrgyzstan (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 68% in 1999 (first eight months only) compared to 99% and 99% in 1998 and 1997 eight months. No cases of poliomyelitis have been reported since 1992. The 1998 SNIDs targeted children targeted ~ 25% of children in high-risk areas, and high coverage was reported for each round (98% and 99%). Mopping-up was carried out in the autumn of 1998 and coverage was 99%. No NIDs or mopping-up operations are planned for spring 2000. AFP surveillance continues to improve with a non-polio AFP rate of 1.4 in 1997, 1.2 in 1998 and 1.2 in 1999. Similarly, the proportion of AFP cases with two adequate stool specimens was 75% in 1997, 60% in 1998 and 71% in 1999. Challenges for 2000 include: (i) maintaining high-quality surveillance; and (ii) preparing for certification of polio-free status.

Russian Federation

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 94% in 1998 compared to 91% in 1997. There are seven administrative territories where the coverage is less than 90% and the lowest level of coverage reported in Chechnya is only 43%. No cases of poliomyelitis have been reported since 1996. The 1999 NIDs reached >3.5 million children in each round for a coverage of 99% in each of the two rounds. Mopping-up activities are planned for the autumn in seven high-risk districts and again in spring 2000. AFP surveillance continues to improve due to intensive training conducted with the assistance of WHO, supported by USAID. The non-polio AFP rate was 2.8 in 1997, 1.2 in 1998 and 1.3 in 1999 (first eight months only). Similarly, the proportion of AFP cases with two adequate stool specimens was 82% in 1998 and 97% in 1999. The timeliness of monthly reporting in 1999 increased to 99%. The national polio laboratory network is operational and includes subnational laboratories (Ekaterinburg, Khabarovsk, Moscow, St Petersburg, Stavropol, Omsk). Laboratories were upgraded with the support of Rotary International. However, there are still a number of so-called silent territories (reporting no AFP cases). Challenges for 2000 include: (i) maintaining high- quality surveillance; (ii) preparing for certification of polio-free status; and (iii) gaining accreditation of the subnational laboratories.

Tajikistan

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 94% in 1998 compared to 91% in 1997. No cases of poliomyelitis have been reported since 1997. The 1999 NIDs targeted children aged 0–4 years, and high coverage (98%) was reported for each round. Mopping-up was carried out in the autumn of 1998 in 32 districts and coverage was 99% for each round. Mopping-up is planned for the autumn of 1999 in 30 districts. AFP surveillance continues to improve with a non-polio AFP rate of 0.3 in 1997, 0.7 in 1998 and 1.3 in 1999. Similarly, the proportion of AFP cases with two adequate stool specimens increased up to 92%

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in 1999. Challenges for 2000 include: (i) maintaining high-quality surveillance; (ii) preparing for certification of polio-free status; and (iii) conducting NIDs in the spring and mopping-up operations in the autumn. Paediatric services remain severely understaffed in many districts (up to 60%).

Turkey

Turkey has made great progress during the past few years in implementing the polio eradication strategies, as reflected by the last reported case to date of poliomyelitis in the country associated with wild poliovirus isolation with onset on 26 November 1998. However, routine coverage with three doses of OPV among children less than one year of age has remained relatively stable between 79% and 81% between 1997 and 1999. Even more worrying is that some provinces report very low routine coverage (<20%).

NIDs have been conducted since 1995 in the spring, and mopping-up operations have been conducted since 1997 in the autumn. NIDs coverage has generally been high, for the most recent year (1999), the reported coverage was 92% and 93% for round 1 and round 2, respectively. Reported coverage achieved during mopping-up was generally lower, 66% for round 1 and 72% for round 2 in the autumn of 1999. However, because of problems with determining both the numerator and the denominator, the actual coverage achieved was probably substantially higher; this assumption is supported by supervisors’ spot checks during and immediately after the mopping-up rounds.

AFP surveillance has also increased substantially, with the non-polio AFP rate increasing from 0.63 in 1997 to 1.0 in 1999. Similarly, the proportion of AFP cases from which two adequate stool specimens were obtained improved from 65% in 1997 to 81% in 1999. Because of an overlapping poliovirus reservoir comprising people of similar ethnicity in Turkey, Syria, Iraq and Iran (and because of low routine coverage in the highest risk provinces), Turkey needs to continue both NIDs and mopping-up operations in 2000 and possibly 2001, or at least four rounds of mopping-up.

A national certification committee has now been formed to prepare the documentation for eventual certification of the Region as polio-free. The committee met for the first time during the last quarter of 1999.

Priorities for 2000 include: (i) raising routine coverage; (ii) carrying out high-quality NIDs and mopping-up operations; (iii) further improving surveillance in all areas of the country; (iv) obtaining full accreditation for national laboratory; and (v) preparing for eventual certification as polio-free.

Turkmenistan (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 99% in 1999 compared to 99% in 1998 and 99% in 1997. No cases of poliomyelitis have been reported since 1996. The 1999 NIDs reached >400 000 children in each round, and high coverage was reported for each round (99% and 99%). Mopping-up was carried out in the autumn of 1998 in 14 districts and coverage was nearly 100% in each of two rounds. Mopping-up is planned for the autumn of 1999 in 18 districts (first round coverage was reported to be 99%). AFP surveillance continues to improve with a non-polio AFP rate of 0.5 in 1997, 1.4 in 1998 and 2.3 in 1999.

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Similarly, the proportion of AFP cases with two adequate stool specimens increased from 50% in 1997 to 54% in 1998 and 78% in 1999. Challenges for 2000 include: (i) maintaining high-quality surveillance; (ii) preparing for certification of polio-free status; and (iii) conducting NIDs in the spring.

Ukraine (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 64% (first eight months only) in 1999 compared to 98% in 1998 and 98% in 1997. No cases of poliomyelitis have been reported since 1996. Mopping-up operations were conducted in 1998 in eight areas vaccinating >500 000 children in each of two rounds. The reported coverage was 98% and 99%, respectively. No mopping-up or NIDs were conducted in 1999 or are planned for 2000. AFP surveillance continues to improve with a non-polio AFP rate of 0.1 in 1997, 0.7 in 1998 and 0.95 in 1999. Similarly, the proportion of AFP cases with two adequate stool specimens increased from 85% in 1997 to 88% in 1998 and 96% in 1999. Challenges for 2000 include: (i) improving AFP surveillance to meet certification standards; (ii) preparation for certification of polio-free status; and (iii) accreditation of national laboratory.

