Meeting Report

ELEVENTH PACIFIC IMMUNIZATION PROGRAMME MANAGERS MEETING

14–16 July 2020 Virtual meeting WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

RS/2020/GE/21(FJI) English only

MEETING REPORT

ELEVENTH PACIFIC IMMUNIZATION PROGRAMME MANAGERS MEETING

Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

AND

UNITED NATIONS CHILDREN’S FUND PACIFIC OFFICE

Virtual meeting 14–16 July 2020

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Printed and distributed by:

World Health Organization Regional Office for the Western Pacific Manila, Philippines

December 2020

NOTE

The views expressed in this report are those of the participants of the Eleventh Pacific Immunization Programme Managers Meeting and do not necessarily reflect the policies of the World Health Organization or the United Nations Children’s Fund.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific and the UNICEF Pacific Office for Member States in the Region who virtually participated in the Eleventh Pacific Immunization Programme Managers Meeting, which was held from 14-16 July 2020.

Contents SUMMARY ...... 1 1. INTRODUCTION ...... 2 1.1 Meeting organization ...... 2 1.2 Meeting objectives ...... 2 2. PROCEEDINGS ...... 2 2.1 Opening session ...... 2 2.2 Updates ...... 3 2.2.1 Conclusions and recommendations from the Tenth Pacific Immunization Programme Managers Meeting ...... 3 2.2.2 Expanded Programme on Immunization overview in the Pacific ...... 3 2.2.3 Vaccine supply system in the Pacific ...... 3 2.2.4 Recommendations from the 29th Meeting of the Technical Advisory Group on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region ...... 3 2.2.5 Regional Strategic Framework for VPDs and Immunization in the Western Pacific ...... 4 2.2.6 Establishment of subregional TAG in PICs ...... 4 2.3 Outbreaks due to measles and other VPDs ...... 4 2.3.1 Regional update on measles and rubella elimination ...... 4 2.3.2 Country experience on outbreak response campaign ...... 5 2.3.3 Country experience on prevention and preparedness campaign ...... 6 2.3.4 Recommendations from the Subregional Committees for the Certification of Poliomyelitis Eradication (SRCC) and Verification of Measles and Rubella Elimination (SRVC)...... 7 2.3.5 Risk of resurgence or import-related large-scale outbreaks of measles and proposed measures for prevention and measles resurgence ...... 7 2.4 COVID-19 pandemic and immunization programme ...... 8 2.4.1 COVID-19: global, regional and PIC overview ...... 8 2.4.2 Impact of COVID-19 pandemic on immunization programmes in PICs ...... 8 2.4.3 Regional action plan for immunization programme during the COVID-19 pandemic ...... 8 2.5 Immunization safety ...... 9 2.5.1 Immunization safety and vaccine regulatory functions ...... 9 2.5.2 Regional guideline on enhancing vaccination demand in the Western Pacific ...... 9 3. CONCLUSIONS AND ACTION POINTS ...... 9 3.1 Conclusions ...... 9 3.2 Action points ...... 11 3.2.1 Action points to Member States ...... 11 3.2.2 Action points for WHO, UNICEF and partners ...... 12 ANNEXES ...... 14 Annex 1. Programme of activities Annex 2. List of participants, temporary advisers, observers and Secretariat Annex 3. Conclusions and recommendations from 8th SRCC/SRVC

Immunization programs / Vaccines / Measles / Rubella / Pacific Islands

SUMMARY

The Eleventh Pacific Immunization Programme Managers Meeting was jointly convened by the World Health Organization (WHO) Regional Office for the Western Pacific and the United Nations Children’s Fund (UNICEF) Pacific Office, and it was held virtually from 14 to 16 July 2020.

National immunization programmes in the 21 Pacific island countries and areas (PICs) have achieved many successes: All countries and areas have remained polio-free since 2000. Chronic hepatitis B infection rates among children have been reduced substantially. And many countries and areas have introduced new and underutilized vaccines or are planning for introduction.

Despite considerable progress in achieving regional immunization goals and strengthening immunization systems and programmes, new challenges are emerging in PICs: safety issues related to deaths following immunization in Samoa (two deaths following measles, mumps and rubella, or MMR, vaccination in 2018) and a subsequent drop in immunization coverage; resurgence of measles with increased measles virus importation, which affected several PICs including Fiji, Kiribati, Samoa and Tonga; outbreaks of diphtheria in some PICs; and increased vaccine hesitancy among the general population. WHO is developing the draft Regional Strategic Framework for Vaccine-preventable Diseases and Immunization in the Western Pacific for 2021–2030 to address these challenges and aims to operationalize this Framework in the Pacific context in line with the “reaching the unreached” thematic priority of For the Future: Towards the Healthiest and Safest Region, WHO’s vision for its work with Member States and partners. The Framework also aligns with the goals of universal health coverage, primary health care and global health security.

Participants included representatives from 16 Pacific island countries and areas, nine observers and one temporary adviser, apart from the Secretariat from WHO and UNICEF.

1 1. INTRODUCTION

1.1 Meeting organization

The Eleventh Pacific Immunization Programme Managers Meeting was convened by the World Health Organization (WHO) Regional Office for the Western Pacific and the United Nations Children’s Fund (UNICEF) Pacific Office virtually from 14 to 16 July 2020.

There were participants from 16 Pacific island countries and areas (PICs), nine observers and one temporary adviser, apart from the Secretariat from WHO and UNICEF.

The topics were finalized after discussions with WHO, UNICEF and Pacific Immunization Programme Strengthening (PIPS) partners.

1.2 Meeting objectives

The objectives of the meeting were: 1) to introduce the final draft of the Regional Strategic Framework for Vaccine-preventable Diseases and Immunization in the Western Pacific for 2021–2030 and discuss its operationalization in the Pacific context; 2) to discuss how to prevent, be prepared for and respond to future outbreaks of measles and other vaccine-preventable diseases (VPDs) based on lessons from measles outbreaks in the Pacific; and 3) to discuss and identify needs in assuring immunization safety, responding to vaccine hesitancy and strengthening vaccine confidence in the Pacific.

2. PROCEEDINGS

2.1 Opening session

Dr Socorro Escalante, Coordinator for Essential Medicines and Technologies, delivered the opening remarks on behalf of Dr Takeshi Kasai, WHO Regional Director for the Western Pacific. Collaborative efforts to strengthen immunization programmes are more important than ever, as the coronavirus disease 2019 (COVID-19) pandemic strains health systems in many countries and threatens basic health services such as immunization. Safety issues related to death following immunization in one country could lead to a decline in immunization coverage and subsequently a resurgence of disease, as affected the region with increased measles virus importation in several countries and areas, including Fiji, Kiribati, Samoa and Tonga. The people working at all levels in immunization programmes have been playing critical roles in planning, preparing and responding to pandemics in many countries.

Mr Sheldon Yett, Representative, UNICEF Pacific, in his remarks noted the achievements of many successes of immunization programme in the PICs. Despite high national immunization coverage, significant numbers of children are missed and do not receive the recommended number of vaccine doses. Equity issues, lack of effective communication, social mobilization and inadequate data quality are constraints for achieving and sustaining high immunization coverage. The 2019 measles outbreaks in Fiji, Samoa and Tonga provided lessons on the importance of ensuring that all children have access to vaccines as the result can be catastrophic when there is a disease outbreak. The partnerships and national immunization campaigns during this time were vital to ensure children had access to the vaccines they need to be protected from the deadly disease. One of the greatest challenges facing health systems today is how to provide front-line health-care workers with the training and support to effectively manage COVID-19 infections when they arise and continue to deliver quality essential health services to the most remote and vulnerable populations. The COVID-19 pandemic is a stark

2 reminder that infectious diseases know no borders. All countries are vulnerable, regardless of income levels or the strength of their health-care systems. If, during these unprecedented times, local response measures cause temporary interruptions of routine immunization services, countries should plan to resume immunization services as quickly as possible after the situation stabilizes.

2.2 Updates

2.2.1 Conclusions and recommendations from the Tenth Pacific Immunization Programme Managers Meeting Dr Nyambat Batmunkh presented a summary of the conclusions and recommendations from the Tenth Pacific Immunization Programme Managers Meeting, which was held on 30 July–3 August 2018 in Nadi, Fiji. The finalized conclusions and recommendations addressed the following areas: i) immunization coverage; ii) polio eradication; iii) health security and emergencies; iv) measles and rubella; v) immunization data; vi) vaccine safety; vii) new vaccines; viii) technical advisory group in the Pacific; ix) surveillance; x) immunization supply chain and effective vaccine management; and xi) communications, advocacy and social mobilization.

