EUR/01/5018750 ORIGINAL: ENGLISH UNEDITED E73496

REGIONAL OFFICE FOR EUROPE ______NINTH MEETING OF THE EUROPEAN REGIONAL CERTIFICATION COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION

Report on a WHO Meeting

Vienna, Austria 19–21 June 2000

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 2001 ABSTRACT

The participants at the Ninth Meeting of the European Regional Certification Commission were briefed on the progress towards poliomyelitis eradication globally and in the European Region. They reviewed the documentation for certification from Albania, Bosnia and Herzegovina, the Republic of Moldova, Romania and the former Yugoslav Republic of Macedonia. The Regional Certification Commission planned to submit complete documentation for the certification of the European Region as polio free to the Global Commission in 2002. Continuing surveillance, however, was stressed as a long-term obligation. With eradication close, virus containment had become essential. The regional plan for the laboratory containment of wild polioviruses was presented. An inventory of laboratories containing wild poliovirus and other targeted potentially infectious materials was to be complete by the end of 2001. The discussion raised significant questions about the extent of the inventory, and indicated the activities and processes needed to start it in all countries. Each country was expected to have a coordinator, and many should have a task force, to oversee the successive steps of the containment process.

Keywords POLIOMYELITIS – prevention and control EPIDEMIOLOGIC SURVEILLANCE – standards IMMUNIZATION PROGRAMS CONTAINMENT OF BIOHAZARDS – standards LABORATORY INFECTION – prevention and control NATIONAL HEALTH PROGRAMS CERTIFICATION EUROPE

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This document was text processed in Health Documentation Services WHO Regional Office for Europe, Copenhagen CONTENTS Page

Introduction ...... 1

Polio eradication: global overview...... 1

Regional Overview...... 2

The certification process: country presentations ...... 3 Albania...... 3 Bosnia and Herzegovina ...... 4 Republic of Moldova ...... 5 Romania ...... 5 The former Yugoslav Republic of Macedonia...... 6 Federal Republic of Yugoslavia...... 7 Country follow-up reports...... 7 Austria...... 7 Belgium...... 8 Bulgaria...... 8 Denmark...... 8 Germany...... 9 Lithuania ...... 9 Portugal...... 9 Switzerland...... 10 Surveillance for enteroviruses...... 10 France...... 11 Netherlands ...... 11 United Kingdom...... 11 Global Action Plan for laboratory containment of wild polioviruses ...... 12

European Region Action Plan for laboratory containment of wild poliovirus...... 14

Country reports on implementation of national plans for laboratory containment of wild poliovirus...... 15 France...... 15 Netherlands ...... 15 United Kingdom...... 15 Summary and conclusions...... 16

Annex 1 Programme...... 17

Annex 2 Participants ...... 20 EUR/01/5018750 page 1

Introduction

The ninth meeting of the European Regional Certification Commission was held in Vienna, Austria on 19–21 June 2000. Sir Joseph Smith chaired the meeting, Secretary was Dr George Oblapenko, Rapporteur was Dr David Salisbury. The purposes of the meeting were as follows:

S to brief the participants on the development of the Global and Regional status of polio eradication; S to review the documentation for certification from Albania, Bosnia and Herzegovina, Republic of Moldova, Romania, the former Yugoslav Republic of Macedonia; S to follow up on the implementation of recommendations given to Member States by the Regional Certification Commission; S to present the Regional Plan for laboratory containment of wild polioviruses and to discuss the strategies for the implementation of the Regional Plan.

The programme of the meeting is attached as Annex 1 and the list of participants as Annex 2.

Sir Joseph explained the tasks that national Committee chairmen faced. He congratulated the national committees on their excellent work, and also thanked all local health workers for the contributions, as well as the considerable efforts of the polio team at the Regional Office, Copenhagen. Sir Joseph also explained the tasks that the Regional Commissions played as their part towards global eradication. The goal will be for the Regional Commission to submit complete documentation for the Region to the Global Commission in 2002, when it should be more than three years since the last case. The Commission will expect annual updates from each National Committee up to the completion of the regional submission. The need for continuing surveillance was stressed, as a long-term obligation, essential until well after eradication had been attained. Dr Oblapenko welcomed participants on behalf of the Regional Director and reminded participants that it had been 18 months since the last case of polio in the Region. In September the Regional Committee will review the progress towards elimination in the Region. Dr Oblapenko thanked the Vienna International Centre for the use of its excellent facilities.

Dr Melgaard welcomed participants on behalf of Dr Brundtland, Director-General. Tremendous progress was being made worldwide with a greater than 90% reduction of cases, in the face of better surveillance. All countries in the world have now embarked on appropriate strategies with every country having AFP or some other relevant surveillance. Three regions have stopped or apparently stopped transmission of wild virus polio with a further three regions set to achieve this in the near future. The global certification goal has been set for 2005, and this is considered to be attainable. Approximately 15 countries – the global reservoirs – may remain endemic until 2001, by which time they are expected to interrupt transmission. With eradication close, the issue of virus containment becomes essential. As part of the legacy of polio eradication, there needs to be a strengthening of all immunization services.

Polio eradication: global overview

Polio now remains in three reservoirs, South Asia, Horn of Africa and Central/West Africa. Last year there were 29 924 cases of AFP reported, 7141 were confirmed as polio. The projected EUR/01/5018750 page 2

annual non-polio AFP rate for 2000 is 0.93/100 000. Surveillance has improved considerably worldwide. Unfortunately there has been slippage of surveillance indictors in some PAHO countries, suggesting surveillance fatigue after so many years of high quality work. Countries where OPV3 coverage remains below 80% will have to adopt intensified campaign activities.

Challenges in reservoir countries have included OPV shortages, no or limited surveillance, destroyed infrastructure because of conflict, difficult access, and all these compounded by intense transmission. The critical limiting factor will be to ensure high quality high coverage NIDs, reaching all children through house-to-house approaches.

The situation in the Western Pacific is most encouraging; 10 years ago there were 8 polio - endemic countries accounting for more than 60 000 cases. The last indigenous case was in 1997 since when more than 18 000 AFP cases have been investigated with over 30 000 stool samples examined: all were negative for wild poliovirus. The region expects to be certified as polio-free at the end of 2000. One paralytic case and one wild virus isolate in a contact occurred in 1999 in an ethnic community in China with probable links through trade routes to India. Intratypic differentiation (ITD) showed the virus responsible to be an Indian-like virus, quite different to any viruses recovered in China. Intensive mop-up activities were undertaken.

Regional overview

In 1998/1999 the Regional Plan was fully implemented with Operation MECACAR Plus successfully completed, involving coordinated NIDs and mopping-up. The quality of AFP surveillance was assessed by international and national experts in almost all countries. In the spring of 1999, NIDs and SNIDs were undertaken in Mecacar Plus countries, repeated in 2000; 84% coverage was achieved, representing 11 million immunized individuals in the Region.

The last identified case of polio was confirmed in South-East Turkey in a 33-month-old child on 26 November 1998. However, the European Region remains under continuous threat from a number of neighbouring countries in the Eastern Mediterranean Region.

Almost all country polio laboratories now are fully accredited. All stool samples from AFP cases country in the Region are tested in an accredited laboratory. Most countries are using AFP surveillance (39), some will use AFP surveys, enterovirus surveillance is in extensive use in some, and one country is using environmental surveillance. To date, more than 3000 AFP cases were investigated with over 6000 stool samples tested since the last confirmed case of polio.

In AFP reporting countries, the overall detection rate is consistently >1/100 000 with good completion of two specimens sent to laboratories. This is strongly influenced by large countries such as Russia and Ukraine. Using an AFP index of 0.8 (basically, the non-polio AFP rate per 100 000 children multiplied by the percentage of appropriate specimens), then recently endemic countries are generally now achieving creditable levels of AFP surveillance: only two of these countries have sub-standard indices in 2000. Belarus, Bulgaria and Estonia have performed well amongst non-endemic countries; however, many of the other such countries using AFP surveillance are not reaching WHO performance standards. Within all countries, there are important variations that should direct the national managers to where improvement is needed.

The activities of the laboratory network included virological surveillance, accreditation and containment. Thirty of the 38 laboratories have now been fully accredited. The mean score of the EUR/01/5018750 page 3

proficiency test was 82% in 1999, a decline from 1998. In 1999, more than 4500 samples were tested from AFP cases. ITD has confirmed that there were no wild viruses in the region in 1999 and so far in 2000. It remains most important that samples should be sent for testing in a timely way. Further accomplishments have included capacity building through upgrading, training, standardisation, external and internal quality control, and communication.

Over 1999, surveillance has continued to improve and in the face of that improvement, there has been no wild virus detected. The challenges that remain include improving sample handling, resolving “silent areas” for surveillance, ensuring that all polioviruses are promptly re-tested in a regional reference laboratory, and validating enterovirus surveillance where used. Major activities for next year include strengthening the laboratory network, improving surveillance, and undertaking additional surveillance assessment visits. All Member States will need to take forward their plans for laboratory containment. NIDs and mopping-up will need to continue in risk countries.

The Regional Commission has now examined reports from national committees from non- endemic and some recently endemic zones. Some of the remaining countries will be assessed later in 2000, with last country reviews of initial documentation to occur in 2001.

The deadline for all countries to submit updated documentation will be December 2001. By mid- 2002, the Regional Commission will have completed its reviews before submission of the report to the Global Commission.