Uzbekistan (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was reported to be 98% in 1999 compared to 97% in 1998 and 95% in 1997. No cases of poliomyelitis have been reported since 1995. The 1999 NIDs targeted children aged 0–4 years, and high coverage was reported for each round (99% and >99%). Mopping-up was carried out in the autumn of 1998 in 12 areas and coverage was 99% and >99% for each round, respectively. Mopping-up is planned for the autumn of 1999. AFP surveillance continues to improve with a non-polio AFP rate of 0.2 in 1997, 1.0 in 1998 and 1.3 in 1999. Similarly, the proportion of AFP cases with two adequate stool specimens increased from 67% in 1997 to 87% in 1998 and 95% in 1999. Challenges for 2000 include: (i) maintaining high-quality surveillance; (ii) preparation for certification of polio- free status; and (iii) conducting NIDs in the spring and mopping-up operations in the autumn.

Country reports, Eastern Mediterrranean Region

Afghanistan

Despite the fact that most of the infrastructure has been destroyed due to the conflict that has been raging for the last 20 years, major gains have been made towards polio eradication in Afghanistan. Routine coverage with three doses of OPV among infants <1 year of age was reported to be 35% in 1998. This figure is expected to have increased in 1999 since EPI acceleration and catch-up campaigns were conducted in 14 urban areas of Afghanistan in 1999. A total of 138 cases of poliomyelitis were reported in 1999, compared with 59 cases in 1998. Two pairs of NIDs were conducted during 1999 that for the first time reached nearly all the 330 districts of the country. The NIDs were synchronized with cross-border campaigns and SNIDs and NIDs in Iran and Pakistan. Two pairs of NIDs with house-to-house vaccination in many districts will be conducted during 2000. A third round immediately following the two autumn rounds is also being planned.

Of the 138 polio cases reported in 1999, 62 have been confirmed virologically. The increase in the number of polio cases in 1999 reflects overall improvements and expansion of the AFP

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surveillance system in Afghanistan. Introduction of surveillance in areas of the north that were not included in routine and supplementary immunization for nearly two years led to identification of an outbreak of polio in the Province of Kunduz bordering Tajikistan and Uzbekistan. The quality of AFP surveillance continues to improve as evidenced by the increase in non-polio AFP rate from 0.66 in 1998 to 1.0 in 1999. During the same period the proportion of AFP cases with adequate stool specimens increased from 50% to 54%. The main challenges in 2000 include: (i) stopping poliovirus transmission through five high-quality NID rounds that reach all children, (ii) improving and expanding AFP surveillance to make it geographically representative and reliable to guide mopping-up, and (iii) ensuring that sufficient human and logistics resources are available.

Iran (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age was maintained at a very high level and was reported to be over 95% in each of the 270 districts during 1999. Three virologically-confirmed cases of polio were reported in 1999 among Afghan children: two had developed paralysis in Afghanistan, and the third case represented first generation indigenous transmission of an imported virus from Afghanistan. A mopping-up campaign was conducted in the spring of 1999 in western and eastern border provinces and other high-risk areas of the country. In the autumn mopping-up was again conducted in border areas, extended in the east to include Kerman province. Mopping-up in border provinces and among high-risk communities will continue during the spring and autumn of 2000. The quality of AFP surveillance remained at a high level in 1999. The reported non-polio AFP rate was 1.16 and the proportion of AFP cases with adequate stool specimens was 75%. Challenges for 2000 include: (i) maintaining high-quality surveillance, especially in border areas to detect virus importations rapidly, (ii) continuing mopping-up and other immunization activities to maintain population immunity and reach the high-risk cross-border populations, and (iii) preparing documentation for the process of certification.

Iraq

Routine coverage with three doses of OPV among infants 1 year of age declined from 92% in 1997 to 86% in 1998 and 89% in 1999. Survey data indicted that the decline was greater than the reported figures, with coverage below 80% in several governorates. Between April 1997 and May 1999, only clinically-confirmed cases of polio were reported. However, since May, 1999 an outbreak of polio has occurred which has resulted in a total of 85 polio cases, of which 72 have been confirmed by isolation of wild poliovirus type 1. Most of the cases in the outbreak are among young children (68% under 24 months) who are either unvaccinated or partially vaccinated (70% had received less than three OPV doses). NIDs were conducted in March and April 1999 with reported coverage of more than 90%. In response to the outbreak, two additional rounds of NIDs were conducted instead of the mopping-up planned for autumn 1999. A survey conducted following the autumn NIDs indicated that compared to the reported coverage figures of 93–99% for the four 1999 NID rounds, the actual coverage was in the range of 77–85%. Intensified NIDs with mainly house-to-house vaccination will be conducted in March and April. The two NID rounds will be followed by two additional house-to-house mopping-up rounds in May and June 2000. A pair of intensified NID rounds will be conducted again in October and November.

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The main factors contributing to the outbreak include: (i) sub-optimal surveillance in northern governorates, especially Dohuk and Nineva, where low-level virus transmission was not detected during most of 1997 and 1998; (ii) a serious decline in routine immunization coverage and gaps in NID coverage during the preceding 18–24 months; (iii) problems with the reverse cold chain due to prolonged power cuts; and (iv) movement of nomadic and cattle-herding populations from northern governorates to south and central Iraq. In addition to rapid implementation of NIDs, the response to the outbreak has included enhancement of AFP surveillance, provisional accreditation of the national poliovirus laboratory, technical and operational assistance from WHO and UNICEF and financial assistance from partner agencies.

The overall quality of AFP surveillance improved during 1999. The non-polio AFP rate increased from 1.19 in 1998 to 1.84 in 1999, and during the same period adequate stool specimens were collected from 72% and 75% of AFP cases, respectively. The challenges for 2000 include: (i) to interrupt wild poliovirus transmission through intensified NIDs and mopping-up campaigns; (ii) to improve the quality of AFP surveillance in northern and other low-performing governorates; and (iii) to mobilize sufficient human and financial resources to ensure adequate implementation.