2.2.2 Expanded Programme on Immunization overview in the Pacific Dr Jayaprakash Valiakolleri presented an overview of the immunization programme in the PICs. Immunization is one of the priority programmes in all countries. Routine immunization coverage (three doses of diphtheria, pertussis and tetanus vaccine, or DPT3) is high at over 90% in 12 PICs, although coverage has been static or fluctuating in some countries. While several countries procure WHO pre- qualified vaccines through UNICEF, Pacific territories associated with the United States of America get their vaccines through the United States Centers for Disease Control and Prevention, and French territories procure vaccines of European standards. Surveillance of adverse events following immunization (AEFI) is weak in many countries. All PICs have remained polio-free since the regional certification in 2000. Several countries have been verified for having achieved the final hepatitis B control goal. Four PICs declared an outbreak of imported measles in 2019. PICs have made progress in the rational introduction of new vaccines. VPD surveillance needs strengthening in several PICs, and quality surveillance is limited to few countries. The laboratory networks are limited, though plans for expansion of laboratory networks are being explored.

2.2.3 Vaccine supply system in the Pacific Dr Ataur Rahman explained that 13 PICs have been procuring vaccines, vaccination logistics and cold chain equipment through the UNICEF Vaccine Independence Initiative (VII) mechanism since 1995. The Initiative ensures a systematic, sustainable vaccine supply for countries that can afford to finance their own vaccine needs, with flexible credit terms allowing payment after the supply is received. The VII ceiling was increased in 2020 from US$ 1.9 million to US$ 5.4 million, and all countries have signed a VII agreement until 2025. UNICEF keeps a three-month buffer stock for each vaccine at the Nadi regional store. The regional vaccine buffer stock offers additional vaccine security in the event of emergencies such as natural disasters, outbreaks, cold chain failures and inaccurate forecasting. The VII buffer stock demonstrates Pacific regionalism and emergency resilience. UNICEF is working closely with suppliers, countries and partners on vaccine supply requirements to reduce the impact of COVID-19 on the vaccine supply chain. Despite the vaccine stock at the Nadi store, delivering vaccines to countries is challenging.

2.2.4 Recommendations from the 29th Meeting of the Technical Advisory Group on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region Dr Ilisapeci Vereti-Tuibeqa presented a summary of the 29th Meeting of the Technical Advisory Group (TAG) on Immunization and Vaccine-Preventable Diseases in the Western Pacific Region, which was held virtually from 16 to 18 June 2020. Since 1991, the TAG has met annually to review the progress of the immunization programmes in the Region and provide guidance on establishing and achieving immunization goals. The 29th TAG Meeting convened during a time when substantial

3 resources, personnel and attention have been are directed towards public health programmes and activities, including those focused on routine immunization and disease elimination initiatives in the Region, to respond to the COVID-19 pandemic. In addition, access to and use of public health programmes have been reduced because of quarantines, other COVID-19 mitigation efforts and concerns by the public about the risk of accessing routine health care because of the risk of exposure to COVID-19. In addition, the Meeting intended to support countries and areas in the Region focusing on immunization programmes and mitigating the negative impact COVID-19 outbreaks on overall immunization services, sustaining performance of routine immunization programmes and preventing the resurgence of VPD outbreaks.

2.2.5 Regional Strategic Framework for VPDs and Immunization in the Western Pacific Dr Yoshihiro Takashima presented the WHO Regional Strategic Framework for Vaccine-preventable Diseases and Immunization in the Western Pacific (2021–2030), which was developed in close collaboration with Member States, stakeholders, partners and experts of the Region. It is intended to expand the scope of immunization, maximize the benefits of vaccines and immunization programmes in the Region, and further accelerate control and achieve and sustain elimination of additional VPDs beyond those traditionally targeted, aiming to make the Region free from vaccine-preventable morbidity, mortality and disability towards 2030. The Regional Strategic Framework proposes to achieve three strategic objectives: i) strengthening and expanding immunization systems and programmes; ii) managing health intelligence on VPDs and immunization; and iii) ensuring preparedness for and response to public health emergencies related to VPDs, vaccines and immunization programmes. These strategic objectives will be achieved by implementing 18 strategies, in the appropriate country-specific context. The Framework also is intended to support countries and areas of the Region to achieve the vision and seven strategic priorities of the Immunization Agenda 2030 (IA2030), which was endorsed in August 2020 by the World Health Assembly. The Agenda calls for action to reduce VPD-related mortality and morbidity, to ensure no one is left behind by increasing equitable access to and the use of new and existing vaccines, and to ensure good health and well-being for everyone by strengthening immunization within primary health care, thus contributing to universal health coverage (UHC) and sustainable development. The Regional Strategic Framework has been prepared to help enhance synergies with: i) health systems strengthening and UHC; ii) prevention of noncommunicable diseases and promotion of a life-course approach to health; and iii) health security and emergencies, including the prevention and reduction of antimicrobial resistance.

2.2.6 Establishment of subregional TAG in PICs Dr Nyambat Batmunkh presented an overview of decision-making processes in the Pacific as well as the status of the National Immunization Technical Advisory Groups (NITAGs) in the region. In addition, he spoke about the experience from the recently established Caribbean Immunization Technical Advisory Group (CiTAG). Both the WHO Regional Committee for the Western Pacific and the TAG have requested Member States to strengthen the functionality and effectiveness of NITAGs or equivalent immunization decision-making bodies to support the formulation of evidence-based immunization policy. NITAGs in the Western Pacific Region operate at varying levels of quality. Some are advanced with clear policies and processes and make use of best evidence-based decision-making practices. Other NITAGs are newly formed. Some lack independence of membership, structure and procedures and have challenges in arriving at sound recommendations. There have been positive examples of success towards having an effective immunization decision-making body in each country, but more needs to be done to meet the regional objective. The establishment of CiTAG in the Caribbean island countries was successful, and this mechanism might be a useful mechanism for PICs also.

2.3 Outbreaks due to measles and other VPDs

2.3.1 Regional update on measles and rubella elimination Dr Jose Hagan presented an update on measles and rubella elimination in the region: nine countries and areas were verified as having sustained elimination of measles, and five countries and areas were

4 verified as having sustained elimination of rubella. No new countries were verified for elimination during 2019. The Western Pacific Region has sustained high overall immunization coverage with measles and rubella containing vaccines: 95% MCV1 (first dose of measles-containing vaccine) and 94% MCV2 (second dose) coverage. However, significant inter-country and especially subnational variability in coverage remain. Only 81% of countries have achieved MCV1 coverage over 90%, and only 45% of countries have achieved MCV1 coverage over 80% in all districts. Case-based surveillance continues to meet sensitivity targets at the national level, but only 47% of second-level administrative units met the target non-measles, non-rubella discard rate of 2 per 100 000 population. A global resurgence of measles and rubella occurred during 2018–2019. In the Western Pacific Region, this included a large nationwide outbreak of measles in the Philippines and a prolonged measles outbreak in New Zealand that spread to multiple PICs, most importantly Samoa. Large rubella outbreaks occurred among young adults in China and Japan in 2019 and in the Philippines in 2020, raising the risk of congenital rubella syndrome (CRS) cases. Laboratory capacity for case confirmation was significantly strained in the Western Pacific Region due to these outbreaks. A total of 4.85 million measles– rubella (MR) vaccine doses were delivered through national and subnational supplementary immunization activities (SIAs) in 2019, including several nationwide campaigns achieving at least 95% coverage. In 2019–2020, a number of publications and guidelines were published and drafted, including a global guidance on clinical case management and infection prevention and control for measles and the final draft guidelines for surveillance of CRS in the Western Pacific Region.

2.3.2 Country experience on outbreak response campaign 2.3.2.1 Fiji Dr Litiana Volavola presented the Fiji measles outbreak response campaign. Based on routine immunization administrative coverage data from 2019, coverage for the first dose of measles vaccine was reported as 83%, which was the lowest compared to the coverage of other routine vaccines. Fiji experienced an outbreak with 31 confirmed cases within the central division. The outbreak predominantly affected children age below 5 years and adults above 19. Among 31 confirmed measles cases, 9 cases reported that they did had not received a measles shot previously. A high proportion of cases had at least one documented dose of measles vaccine. The last confirmed measles case was tested and reported on 19 March 2020. Fiji mounted a rapid and aggressive response to the imported cases, including a nationwide SIA delivering over 300 000 doses, targeting children 6 months–5 years old and adults 19–39 years old, with 100% coverage nationwide of children under 5 and 94% among adults aged 19–39 years.