The certification process: country presentations

Albania There was endemic circulation of wild polioviruses up to 1985 with a P3 outbreak in 1978 after shortage of vaccine had occurred in 1977. OPV coverage had been consistently above 90% except for 1977 (38%) and 1991 (82%). There was good evidence for lack of wild polio circulation between 1986–95. However, in 1996 there was an outbreak of P1 with 138 confirmed cases. P1 was isolated from 69/138 cases; the case fatality ratio was 12%. The outbreak was successfully controlled through a mass OPV campaign, targeting all persons between 0 – 50 years in two rounds in 1996. In addition, from 1996 to 1998, a total of three sets of NIDs were conducted in children <5 years with coverage >90%, as supplementary activities. There is compulsory AFP reporting nationwide, with reporting within 24 hours from the lowest health level upwards. There is only one tertiary referral centre in Tirana and it is mandatory for all clinical cases of AFP to be sent to Tirana. There is a system for active surveillance by the Institute of Public Health for cases occurring in peripheral hospitals. The non-polio AFP rate, however, has consistently been under 1/100 000. The National Expert Committee reviews all AFP cases – none have been considered to be polio-compatible. Approximately 67% of AFP cases are investigated with two stool specimens. The national EV reference laboratory is based in Tirana. NPEV isolation rates are consistently 6–8% since 1996. The laboratory proficiency test scores have been 100% for the last two years. ITD is undertaken at the Istituto Superiore di Sanità (ISS), Rome. There have been no further polio cases since 1996. The National Committee believes that there is appropriate data on surveillance to meet requirements for certification, and that the national programme is appropriately robust to prevent any cases of poliomyelitis. EUR/01/5018750 page 4

The European Certification Commission congratulates the national committee on its work in assembling the information. AFP data indicates that there have been some delays in case investigation after reporting. It is most important that still further improvement is achieved in AFP surveillance and sample collection in order to fulfil the criteria needed by the Regional Certification Commission. There have been no reported AFP cases in 2000 to date until two cases have been found recently through active searching. “Zero reporting” has improved in 2000. High vaccine coverage must be maintained, particularly in urban settings. Efforts must continue to be made in assuring the integrity of the cold chain in Albania. It was apparent to the Commission members who visited Tirana that there was a high turnover of laboratory staff, and although the laboratory had been accredited in past years, this was presently pending.

Bosnia and Herzegovina The last case of wild virus poliomyelitis occurred in 1974. Immunisation against polio started in 1960 with coverage rising from low in 1992 until the last five years when it has been consistently above 90%. In recent years (1996, 1997, 1999 and 2000) there have been NIDs and SNIDs targeting children <60 months with coverage between 80 – 90%. Mopping up in refugee’s camps has involved children under 5 years or under 15 years as appropriate: these activities have involved 52 camps. In each political entity there is a different Ministry of Health with two Public Health Institutes. AFP surveillance is on a nationwide basis with weekly reports from all localities. AFP has been statutorily notifiable since 1996 and 1998 according to the political locality. Diseases such as AFP are reported from lowest health levels on a daily basis, reviewed by Public Health departments weekly, for further action if needed. In last 30 months there have been 30 AFP cases, 9 GBS, one transverse myelitis. All stools from cases and contacts were sent to ISS, Rome. However, AFP cases are being recognised in central level hospitals but not at peripheral level.

There are borders with Federal Republic of Yugoslavia where there have been cases of polio in 1996 (Kosovo). The post-war period and economic difficulties have hindered public health, and surveillance remains most important given the influx of refugees and the intense internal migration of displaced persons and refugees. It was noted that there is a possibility that there could be gaps in immunity in children born 1991–1993 when vaccinations could not be always carried out. The NIDs in 1996 and 1997 and SNIDs that were undertaken in 1999 and 2000 may have missed some of these children since they are now over 5 years. It is of importance to note that immigrants from Bosnia Herzegovina may not have documentation of immunisation from their states of origin.

The National Committee concludes that there is now good cooperation on surveillance between the two political entities; there are coordinated activities for polio control, and less risk now for importation.

The European Certification Commission recognizes the hard work undertaken by the National Committee in the face of many difficulties. However, the Commission was concerned at the shortage of some specific details in the report that is essential for the Commission’s deliberations. The Commission was impressed by the efforts in routine service provision as well as the NIDs and SNIDs that had been undertaken. More work was needed on the definitions that were being used for case classification. The AFP data indicate that surveillance does not yet meet certification standard criteria. There appear to be disparities between the two entities with higher AFP reports from the smaller population. There needs to be clarification on what is “active search for cases” as opposed to “zero reporting”. EUR/01/5018750 page 5

Republic of Moldova Immunization against poliomyelitis started in 1960. There was an outbreak of poliomyelitis between 1982 and 1984 involving more than 130 cases. The last case of wild virus poliomyelitis occurred in 1991. No wild viruses have been identified since 1996 through any form of surveillance, including environmental methods. Since 1983, vaccine coverage has been consistently above 90%. There are no borders with endemic countries or population subgroups with links to polio-risk countries. Cold chain and storage are of high quality with continuous training of health personnel. Serosurveys demonstrate high population immunity. NIDs were carried out in 1996 with >95% coverage obtained.

AFP surveillance, which has statutory reporting, involves all appropriate health personnel at all levels. Active surveillance is functioning well. Since 1998, the AFP rate has been >1/100 000 with >85% with two stool specimens. For the two previous years it was >0.75/100 000. An independent committee reviews all cases. The national laboratory has been accredited; cases that have been detected by the national laboratory have been shown to be Sabin strains, confirmed by the Moscow laboratory. Each year, around 450 stool and other samples are tested for enterovirus; 9% are positive.

The National Committee believes that there is appropriate data on surveillance to meet requirements for certification, and that the national programme is appropriately robust to prevent any cases of poliomyelitis.

The Commission commended the Moldova Committee on its report. The Ministry of Health fully supports the implementation of the programme. Active surveillance covering main hospitals appears to be functioning well. There does appear to be one relatively silent area, Transdniester; however, recent review of vaccine coverage and AFP surveillance there is reassuring. Immunization services improved in the Roma (gypsy) communities after 1995, through provision of a special team and now there does appear to be good coverage of gypsy groups, who are basically stable, accessing health facilities appropriately. It will be important to maintain this improved immunization coverage. The Commission stresses the importance of maintaining high quality AFP surveillance.

Romania Immunization started in 1957 with IPV with a switch to OPV in 1961. As a consequence there was a more than 99% decline in polio. Coverage in the last decade has been consistently over 94%; in most districts coverage has been significantly higher. Up to 1995 immunization was provided in once yearly campaigns; from 1995, with a secure cold chain, there has been year- round immunization. The VAPP rate was higher than reported elsewhere. A case-control study revealed an association between VAPP and administration of multiple injections in young children, particularly those children admitted to orphanages. Following an educational programme on the appropriate use of injections, changes in immunization policy (to use of IPV in orphanages), and the availability of oral antibiotics, the VAPP rate has now fallen dramatically. There was an NID undertaken in 1996 with coverage >95%.

Since 1970 there has been an AFP-like surveillance system, originally implemented for VAPP surveillance. There were no wild polio cases detected between 1980 and 1990. The last cases of epidemic polio were 13 cases of P1 between 1990 and 1992. There appeared to be a “loose chain” epidemic characteristic of a well-immunized population in which there are small pockets of mobile groups that are un-immunized. Since 1995, polio cases have been associated with EUR/01/5018750 page 6

Sabin strains, except one compatible case that was probably VAPP. Full AFP surveillance was implemented in 1992 with appropriate stool samples. Cases of facial paralysis were kept within the surveillance and investigation system as a way of obtaining more samples. Since 1998, non- polio AFP rates have been between 0.8 and 1.0/100.000, excluding facial palsy. Active surveillance is carried out in rehabilitation hospitals. The National Committee considers available data on all AFP cases.

There is one laboratory for all Romania that also investigates other enterovirus-related disorders. The laboratory has been fully accredited. It has carried out ITD since 1983 and parallel tests in Pasteur Institute, Paris have given consistent results. PCR is now routinely available with primers from Pasteur Institute. Enteroviruses are consistently identified between 5 and 30% according to the season. There are 50–60 Sabin strains identified annually through routine virological investigations, especially of young children.

The conclusions of the National Committee are that there has been no wild virus case since 1992, vaccine coverage is uniformly high, there is efficient AFP surveillance, and there have been no imported cases. Through excellent collaboration with the community leaders, there has been involvement in the immunization programme of Roma (gypsies) so that susceptible subgroups should not pose a risk to polio eradication. There are risks for poliovirus importation because of migration and international travel, but surveillance and the immunization programme is of sufficient quality to minimize such risks. The National Committee is entirely independent of the Ministry of Health and has been able to fully verify the data presented.

The Certification Commission congratulates the Romanian National Committee on outstanding work and the report; it was particularly pleasing to see the reduction of VAPP cases. The involvement of the gypsy community is to be commended, especially as this appears to be leading to continuing maintenance of high coverage in this group. Although the AFP surveillance has been well supported, it needs to achieve concordance with all of the indicators. There may be some under-reporting of GBS cases by experienced neurologists who may not appreciate the purpose of AFP surveillance to prove absence of transmission of wild polioviruses. All evidence suggests that the national laboratory is proficient in performing ITD, but poliovirus isolates must continue to be tested in laboratories in the network accredited by WHO for ITD.

The former Yugoslav Republic of Macedonia The last case of wild virus polio was a P2 strain, occurring in 1987, despite both sporadic and epidemic polio in surrounding countries since that time. OPV was introduced in 1960 and over the last 10 years, coverage has been >95%. There had been variation in such coverage over the early years of the programme. The former Yugoslav Republic of Macedonia introduced routine suspected polio surveillance 30 years ago, with active AFP surveillance introduced 3 years ago. Notification has been mandatory throughout this time. The surveillance is on a weekly basis with “zero reporting”. The active surveillance involves monthly visits to hospitals, health units and “institutions for health protection”. All cases of AFP are referred to one of the three specialist centres for full evaluation. Except for 1997, all indices were within expected rates (0.6 to 2.7), acceptable allowing for the small population. All virological investigations are carried out in the accredited laboratory in Sofia.