Jordan (not presented at the meeting)

Based on provisional data, the reported routine coverage with three doses of OPV among infants <1 year of age during 1999 is expected to exceed 90%. No case of poliomyelitis has been reported from Jordan since 1994. NIDs conducted in March and April achieved a coverage of 89% and 95%, respectively. NIDs will be conducted again in March and April 2000. AFP surveillance continues to function well with a non-polio AFP rate of 1.48 and collection of adequate stool specimens from 79% of AFP cases during 1999. Challenges for 2000 include: (i) maintaining high-quality surveillance; (ii) preparation for certification of polio-free status; and (iii) maintaining polio-free status in the presence of a polio outbreak in neighbouring Iraq.

Lebanon (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age during 1999 is estimated to have remained above 90%. No case of poliomyelitis has been reported from Lebanon since 1994. High coverage of 97% was reported for each of the NID rounds in March and April 1999. NIDs will be conducted again in March and April 2000. AFP surveillance continued to improve during 1999. The non-polio AFP rate increased to 1.61 in 1999 from 1.26 in 1998 and the proportion of AFP cases with adequate stool specimens also increased to 21% from 0 during the same period. Challenges for 2000 include: (i) establishing high-quality AFP surveillance; (ii) preparing for certification of polio-free status; and (iii) maintaining polio-free status through sustaining high routine and supplementary immunization coverage.

Palestine (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age during 1999 is estimated to have remained above 95%. The area under the Palestinian National Authority has remained polio-free for more than five years. The NIDs were conducted in the autumn of 1999 instead of the usual spring time and achieved a coverage of 92% and 88% in the two rounds. NIDs will be conducted in March and April 2000. The AFP surveillance system continues to function at a high level of performance with a non-polio AFP rate of 1.07 and collection of

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adequate specimens from 92% of the AFP cases during 1999. Challenges for 2000 include: (i) maintaining high-quality AFP surveillance; (ii) preparing for certification of polio-free status; and (iii) maintaining polio-free status through sustaining high routine and supplementary immunization coverage.

Pakistan

Routine coverage with three doses of OPV among infants <1 year of age during 1999 is estimated to have increased compared with the figure of 79% reported during 1998. This is partly because Punjab, the largest province in the country conducted a three-round multi-antigen catch-up campaign in autumn of 1999. However, coverage assessments in a number of districts have identified lower coverage rates than reported using the administrative method. Pakistan reported a total of 466 polio cases, of which 294 were laboratory confirmed. The reported 1999 NID coverage was more than 95% in each round, although assessment of coverage in several districts in each province identified an average NID coverage of 90.5%.

In the spring of 1999, a massive house-to-house sub-national campaign was conducted in Sind, Baluchistan and parts of N.W.F.P. provinces that on average reached 10–15% more children than the maximum number of children any previous NID round had reached in the same areas. A total of 11.2 million children were immunized. The campaign led to a sharp decline in reported cases, especially from the province of Sind. Most of the cases during the second half of the year were reported from Punjab, where the campaign was not conducted, and parts of NWFP, where the campaign quality was sub-optimal. Pakistan is planning to conduct house-to-house NIDs in the spring of 2000 that in a staggered fashion from March through June. Three additional NID rounds, predominantly using house-to-house vaccination, will be conducted in the autumn of 2000, provided OPV is available.

AFP surveillance improved markedly in Pakistan during 1999 and accounted in part for the higher number of polio cases reported during 1999 compared with 1998. The non-polio AFP rate increased from 0.64 in 1998 to 1.32 in 1999 and the collection of adequate specimen improved from 60% to 70% during the same period. The main challenges for 2000 include (i) stopping transmission of poliovirus through conducting high quality campaigns reaching previously unreached children; (ii) further improving the quality of AFP surveillance; (iii) coordinating effectively with Afghanistan to stop cross-border poliovirus transmission; (iv) ensuring sufficient human and financial resources as well as the national commitment needed to stop virus transmission.

Syria (not presented at the meeting)

Routine coverage with three doses of OPV among infants <1 year of age during 1999 is estimated to have remained above 90%. Syria has remained polio-free since 1995. NIDs in the spring and border area campaigns coordinated with Iraq and Turkey in the autumn achieved coverage levels of more than 95% in each round. NIDs will again be conducted in the spring and border area campaigns in the autumn of 2000. The quality of AFP surveillance remained high during 1999. The non-polio AFP rate was 1.3 and adequate stool specimens were collected from 83.5% of AFP cases. Challenges for 2000 include: (i) maintaining high-quality surveillance; (ii) preparation for certification of polio-free status; and (iii) maintaining polio-free status in the presence of a polio outbreak in neighbouring Iraq.

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Partnership

A special session was devoted to partnership, with the purpose of exploring the value, types and frequency of partnerships that have developed during the past few years as a result of MECACAR and determining if there is interest among the participants in continuing to foster partnerships

In preparation for this session a survey instrument entitled “Partnerships: how to do better” was sent to 12 countries – 10 in EURO and 2 in EMRO. The responses to the specific questions contained in the questionnaire can be found in Annex 1.