2.3.2.2 Samoa Ms Teuila Pati presented the Samoa experience dealing with the largest outbreak among PICs, which occurred after a large immunity gap accumulated during 2018–2019 due to a 10-month suspension of the MR immunization programme beginning July 2018. The programme was suspended following two user-error-related fatal AEFI. This resulted in MCV2 coverage in 2018 of 13%. Anti-vaccination messaging also may have contributed to decreased uptake of vaccination after the vaccination programme was restarted. The outbreak in Samoa had 5707 cases between September 2019 and January 2020. Cases occurred across a very wide age range up to and beyond age 60, but most cases were in children under age 3, consistent with the known age gap in immunization coverage. The response to the outbreak involved a massive coordinated effort from the Government of Samoa and partners. Mass vaccination with MR vaccine was implemented for all Samoans aged 6 months to 60 years, with overall coverage of 93%. The total number of vaccines administered covered 68% of the complete population.

2.3.2.3 Tonga Ms Afu Tei presented the Tonga measles outbreak response campaign. An outbreak occurred after a high school rugby team became infected in New Zealand during an international rugby tournament. A total of 665 cases were reported, though only 21 were hospitalized and there were no deaths. The overall vaccination coverage was very high in Tonga through routine and supplemental immunization, and it was thought to be at low risk of an outbreak. The outbreak predominantly occurred among older

5 adolescents and young adults, as well as infants below 1 year of age. Avery high proportion of cases had complete documentation of two measles vaccine doses. Measles IgG (immunoglobulin) avidity testing is ongoing with support from the Victorian Infectious Diseases Reference Laboratory, or VIDRL, to determine to what extent vaccine failure may have contributed to the outbreak. A nationwide mass vaccination campaign was conducted for the population aged 10–24 years and a zero dose for children aged 6–11 months. Booster doses were also given to children aged 1–9 years. Overall SIA coverage was 94% nationwide.

2.3.2.4 Logistical support to countries during measles outbreak Dr Ataur Rahman presented about the logistical support to countries during the measles outbreak in the Pacific. Outbreaks in the PICs were successfully contained without leading to endemic spread. UNICEF delivered MR-bundled vaccines to 13 PICs, both affected and unaffected. Timely response was possible because the vaccines could be made available and delivered timely to countries. For the initial response, UNICEF released MR-bundled vaccines from buffer stock and immediately placed orders for replenishment and additional doses using UNICEF core resources. The Fund procured 1.3 million doses of MR bundled vaccines, 622 500 vitamin A capsules, cold chain and medical equipment, and tents. The Australian Department of Foreign Affairs and Trade (DFAT) and the New Zealand Ministry of Foreign Affairs and Trade (MFAT) are the major donors that supported the bundled vaccine through UNICEF. The Fund arranged 51 shipments/deliveries between October and December from Nadi to all 13 countries. The success was made possible thanks to the cooperation of many partners in procuring and distributing the vaccines; DFAT, MFAT, airline and airport ground staff, Nadi cold storage staff, freight forwarders, and Expanded Programme on Immunization (EPI) country teams. Following an urgent request from the Samoan Government on the day of the countrywide shutdown of door-to-door vaccination, UNICEF requested additional 50 000 vaccine doses, with MFAT arranging for New Zealand Air Force planes to deliver vaccines from Nadi to Samoa.

2.3.3 Country experience on prevention and preparedness campaign 2.3.3.1 Federated States of Micronesia Mr Carter J. Apaisam presented their experience on prevention and preparedness campaign. Children in the Federated States of Micronesia are getting two doses of measles, mumps and rubella (MMR) vaccine at age 12 months and 13 months, respectively. Starting from 2014, the country conducted several SIAs to respond and prevent a measles outbreak. For example, a measles SIA was conducted in Chuuk Province in 2017 and 2019, with overall coverage of 75% and 81%, respectively, as well as in Pohnpei Province in 2018, with coverage reported of 88%. The most recent nationwide SIA responding to the threat of a measles outbreak from neighbouring islands was conducted 2020, with coverage of 94% for the first dose and 84% for the second dose. Despite the successful campaign, the country could not avoid the challenges, including: i) high operational cost due to the remote and isolated islands in the country; ii) unreliable government transportation/ships for these isolated islands, which leads to low coverage; iii) no cost sharing with other departments for the outreach activities; iv) mobility of families off the islands; and v) registry data issues.

2.3.3.2 Solomon Islands Ms Jenny Anga presented the country’s experiences with maintaining immunization services while supporting COVID-19 preparation and response plans. In early 2020, Solomon Islands experienced a reduction in immunization coverage of approximately 20% (most antigens) when compared to previous years’ coverage rates. However, the country is preparing well for Periodic Intensification of Routine Immunization (PIRI) catch-up activities and has experience in rolling out catch-up activities, having completed a successful measles and rubella SIA campaign in December 2019, with 99% coverage in children aged 6 months to 6 years. Further to this, the country has now almost completed the new rotavirus vaccine introduction, training staff and disseminating materials in eight out of nine provinces and in Honiara City Municipality. This new vaccine introduction follows the recent introductions of human papillomavirus (HPV) and MR second dose, with the National Immunization Programme and United Nations partners providing supportive supervision to provinces to ensure new vaccines become

6 routine within the immunization schedule. Some of the recent challenges Solomon Islands faces include low stock levels at national medical stores of some vaccine antigens, which were scheduled for re- supply but due to COVID-19 and the cancellation of international flights have been delayed. The COVID-19 pandemic has also diverted National Immunization Programme resources and reduced human resource capacity, which affected service delivery, although the Ministry of Health has identified EPI as a priority programme that should continue despite COVID-19 preparations.

2.3.4 Recommendations from the Subregional Committees for the Certification of Poliomyelitis Eradication (SRCC) and Verification of Measles and Rubella Elimination (SRVC) Dr Lisi Tikoduadua presented the conclusions and recommendations from the combined Subregional Committees for the Certification of Poliomyelitis Eradication (SRCC) and Verification of Measles and Rubella Elimination (SRVC) in Pacific Island Countries and Areas. The Subregional Committees serve as expert review groups to classify all cases of acute flaccid paralysis (AFP) reported in the PICs. The SRCC/SRVC produce the annual report on the polio-free status of PICs to be submitted to the Regional Certification Commission and develop the annual report on progress towards achieving measles elimination to be submitted to the Regional Verification Commission. The Eighth Meeting of the SRCC and SRVC was held via videoconference from 26 to 28 May 2020. The conclusions and recommendations are available in Annex 3.

2.3.5 Risk of resurgence or import-related large-scale outbreaks of measles and proposed measures for prevention and measles resurgence The recent outbreaks have highlighted new and old risks for measles and rubella elimination in the Western Pacific Region. There continues to be large unfilled immunity gaps among young children in some countries due to broad limitations in immunization service delivery (such as the Philippines, Papua New Guinea and the Lao People’s Democratic Republic). Young adults who were never targeted for routine and supplemental immunization continue to be susceptible to both measles and rubella, and this is reflected in adult-predominant outbreaks, especially in countries and areas that have achieved measles and rubella elimination. Some countries and areas also have immunity gaps among sub- populations who are chronically unreached by the immunization programme, due to either mismatch between the programme strategy and this target population; or variability in programme implementation at the local level. Examples include: outbreaks among ethnic minorities in the Lao People’s Democratic Republic; ongoing cases in Cambodia and Viet Nam among children of migrant factory workers; transmission among non-citizens, refugees and state-less groups in Malaysia; and a prolonged outbreak among Māori and Pacific peoples in New Zealand. These gaps may not be apparent from coverage data but may be reflected in the epidemiology, as well as careful efforts to triangulate data to assess risk, such as use of the Measles Programmatic Risk Assessment Tool. In particular, cross-border, stateless and migrant populations are not adequately targeted by immunization or surveillance strategies. During 2019–2020, a number of countries reported a large proportion of so-called breakthrough measles cases among vaccinated individuals in Tonga, the Republic of Korea, Macao SAR (China), Fiji, and Hong Kong SAR (China). There is chronic pressure of measles and rubella virus importation into the Western Pacific Region from endemic countries worldwide, which causes a significant burden and uncertainty for countries that have achieved measles and rubella elimination. Experience in the Region also indicates that health-care facilities may sometimes play a very important role in amplifying initial transmission of measles outbreaks, and investigation of the ongoing outbreak in Cambodia indicates that hospitals may even sustain prolonged measles transmission in a country despite limited community transmission. The experience in Samoa in 2019 demonstrates the rapid accumulation of susceptible children when the immunization programme is interrupted, as is currently happening due to COVID-19. Lastly, external resources for measles and rubella elimination are uncertain, inadequate and not spent strategically to be able to achieve measles and rubella elimination. A number of strategic directions are proposed, including taking proactive action to identify and prepare for periodic catch-up of children who have missed vaccination due to COVID-19, maximizing data use for action, including by better understanding the “numerator” of missed children and of measles cases. Residual immunity gaps among adults present an ongoing threat to measles and rubella elimination, and filling these will require creativity, whole of government approaches, and new global guidance. The possibility of waning

7 immunity to measles after vaccination, leading to increasing observation of breakthrough infections among vaccinated individuals, will require further research and strategic thought in order to guide countries to prevent, prepare for and respond to new outbreaks among immunized individuals. Significant investment in preventing nosocomial transmission of measles will be needed. Finally, achieving elimination will require a much broader view towards measles and rubella elimination strategies, including greater coordination and synchronization of immunization interventions and clarity and agreement on the use of International Health Regulations (IHR) mechanisms for measles notification and coordinated responses.