The former Yugoslav Republic of Macedonia undertook NIDs in 1996 with a target population from 3 months up to 18 years, and with 97% coverage. One NID was carried out in 1997 with 85% coverage of children up to 4 years. In 1999, two SNIDs were carried out involving EUR/01/5018750 page 7

Albanian Kosovar refugee children under 4 years, with >90% coverage, achieved under very difficult circumstances. Additional measures include immunisation for travellers to and from endemic countries.

The Commission commended the National Committee on their report of excellent work. The refugee crisis made for many challenges and much work was carried out under very difficult circumstances. High levels of continuing vigilance are needed. Very minor details within the report need amendment. A more detailed outbreak response plan is advisable.

Federal Republic of Yugoslavia The report of the National Committee has not yet been submitted. The Commission hopes that the national report becomes available in July and it should then be available for review by the Regional Certification Commission at its next meeting in October.

Country follow-up reports

Thirty-two countries presented documentation to the Regional Certification Committee during 1998–1999. The Commission made 122 specific recommendations to countries and six general recommendations, along with a full page of considerations.

The general recommendations of the RCC’s September 1999 meeting include that:

S All countries must meet minimum requirements for AFP surveillance (non-polio-AFP rate, adequate specimen collection); S if not, additional surveillance activities need to be carried out (e.g. retrospective record reviews, active searches, prospective AFP study); S national documentation is expected to be as high quality as possible with detailed information on all relevant activities carried out (especially in low performing and silent areas).

Despite a clear request, only 19 committees have so far provided a summary that justifies their claims for polio elimination. Nineteen countries were asked to show improvements in AFP surveillance and 17 to validate their EV surveillance data. Five were asked to re-submit their manuals. Other requests included the need for information on laboratory quality assurance and on coverage measurement; 75% of countries had submitted revised information by June 2000.

The data required for annual reports should include the following:

S Vaccination coverage; S surveillance indicators &/or update for EV surveillance; S geographic distribution of AFP cases and investigation of measures of concern; S data on polio compatible cases; S reports of the investigation and control of any importation of wild poliovirus.

Austria AFP surveillance was introduced in 1998 after one-year preparation, on an unfunded and entirely voluntary basis. It was difficult to convince clinicians of the need for AFP surveillance since polio had been absent for 20 years. Surveillance is based on monthly reports with rate of 0.87/100 000 in 1999; the stool sample rate was 50%. No polio-compatible cases were found. EUR/01/5018750 page 8

EV surveillance also was introduced with 3 laboratories participating. Of 3812 samples collected in 1999 there were 341 positive results (11%): all were typed. Sabin strains have been identified in each of the last three years. The laboratories take part in NEQAS schemes and are fully accredited.

The Commission was impressed with the improvements in surveillance, giving greater confidence that Austria has no circulation of polioviruses.

Belgium There remains no AFP surveillance, or virological surveillance. The latter was stopped in 1994 for financial/political reasons. There remains little political interest in establishing virological surveillance. The only available information is on vaccine coverage, which is estimated to be above 90% in all parts of Belgium. One VAPP (contact) case was detected in 1999.

The Commission remains deeply concerned at the lack of adequate surveillance data from Belgium. The Certification Commission or the Regional Office will contact the Belgian authorities expressing their concern and offering a visit from Commission members.

Bulgaria Weekly active surveillance for AFP cases was initiated in 1999. Information reported from all levels to the Ministry of Health. No unreported cases were detected. A new committee was established in 1999 to review all AFP cases for establishment of a final diagnosis. The Committee discusses cases immediately after notification. Since 1998, the national reference laboratory has been responsible for testing all specimens from AFP cases, and for providing EV surveillance. There has been extra effort made to improve sample handling. There have been improvements in the timely investigation of AFP cases.

The Commission was pleased by the response from Bulgaria to further improve their polio surveillance activities. A number of other questions raised by the previous report have been answered satisfactorily.

Denmark The samples for the national serosurvey for polio immunity came from blood tests taken at random and tested in the national laboratory. Over 900 samples covered all age bands. In 1999, 1310 EV tests were done with 104 positive (9%); 50% were stool samples with almost all samples coming from children under 4 years. One child per 800 is tested annually for EV; half of these are stool samples. The testing is done throughout the year but shows some increase in the second part of the year. The sampling varies across the counties of Denmark. One further laboratory will be contributing to the surveillance later this year. All testing is done by PCR. Two Sabin strains were identified in 1998, and three in 1999. It is still difficult to identify the clinical basis for the requests for EV tests, but this may be improved. There is an accreditation scheme for the laboratories undertaking EV identification. Resources that were previously lacking for culture of PCR positive EVs have now been found. A database has been established in Copenhagen for this surveillance.

The Commission appreciated the efforts that had been made to improve the background to the EV surveillance in Denmark, and how the National Committee had responded so positively to the recommendations of the Certification Commission. EUR/01/5018750 page 9

Germany It is now a statutory requirement for reporting of polio cases, on suspicion rather than confirmation. A federally funded scheme for AFP reporting has been improved by an active approach that has lead to an increase in the number of reports, although numbers of stools for testing has increased relatively little. There remains considerable variation amongst Länder. Sixty percent of AFP cases were GBS, followed by transverse myelitis. A “zero reporting” system was introduced in 1999 with retrospective submission of cards detailing any or no cases. There is better compliance from paediatric departments (90%) than neurological departments. Continuing efforts are being made to improve compliance from physicians. Quarterly information sheets go to all participants in the AFP scheme. Coverage can only be assessed at school entry but coverage appears to be >90% at that age. Serological data is also very encouraging. A network of EV laboratories has been established although it is difficult to estimate population based data. Following the immunization policy change to IPV in 1998, there have been fewer Sabin strains identified.

The Commission much appreciated the considerable efforts made in Germany to improve surveillance. The probability of continuing significant difficulties was noted. There will still need to be improvements in those parts of the country where AFP rates are below standard; additionally, there will need to be more efforts to obtain timely stool samples from AFP cases. The Commission supports additional efforts to achieve highest possible immunization coverage of the indigenous and immigrant populations, particularly by the second birthday.

Lithuania Coverage remains at close to 97% with lowest coverage in 1999 at 81%. The localities where low coverage has been detected have very small childhood populations.

Retrospective medical reviews were undertaken in 1999 and 2000. Despite thousands of case reports being reviewed retrospectively, no cases of polio had been reported. AFP surveillance will hopefully become established more effectively, as so far, no AFP cases have been reported. The national virology laboratory has not yet been accredited but in July 2000, there will be new arrangements.

The Commission had made many comments when the Lithuania National Committee had first submitted their report. There did appear to be improvements since then. AFP cases were found in the retrospective record review that should have been reported by clinicians through the AFP programme. There remains a need for high quality AFP surveillance that so far has not been achieved. A technical visit may assist in resolving some of the shortcomings.

Portugal There have been three visits to Portugal – one by a WHO team, one from Commission members, and one to assess the status of the national laboratory. AFP surveillance had started in 1995 but no cases had been reported in four years. At the time of the original submission in 1998, no approaches appeared to be used to cover immigrants, and the national laboratory was not accredited; there was no contingency plan to deal with importations.

Currently, a retrospective study has been completed to try to elucidate why AFP surveillance had failed. Over the study period, 21 hospitals confirmed that AFP cases were admitted, usually with GBS or transverse myelitis, but not reported. There is now an active scheme for AFP reporting including zero reporting, with a named physician in every hospital responsible for reporting EUR/01/5018750 page 10

cases and sending stool samples to the national laboratory. There is an active follow-up for any failed reports. Two GBS cases were reported in December 1999; both had two stool samples tested. This year hospitals are now sending monthly reports. Seven cases were reported in the first five months of the year; six had appropriate samples. The current rate is 1.1/100 000.

A national survey was undertaken in 1999 to identify pockets of unvaccinated susceptibles. A programme is in place to immunise these groups: evaluation will be done in September 2000. The National Respiratory and EV laboratory was accredited in November 1999. It is the reference laboratory for the AFP surveillance. A contingency plan was prepared and tested during the Angola outbreak. No importations were detected.

The Commission congratulates the Portuguese National Committee on its excellent responses to the earlier concerns. The efforts made to improve the AFP surveillance are excellent: this and the laboratory efforts must be maintained. The importance of immunising immigrants, especially from high-risk countries, was stressed.

Switzerland Suspected or confirmed polio must be reported, statutorily. A voluntary AFP system was set up in 1995. The individual providers are expected to report on a monthly basis, including “zero reporting”. The surveillance, including laboratory testing, is free to the physician and patient.

In 1999, there were eight AFP cases giving a rate of 0.6/100 000 with a stool-sampling rate of 14%. Most cases were GBS. There remain a number of further tasks for the National Committee including agreeing the definitions that the Committee will use, and supporting the level of immunization coverage. More work will be done to encourage AFP reporting in 2000.

A reference laboratory has been set up for EV and poliovirus surveillance.

The Commission notes the efforts being made by the Swiss National Commission, but remains concerned at the low level of AFP and corresponding stool sampling. The finding of funds for the laboratory investigation of AFP cases is a welcome step; hopefully this will have an impact on case investigation in the near future.