Summary of discussion and suggestions for improvement

· Partnerships are very valuable for technical quality; human and financial resource mobilization; avoiding duplication; and maintaining advocacy. · Partnerships are necessary at the international, regional, national and subnational levels. A matrix was presented that indicated the effectiveness, to date, of different fora for a variety of tasks. · Partnerships function best when there is a common goal, a short- and medium-term plan of action, and a detailed budget. Then each partner can make contributions based on its institutional mandates, budget cycles, and other administrative or political restrictions. · Effective partnerships require leadership (particularly from the host country), a regular flow of information and feedback and opportunities for recognition. · Frequency of meetings, agendas for meetings and selection of meeting participants need to be better tailored to meet the needs of the current or future programme and the operational realities of implementation. · Some countries felt political or economic sanctions from the international community precluded formal partnerships in technical fora although informal discussions may be possible. · MECACAR was considered a very effective forum for developing consensus and recommendations on technical issues, coordinating NIDs across borders; providing feedback/monitoring on the status of eradication activities, and highlighting particularly interesting lessons learned. The strong leadership from WHO from both participating regions was noted and applauded by the participants. · This forum had not, however, been as successful in mobilizing resources, attracting new partners or providing advocacy opportunities. In addition, the future of MECACAR was discussed in the light of the different stages of eradication between EMRO and EURO countries. There was over-representation of central Asian and Caucasus countries at this meeting and less than expected representation from countries in EMRO, which some felt limited the usefulness of the cross-regional meeting. · Most participants felt that MECACAR should continue, perhaps less frequently (every 18– 24 months), as a forum to discuss a range of cross-regional issues (such as EPI/integrated disease control/social mobilization) or to share lessons learned on innovative programmes or policies (such as health sector reform/introduction of new vaccines/measles control). · Regional Meetings (EURO and EMRO) were seen as very important for coordinating and sharing information related to continuing polio eradication activities. Participants

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expressed interest in a) expanding the topics included during these meetings, and b) increasing the amount of time spent sharing lessons learned on operational aspects of their programmes (e.g. cold chain and logistics, efforts to reach the unreached, conducting activities in areas with local conflict, and AFP reporting from remote/silent areas). · Participants felt that it would be more effective to use cross-border meetings, or perhaps to establish epidemiological blocs, to address immediate operational constraints. A forum dedicated to specific issues and logistics common to countries that share borders or that are more similar in terms of epidemiology, geography, level of development, or in access to services was seen as very valuable. At the least, the participants requested EURO and EMRO to share district-level information about NID/SNID/mop-up planning and AFP cases as soon as possible. · Establishing effective national interagency coordination committees (ICCs) was seen as an important goal, not only for polio eradication but for a variety of EPI and disease control issues. In large countries, participants recognized that sub-national ICCs could also be very useful. Some participants expressed a need for more guidance and facilitation by the Regional Offices to help establish an ICC framework and invite donors and other partners. · Participants recognized the importance of effective partnership and communication within the polio eradication programme, particularly between the EPI managers and the laboratories and increasingly with the social mobilization experts. No one partner can do everything, yet all can contribute something. · The lack of participation by bilateral donors and foundations was noted. There seemed to be a lack of information about the various donors, what their programme priorities are, how their budget cycles work, and the process for requesting funds or technical assistance. The Regional Offices in EURO and EMRO were asked to increase their dialogue with donors and provide guidance/facilitation to countries to increase donor participation. · Some participants felt that intracountry, local conflicts would undermine the effectiveness of the regional polio eradication programme and called on WHO and UNICEF for assistance to negotiate days of tranquillity in these situations. · Participants were asked to submit suggestions to EURO or EMRO for topics they would like to see discussed in more detail at the various fora provided in the attached matrices.

Conclusions and recommendations

Operations MECACAR/MECACAR Plus had led to unprecedented collaboration among the 18 WHO EURO and EMRO Member States in coordinating the implementation of polio eradication strategies. As a result, the last case of polio in EURO to date had been reported from Turkey with onset on 26 November 1998. Extraordinary progress toward polio eradication has also been achieved in EMRO and reported polio is now at record low levels. Programme activities carried out under Operation MECACAR Plus are shown in Table 1.

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Table 1. National immunization days, subnational immunization days and mopping-up operations conducted in the framework of Operation MECACAR Plus, 2000

European Region (EURO) Eastern Mediterranean Region (EMRO)

Country Date of 1st round Date of 2nd Country Date of 1st round Date of 2nd round round

Armenia 24–29 April 29 May – 3 June Afghanistan 1–3 May 3–5 June Azerbaijan 13–18 March 17–22 April Iran April May Georgia April May Iraq 28 March–1 April Late April Russian 10–15 April 15–20 May Jordan March April Federation Tajikistan 28 March – 1 April 2–6 May Lebanon 4–9 March 8–13 April Turkey 22–28 April 27 May – 2 June Pakistan March–May April–June Turkmenistan 10–14 April 15–20 May Palestine March April Uzbekistan 17–19 April 17–19 May Syria 4–9 March 8–13 April

Nevertheless, wild poliovirus transmission is still occurring in some MECACAR Plus countries of EMRO, including Afghanistan, Iraq and Pakistan. The recent outbreak of polio in Iraq after a 24-month absence of documented poliovirus circulation highlighted the critical importance of high-quality epidemiological and virological AFP surveillance and, in particular, appropriate handling, transport and testing of specimens. It also emphasized the importance of identifying and providing immunization services to populations that were hard to reach, including nomads. Activities in response by the authorities in Iraq, including the implementation of NIDs, have been carried out in time and offer the potential to limit further transmission.

In May 1999, the World Health Assembly reaffirmed the goal of global polio eradication by the end of 2000 and called on Member States to accelerate their efforts to achieve this target through intensification of NIDs and other supplemental immunization activities, improvement in the quality of NIDs, and further strengthening of surveillance. Although substantial progress has been made toward establishing sensitive surveillance for AFP in both regions, in most of the countries the quality of surveillance is insufficient to identify all areas with possible poliovirus circulation, and thus would not currently meet certification standards.

Recommendations

The following recommendations supplement those made during the meetings in 1999 of selected MECACAR Plus participating countries in Istanbul (Turkey), Damascus (Syria), St Petersburg (Russian Federation), and Baku (Azerbaijan).

1. The coordination of activities under MECACAR Plus must continue but the focus and objectives of such coordination require further discussion. In addition, the frequency and scope of coordination meetings need to be determined to ensure continued optimal collaboration among the 18 MECACAR Plus countries, the respective offices of WHO and UNICEF and partners. As a minimum, two cross-border coordination meetings will be conducted in 2000 and a meeting of all MECACAR Plus countries is planned for the first quarter of 2001.

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2. Regional programme communication and advocacy plans should be developed by WHO and UNICEF Regional Social Mobilization Committee to ensure that adequate political and financial support for polio eradication activities will remain available beyond the year 2000.