2.4 COVID-19 pandemic and immunization programme

2.4.1 COVID-19: global, regional and PIC overview Dr Angela Merianos presented a global, regional and Pacific update on COVID-19. At the time of the presentation, over 13 million cases and almost 580 000 deaths had been reported globally and almost 250 000 cases and over 8 000 deaths in the Western Pacific Region. In the Pacific, 466 confirmed COVID-19 cases had been reported so far, of which 312 were in Guam followed by 62 in French Polynesia, with the remaining cases in Fiji, the Commonwealth of the Northern Mariana Islands, New Caledonia and Papua New Guinea. The most common disruptions to essential services in the Western Pacific Region have been to routine outreach immunization services and malaria prevention campaigns, but even in countries with few or no cases (such as the PICs), medical referrals have been suspended due to border closures and travel restrictions, and service innovations have emerged to overcome disruptions, including triaging, novel dispensing, telemedicine, task shifting and community outreach. The Joint Incident Management Team (JIMT) was established to support the COVID-19 preparedness and response in the Pacific, with a focus on supporting the containment and mitigation efforts of all Pacific island nations.

2.4.2 Impact of COVID-19 pandemic on immunization programmes in PICs Dr Jayaprakash Valiakolleri gave an overview of the impact of the COVID-19 pandemic on immunization programmes in the PICs. An interim guidance document on delivery of essential health services including immunization during the COVID-19 response was developed by the Pacific JIMT to assist health ministries and their partners with strategic planning and coordinated action to maintain essential health service delivery during the pandemic. Though immunization services are not interrupted in several countries as of now, the situation may change. Staff working in the immunization programme have been reassigned for pandemic-related activities. Continued closures of airports will lead to shortage of vaccines in many countries. Monitoring of immunization coverage is critical, and coverage remained high in some countries where there has been no interruption. However, several countries (both where there has been no interruption and where services are interrupted) have not reported coverage data.

2.4.3 Regional action plan for immunization programme during the COVID-19 pandemic Dr Ananda Amarasinghe presented a regional action plan for immunization programmes during the COVID-19 pandemic. Since early 2020, immunization services and VPD surveillance have been affected in many countries in the Western Pacific Region. The negative impact of the COVID-19 pandemic in PICs is relatively low, but it can pose a risk of resurgence of VPDs. The regional action plan aims to provide interim technical guidance for better planning, preparedness and implementation of activities depending on the local COVID-19 transmission scenario (either high or low transmission status). Focus areas of the plan are: i) routine immunization, SIAs, school-based immunization, periodic intensification of routine immunization, ensuring vaccine supply and other logistics; ii) laboratory supported VPD surveillance, possibly leveraging ongoing COVID-19 surveillance efforts; and iii) re- establishing community demand. Also important is ensuring the safety and health of staff, recipients and community through strict adaptation of infection control practices. The COVID-19-related situation varies largely between the countries, and the decision-makers in the respective country are expected to refer to this document and adjust/modify recommended activities to their specific context, for a feasible

8 and sustainable response in sustaining immunization and surveillance of VPDs, particularly those which are outbreak prone. The introduction of COVID-19 vaccines needs careful and comprehensive planning, and due consideration in the following areas is necessary and important: vaccine product profile, target populations, vaccine delivery strategies, access to vaccine including financing, vaccine supply and storage, safety surveillance, record keeping, advocacy and communication, and stakeholder coordination.

2.5 Immunization safety

2.5.1 Immunization safety and vaccine regulatory functions Dr Ananda Amarasinghe presented about the immunization safety and vaccine regulatory function in the Region. Surveillance of AEFI and functional national regulatory authorities (NRAs) are important and essential components to ensure immunization and vaccine safety. As of 2019 WHO/UNICEF Joint Reporting Form data, only eight PICs reported having AEFI surveillance in place. This highlights the significant under-reporting of AEFI in PICs. Also noteworthy is that vaccine regulatory capacity in PICs is either very low or does not exist except in Fiji, French Polynesia and New Caledonia. Vaccine safety events reported in Samoa and Solomon Islands are considered as opportunities for learning lessons. In line with the Regional Strategic Framework for VPD and Immunization in the Western Pacific (2021–2030), the PICs would need to pay attention to the following: i) establish a subregional regulatory body to perform NRA functions for PICs; ii) ensure safe immunization through strengthening technical capacity of health-care providers at all levels and immunization safety supplies; iii) ensure environmentally responsible waste management; iv) timely detect, report, investigate and respond to AEFI through well-functioning immunization safety surveillance; v) establish a Subregional Immunization Safety Expert Committee to conduct causality assessment and provide evidence-based recommendations in response to vaccine and immunization safety events; and vi) prepare the response to public demand for vaccine injury compensation.

2.5.2 Regional guideline on enhancing vaccination demand in the Western Pacific Dr Ananda Amarasinghe presented about the regional guideline on enhancing vaccination demand in the Western Pacific. Vaccine hesitancy is one of the top 10 global health threats identified by WHO and health partners for their attention in 2019. Vaccine hesitancy has been reported by several countries in the Western Pacific Region, and reasons for vaccine hesitancy vary by countries across the Region. The regional guideline was developed through comprehensive discussions and reviews with country national immunization programmes, communication specialists and partners (UNICEF, United States Centers for Disease Control and Prevention) and endorsed by the Immunization and VPD TAG at its meeting in June 2020. The guide is aimed at programme managers and other stakeholders for strategies assessing and addressing hesitancy and sustaining vaccination uptake The guideline covers: the concepts related to demand and vaccine hesitancy; vaccine hesitancy in the Western Pacific Region; lead reasons and case examples; diagnosis and assessment of vaccine hesitancy and under-vaccination; strategies enhancing acceptance and demand and sustaining vaccination uptake; stakeholders to engage in supporting vaccination; and references. Printed and electronic copies of the guide will be made available by October 2020 for the use by countries.

3. CONCLUSIONS AND ACTION POINTS

3.1 Conclusions

Regional Strategic Framework for Vaccine-preventable Diseases and Immunization in the Western Pacific (2021–2030)

Participants supported the draft Regional Strategic Framework for submission to and endorsement by the WHO Regional Committee for the Western Pacific in October 2020.

9 Technical Advisory Group on Immunization in the Pacific

Participants reaffirmed the need of an inter-country, evidence-based technical advisory body for immunization policies in the Pacific.

Outbreaks due to measles and other VPDs

Participants supported and agreed on the conclusions from the 2020 Pacific SRVC: • Outbreaks in American Samoa, Fiji, Samoa and Tonga in 2019–2020 highlighted the vulnerability of Pacific island communities to importation of measles virus, while measles remains a globally endemic disease. • Outbreaks in the PICs were all successfully contained without leading to endemic spread across the islands, demonstrating the capacity to sustain elimination within the subregion. • A large outbreak of measles in Samoa in 2019 occurred after rapid accumulation of susceptible children during the 10-month period of paused routine MR immunization following two immunization error-related deaths. It illustrates the importance of identifying and taking proactive steps to fill known immunity gaps through catch-up or non-selective mass vaccination activities. • Outbreak cases in Tonga had a very high proportion of breakthrough infection among fully vaccinated children and young adults, demonstrating that even highly vaccinated populations may have unknown immunity gaps and may be at risk of outbreaks after importation. • Both affected and unaffected PICs are to be commended for mounting coordinated and capable responses to suspected and confirmed measles cases, and for conducting proactive and comprehensive preparedness activities to prevent uncontrolled spread. These activities have filled immunity gaps and significantly strengthened the subregion’s capacity to prevent and respond to future measles outbreaks. • Public health and physical distancing measures to respond to the ongoing COVID-19 pandemic may threaten the performance of routine immunization services, which may result in rapid accumulation of susceptible children if proactive measures are not taken to ensure missed children are vaccinated.