Surveillance for enteroviruses

Enterovirus surveillance (EV) data represents a potential source of information for the certification process. France, the Netherlands and the United Kingdom national committees (among others) are replying on EV surveillance data to support the certification process as the primary surveillance data. The challenge for use of this data source is to demonstrate comparability with the reference AFP surveillance system data. All surveillance systems can be assessed on the basis of the critical components that comprise the total system. The individual components have separate and additive effects on the sensitivity for the detection of poliovirus. One way to address enterovirus surveillance data is to demonstrate the comparability of components in these systems to components of AFP surveillance and their contribution to the sensitivity of the system.

By assessing the sensitivity of the individual enterovirus surveillance systems from different countries, it should be possible to evaluate this data source for the purposes of certification. EUR/01/5018750 page 11

For this assessment, it is necessary to know the structure of the enterovirus surveillance system including laboratories and reporting. It is important to provide critical demographic information about the individuals who are providing specimens, including age, location, and clinical condition. Distribution of sampling across geographical regions and throughout the year is important. To assess the sensitivity of the system, it is also important to provide information about the ratio at which specimens for specific clinical conditions are tested (by methods which could potentially detect poliovirus). If this information is provided, the enterovirus surveillance data can be used as a valuable supplement for the certification process. Multiple years of evidence amplifies the confidence that can be placed in enterovirus surveillance data.

France The last paralytic indigenous case occurred in 1989, the last imported case was in 1995, and the last imported virus was identified in 1998. The main risk remains of importation from Francophone Africa. There are now laboratories monitoring EV in 75% of France. Information is received from laboratories covering 90% of the French population. There is a standard form used on a monthly basis for monitoring all EV positive isolations. The laboratory network retains competence to isolate Sabin and non-Sabin like viruses. Over the last four years, 13 359 samples were tested from cerebrospinal fluid (CSF) in aseptic meningitis cases – 9% were positive. Sewage sampling from the region of Paris shows ability to identify a wide range of EVs, including rarely, polioviruses. In Lyon, more than 7000 samples are tested each year from hospital patients. Age-specific sampling rates and sources of samples by clinical material are known.

Netherlands The study covers 1996–1999. The data collected includes number of faecal specimens inoculated onto susceptible cells, number and type of polioviruses and enteroviruses isolated, and information on age and diagnosis of patients tested. It is obligatory to further analyse non- typable EVs, and data are only accepted from qualified virology laboratories that fulfil QA/QC requirements.

In the Netherlands, there is a clear EV season between May and October. The virus diagnostic laboratories (19) are geographically representative of the population distribution. Performance indicators suggest that laboratories are contributing well over the last five years. Poliovirus isolates are not unusual, either reflecting recent OPV immunization, or children returning from abroad. Each year over 8000 stool samples are tested with most (75%) coming from children. One in every 500 children submits a stool sample for EV analysis each year; 7% are usually positive (range 0–28%). Eighty-five percent of EVs have been typed. Only one non- typed/typable isolate has been found to be a poliovirus when tested at RIVM. Proficiency panels that are sent to all laboratories have shown high abilities to identify polioviruses from other EVs. Future use of PCR will raise challenges for the continuation of this form of surveillance.

United Kingdom AFP surveillance, through the British Surveillance Unit, only led to 0.34/100 000 reports with low sampling rates. Other methods of surveillance were sought. It was appreciated that viral culture was frequently performed, laboratories were part of a NEQAS scheme, positive isolates were referred to PHLS, and so were non-typed/typable isolates.

The quality of isolation was high as were the proportion correctly typed from proficiency panels. Over 250 National Health laboratories are reporting all positive isolates to PHLS, now EUR/01/5018750 page 12

increasingly electronically. The majority of isolates is from stools in children but the denominator was not known. Therefore five laboratories were asked to identify all clinical and laboratory details from EV samples. Around 5% were positive from stool samples, with higher yields from stools even in cases of aseptic meningitis. The data could be extrapolated to give estimates of numbers of children and adults with aseptic meningitis. Also, the total number of individuals being examined with EV tests could be estimated. A high rate of viral culture is performed with approximately one sample per 850 children annually or 3000 adults each year. However, only some 5% of samples are derived from neurological cases. Polioviruses have been received from 1009 cases, almost all less than one year of age. ITD has confirmed that these are Sabin strains, coming from children mostly recently immunized.

This system faces challenges from changes in laboratory practice with increasing proportions of isolates not being fully typed as the result does not affect clinical practice, and there is increasing use of PCR on CSF samples from meningitis cases. With reductions in use of monkey kidney cell lines being considered, efforts are being made to provide alternative suitable continuous cell lines, with central preparation of tissue culture media.

Global Action Plan for laboratory containment of wild polioviruses

Once polio is eradicated, the laboratories of the world will be the only remaining source of the virus. Safe handling and, ultimately, maximum containment of poliovirus and potentially infectious materials in the laboratory is crucial.

Until now, poliovirus biosafety concerns have been minimal. Universal immunization with inactivated polio vaccine (IPV) or oral polio vaccine (OPV) has reduced the risk of disease for laboratory workers and the general public. Current technologies and biosafety practices have further reduced the risks of poliovirus contamination of the environment.

The probability of a laboratory-associated poliovirus infection is small, but the consequences of an infection grow greater with time. A chance reintroduction of wild poliovirus from the laboratory into the community after cessation of transmission presents a threat to polio eradication. A chance reintroduction of wild poliovirus after cessation of immunization presents a threat to public health of global proportions.

The world now faces the formidable, but not insurmountable, challenge of locating the many laboratories that have wild poliovirus infectious, or potentially infectious, materials and ensuring that they are adequately contained in the laboratory, rendered non-infectious, or destroyed. The Global Action Plan addresses these responsibilities. It is linked to the major eradication objectives, and consists of three phases.

Pre-Eradication: Safe Handling of Wild Poliovirus Infectious or Potentially Infectious Materials (BSL-2/polio): The pre-eradication phase covers the present, when wild poliovirus is decreasing or no longer circulating in many areas of the world. Three tasks are critical to this phase.

1. Nations must identify and develop an inventory of laboratories that have wild poliovirus infectious materials or potentially infectious materials. 2. Laboratories must institute enhanced biosafety level-2 (BSL-2/polio) procedures for safe handling of all such infectious or potentially infectious materials. EUR/01/5018750 page 13

3. Nations must begin planning for implementation of biosafety requirements for Post-Global Eradication.

The purpose of the Global Survey is to acquaint all medical/biological laboratories that might possess wild poliovirus infectious and/or potentially infectious materials with the Global Action Plan; to effect disposal of all wild poliovirus infectious and/or potentially infectious materials no longer needed by the laboratory; to ensure safe handling of all such materials; and to establish a Global Inventory of laboratories that retain such materials.

The Survey is hierarchical, beginning with notification by WHO and proceeding through Ministries of Health, agencies and institutions, and to laboratories. Because many laboratories that might possess such materials are outside the health sector, completion of the survey will require Ministries of Health to enlist the cooperation of other ministries, including Education, Defence, and Environment.

The purpose of the inventories is:

S to document the location and type of wild poliovirus infectious and/or potentially infectious materials being retained; S to meet the country requirements for Regions to be certified as polio-free; and S to maintain a current list of laboratories to be notified to initiate an enhanced containment procedures one year after detection of the last wild poliovirus.

Data from the laboratories are submitted by parent agency/institutions to the National Inventory maintained by each country. Data from the National Inventory are provided to the National Committee for the Certification of Poliomyelitis as well as to the appropriate WHO Regional Office.

Post-Global Eradication: High containment of wild poliovirus infectious and potentially infectious materials (BSL-3/polio): To begin one year after detection of the last wild poliovirus at which time the probability is high that all human transmission has ceased. All laboratories possessing wild poliovirus infectious materials or potentially infectious materials must elect one or more of the following three options:

1. Implement containment (BSL-3/polio) procedures, or 2. transfer wild poliovirus infectious and potentially infectious materials to WHO designated repositories, or 3. render such materials non-infectious, or destroy them, under appropriate conditions.

All biosafety actions are to be implemented and documented as complete before certification of polio eradication can be considered.

Post-OPV Immunization: Maximum containment (BSL-4) of wild poliovirus infectious and potentially infectious materials and high containment (BSL-3/polio) of OPV and OPV- derived viruses: To begin when OPV immunization stops EUR/01/5018750 page 14

The post-OPV immunization phase begins with the worldwide cessation of OPV administration and the subsequent rapid increase of non-immune (susceptible) children. The biosafety requirements for wild poliovirus infectious and potentially infectious materials increase from BSL-3/polio to BSL-4, consistent with the increased consequences of inadvertent transmission of wild poliovirus from the laboratory to the community. Biosafety requirements for OPV and OPV-derived viruses increase from BSL-2/polio to BSL-3/polio to prevent reintroduction and theoretical circulation of these viruses in un-immunized populations. Procedures will be developed to control or destroy unused OPV in clinics, immunization centres, physician’s offices, and other sites.

European Region Action Plan for laboratory containment of wild poliovirus

Guidelines for implementation of laboratory containment of wild poliovirus have been completed and sent to the Ministries of Health of all European countries. These guidelines cover the laboratory searches and inventories that will comprise the first phase of the Action Plan for the WHO European Region. The Action Plan describes two critical steps:

S A national search for all medical/biological laboratories that might possess wild poliovirus infectious and/or potentially infectious materials; S A national inventory system for laboratories that contain such material.