3. Polio-endemic countries should urgently finalize their acceleration plan. Other MECACAR Plus countries are encouraged to review the current status of polio eradication to determine whether accelerated activities are necessary to meet the end of 2000 polio eradication target. Accelerated activities may include additional rounds of NIDs mopping-up, house- to-house administration of vaccine, and intensified monitoring and supervision. The quality of these activities must be assured by careful micro-planning; monitoring should include the tallying of zero-dose children (i.e. children receiving their first dose of OPV).

4. Supplemental immunization, including NIDs and mopping-up, needs to be continued in 2000 and possibly beyond in all polio-endemic countries in EMRO, Turkey and the countries in EURO bordering Afghanistan (Tajikistan, Turkmenistan and Uzbekistan). Countries which intend to discontinue NIDs should establish a dialogue with WHO to ensure that the established criteria for stopping NIDs are followed (i.e. absence of documented wild poliovirus transmission, certification level of surveillance, low risk of poliovirus importation and plan of action for responding to importation) and that the implication of this decision for other countries in the Region and for the global initiative can be evaluated. To ensure high population immunity against poliovirus, SNIDs should be conducted regularly in areas with sub-optimal OPV coverage (<90%).

5. Surveillance needs to be intensified in many countries of both regions to ensure that programme activities can be targeted appropriately and that the certification process remains on target. Active surveillance with regular visits to health facilities has been instrumental in rapidly improving AFP surveillance in many countries. Countries should focus on silent areas (i.e. areas that do not report AFP cases), monitor performance indicators by region and district, and analyse data locally to enhance the capacity for programme activities.

6. Regional surveillance data, including wild poliovirus distribution, should be analysed regularly by WHO’s Regional Offices and shared with all countries in both regions.

7. AFP cases that are suspected or known to be associated with wild poliovirus infection based on epidemiological, clinical and virological grounds should be reported immediately to Regional Offices of WHO. All poliovirus isolates must immediately undergo intratypic differentiation, and if wild-type poliovirus is confirmed, genomic sequencing should be conducted in the appropriate reference laboratory as soon as possible to identify virus reservoirs, detect importations and rule out contamination.

8. At this stage of the programme, the close collaboration among programme and laboratory staff is critical to ensure that the most recent information is available to the staff concerned and that immediate action can be taken. This close collaboration should be maintained and further strengthened in some countries. The laboratory accreditation process should be completed by the beginning of 2000 and all stool specimens from AFP cases should be processed in accredited laboratories.

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9. Regional plans of action for the containment of wild poliovirus must be prepared as soon as possible to facilitate the certification process. These regional plans should contain guidelines for countries to develop and implement specific national containment plans. Because containment will affect several government sectors in each country, a high-level task force should monitor its implementation in collaboration with the national certification committee. Successful implementation of containment is a prerequisite for certification.

10. The countries of MECACAR Plus gratefully acknowledge the contribution of all partners for polio eradication. Partner organizations should, however, note that the acceleration of activities will require additional support from them, as well as increased political support from the office of the United Nations Secretary-General to negotiate days of tranquillity in war-torn areas that will be critical to carry out polio eradication activities.

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Annex 1

RESULTS OF PARTNERSHIP QUESTIONNAIRE

Question 1 List your main partners and the kind of support provided by each · UNICEF (funds, vaccine, supplies/equip, technical) · WHO (surveillance, laboratories, technical) · Rotary (funds, vaccine, social mobilization, laboratory) · Japan International Cooperation Agency (vaccine, funds) · DFID (vaccine) · Centers for Disease Control and Prevention (funds, vaccine, technical) · UNF (funds) · DANIDA (funds) · Norway (EPI training) · Nongovernmental agencies · Red Cross (vaccine) · USAID (technical) · Other United Nations agencies · Neighbouring countries (vaccine storage, laboratory facilities)

Question 2 Was the partnership important in making progress? No 0 Important 1 Crucial 11

Question 3 At what level of efficiency did the partnership work? Low 0 Medium 2 conditions imposed by the donor, delays in release of funds Medium/high 3 High 7 regular meetings, action-oriented, defined roles and responsibilities, support on time, responded to government priorities

Question 4 What were the factors that made the partnership successful? · Common objective to reduce burden of disease and alleviate human suffering · Long-term gains in social and economic benefits · Responsiveness of partners to requests from government · Leadership of EPI programme manager/national leadership · Leadership from respected organizations, e.g. WHO, CDC · Clear and well defined national plans · Regular feedback on programme outcomes · Transparency and accountability for use of funds · Ability to have a dialogue on key issues with partners as necessary (sometimes informally) · Longer-term objectives and openness of the programme to suggestions · Coordination with regional offices of WHO.

Question 5 Do you think it is important to coordinate partners at the national level? Yes 12 No 0

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Question 6 Ideas and activities to coordinate partnerships better and make them successful: · Establishment of a national level coordinating body, with set and harmonized priorities which has frequent and timely meetings for joint planning, provision and distribution of support to prevent overlaps and gaps, and sharing experiences · Development of national plans · Regular feedback to partners on outcomes of key activities · Build on the comparative advantage of each partner · Build trust among partners by transparent and regular sharing of information · Identify links with partners with common interests · More cross-border activities, joint planning, synchronization of activities and sharing information · For some countries the question is not appropriate · Continue annual meetings at regional level · Strengthen coordination and technical support · Re: certification committees (add a post in WHO/EURO).

Question 7 Which partners can assist you further, both now and following polio eradication in specific programme areas or other programmes? UNICEF: Vaccine supply, training, equipment, cold chain, EPI management, vaccine self sufficiency, safe injection WHO: Technical support, surveillance for infectious diseases; EPI management, surveillance, education and training JICA: Cold chain, safe injections, TT campaigns DFID: Cold chain, EPI management, safe injections CDC: Technical surveillance, new vaccines Rotary: Social mobilization, lab supplies, health information USAID: Vaccine self sufficiency, vaccine quality control, surveillance Red Cross: Support for immunization campaigns, vaccine, education and training CIDA: Vaccine quality control, vaccine World Bank: ? UN Foundation: ? Gates Foundation: ?