Participants acknowledged the following: • Periodic intensification of routine immunization programmes, including SIAs for measles and rubella, is important to identify and vaccinate not fully vaccinated children. • Significant technical and financial support was received from development partners to support the measles outbreak response and preparedness activities in PICs. • Technical and financial support from WHO, UNICEF and other development partners will be essential to achieve and maintain high levels of population immunity by providing high-quality immunization activities.

COVID-19 pandemic and immunization programme

The routine immunization, SIAs and VPD surveillance are affected in many countries due to the COVID-19 pandemic: • decline in number of children who were immunized in the first quarter of 2020 compared to the same period in 2019; • SIAs planned in the first half of 2020 were postponed to later dates; • inadequate systems to monitor coverage and identify unvaccinated individuals for catch-up;

10 • reporting and investigation of VPD cases and their sample collection and transport have been slowed down; and • most of the staff working on immunization programme and VPD surveillance have been reassigned temporarily to support COVID-19 response activities.

Participants appreciated the PIC efforts in sustaining immunization programme and VPD surveillance while responding to COVID-19. They also appreciated the regional action plan for immunization programme and VPD surveillance in the Western Pacific for 2020–2021 during the COVID-19 pandemic. They acknowledged the importance of introducing a potential COVID-19 vaccine considering local needs.

Immunization safety and vaccine regulatory functions

There is limited capacity among NRAs to perform WHO-recommended regulatory functions in PICs. NRAs are in place in Fiji, French Polynesia and New Caledonia.

Most PICs are under-reporting AEFI, lacking timely and comprehensive AEFI case investigation, and missing capacity for causality assessment. The surveillance of AEFI is in place in eight PICs only.

Proper immunization waste disposal considering environmental safety is lacking, as is capacity to apply modern and costly waste disposal methods in PICs.

Guide for Programme Managers in the Western Pacific Region on Strategies for Assessing and Addressing Hesitancy, Building Acceptance and Sustaining Vaccination Uptake

The participants recognized the growing challenge of vaccine hesitancy and possible negative impact on immunization. The participants appreciated the Guide for Programme Managers in the Western Pacific Region on Strategies for Assessing and Addressing Hesitancy, Building Acceptance and Sustaining Vaccination Uptake.

3.2 Action points

3.2.1 Action points to Member States Participants recommended the following action points for Member States: Regional Strategic Framework for Vaccine-preventable Diseases and Immunization in the Western Pacific (2021–2030)

Participants to provide the WHO Secretariat with comments, suggestions or proposed inputs, if any, for the draft Regional Strategic Framework before 25 July 2020.

Technical advisory group on immunization in the Pacific

Countries to discuss the needs and possibility of forming an independent evidence-based decision- making process for immunization policies in the Pacific (such as a subregional TAG for PICs).

Outbreaks due to measles and other VPDs

Participants supported the following recommendations from the 2020 Subregional Verification Committee of Measles and Rubella Elimination in PICs: • Maintain an intensified level of surveillance to detect imported measles cases to prevent outbreaks among children whose vaccination was delayed or missed due to programme interruption related to the ongoing COVID-19 pandemic.

11 • Continue to maintain a collaborative approach to measles and rubella surveillance and outbreak preparedness by rapidly notifying WHO and other PICs of newly detected measles cases. • Review national vaccination schedules and consider changing the timing of the second dose of measles and rubella containing vaccine, or MRCV, to occur during the second year of life, if appropriate and feasible, in order to better protect young children from imported measles and rubella virus. • Develop plans and policies for when disasters and outbreaks (such as the ongoing COVID-19 pandemic) impact immunization programme performance to: assess immunity gaps; track, follow up and vaccinate those individuals having missed vaccinations; and re-establish community demand for vaccines.

COVID-19 pandemic and immunization programme

• Consider prioritizing and continuing immunization as a core health service for the prevention of communicable diseases and safeguard its continuity during the COVID-19 pandemic, where feasible. • Perform a risk–benefit analysis weighed against COVID-19 transmission and VPD risk in the short and medium terms. Plan and conduct catch-up immunization activities to close population immunity gaps. • Develop immunization delivery strategies according to local contexts and implement them under safe conditions, without undue harm to health workers, caregivers and the community. • Maintain and reinforce VPD surveillance to enable the early detection and management of VPD cases, and use ongoing COVID-19 surveillance efforts and investments to further strengthen VPD surveillance. • Strengthen the use of data to identify children who need catch-up vaccination, and strengthen coverage monitoring and reporting, particularly in view of expected large proportions of children receiving late vaccination. • Advocate and communicate with the public, reassuring them of the importance of continuing immunization despite ongoing COVID-19 transmission.

Immunization safety and vaccine regulatory functions

• Develop national guidelines, build staff capacity on implementing safe immunization practices, and establish and/or strengthen AEFI surveillance. • Ensure timely detection, reporting, investigation and response to AEFI through well- functioning AEFI surveillance. • Ensure environmentally responsible waste management to be properly carried out with adequate disposal facilities, supplies and correct practices.

Guide for Programme Managers in the Western Pacific Region on Strategies for Assessing and Addressing Hesitancy, Building Acceptance and Sustaining Vaccination Uptake

Member States to use the Guide with consideration of country-specific context.

3.2.2 Action points for WHO, UNICEF and partners Participants recommended the following action points for WHO, UNICEF and development partners: Technical advisory group on immunization in the Pacific

12 WHO, UNICEF and other development partners to support PICs in having active dialogue or an international consultation on forming an inter-country, evidence-based technical advisory body for immunization policies in the Pacific and exploring possibilities of inclusion of this agenda topic in the next Pacific Heads of Health Meeting.

Outbreaks due to measles and other VPDs

• Work with priority countries and areas to identify and address challenges to reporting immunization coverage via the WHO–UNICEF Joint Reporting Form and case-based surveillance data to the WHO Regional Office. • Prioritize and work with PICs to expand national laboratory capacity for measles and rubella case confirmation. • Continue to advocate strongly to the international community and to immunization partners for a new global commitment to achieving measles and rubella eradication, and a vastly increased mobilization of resources and expertise in support of this goal, to protect the PICs against the continued threat of measles and rubella importation from endemic areas. • All development partners to advocate and support measles and rubella elimination activities as a means to strengthen immunization programmes and overall public health systems.

COVID-19 pandemic and immunization programme

• Expand support to PICs in maintaining the performance of immunization programme and VPD surveillance in line with the regional action plan. • Continue technical support in developing technical guidelines, training materials and tools and capacity-building to strengthen immunization services to reach underserved persons and achieve high immunization coverage across all population groups. • Provide technical support in developing country preparedness/readiness plans for the introduction of a potential COVID-19 vaccine.

Immunization safety and vaccine regulatory functions

• WHO and UNICEF to provide technical support on staff capacity-building in the area of safe immunization practices and AEFI surveillance. • Collaborate with other countries to establish a subregional regulatory body to perform NRA functions for PICs.

Guide for Programme Managers in the Western Pacific Region on Strategies for Assessing and Addressing Hesitancy, Building Acceptance and Sustaining Vaccination Uptake

• Widely disseminate the regional Guide. • Support PICs to enhance vaccine demand using the Guide, with consideration of country- specific contexts. • Collaborate with partners to mobilize resources to support Member States to enhance vaccine demand among the general population and support clinicians to respond effectively to misinformation.

13 ANNEXES

Annex 1. Programme of activities

11TH PACIFIC IMMUNIZATION WPR/DDC/VDI(06)/2020.1 PROGRAMME MANAGERS MEETING 15 July 2020

14–16 July 2020 ENGLISH ONLY

VIRTUAL MEETING DETAILS

WHEN : 14–16 July 2020 TIME : 07:30–11:30 (Philippines Time)

To join the meeting, kindly click the zoom link below.