The National Search is hierarchical, beginning with notification by WHO to the highest authority of each country or Ministry of Health which, in turn, will appoint a Focal Person/Group for containment. This person/group will create the National Plan for containment and will be responsible for contacting agencies and institutions who, in turn, will make requests to the laboratories. Because many of the laboratories that might possess infectious or potentially infectious wild poliovirus materials are outside the health sector, completion of the search will require the focal person/group to enlist the cooperation of other Ministries, including Education, Defence, Agriculture and Environment.

The data for the National Inventory System are obtained from the National Search. Each laboratory identified as containing wild poliovirus infectious or potentially infectious material will submit a complete list of all such materials to its parent agency/institution, which in turn will create an Agency/Institution Inventory. Data from all laboratories listed on the latter are included in the National Inventory, maintained by each country. Summary data from the National Inventory are submitted to the WHO Regional Office to be included in the Regional Inventory, which in turn, will compile the data for the WHO Global Inventory.

Phases II and III of the Action Plan call for all infectious and potentially infectious materials listed in the inventories to be rendered non-infectious, destroyed, or properly contained in a WHO-approved poliovirus laboratory. Completion of a National Inventory will be a prerequisite for certification of a country as “polio- free”. EUR/01/5018750 page 15

Country reports on implementation of national plans for laboratory containment of wild poliovirus

France A review has already been undertaken of the laws and regulations that apply to laboratory practice and the handling and storage of infectious and potentially infectious materials. A new regulation was passed in November 1999 – “Good Execution of Biological Analysis” – and it is hoped that this will facilitate the development on a National Inventory. It is also possible that the National Quality Control laws will help identify a number of agencies possibly handling polioviruses. However, it has been estimated that there are likely to be more than 5000 laboratories (private sector, hospitals, institutes, and blood transfusion), and all will need to be involved. Meanwhile, a questionnaire is routinely sent annually to each laboratory for quality control purposes and this may be utilized for specific requests as will be needed for the National Inventory.

Concerns involve the scale of the task, the complex regulatory environment that exists, the multiplicity of agencies/government departments, and the extent that is outside of the health structure. On the more positive side is the already existing network of laboratories (185 at present) that are collaborating over enterovirus surveillance, since these are the most likely to be the most important for the National Inventory.

Netherlands The Containment Manual has been reviewed in the Netherlands and the tasks required linked to the activities of the National Certification Committee. The agency responsible – the Dutch Inspectorate for Health Care – is directly linked to the National Committee. The Inventory will undoubtedly be time-consuming and the provisional date for completion in 2000 is now seen as over-optimistic. It is considered important for laboratories that are included in the Inventory to continue to provide “zero reports” after the entry into the Inventory. The Inspectorate for Health Care will be writing to hospitals, laboratories, institutions, other ministries, public health agencies and relevant national organizations. The accountability for returning the information will be made explicit.

Implementation will include a system of quarterly reporting from laboratories to the National Committee. On-site inspections will be carried out, especially looking for samples from 1992 to 1993 when there was some circulation of wild polioviruses. Two laws will be used to ensure compliance from the laboratories, and laboratory accreditation schemes will be used to include safe handling and storage of samples at biosafety level 2 and then 3.

United Kingdom The topic of containment of polioviruses was referred both to the Advisory Committee on Dangerous Pathogens (ACDP), and to the Joint Committee on Vaccination and Immunisation (JCVI). Both committees agreed on the importance of this work, and noted the implications for laboratories, and especially for the research community who may not appreciate the relevance of samples that they hold. It was agreed that a joint working party between the two committees should be set up, and its work will be made available to the National Certification Committee. The first step of the Inventory is being planned. This will involve contacting the Public Health Laboratories (PHLS) and hospital based non-PHLS laboratories enquiring if they work on wild polioviruses. The Research Councils and other appropriate institutions will also be approached. EUR/01/5018750 page 16

In Great Britain, the Health and Safety Executive (HSE) has statutory responsibility for biosafety in all laboratories and workplaces. The cooperation of the HSE has already been obtained to take forward the necessary steps to change the biosafety level for wild polioviruses to level 3 in the first instance. The view of the HSE is that while this can be done through United Kingdom legislation, the simplest way would be through an EU directive that would then be binding on all laboratories. It is the second step of the inventory process, of contacting all laboratories to see if they hold potentially polio infected material, that is seen as the most difficult. A post has now been funded for an individual to take forward the inventory process, jointly supervised by the HSE and DH. A National Working Group has been set up, answerable to both the ACDP and JCVI, and letters for laboratories are now in preparation.

Discussions on the implementation of a plan for laboratory containment of wild polioviruses were conducted in four working groups; potential problems were identified and WHO/EURO was requested to take specific actions to further political awareness. Issues discussed included aiming for the use Sabin strains for all serologic tests, handling frozen tissue also potentially infectious, (if relevant tissue and time period), and promoting the containment process at all scientific meetings. The RCC fully endorsed the Regional Plan of Action and emphasized that the containment process is an important part of the certification process (copies of the report are available from the WHO Regional Office for Europe).

Summary and conclusions

More than 18 months have passed since the last identified poliomyelitis case occurred in the European Region, strongly suggesting than poliovirus transmission has been interrupted. The European Region has made considerable progress in the certification process, even if the timeline has been altered from the original plans of 1996. With this meeting, the Regional Certification Commission has begun review of recently endemic countries, with plans to submit complete documentation for the Region certified as polio-free to the Global Commission in 2002, when, it is hoped, more than three years will have passed after the onset of last case. For several non-endemic countries, the Commission has reviewed country updates and observed definite progress in most areas, where Commission recommendations and other improvements were implemented. Unfortunate exceptions to this were noted. The Commission will expect annual updates from each National Committee up to the completion of the regional submission and regular updates until the time of certification of global polio eradication, targeted for 2005. The need for sensitive, continuing surveillance was stressed, as a long-term obligation, essential until well after eradication had been attained and certified up through the time when poliovirus vaccination is stopped. Enterovirus surveillance data can support the certification process if the data are accompanied with sufficient detail to demonstrate its sensitivity in the testing of faecal specimens from ill children. With eradication close, the issue of laboratory containment of wild poliovirus and potentially infectious material becomes essential. With containment as an integral part of the certification process for this Region, an inventory of laboratories containing wild poliovirus and potentially infectious materials targeted is to be completed by all Member States by the end of 2001. EUR/01/5018750 page 17

Annex 1

PROGRAMME

Sunday, 18 June 2000 Arrival of WHO Staff Arrival of the Regional Certification Commission members

Monday, 19 June 2000

09.30 – 10.30 Executive meeting of the Regional Certification Commission 10.00 Registration of participants 10.30 – 11.00 Coffee break 11.00 Introduction by Sir Joseph 11.10 – 12.00 Country presentation: Albania (15 min) WHO comments Discussion 12.00 – 13.00 Lunch break 13.00 – 13.40 Country presentation: Bosnia and Herzegovina (15 min) WHO comments Discussion 13.40 – 14.20 Country presentation: Republic of Moldova (15 min) WHO comments Discussion 14.20 – 15.00 Country presentations: Romania WHO comments and Discussion 15.00 – 15.30 Coffee break 15.30 – 16.10 Country presentation: the former Yugoslav Republic of Macedonia (15 min) WHO comments Discussion 16.10 – 18.00 Private meeting of the Regional Certification Commission: Conclusion Tuesday, 20 June 2000

08.30 – 9.00 Registration 09.00 – 10.00 Opening of the Meeting: The Regional Director · WHO/headquarters · The Chairperson of the Regional Certification Commission EUR/01/5018750 page 18

10.30 – 11.00 Coffee break 10.30 – 12.00 Session 1: Poliomyelitis Eradication: Progress achieved, Situation, Acceleration and plans: · Global perspective · WPRO situation · The Regional vision · Discussion · Surveillance for the Certification · The Regional Laboratory Network · Discussion

12.00 – 13.30 Lunch break 13.30 – 15.00 Session 2: Surveillance for enteroviruses as tool for the certification + Surveillance for enteroviruses: how to measure the quality Dr Mark Pallansch (25 min) Discussion + Experience of France (15 min) + Experience of Netherlands (15 min) + Experience of United Kingdom (15min) Discussion (10 min)

15.00 – 15.30 Coffee break 15.30 – 18.30 Session 3: The Certification process in the Region – Country Reports to follow up on the recommendations given by the Regional Certification Commission : Summary of country updates presented by WHO Country presentations: (20 min for each country: 10 min presentation followed by 10 min discussion) · Austria · Belgium · Bulgaria · Denmark · Germany · Lithuania · Portugal · Switzerland EUR/01/5018750 page 19

Wednesday, 21 June 2000 08.30 – 10.00 Session 4: Laboratory containment of wild polioviruses: Global plan of action for laboratory containment of wild polioviruses Discussion

The Regional plan of action for laboratory containment Discussion

10.00 – 10.30 Coffee break 10.30 – 11.30 Country Experience with the preparation of national plans: · France Discussion · Netherlands Discussion · United Kingdom Discussion 11.30 – 12.30 Discussions in four working groups: Strategies to implement the regional plan of action for laboratory containment of wild polio viruses 12.30 – 13.30 Lunch break 13.30 – 14.30 Reports from the working groups Discussion 14.30 Closure of the meeting 14.30 – 15.00 Coffee break 15.00 – 15.30 Meeting the Regional Certification Commission with the countries who have presented documentation Providing feed-back 15.30 – 16.30 Executive meeting of the Regional Certification Commission: S Strategic vision of the certification S Next meeting S Participation in the assessment of the quality of surveillance for AFP in Turkey

16.30 – 18.30 Executive meeting of the Regional Laboratory Network EUR/01/5018750 page 20