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Annex 2

PROGRAMME

Wednesday, 20 October 1999

09.00–09.30 Registration 09.30–10.00 Opening Election of Chairperson and Rapporteur Administrative matters Session 1 Overview of the situation of poliomyelitis eradication 10.00–10.30 Global overview Dr Bruce Aylward 10.30–11.00 Coffee break 11.00–11.30 EMR overview Dr Rafi Aslanian 11.30–11.45 Discussion 11.45–12.15 EUR overview Dr George Oblapenko 12.15–12.30 Discussion 12.30–14.00 Lunch break Session 2 Acceleration of poliomyelitis eradication 14.00–14.15 Why is acceleration needed ? Dr Bruce Aylward, WHO/HQ 14.15–14.45 Afghanistan Discussion 14.45–15.15 Tajikistan Discussion 15.15–15.45 Pakistan Discussion 15.45–16.15 Coffee break 16.15–16.45 Turkey Discussion 16.45–17.15 Iraq Discussion 17.15–17.45 Russian Federation Discussion

Thursday, 21 October 1999

Session 3 3.1 Surveillance for wild polioviruses: problems and challenges 08.30–08.45 EMR surveillance overview Dr Hamid Jafari 08.45–09.00 EMR laboratory network Dr Esther de Gourville 09.00–09.15 Discussion 09.15–09.30 EUR surveillance overview Dr Steve Wassilak 09.30–09.45 EUR laboratory network Dr Galina Lipskaya 09.45–10.00 Discussion 10.00–10.30 Coffee break 10.30–11.00 Molecular epidemiology of wild polioviruses – global vision Dr Olen Kew, CDC Atlanta 3.2 Strategic plans for containment of wild poliovirus 11.00–11.20 Global overview Dr Walt Dowdle, USA 11.20–11.40 EUR overview Dr George Oblapenko 11.40–12.00 General discussion 12.00–13.30 Lunch break

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Session 4 Target zero polio just around the corner? 13.30–14.30 EMR plans for 2000–2001 Dr Rafi Aslanian Discussion 14.30–15.30 EUR plans for 2000–2001 Dr George Oblapenko Discussion 15.30–16.00 Coffee break 16.00–16.30 Criteria for continuation of NIDs and mopping-up Dr Roland Sutter, CDC Atlanta 16.30–17.00 Discussion

Friday, 22 October 1999

09.00–10.00 Assuring high quality NIDs & mopping-up operations Dr Bruce Aylward, WHO/HQ Discussion 10.00–11.00 Partnership – the role of the partners in polio eradication: Round table discussion chaired by Dr Ellyn Ogden, USAID Rotary International CDC Atlanta USAID UNICEF DFID 11.00–11.30 Coffee break 11.30–12.00 Advocacy Dr Bruce Aylward, WHO/HQ 12.00–13.30 Lunch break 13.30–15.00 Recommendations of the meeting 15.00 Closure of the meeting

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Annex 3

PARTICIPANTS

World Health Organization European Region

Armenia Dr Ara Asoyan Tel.: +374 2 610 417 Chief Doctor Fax: +374 2 151 097 Republican Paediatric Infectious Diseases Hospital Ministry of Health Toumanian Str. 8 Yerevan 375001

Dr Margarita Balasanian Tel.: +374 261 33 69 Medical Epidemiologist Fax: +374 215 1098 Deputy Director E-mail: [email protected] Centre of Hygiene and Anti-Epidemic Surveillance D Malian Str. 37 Yerevan 375051

Azerbaijan Dr Firuddin Husseynov Tel.: +994 12 94 84 31 General Director Fax: +994 12 94 70 12 Republican Centre of Epidemiology and Hygiene 34 J. Jabbarly str. 370065 Baku

Dr Abbas Soltan ogly Velibekov Tel.: +994 12 933190 Deputy Minister of Health Fax: +994 12 947846 EPI Manager Republican Centre of Hygiene and Epidemiology 34, J. Jabbarly Str. 370065 Baku

Georgia Dr Levan Baidoshvili Tel.: +995 32 39 89 46 Coordinator, Immunization Programme Fax: +995 32 94 04 85 National Centre for Disease Control E-mail: [email protected] Asatiani Str. 9 380077 Tbilisi

Dr Tamara A. Dolakidze Tel.: +995 32 35 09 61 Department of Immunization Fax: +995 32 94 04 85 Ministry of Health E-mail: [email protected] National Centre for Disease Control 9 M. Asatiani st. 380077 Tbilisi

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Kazakhstan Dr Albert Askarov Tel.: +7 327 2 33 72 62 Deputy Head, Sanitary-Epidemiological Department Fax: +7 317 2 43 16 66 Committee of Health E-mail: [email protected]. Ministry of Education, Culture and Health Astana

Dr Raisa Iosifovna Bondareva Tel.: +73272431533 Head, Virology Laboratory Fax: +73272431666 Health and Epidemiology Unit E-mail: [email protected] Ministry of Education, Culture and Health ul. Ayezova 84 480008 Almaty

Dr Gulnur Kembabanova Tel.: +7 3272 33 71 18 Chief Sanitarian Physician Fax: +7 3272 43 16 66 Committee of Health Ministry of Health, Education and Sport EPI unit 4 Republic Square Almaty 480091

Kyrgyzstan Dr Svetlana N. Firsova Tel.: +996 312 66 11 43 Head, Centre for Immunoprophylaxis Fax: +996 312 66 02 24 Ministry of Health E-mail: Balkabek@imfikobishk 535 Frunze str. 720033 Bishkek

Dr Ljudmila Steinke Tel.: +996 312 66 1777 Consultant Tel.: +996 312 66 0224 Ministry of Health of Ukraine Toktogoul str.62 720021 Bishkek

Russian Federation Dr A.A. Monisov Tel.: +7 095 973 26 66 Deputy Chairman Fax: +7 095 978 68 05 State Committee for Sanitary and Epidemiological Surveillance 18/20 Vadkovsky Bystreet Moscow 101479

Tajikistan Dr D. Kurbanov Tel.: +7 3772 211248 Deputy Director, Centre of Immunoprophylaxis Leninobad oblast Ministry of Health Szevczenko 69 734025 Dushanbe 25