ZOOM LINK: https://wpro-who.zoom.us/j/92995451428 Password : 519083

PROGRAMME OF ACTIVITIES

Activity/Agenda item/Subject of presentation Presenter

Day 1 – Tuesday, 14 July

07:30 – 07:35 Devotion

07:35 – 08:15 1. Opening session

• Opening remarks Dr Takeshi Kasai Regional Director WHO/WPRO

Mr Sheldon Yett UNICEF Representative for Pacific Island Countries

• Self-introduction

• Photo session

08:15 – 08:20 1.1 Objectives and agenda of the meeting Dr Y. Takashima VDI/WPRO

14

2. Updates

08:20 – 08:30 2.1 Conclusions and recommendations Dr Nyambat Batmunkh from 10th PIMM VDI/WPRO

08:30 – 08:45 2.2 EPI overview in the Pacific Dr Prakash Valiakolleri DPS/WPRO

08:45 – 09:00 2.3 Vaccine Supply System in the Pacific Dr Ataur Rahman UNICEF Pacific

09:00 – 09:20 Discussion

09:20 – 09:35 Break

09:35 – 09:55 2.4 Recommendations from Dr I. Vereti-Tuibeqa 29th TAG Meeting Chair, SRCC/SRVC

09:55 – 10:25 2.5 Regional Strategic Framework for VPDs Dr Yoshihiro Takashima and Immunization in the Western Pacific VDI/WPRO

10:25 – 10:45 2.6 Establishment of sub-regional TAG Dr Nyambat Batmunkh in PICs VDI/WPRO

10:45 – 11:15 Discussion

Day 2 – Wednesday, 15 July

3. Outbreaks due to measles and other VPDs

07:30 – 07:35 Devotion

07:35 – 07:55 3.1 Regional update on measles Dr José Hagan and rubella elimination VDI/WPRO

3.2 Country experience on outbreak response campaign

07:55 – 08:10 – Fiji Ms Litiana Volavola

08:10 – 08:25 – Samoa Ms T. McDonald-Pati

08:25 – 08:40 – Tonga Ms Atalua Fatafehi Tei

08:40 – 08:50 3.3 Logistical support to countries during Dr Ataur Rahman measles outbreak UNICEF Pacific

08:50 – 09:10 Discussion

09:10 – 09:25 Break

15 3.4 Country experience on prevention and preparedness campaign 09:25 – 09:40 – Federated States of Micronesia Mr Carter Apaisam

09:40 – 09:55 – Solomon Islands Ms Jenniffer Anga

09:55 – 10:10 3.5 Recommendations from SRCC/SRVC Dr I. Vereti-Tuibeqa Chair, SRCC/SRVC

10:10 – 10:30 3.6 Risk of resurgence or imported-related Dr José Hagan large scale outbreaks of measles and proposed VDI/WPRO measures for prevention and measles resurgence

10:30 – 11:00 Discussion

Day 3 – Thursday, 16 July

4. COVID-19 pandemic and immunization programme

07:30 – 07:35 Devotion

07:35 – 07:55 4.1 COVID-19: Global, regional and Dr Angela Merianos PICs overview DPS/WPRO

07:55 – 08.10 4.2 Impact of COVID-19 pandemic on Dr Prakash Valiakolleri immunization programme in PICs DPS/WPRO

08:10 – 08:30 4.3 Regional Action Plan for Immunization Dr Ananda Amarasinghe Programme during the COVID-19 pandemic VDI/WPRO

08:30 – 08:50 Discussion

08:50 – 09:05 Break

5. Immunization safety

09:05 – 09:20 5.1 Immunization safety and vaccine Dr Ananda Amarasinghe regulatory functions VDI/WPRO

09:20 – 09:30 5.2 Regional guideline on enhancing vaccination Dr Ananda Amarasinghe demand in the Western Pacific VDI/WPRO

6. Conclusions and action points

09:30 – 10:45 6.1 Discussion on meeting conclusions and action points

10:45 – 10:55 7. Closing

16

17 Annex 2. List of participants, temporary advisers, observers and Secretariat

1. PARTICIPANTS

COOK ISLANDS Ms Rufina TUTAI, Public Health Nurse Manager/Immunization Coordinator, Public Health Department, Ministry of Health P O Box 109, Rarotonga, Tel. No.: (682) 29110, Fax No.: (682) 29100, Mobile: (682) 50241, Email: [email protected]

FIJI Sr Litiana VOLAVOLA, National EPI Program Officer Ministry of Health and Medical Services, Dinem House, Suva Mobile : (679) 890 5018, Email: [email protected]

FRENCH POLYNESIA Dr Pierrick ADAM, Responsable du Bureau des Pogrammes de Pathologies Infectieuses, Departement des Programmes de Prevention Direction de la Santé (Directorate Health), BP 611 Papeete 98713 Tahiti, Tel. No.: (689) 4048 8220, Fax No.: (689) 4048 8213, Email: [email protected]

GUAM Ms Annette AGUON, Administrator, Bureau of Communicable Disease Control, Department of Public Health and Social Services, 590 s. Marine Corps Drive, Tamuning 96913-3532, Tel. No.: (671) 735 7143 Fax No.: (671) 734 1475, Email: [email protected]

MARSHALL ISLANDS Ms Daisy PEDRO, Program Manager, National Immunization Program, Ministry of Health, P.O. Box16, Majuro, MH 96960, Tel. No.: (692) 625 6633, Fax No.: (692) 625 3432/ 4543 Email: [email protected]

FEDERATED STATES Mr Carter APAISAM, Immunization Program Manager, Department of OF MICRONESIA Health & Social Affairs, P.O. Box PS-70, Palikir, Pohnpei FM 96941 Tel. No.: (691) 320 2619/ 2643/ 2872, Fax No.: (691) 320 5263 Email: [email protected]; [email protected]

NAURU Ms Celestine EOAEO, Primary Health Nurse, Ministry of Health Government Office, Yaren District, Tel. No.: (674) 557 3916/ 554 2569 Email: [email protected]

NIUE Ms Tesl Tahafa-VILIAMU, Maternal Child Health Nurse, Community Health Services, Ministry of Health, Alofi, Tel. No.: (683) 4100 Mobile: (683) 5127, Email: [email protected]

COMMONWEALTH OF Ms Gloria RAMON, Immunization Response Coordinator, THE NORTHERN Commonwealth Healthcare Corporation, P.O. Box 500409, Saipan, MARIANA ISLANDS MP 96950, Tel. No.: (670) 236 8745, Fax No.: (670) 233 0030 Email: [email protected]

PALAU Ms Merlyn BASILlUS, Immunization Program Manager, Ministry of Health, P.O. Box 6027, Koror 96940, Tel. No.: (680) 488 2212 ext. 300 Fax No.: (680) 488 4800, Email: [email protected]

SAMOA Ms Teuila McDONALD-PATI, EPI Coordinator, Ministry of Health Motootua, Apia, Tel.No.: (685) 767 6138, Email: [email protected]

18 SOLOMON ISLANDS Ms Jenniffer ANGA, National EPI Coordinator, Reproductive and Child Health Division, Ministry of Health and Medical Services, P.O. Box 349 Honiara, Tel. No.: (677) 20831, Email: [email protected]

TOKELAU Ms Asena SENIMAKOSOI, National EPI Coordinator, Department of Health, Health Head Office, Nukunonu, Tel. No.: (690) 24211 Email: [email protected]

TONGA Ms Atalua Fatafehi TEI, Supervising Nursing Sister for Public Health/EPI Coordinator, Public Health Division, Ministry of Health, P.O. Box 59 Nuku’alofa, Tel. No.: (676) 23200 ext. 1320, Mobile: (676) 771 4623 Fax No.: (676) 24291, Email: [email protected]

TUVALU Ms Tilesa TEPAULA, Senior Staff Nurse (MCH Nurse), Princess Margaret Hospital, Funafuti, Tel. No.: (688) 20480 / 20749, Email: [email protected]

VANUATU Mr Leonard TABILIP, National EPI Officer, Ministry of Health Private Mail Bag 9009, Port Vila, Tel. No.: (678) 771 5297 Email: ltabilip@vanuatu.gov.vu

2. TEMPORARY ADVISER

Dr Ilisapeci Vereti TUIBEQA, Chair of SRCC/SRVC, Head Paediatrician, Department of

Paediatrics, Colonial War Memorial Hospital, Box 115, Suva, Republic of Fiji, Tel. No.: (679) 3313444, Mobile: (679) 7522778, Emai: [email protected]

3. REPRESENTATIVES/OBSERVERS

ASIAN DEVELOPMENT Mr Ki Fung Kelvin LAM, Health Specialist, Social Sectors and Public BANK(ADB) Sector Management Division, Pacific Department, Asian Development Bank, # 6 ADB Avenue, Mandaluyong City 1550, Philippines Telefax No.: (632) 8632 5460, Email: [email protected]

AUSTRALIA Dr Frances BINGWOR, Program Manager Regional Health, DEPARTMENT OF Department of Foreign Affairs and Trade (DFAT), Australian High FOREIGN AFFAIRS AND Commission, 37 Princess Road. Suva, Republic of Fiji TRADE Tel. No.: (679) 338 8383, Mobile: (679) 927 0270 (DFAT) Email: [email protected]