Annex 2

PARTICIPANTS

Albania Dr Silva Bino Tel. No.: +355 42 70058/59 Director Fax No.: +355 42 70058 Institute of Public Health Email: [email protected] Rruga 'Aleksander Moisiu' Tirana

Mr Eduard Kakarrigi Institute of Public Health Fax No.: +355 42 70058 Rruga 'Aleksander Moisiu' Tirana

Dr Petrit Vasili Email: [email protected] Director Primary Health Care Department Ministry of Health Pr.B. Curri Tirana

Andorra Dr Margarida Coll Armengué Chef Service de l'Information et Etudes sanitaires Tel. No.: +376 860 345 Ministère de la Santé et du Bien-être Fax No.: +376 825 838 Av. Princep Benlloch, 30. 4eme Email: [email protected] Andorra la Vella

Dr Josep Vidal Tort Tel. No.: +376 86 03 45 ex.229 Microbiòlog Fax No.: +376 86 19 33 Hospital de Clínic de Barcelona c/o Dr Margarita Coll Armangué Information and Sanitary Studies Service Ministry of Health and Welfare Av. Princep Benlloch num. 30 Andorra La Vella

Austria Dr Helga Halbich-Zankl Leiterin der Abteilung für Tel. No.: +43 1711724103 Infektionskrankheiten Fax No.: +4317187183 Bundesministerium Email: [email protected]. at für Soziale Sicherheit und Generationen Sektion Gesundheitswesen Stubenring 1 A-1010 Wien EUR/01/5018750 page 21

Professor Ingomar Mutz Tel. No.: +43 3842 401 2330 Vorstand der Abteilung für Kinder und Fax No.: +43 3842 401 2738 Jugendliche Email: [email protected] A.ö. Landeskrankenhaus Leoben Vordernberger Strasse 42 A-8700 Leoben

Professor Günther Wewalka Tel. No.: +43 14051557/0 Director Fax No.: +43 14023900 Federal Public Health Laboratory and Email: [email protected] Polio Reference Laboratory Bundesstaatliche bakteriologisch- serologische Untersuchungsanstalt Währingerstrasse 25a - Postfach 91 A-1096 Wien

Belgium Dr René Snacken Adviser of the Minister of Public Health Tel. No.: +32 2 220 2011 Office of the Minister Fax No.: +32 2 220 2067 7 rue des Arts Email: [email protected] 1210 Brussels

Bosnia and Herzegovina Dr Srboljub Golubovic Head, Clinic for Infectious Diseases Tel. No.: +387 71 309 993 Clinical Center Banja Luka Fax No.: +381 71 216 601 Zdrave Korde 78000 Banja Luka

Professor Zlatko Puvacic Tel. No.: +387 71 658 421 EPI Coordinator for B&H Fax No.: +387 71 651 120 Chief Epidemiologist Federal Public Health Institute Marsala Tita 9 71000 Sarajevo

Professor Zlatko Puvacic Tel. No.: +387 71 658 421 EPI Coordinator for B&H Fax No.: +387 71 651 120 Chief Epidemiologist Federal Public Health Institute Marsala Tita 9 71000 Sarajevo

Dr Mitar Tesanovic Epidemiologist, Public Health Institute Tel. No.: +381 78 43 315 Zavod za zastituto zdravlja Fax No.: +381 78 43 390 Jovana Ducica 1 78000 Banja Luka EUR/01/5018750 page 22

Bulgaria Professor Ivan Dikov Head, Department of Infectious Diseases, Epidemiology, Parasitology and Tropical Medicine Tel. No.: +359 2 981 0225 National Consultant, Fax No.: +359 2 987 2792 Infectious Diseases Email: [email protected] Medical University of Sofia Sofia

Dr Radosveta Ivanova Fax No.: +359 98 72 792 Chief expert of MoH Email: [email protected] Ministry of Health 5, Sveta Nedelja sq. Sofia 1000

Croatia Dr Bernard Kaic Epidemiologist Department of Epidemiology Fax/Phone +385 1 4683 004 Croatian National Institute of Public Health Rockerfellarova 7 10000 Zagreb

Czech Republic Professor D. Slonim Chief, NCPE Tel. No.: +420 2 333 23 630 Mickiewitzova 15 Fax No.: +420 2 4915430 16000 Prague 6

Dr Gustav Walter Tel. No.: +420 2 2497 2184 Department of Epidemiology and Fax No.: +420 2 2491 6007 Microbiology Email: [email protected] Ministry of Health of the Czech Republic Palackého nam. 4 128 01 Prague 2

Denmark Dr Klaus Bro-Jørgensen Division of Biologicals Tel. No.: +45 32 68 34 36 Statens Serum Institute Fax No.: +45 32 68 39 73 Artillerivej 5 Email: [email protected] DK-2300 Copenhagen S

Dr Tove Rønne Tel. No.: +45 32 68 34 44 Chief, Department of Epidemiology Fax No.: +45 32 68 38 74 Statens Seruminstitut Email: [email protected] dk Artillerivej 5 DK-2300 Copenhagen S EUR/01/5018750 page 23

Dr Peter Skinhøj Chief Physician Tel. No.: +45 35 45 7741 Dept. of Infectious Diseases Fax No.: +45 35 45 6648 Rigshospitalet Tagensvej 20 DK-2200 Copenhagen

Estonia Dr Silver-Lello Joks Head, Central Laboratory of Virology Tel. No.: +372 6 513 559 Health Protection Inspectorate Fax No.: +372 6 552 534 Kotka 2 Email: [email protected] 11315 Tallinn

Dr Kuulo Kutsar Fax/Phone +372 6 567 700 Deputy Director General Fax/Phone +372 6 567 702 EPI Manager E-mail [email protected] Editor of Eesti Arst Inspectorate of Health Protection Paldiski mnt. 81 EE-10617 Tallinn Estonia

Finland Dr Aimo Salmi Professor of Virology Department of Virology Tel. No.: +358 2 3337460 The University of Turku Fax No.: +358 2 2513303 Kiinamyllynk 13 20520 Turku

France Dr Roberte Manigat Médecin Inspecteur de Santé Publique Tel. No.: +33 1 4056 4392 Direction Générale de la Santé Fax No.: +33 1 4056 5056 Bureau des Maladies Transmissibles Email: dgs.vs2@santé.gouv.fr Ministère de l'Emploi et de la Solidarité 8, avenue de Ségur F-75007 Paris

Professor Michel Rey Tel. No.: +33 1 45 67 96 78 Ligue Française pour la Prévention des Email: [email protected] Maladies Infectieuses 5 Bvd Montparnasse F-75006 Paris

Germany Professor Dr Adolf Windorfer Niedersächsisches Tel. No.: +49 511 4505 501 Landesgesundheitsamt Fax No.: +49 511 4505 502 Roesebeckstr. 4-6 D-30449 Hanover EUR/01/5018750 page 24

Greece Professor Antonis Antoniadis Tel. No.: +30 31 999 081 Laboratory of Enterovirus Fax No.: +30 31 999 149 School of Medicine Email: [email protected] Dept. of Microbiology Aristotelian University of Thessaloniki Thessaloniki T.K. 54006

Professor Christos Kattamis Tel. No.: +30 1 7467467 Professor of Paediatrics Fax No.: +30 1 7795762 University of Athens Children's Hospital AGIA SOFIA Thivon and Livadias Goudi, TK 11527

Professor Jenny Kourea-Kremastinou Tel. No.: +30 1 646 5982 Athens School of Public Health Fax No.: +30 1 643 2258 196, Alexandras Avenue Email: [email protected] GR-Athens 11521

Hungary Dr Györgu Berencsi Tel. No.: +36 1 2155469 Head, Department of Virology Fax No.: +36 1 2150148 B. Johan National Institute of Hygiene Email: [email protected] 2-6 Gyali Street, P.O. Box 64 H-1966 Budapest

Dr Katalin Rapi Director Fax No.: +36 1 2156501 Szent Laszlo Hospital Gyali ut 5-7 1097 Budapest

Dr Adam Vass Tel. No.: +36 1 215 5331 Head, Division of Epidemiology Fax No.: +36 1 215 5311 National Medical & Public Health Office Email: [email protected] P.O. Box 839 H-1437 Budapest

Iceland Dr Haraldur Briem State Epidemiologist Tel. No.: +354 510 1900 Section for Infectious Disease Control Fax No.: +354 510 1920 Directorate of Health Email: [email protected] Laugavegur 116, 2nd floor IS-150 Reykjavik

Ireland Dr John Devlin Deputy Chief Medical Officer Department of Health Tel. No.: 353 1 635 42 49 Hawkins House, Fax No.: +353 1 671 0148 Hawkins Street Email: [email protected] Dublin 2 EUR/01/5018750 page 25

Professor William W. Hall Tel. No.: +353 1 706 1325 Virus Reference Laboratory Fax No.: +353 1 269 7611 University College Dublin Email: [email protected] Belfield Dublin 4

Israel Dr Chantal Sadik Department of Epidemiology Fax +972 2 6722 066 Ministry of Health Fax +972 2 6706 876 PO Box 1176 Jerusalem 90100

Dr Rachel Handsher Tel. No.: +972 3 530 2388 Head, Fax No.: +972 3 530 2457 National Centre of Poliomyelitis Email: [email protected] Central Virology Laboratory Claim Sheba Medical Centre 52621 Tel-Hashomer

Italy Dr Dina De Stefano Caraffa Chief, Communicable Diseases Unit Tel. No.: +39 06 599 44 211 Dipartimento della Prevenzione, Uffi III Fax No.: +39 06599 44 319/320 Ministero della Sanita Email: [email protected] Via della Sierra Nevada 60 I-00144 Rome