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Dr K. Odinaev Tel.: +7 3772 211248 Head, Sanitary Epidemiological Department Ministry of Health Szevczenko 69 734025 Dushanbe

Turkey Dr Iffet Alaeddinoglu Tel.: +90 312 431 2882 Head, Tissue Culture and Enterovirus Laboratory and Fax: +90 312 435 3546 Viral Vaccine Control Unit E-mail: Poliolab@superonline Central Institute of Hygiene Laboratory of Virology Cemal-Gursel Cad.No.16 Sihhiye/Ankara

Professor Sefer Aycan Tel.: +90 312 431 4863 General Director, Primary Health Care Directorate Fax: +90 312 435 0992 Ministry of Health Saglik Bakanligi 06434 Sihhiye/Ankara

Dr Senay Coskun Tel.: +90 232 2856388 Chief of Virology Fax: +90 232 2245989 Regional Public Health Institute E-mail: [email protected] Yzmir Bolge Hyfzyssyhha Enstitüsü 35350 Güzelyaly/Yzmir

Dr Aysegul Sarac Tel.: +90 312 435 29 71 Primary Health Care Fax: +90 312 432 2994 Ministry of Health Sihhiye/Ankara

Dr Sehnaz Tumay Tel.: +90 312 435 29 71 Chief, Immunization Department Fax: +90 312 434 44 49 Primary Health Care General Directorate Ministry of Health Saglik Bakanligi 06434 Sihhiye/Ankara

Dr Elem Ozkaya Tel.: +90 312 435 29 71 Ministry of Health Saglik Bakanligi 06434 Sihhiye/Ankara

Turkmenistan Dr Enebay Ataeva Tel.: +993 12 390454 Deputy Minister Fax: +993 12 355838 Ministry of Health and Medical Industry Mahtumkuli pr. 90 744000 Ashgabat

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Ukraine Dr Eleonora A. Laugen Tel.: +380 44 253 17 84 Head Coordinator on HIV/AIDS Fax: +380 44 253 52 03 Main Sanitary Epidemiological Department Ministry of Health 7, Hrushevsky Str. 252021 Kiev

Dr Liudmila Moukharskaya Tel.: +380 44 253 17 84 Head, Communicable Disease Control Department Fax: +380 44 253 52 03 Ministry of Health Kiev

Uzbekistan Dr Bakhtiar I. Niyazmatov Tel.: +998 712 41 16 24 Deputy Minister, Ministry of Health Fax: +998 712 41 16 41 Navoi Str. 12 Tashkent 700011

Dr Galina G. Osipchuk Tel.: +998 3712 78 46 63 Head, Virology Laboratory Fax: +998 3712 41 86 14 Republican Sanepid Centre Ministry of Health Druzba Narodov Str.46 700097 Tashkent

Dr Sammariddin Tilavov Tel.: + 998 712 411 791 Deputy Chief, Main Department of Maternity and Child Protection Fax: +998 712 418 614 Ministry of Health Navoi str. 12 700011 Tashkent

World Health Organization Eastern Mediterranean Region

Afghanistan Dr N. Ahmed Sadozai Tel.: +115 92 51 25 22 72 Medical officer Fax: +115 92 51 280 830 WR office

Iran (Islamic Republic of) Dr Parviz Vazirian Deputy Director General, Disease Control Department Ministry of Health Teheran

Jordan Dr Haider Otoum EPI manager

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Lebanon Dr Ali Jaber Chief, Health Directorate, South Lebanon Beirut

Palestine Mr Assa’adi Ramlawi Tel.: 295 73 92/3 Director, Preventive Medicine Fax: 295 56 57 Ministry of Health Ramallah Palestina

Syrian Arab Republic Dr Abdul Latif Badawi Chief, Immunization and Child Health Section Aleppo Damascus

Observers

Ministry of Health, Ankara, Turkey Dr Birhan Altay Tel.: +90 312 433 71 32 Head, Communicable Diseases Department Fax: +90 312 434 44 49 Primary Health Care General Directorate

Dr E. Didem Eyci Tel.: 90 312 431 47 97 Department of External Relations Fax: 90 312 433 98 85 E-mail: [email protected]

Dr Ünal Ertugrul Fax: +90 312 4339885 General Directorate Primary Health Care Department

Dr Nilgün Satirlar Tel.: +9044314828 Chief Fax: +9044314879 Directorate-General of Primary Health Care

Dr M. Ali Torunoglu Fax: +90 312 4339885 General Directorate Primary Health Care Department

Ms Gulbiye Yenimahalleli Tel: +90 312 431 47 97 Protocol Officer Fax: +90 312 433 98 85 External Relations Department E-mail: [email protected]

Institute of Mother and Child Health Care of Serbia Professor Milos Banicevic Tel.: +381 11 671122 Director, Medical Faculty Belgrade Fax: +381 11 697 232 Radoja Dakica 8 YU-11070 Belgrade Yugoslavia

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Temporary Advisers

Dr Norman Begg (Chairperson) Tel.: +44 181 200 6868 Public Health Laboratory Service Fax: +44 181 200 7868 Communicable Disease Surveillance Centre 61, Colindale Avenue GB-London NW9 5EQ United Kingdom

Professor Istvaan Dömök Tel.: +36 1 215 859 Scientific Adviser Fax: +36 1 215 17929 National Centre for Epidemiology Gyali Street 2-6, P.O. Box 64 H-1966 Budapest Hungary

Dr Walter Dowdle Tel.: +1 404 371 0466 Director of Programs Fax: +1 404 371 1087 The Task Force for Child Survival and Development E-mail: [email protected] 750 Commerce Drive Suite 400 Decatur, Georgia 30030 USA

Dr G.F. Drejer Tel.: +31 70 312 7200 Paediatrician, Juliana Children’s Hospital Fax: +31 70 312 6125 P.O. Box 60604 NL-2506 The Hague Netherlands

Dr Olga Eugenyevna Ivanova Tel.: +7 0954399054 Chief, Laboratory of Environmental Virology Fax: +7 095 4399321 Institute of Poliomyelitis and Viral Encephalitis E-mail: [email protected] Academy of Medical Sciences Kievskoe Shosse 27 142782 Moscow Oblast Russian Federation