EMBASSY OF JAPAN Ms Vanessa VUDIKARIA, ODA Coordinator, Embassy of Japan (IN THE REPUBLIC 2nd Floor BSP Life Centre, Thomson Street, Suva, Republic of Fiji OF FIJI) Tel. No.: (679) 330 4633, Fax No.: (679) 330 2984 E-mail: [email protected]

FIJI NATIONAL Dr Torika TAMANI, Associate Professor, School of Public Health & UNIVERSITY Primary Care, College of Medicine, Nursing & Health Science, (FNU) Fiji National University, Hoodless House, Suva, Republic of Fiji Tel. No.: (679) 331 1700, Email: [email protected]

19 NATIONAL CENTRE Professor Kristine MACARTNEY, Director, National Centre for FOR IMMUNISATION Immunisation, Research and Surveillance, Kids Research, Sydney RESEARCH AND Children’s Hospitals Network, Cnr Hawkesbury Road and Hainsworth SURVEILLANCE Street, Locked Bag 4001, Westmead NSW 2145, Australia (NCIRS) Tel. No.: (61-2) 9845 1419, Mobile: +61 408617358 Email: [email protected]

UNITED STATES Mr Gabriel ANAYA, Deputy Chief, Strategic Information and CENTERS FOR Workforce Development Branch, Global Immunization Division DISEASE CONTROL US Centers for Disease Control and Prevention, 1600 Clifton Road AND PREVENTION NE 30329, Atlanta, Georgia, United States of America (US CDC) Email: [email protected]

Dr Elisabeth Raquel KROW-LUCAL, Epidemiologist Global Immunization Division, US Centers for Disease Control and Prevention, 1600 Clifton Road NE 30329, Atlanta, Georgia United States of America, Tel. No.: (1404) 398 7416 Email: [email protected]

Ms Jennifer KNAPP, Epidemiologist, Rubella Team, Accelerated Disease Control and Surveillance of Vaccine-Preventable Disease Branch, Global Immunization Division, US Centers for Disease Control and Prevention, 1600 Clifton Road NE 30329, Atlanta, Georgia United States of America, Tel. No.: (1404) 358 7558 Fax No.: (1404) 471 8542, Email: [email protected]

Dr Robert ALLISON, Epidemiologist, Global Immunization Division US Centers for Disease Control and Prevention, 1600 Clifton Road NE 30329, Atlanta, Georgia, United States of America, Email: [email protected]

4. SECRETARIAT

WHO WESTERN Dr Yoshihiro TAKASHIMA, Coordinator, Vaccine-Preventable ; PACIFIC REGIONAL Diseases and Immunization, World Health Organization OFFICE Regional Office for the Western Pacific, United ations Avenue (WPRO) 1000 Manila, Philippines Tel. No.: (632) 8528 9746 Fax No.: (632) 8521 1036, Email: [email protected]

Dr Nyambat BATMUNKH, Technical Officer, Vaccine-Preventable Diseases and Immunization, World Health Organization Regional Office for the Western Pacific, United Nations Avenue 1000 Manila, Philippines, Tel. No.: (632) 8528 9741 Fax No.: (632) 8521 1036, Emai : [email protected]

Dr Ananda AMARASINGHE, Technical Officer, Vaccine-Preventable Diseases and Immunization, World Health Organization, Regional Office for the Western Pacific United Nations Avenue, 1000 Manila, Philippines Tel. No.: (632) 8528 9032, Fax No.: (632) 8521 1036 Email: [email protected]

20 WHO WESTERN Dr José HAGAN, Technical Officer, Vaccine-Preventable Diseases PACIFIC REGIONAL and Immunization, World Health Organization, Regional Office for the OFFICE Western Pacific, United Nations Avenue, 1000 Manila, Philippines (WPRO) Tel. No.: (632) 8528 9034, Fax No.: (632) 8521 1036 (cont.) Email: [email protected]

WHO SOUTH PACIFIC Dr Angela MERIANOS, Team Coordinator, Pacific Health Security, Communicable Disease and Climate Change, Office of the WHO Representative in South Pacific, Level 4, Provident Plaza One Downtown Boulevard, 33 Ellery Street, Suva, Republic of Fiji Tel. No.: (679) 323 4136, Fax No.: (679) 323 4166 / 323 4177 Email: [email protected]

Dr Subhash YADAV, Medical Officer, Office of the WHO Representative in South Pacific, Level 4, Provident Plaza One Downtown Boulevard, 33 Ellery Street, Suva, Republic of Fiji Tel. No.: (679) 323 4100, Fax No.: (679) 323 4166 Email: [email protected]

Dr Jayaprakash VALIAKOLLERI, Short Term Consultant Office of the WHO Representative in South Pacific, Level 4, Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Republic of Fiji, Tel. No.: (679) 323 4113, Fax No.: (679) 323 4166/ 323 4177 Email: [email protected]

WHO SAMOA Ms Lepaitai Blanche HANSELL, National Professional Officer Office of the WHO Representative in Samoa, American Samoa, Cook Islands, Niue and Tokelau, Ioane Viliamu Building Beach Road, Apia, Tel. No.: (685) 23756/ 757, Fax No.: (685) 23765 Email: [email protected]

WHO SOLOMON Dr Simon BURGGRAAF, Technical Officer, Office of the ISLANDS WHO Representative in Solomon Islands, P.O. Box 22 Honiara, Tel. No.: (677) 23406, Fax No.: (677) 21344 Email: [email protected]

WHO VANUATU Dr Philippe GUYANT, Medical Officer, Office of the WHO Representative in Vanuatu, MOH Iatika Complex P.O. Box 177, Port Vila, Tel. No.: (678) 22 512 Fax No.: (678) 22 691 Email: [email protected]

UNITED NATIONS Mr Sheldon YETT, UNICEF Representative, UNICEF Pacific Office CHILDREN’S FUND Third Floor, Fiji Development Bank Building, 360 Victoria Parade (UNICEF) Private Mail Bag, Suva, Republic of Fiji, Tel No.: (679) 323 6133 Fax No.: (679) 330 1667, Email: [email protected]

Ms Vathinee JITJATURUNT, Deputy Representative UNICEF Pacific Office, Third Floor, Fiji Development Bank Building 360 Victoria Parade, Private Mail Bag, Suva, Republic of Fiji Tel. No.: (679) 323 6135, Fax no.: (679) 330 1667 Email: [email protected]

21 UNITED NATIONS Ms Wendy ERASMUS, Chief of Child Survival & Development CHILDREN’S FUND Programme, UNICEF Pacific Office, Third Floor, Fiji Development (UNICEF) Bank Building, 360 Victoria Parade, Private Mail Bag, Suva, Republic (cont.) of Fiji, Tel. No.: (679) 323 6118, Fax no.: (679) 330 1667 Email: [email protected]

Dr Ataur RAHMAN, Maternal and Child Health Specialist UNICEF Pacific Office, Third Floor, Fiji Development Bank Building 360 Victoria Parade, Private Mail Bag, Suva, Republic of Fiji Tel. No.: (679) 323 6134, Fax No.: (679) 330 1667 Email: [email protected]

Mr Ignacio GIMENEZ, Procurement Services Specialist UNICEF Pacific Office, Third Floor, Fiji Development Bank Building 360 Victoria Parade, Private Mail Bag, Suva, Republic of Fiji Tel. No.: (679) 323 6102, Fax No.: (679) 330 1667 Email: [email protected]

Dr Frances VULIVULI, Health and Nutrition Specialist UNICEF Pacific Office, Third Floor, Fiji Development Bank Building 360 Victoria Parade, Private Mail Bag, Suva, Republic of Fiji Tel. No.: (679) 809 4076, Fax No.: (679) 330 1667 Email: [email protected]

UNICEF EAST ASIA Dr Khin Devi AUNG, Regional Health Specialist, Immunization and AND THE PACIFIC Health Systems, UNICEF Regional Office for East Asia and Pacific REGIONAL OFFICE 19 Phra Atit Road, Bangkok 10200, Thailand, Tel. No.: 662 356 9257 (EAPRO) Mobile: 669 885 99623, Email: [email protected]

Mr Abu Obeine ELTAYEB, Health Specialist, Immunization and Health Security, UNICEF Regional Office for East Asia and Pacific 19 Phra Atit Road, Bangkok 10200, Thailand, Tel. No.: 662 356 9207 Mobile: 6692 0055942, Fax No.: 662 280 3563, Email: [email protected]

UNICEF Mr Mohammed DIAALDEEN, Maternal and Child Health Specialist KIRIBATI UNICEF Kiribati Field Office, Tarawa, Tel. No.: (686) 29267/ 68/ 69 Email: [email protected]