Professor Gaetano Maria Fara Tel. No.: +39 06 499 14 602 Director, Inst. Hygiene Fax No.: +39 06 44 56 371 University 'La Sapienza' Email: [email protected] Piazzale Aldo Moro 5 I-00185 Rome

Latvia Dr Jurijs Perevoscikovs Head, Department of Epidemiological Tel. No.: +371 737 6339 Surveillance of Infectious Diseases Fax No.: +371 733 9006 National Environmental Health Centre Email: [email protected] 7 Klijanu str. LV 1012 Riga

Professor Ludmila Viksna Tel. No.: +371 701 4500 Chair, Infectious Diseases Department Fax No.: +371 701 4568 Infectology Center of Latvia Email: [email protected] Latvian Medical Academy 3 Linezera Str. LV-1006 Riga EUR/01/5018750 page 26

Lithuania Dr Vytautas Bakasenas EPI Manager Deputy Director Tel. No.: +370 2 22 56 34 Centre for Communicable Diseases Prevention Fax No.: +370 2 22 77 07 and Control Email: [email protected] Ministry of Health 4a Roziu Avenue LT-2090 Vilnius

Professor Vytautas Usonis Tel. No.: +370 9 830779 Vilnius University Paediatric Center Fax No.: +370 2 757179 P.O. Box 2561 Email: [email protected] LT-2009 Vilnius

Malta Dr Malcolm Micallef Director, Public Health Tel. No.: +356 32 40 85 Department of Health Fax No.: +356 31 92 43 15, Merchants Street Email: [email protected] Valletta VLT03

Dr Mark Muscat Tel. No.: +356 32 40 86 Senior Medical Officer Fax No.: +356 31 92 43 Disease Surveillance Branch Email: [email protected] Department of Public Health 37-39 Rue d'Argens MSIDA Valletta VLT03

Netherlands Dr Jan K. van Wijngaarden Inspector for Infectious Diseases Tel. No.: +31703405979 Inspectorate for Health Care Fax No.: +31703405394 P.O. Box 1611 g Email: [email protected] NL-2500 BC The Hague

Mrs Judith Verlind Tel. No.: +31 70 340 7222 National Certification Committee Ministry of Health P.O. Box 16119 2500 BC The Hague

Norway Professor Miklos Degre Tel. No.: +47 23 07 11 63 Institute of Microbiology, Rikshospitalet Fax No.: +47 23 07 11 10 N-0027 Oslo Email: [email protected] EUR/01/5018750 page 27

Dr Viggo Hasseltvedt Tel. No.: +47 22 04 26 43 Senior Physician Fax No.: +47 22 04 25 13 Departmen Infectious Disease Control Email: [email protected] National Institute of Public Health P.O. Box 4404 Torshov N-0403 Oslo

Dr Ivar Oerstavik Tel. No.: +47 2 2042286 Director, Department of Virology Fax No.: +47 2 2042447 National Institute of Public Health Geitmyrsveien 75 -Postboks 4404, Torshov N-0403 Oslo

Poland Professor Wieslaw Magdzik Chief, Department of Epidemiology Tel. No.: +48 22 849 31 04 National Institute of Hygiene Email: [email protected] ul. Chocimska 24 PL-00791 Warsaw

Portugal Dr Maria da Graça de Freitas Chefe da Divisao das Doenças Transmissiveis Tel. No.: +351 21 843 0606 Direcçao Geral da Saude Fax No.: +351 21 843 0620 Alameda D. Afonso Henriques, 45 Email: [email protected] P-1049-005 Lisbon

Professor Antonio Guilherme Goncalves Tel. No.: +351 22 510 5537x133 Adjunto do Coordenador do Fax No.: +351 22 510 5591 Centro Regional de Saude Publica do Norte Email: [email protected] Rua Latino Coelnho 260 4049-032 Porto

Republic of Moldova Dr Victoria Ghidirim Tel. No.: +373 2 79 96 11 Chief, Polio National Laboratory Fax No.: +373 2 72 97 25 Laboratory of Virology Email: [email protected] National Centre for Preventive Medicine Str. Gh. Asachi 67a 277028 Chisinau

Dr Mihai Magdei Tel. No.: +373 2 72 99 07 Director General Fax No.: +373 2 72 97 25 National Centre for Preventive Medicine Email: [email protected] Gh. Asachi Str. 67A 2028 Chisinau

Professor Nicolae I. Opopol Tel. No.: +373 273 58 22 Scientific Director Fax No.: +373 272 97 25 National Centre of Preventive Medicine Email: [email protected] 67A, G. Asachi Str. Chisinau MD 2028 EUR/01/5018750 page 28

Professor Constantin Spynu Tel. No.: +373 2 72 97 14 Deputy Director General Fax No.: +373 2 72 97 25 National Centre for Preventive Medicine Gh. Asachi Str. 67A 2028 Chisinau

Romania Dr André Aubert Combiescu Director Tel. No.: +40 1 411 21 59 Cantacuzino Institute Fax No.: +40 1 411 56 72 Splaiul Independenti 103 Email: [email protected] R-70100 Bucharest

Dr Mariana Combiescu Tel. No.: +40 1 411 2159/3800 Head, National Reference Centre for Fax No.: +40 1 411 5672 Enteroviruses Email: [email protected] Cantacuzino Institute PO Box I-525 Splaiul Independentei 103 70100 Bucharest

Dr Daniela Pitigoi Tel. No.: +40 1 310 39 19 Director, Department for Public Health Fax No.: +40 1-313 66 60 Ministry of Health Email: [email protected] Ministerului Street, nr. 1-3, sector 1 70109 Bucharest

Dr Mircea Ioan Popa Tel. No.: +40 1 313 80 14 General Director, Department for Public Health Fax No.: +40 1 313 66 60 Ministry of Health Email: [email protected] 1-3 Ministerului Str., Sector 1 70052 Bucharest

Slovakia Dr Beata Cernakova Centre of Epidemiology and Microbiology Tel. No.: +421 7 443 727 43 Department of Virology Fax No.: +421 7 443 726 41 State Institute of Public Health Email: [email protected] Trnavska 52 82645 Bratislava

Professor Juraj Cervenka Tel. No.: +421 7 52 49 85 66 Chairman, National Certification Committee Fax No.: +421 7 52 92 16 16 Blumentalska 17 Email: [email protected] SK-81107 Bratislava

Dr Eva Maderova Fax No.: +421 7 54 77 61 42 Head of Department Email: [email protected] Epidemiology of Infectious Diseases Section of Health Protection Ministry of Health of the Slovak Republic Limbova 2 83341 Bratislava 37 EUR/01/5018750 page 29

Slovenia Dr Alenka Kraigher Head, Epidemiology Department Fax/Phone +38 6 61 323940 Centre for Communicable Diseases Email: [email protected] NationaI Institute of Public Health Trubarjeva 2 61000 Ljubljana Slovenia

Dr Dunja Piskur-Kosmac Tel. No.: +386 61 1786004 State Secretary Fax No.: +386 61 217 755 Ministry of Health Email: [email protected] Stefanova 5 1000 Ljubljana

Spain Dr Fernando Martinez-Navarro Epidemiologic Surveillance Area Tel. No.: +34 91 387 7802 National Centre of Epidemiology Fax No.: +34 91 387 7815/6 Sinesio Delgado 6 Email: [email protected] E-28029 Madrid Dr Isabel Pachon Tel. No.: +34 91 387 7802 Chief, Section of Vaccine-preventable Diseases Fax No.: +34 91 387 7816 National Centre of Epidemiology Email: [email protected] Sinesio Delgado 6 E-28029 Madrid Tel. No.: +34 91 509 7901 Dr Pilar Perez Brena Fax No.: +34 91 509 7966 Centro Nacional de Microgiologia Email: [email protected] Virologia e Immunologia Sanitarias Carretera de Majadohonda-Pozuelo Pozuelo, km2 E-28220 Majadahonda (Madrid)

Sweden Dr Patrick Olin EPI Programme Manager Tel. No.: +46 8 457 2533 Department of Vaccine Research Fax No.: +46 8 303 960 Swedish Institute for Infectious Disease Email: [email protected] Control Nobelvägen 18 SE-171 82 Solna

Dr Peet Tüll Tel. No.: +46 8 55553423 Medical Director Fax No.: +46 8 55553409 Department of National Supervision Email: [email protected] National Board of Health and Welfare Rålambsvägen 3 S-106 30 Stockholm EUR/01/5018750 page 30

Switzerland Dr Hans Binz Cantonal Officer of Health Tel. No.: +41 32 627 93 77 Ambassadorenhof Fax No.: +41 32 627 9551 4509 Solothurn Email: [email protected]

Dr Catherine Bourquin Tel. No.: +41 31 323 87 25 Scientific Adviser for Vaccination Programme Fax No.: +41 31 323 87 95 Swiss Federal Office of Public Health Email: [email protected] Section Programme de Vaccination Hess Strasse 27 e CH 3097 Berne-Liebefeld

The former Yugoslav Republic of Macedonia

Dr Milka Kalajdziska-PetrusevskaHead, Virology Department Tel. No.: +389 91 12 50 44 Republic Institute for Health Protection Fax No.: +389 91 22 33 55 ul. '50-ta Divizija' br. 6 91000 Skopje

Dr Kiro Salvani Tel. No.: +389 91 113 429 Undersecretary Fax No.: +389 91 113 014 Ministry of Health 50 Divizija No. 6 91000 Skopje

Dr Nikola Sofijanov Tel. No.: +389 91 147484 Professor of Paediatrics Fax No.: +389 91 229156 Clinic for Child Diseases Clinical Centre Skopje Vodnjanska No.17 Skopje 91000