Professor Burghard Stück Fax no. 49 307 85 90 08 Schulenburgring 126 E-mail: [email protected] D-12101 Berlin Germany

Dr Harrie van der Avoort Tel.: +31 30 274 2059 Senior Scientist, Polio Fax: +31 30 274 4418 Laboratory of Infectious Diseases and Perinatal Screening E-mail: National Institute of Public Health and Environmental Protection harrie.van.der.avoortorivm.nl Antonie van Leeuwenhoeklaan 9 P.O. Box 1 NL-3720 BA Bilthoven Netherlands

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Representatives of Other Organizations

Centers for Disease Control and Prevention Dr Stephen L. Cochi Tel.: +1404 639 8252 Director, Vaccine-Preventable Disease Eradication Fax: +1 404 639 8573 Division, National Immunization Program E-mail: [email protected] 1600 Clifton Rd., NE Atlanta, GA 30333 USA

Dr Olen Kew Tel.: +1 404 639 8252 Chief, Molecular Virology Fax: +1 404 639 2648 1600 Clifton Rd., NE Atlanta, GA 30333 USA

Dr Roland Sutter (Co-rapporteur) Tel.: +1 404 639 8252 Chief, Technical Services Branch Fax: +1 404 639 8573 National Immunization Program Polio Eradication Activity E-mail: [email protected] Corporate Square Bldg. 12, Mailstop E05 Atlanta, GA 30333

Japan International Cooperation Agency Mr Mineo Arita Tel.: +90 312 433 78 33 Infectious diseases control project in Turkey Fax: +90 312 433 78 33 Refik Sadam Hygiene Centre Ministry of Health AB-Block 4th fl. Sihhiye/Ankara Turkey

Mr Morihiro Morita Tel.: +90 433 98 33 Team Leader Fax: +90 433 98 33 Infectious diseases control project in Turkey E-mail: morita@oda. net.tr Refik Sadam Hygiene Centre

Mr Iwao Yoshida Tel.: +90 433 98 33 Project Expert Fax: +90 433 98 33 Infectious diseases control project in Turkey E-mail: morita@oda. net.tr Refik Sadam Hygiene Centre

Rotary International Mr Safak Alpay Tel.: +90 312231 80 93 Rotary Polio Fax: +90 312 230 23 01 Kumrular Sokak No.26 Yenisehir 06440 E-mail: salpays@superonline Ankara, Turkey

United Nations Children’s Fund Mr Paula Abdulh’hadeer Iraq

EUR/ICP/CMDS 03 02 04 page 28

Mr Osman Adikutlu Turkey

Dr Alexander Malyavin Tel.: +41 22 909 5642 Project Officer, Health Fax: +41 22 909 5909 UNICEF Regional Office for CEE/CIS/BS E-mail: [email protected] Palais des Nations 5–7 avenue de la Paix CH-1211 Geneva 10 Switzerland

Dr Ahmed Mohamed Magan UNICEF/MENARO Postbox 811721 Amman, Jordan

Dr Jane Zucker Tel.: +1 212 824 63 12 UNICEF/NY Fax: +1 212 824 64 60 3 United Nations Plaza, TA-24A New York, NY 10017 USA

United States Agency for International Development Ms Ellyn Ogden Tel.: +1 2027121276 Worldwide P.E. Coordinator Fax: +1 2022163702 Center for Population, Health and Nutrition RRB, 3.07-075M, 3rd floor Washington, DC 20523-3700 USA

World Health Organization

Regional Office for Europe Dr Sergei Deshevoi (Co-rapporteur) Tel.: +7 3272 301 655 Medical Officer Fax: +7 3272 301451 Expanded Programme for Immunization E-mail: [email protected]

Dr Nedret Emiroglu Tel.: +90 3124314863 Medical Officer for WHO/EURO Fax: +90 312 432 2994 E-mail: [email protected]

Ms Louise J. Gare Tel.: +45 39 17 14 74 Short-term Professional E-mail: [email protected]

Ms Marina Hansen Tel.: +45 39 17 13 94 Secretary Fax: +45 39 171818 E-mail: [email protected]

Ms Johanna Kehler Tel.: +45 39 1712 44 Programme Assistant Fax: +45 39 171818 Eradication of Poliomyelitis E-mail: [email protected]

EUR/ICP/CMDS 03 02 04 page 29

Dr Galina Lipskaya Tel.: +45 39 17 1469 Scientist, Coordinator Fax: +45 39 171818 European Polio Laboratory Network E-mail: [email protected]

Dr Serguei K. Litvinov Tel.: +45 39 17 1352 Director E-mail: [email protected] Department of Infectious Diseases

Dr George Oblapenko (Co-secretary) Tel.: +45 39 17 1294 Medical Officer Fax: +45 39 171818 Eradication of Poliomyelitis E-mail: [email protected]

Dr Steven Wassilak Tel.: +45 39 17 1258 Medical Officer Fax: +45 39 171818 Eradication of Poliomyelitis E-mail: [email protected]

Headquarters Dr Bruce Aylward Tel.: +41 22 791 4419 Medical Officer Fax: +41 22 791 41 93 Expanded Programme on Inmmunization E-mail: [email protected]

Dr Daniel Tarantola Tel.: +41 22 791 29 81 Special Envoy of the Director General E-mail: [email protected]

Regional Office for the Eastern Mediterranean Dr Rafi Aslanian (Co-secretary) Tel.: +203 483 9240 Medical Officer Fax: +203 4838916

Dr Esther de Gourville Tel.: +20 3 4839240 STC/Polio Fax: +20 3 4838916 Laboratory Coordinator

Dr H. Jafari (Co-rapporteur) Tel.: +20 3 483 9240 Medical Officer Fax: +20 3 483 8916 WHO/Polio

Ms Sonia Miskjian Administrative Assistant Regional Director’s Office

Interpreters

Ms Ludmila Funso Tel.: +7 3272 301485 Fax: +7 3272 301655

Ms Catherine Ganson Tel.: +44 171 Fax: +44 171 1784

Mr Vladimir M. Ilyukhin Tel.: +7 095 912 3801 Fax: +7 095 912 3801 E-mail: [email protected]