United Kingdom Professor Alex Campbell Chairman, UK Certification and Containment Committee Emeritus Professor of Child Health 34 Woodburn Crescent Aberdeen AB15 8JX

Dr Mary Ramsay Tel. No.: +44 1812006868 Public Health Laboratory Service (PHLS) Fax No.: +44 1812007868 Communicable Disease Surveillance Centre Email: [email protected] 61 Colindale Avenue GB-London NW9 5EQ EUR/01/5018750 page 31

Temporary Advisers Members of the Regional Certification Commission

Professor Margareta Böttiger Tel. No.: +46 5 70 300 46 Gransäter Fax No.: +46 5 70 300 46 S-132 36 Saltsjö-Boo Email: [email protected]

Professor Istvaan Dömök Tel./Fax No.: +36 1 252 95 30 Scientific Adviser Fax No.: +36 1 215 1792 National Centre for Epidemiology Gyali Street 2-6, P.O. Box 64 H-1966 Budapest

Dr Walter Dowdle Tel. No.: +1 404 371 0466 Director of Programs Fax No.: +1 404 371 1087 The Task Force for Child Survival and Email: [email protected] Development 750 Commerce Drive Suite 400 Decatur, Georgia 30030

Dr G.F. Drejer Tel. No.: +31 252 21 11 89 Paediatrician Fax No.: +31 252 21 36 37 Leeuwerikenlaan 10 Email: [email protected] 2215 NT Voorhout

Professor Sergei G. Drozdov Tel. No.: +7 095 439 9007 Director, Institute of Poliomyelitis and Fax No.: +7 095 439 9321 Virus Encephalitis Russian Academy of Medical Sciences Institute of Poliomyelitis Kievskoye Shosse 27 142782 Moscow

Dr Donato Greco Tel. No.: +39064990 3390 Director Fax No.: +39064938 7069 WHO Collaborating Centre for Email: [email protected] Communicable Diseases Surveillance Laboratory of Epidem. & Biostatistics Istituto Superiore di Sanità Viale Regina Elena, 299 I-00161 Rome

Dr David M. Salisbury Tel. No.: +44 171 972 4488 Principal Medical Officer Fax No.: +44 171 972 4468 Department of Health Email: [email protected] 707 Wellington House 135-155 Waterloo Road GB-London SE1 8UG EUR/01/5018750 page 32

Sir Joseph Smith Email: [email protected] Chairman EURO Commission of Certification of Polio Eradication 95 Lofting Road Islington, London N1 1JF

Professor Burghard Stück Fax/Phone +49 30 785 9008 Schulenburgring 126 E-mail [email protected] D-12101 Berlin Germany

Regional Reference Laboratories

Dr Radu Crainic Tel. No.: +33 1 4568 8763 Chief of Laboratory Fax No.: +33 1 4568 8780 Molecular Epidemiology of Enteroviruses Email: [email protected] Institut Pasteur 25 rue du Dr Roux F-75724 Paris Cedex 15

Dr Sabine Diedrich Tel. No.: +49 30 4547 2378 National Reference Laboratory Fax No.: +49 30 45472617 for Polio Email: [email protected] Robert Koch Institut Nordufer 20, Postfach 330013 D-13353 Berlin

Dr Lucia Fiore Tel. No.: +39 06 4990 2664 Director of Enterovirus Unit Fax No.: +39 06 49902082 Laboratory of Virology Email: [email protected] Public Health Institute Via Regina Elena 299 I-00161 Rome

Professor Tapani Hovi Tel. No.: +358 9 4744 8321 Head, Entovirus Laboratory Fax No.: +358 9 47448355 National Public Health Institute Email: [email protected] Mannerheimintie 166 00300 Helsinki

Dr Olga Eugenyevna Ivanova Tel. No.: +7 095 439 9014 Chief, Laboratory of Environmental Virology Fax No.: +7 095 439 9321 Institute of Poliomyelitis and Viral Encephalitis Email: [email protected] Academy of Medical Sciences Kievskoe Shosse 27 142782 Moscow EUR/01/5018750 page 33

Dr Harrie van der Avoort Tel. No.: +31 30 274 2059 Senior Scientist, Polio Laboratory of Fax No.: +31 30 274 4418 Infectious Diseases and Perinatal Screening Email: [email protected] National Institute of Public Health and Environmental Protection (RIVM) Antonie van Leeuwenhoeklaan 9-PO Box 1 NL-3720 BA Bilthoven

Dr Anton van Loon Head, Department of Virology Tel. No.: +31 30 250 7629 Eijkman Winkler Institute Fax No.: +31 30 250 5426 University Hospital Utrecht Email: [email protected] Heidelberglaan 100 NL-3584 CX Utrecht

Professor Michèle Aymard Tel. No.: +33 478777029 Directeur, Laboratoire de Virologie du C.H.U. Fax No.: +33 478014887 Lyon Email: [email protected] Centre Nationale de Référence des Enterovirus 8, avenue Rockefeller F-69373 Lyon Cedex 08

Mr Fergal Goodman Fax +353 1 635 4001 Assistant Principal Office +353 1 635 4345 Community Health Division E-mail: [email protected] Department of Health and Children Hawkins House Hawkins Street Dublin 2 Ireland

Observers

Professor Heidemarie Holzmann Tel. No.: +43 1 404 90 79522 Associate Professor Fax No.: +43 1 406 21 61 Institute of Virology Email: [email protected] University Vienna Kinderspitalgasse 15 A-1090 Vienna Austria

Dr Begona Merino Tel. No.: +34 91 596 4194 Adviser to Dr Martinez-Navarro Fax No.: +34 91 596 4195 Ministry of Health and Consumer Affairs Paseo del Prado 18-20 E-Madrid 28071 Spain

Dr Birgit Ortner Fax No.: +43 1 402 3900 Bundesstaatliche bakteriologisch-serologische Untersuchungsanstalt Währinger Strasse 25a A-1090 Vienna Austria EUR/01/5018750 page 34

Professor Walter Pasini Tel. No.: +39054124301 Director, WHO Collaborating Centre for Fax No.: +39054125748 Tourist Health and Travel Medicine Email: [email protected] Viale Dardanelli 64 I-47900 Rimini Italy

Mrs Anna Prager Tel. No.: +43 1 405 15570 Medical Laboratory Technician Fax No.: +43 1 402 3900 WHO Poliovirus Laboratory Vienna Bundesstaatliche bakteriologisch- serologische Untersuchungsanstalt Wien Währinger Strasse 25 a A-1096 Vienna, Austria

Dr Reinhild Strauss Fax +43 1 718 71 83 Bundesministerium Office +43 1 711 72 - 43 67 für Soziale Sicherheit und Generationen E-mail [email protected] Abteilung für Infektioskrankhtein (VIII/D/2) Radetzkystrasse 2 1030 Wien Austria

Representatives of other Organizations European Union

Dr Amal Rushdy Detached National Expert Tel. No.: +352 4301 32 118 European Commission Fax No.: +352 4301 33248 Batiment EURO 3258 A Email: [email protected] Rue Alcide Degasperi L-2920 Luxembourg

CDC Atlanta

Dr Mark Pallansch Tel. No.: +1 4046392749 Chief, Enterovirus Section Fax No.: +1 4046391307 Centers for Disease Control and Prevention Email: [email protected] 1600 Clifton Rd., NE, Mailstop G17 Atlanta, GA 30333

World Health Organization

Regional Office for Europe Tel. No.: +90 312 433 2331 Dr Nedret Emiroglu Fax No.: +90 312 434 4449 Medical Officer Email: [email protected]

Ms Johanna Kehler Tel. No.: +45 39 17 1244 Programme Assistant Fax No.: +45 39 17 1863 Email: [email protected] EUR/01/5018750 page 35

Dr Helena Kopecka Tel. No.: +33 1 46 60 41 27 Pasteur Institute, Paris Email: [email protected]

Dr Galina Lipskaya Tel. No.: +45 39 17 1469 Scientist, Coordinator of the EUR Polio Fax No.: +45 39 17 1863 Laboratory Network Email: [email protected]

Ms Tanya Michaelsen Tel. No.: +45 39 17 1497 Programme Assistant Fax No.: +45 39 17 1863 Email: [email protected]

Dr George Oblapenko Tel. No.: +45 39 17 1294 Medical Officer, Eradication of Poliomyelitis Fax No.: +45 39 17 1863 Email: [email protected]

Ms Doris Sørensen Tel. No.: +45 39 17 1717 Secretary Fax No.: +45 39 17 1818 Email: [email protected] Dr Steven Wassilak Tel. No.: +45 39 17 1258 Medical Officer, Eradication of Poliomyelitis Fax No.: +45 39 17 1863 Email: [email protected]

Headquarters

Dr M.V. Karam Tel. No.: +41 22 791 4389 Medical Officer, Communicable Diseases Fax No.: +41 22 791 4777 Email: [email protected]

Dr B. Melgaard Email: [email protected] Director, Vaccines and other Biologicals

Dr Raymond Sanders Tel. No.: +41 22 791 3799 Global Coordinator of Polio Network Fax No.: +41 22 791 4210 Email: [email protected]

Dr Rudi Tangermann Tel. No.: +41227914358 Medical Officer Fax No.: +41227914193

WPRO

Dr S. Roesel Tel. No.: +63 2 5218421 EPI Coordinator Fax No.: +63 2 5211036 WHO Regional Office for the Western-Pacific P.O. Box 2932 1099 Manila Philippines

Interpreter

Mr Georgy G. Peegnasty Email: [email protected] Conference Interpreter/Translator