UNICEF Ms Nozizwe CHIGONGA, Maternal and Child Health Specialist FEDERATED STATES UNICEF FSM Field Office, Palikir, Email: [email protected] OF MICRONESIA

UNICEF SAMOA Dr Akshaya MISHRA, Child Health Specialist (Immunization) UNICEF Samoa Field Office, 19 Phra Atit Road, Apia Email: [email protected]

UNICEF Dr Ibrahim DADARI, Maternal and Child Health Specialist SOLOMON ISLANDS UNICEF Solomon Islands Field Office, City Centre Building, Mendana Avenue, P.O. Box 1786, Honiara, Tel. No.: (677) 28001/ 28002/ 28024/ 21242/ 21243, Email: [email protected]

Mr Kendrick MANA, Health Officer, UNICEF Solomon Islands Field Office, City Centre Building, Mendana Avenue, P.O. Box 1786, Honiara, Email : [email protected]

22 UNICEF Dr Surenchimeg VANCHINKHUU, Maternal and Child Health VANUATU Specialist, UNICEF Vanuatu Field Office, Office 6A, Equity Investment Group House, Rue De Paris, P.O. Box 926, Port Vila, Tel. No.: (678) 771 3623, Email: [email protected]

Mr Ben John TAURA, EPI Officer, UNICEF Vanuatu Field Office Office 6A, Equity Investment Group House, Rue De Paris, P.O. Box 926, Port Vila, Tel. No.: (678) 771 3623 Email: [email protected]

23 Annex 3. Conclusions and recommendations from 8th SRCC/SRVC

PROCEEDINGS OF THE SRVC Conclusions and recommendations Conclusions The SRVC noted that reporting of coverage data through the WHO–UNICEF Joint Reporting Form is continuously lacking by American Samoa.

The SRVC concluded the following: • While there continues to be no evidence of ongoing endemic measles or rubella transmission in the PICs, outbreaks in American Samoa, Fiji, Samoa and Tonga in 2019–2020 highlighted the vulnerability of Pacific island communities to importation of measles virus, while measles remains a globally endemic disease. • Outbreaks in the PICs were all successfully contained without leading to endemic spread across the islands, demonstrating the capacity to sustain elimination within the subregion. • The epidemiology and age distribution of the outbreaks varied significantly between affected PICs, reflecting the history of their immunization programme as well as distinct issues and challenges in each country or area. • The large outbreak of measles in Samoa in 2019 occurred after a rapid accumulation of susceptible children during the 10-month period of paused routine measles and rubella immunization following two immunization error-related deaths. This illustrates the importance of identifying and taking proactive steps to fill known immunity gaps through catch-up or non- selective mass vaccination activities. • The outbreak in Samoa had a high case fatality, which may have been in part due to an overwhelmed health-care system and a shortage of vitamin A. • The response to the outbreak in Samoa was supported by a massive collaborative effort from multiple international partners to conduct epidemiological analysis, vaccinations and clinical care. • Outbreak cases in Tonga had a very high proportion of breakthrough infection among fully vaccinated children and young adults associated with a boarding school, demonstrating that even highly vaccinated populations may have unknown immunity gaps and may be at risk of outbreaks after importation. This finding gives greater urgency to accelerate measles elimination globally. • Outbreak cases in Tonga had a very low rate of hospitalization, reflecting a massive public education effort as well as the high rate of cases among fully vaccinated people, which is known to cause less severe disease. • Both affected and unaffected PICs are to be commended for mounting coordinated and capable responses to suspected and confirmed measles cases, and for conducting proactive and comprehensive preparedness activities to prevent uncontrolled spread. This included implementation of zero-dose immunization policies for infants aged 6–11 months in several PICs and mass vaccination activities in Fiji, Kiribati, the Marshall Islands, the Federated States of Micronesia, Nauru, the Commonwealth of the Northern Mariana Islands, Samoa, Tonga and Vanuatu. These activities have filled immunity gaps and significantly strengthened the subregion’s capacity to prevent and respond to future measles outbreaks. • Public health and physical distancing measures to respond to the ongoing COVID-19 pandemic may threaten the performance of routine immunization services, which may result in rapid accumulation of susceptible children if proactive measures are not taken to ensure missed children are vaccinated. • Although there was a low overall proportion of laboratory-confirmed cases, imported laboratory-confirmed cases were detected in multiple PICs and most islands had some genotype

24 data. There was a delay in the shipment of samples from the PICs to regional reference laboratories due to a measles outbreak in New Zealand. PIC specimens were forwarded from New Zealand to Australia for testing as the laboratory in New Zealand does not have reference laboratory status for measles and was overwhelmed by domestic specimens for measles testing. • The Mataika House measles and rubella national laboratory in Fiji is congratulated for introducing the capacity for molecular detection of measles in 2019 and passing the proficiency test. The laboratory will undergo the WHO accreditation process to add this capacity to its programme. • Following the initial detection of an outbreak in Samoa, both affected and unaffected PICs intensified surveillance activities to detect acute fever and rash and conducted preparedness and pre-emptive response activities. This demonstrated the capacity of the subregion to communicate and collaborate as a region to detect and contain measles outbreaks. However, timeliness of these activities should be improved when risk of importation is high from countries outside the subregion, such as from New Zealand. • The SRVC should prepare evidence to present to the Regional Verification Commission for verification of measles and rubella elimination in the PICs.

Recommendations for Member States The SRVC encouraged Member States to consider the following: 1) Maintain an intensified level of surveillance to detect imported measles cases and to prevent outbreaks among children whose vaccination was delayed or missed due to programme interruption related to the ongoing COVID-19 pandemic. 2) Continue to maintain a collaborative approach to measles and rubella surveillance and outbreak preparedness by rapidly notifying WHO and other PICs of newly detected measles cases. 3) Develop plans and policies for when disasters and outbreaks (such as the ongoing COVID-19 pandemic) impact immunization programme performance to: assess immunity gaps; track, follow up and vaccinate those individuals having missed vaccinations; and re-establish community demand for vaccines. 4) Encourage the collection of virological samples during investigation of suspected measles and rubella cases, to allow tracking of imported virus genotype and lineage. 5) Ensure that suspected congenital rubella syndrome (CRS) is a disease of mandatory notification in each country or area and work with WHO to identify an appropriate case definition for suspected CRS in the local context. 6) For countries with national capacity for rubella serology, consider adding rubella serological testing to antenatal screening and provide rubella vaccine to seronegative mothers after delivery. 7) Review national vaccination schedules and consider changing the timing of the second dose of measles and rubella containing vaccine, or MRCV, to occur during the second year of life, if appropriate and feasible, in order to better protect young children from imported measles and rubella virus. 8) For countries with uncertainty about immunization coverage or level of immunity among specific population groups (for example where large-scale population movement may have occurred), consider working with WHO and partners to implement serological surveys to map population immunity. These serological surveys may assess multiple antigens through techniques such as microscopic bead assay, or MBA, and may be simplified for remote island settings through the use of dried blood spot sample collection methods. 9) Work with WHO to conduct the previously planned surveillance assessment for measles and rubella and develop a collaborative framework for detecting imported cases and documenting measles elimination.

25 10) Work with WHO to strengthen the capacity of national laboratories to conduct antibody and polymerase chain reaction, or PCR, testing for measles and rubella case detection, and establish clear referral relationships with one of the regional reference laboratories in the Western Pacific for confirmatory testing. 11) Work with WHO and UNICEF to ensure the availability of measles and rubella containing vaccines and supplies, including contingency resources for outbreak responses. Further, the SRVC urged Vanuatu to introduce a second dose of measles and rubella containing vaccine in the second year of life, as soon as possible, and to seek technical assistance from WHO, if needed.

Recommendations for WHO The SRVC requested that WHO fill an EPI vacancy in the WHO Representative Office in the South Pacific in Fiji to ensure continuous technical support to the PICs, which is critical for the subregion in addressing immunity gaps.

The SRVC requested that WHO consider the following: 1) Continue to work with PICs to explore expanding national laboratory capacity for measles and rubella case confirmation. 2) Work with priority countries and areas to identify and address challenges to reporting immunization coverage via the WHO–UNICEF Joint Reporting Form and case-based surveillance data to the WHO Regional Office. 3) Support PICs to conduct CRS surveillance by conducting diagnostic testing of serological and virological samples from suspected CRS cases and by serving as an expert committee to guide individual countries and areas in the investigation and final classification of suspected cases. 4) Provide PICs with tools to support demand generation, support clinicians to educate their patients and respond effectively to misinformation. 5) Continue to advocate strongly to the international community and to immunization partners for a new global commitment to achieving measles and rubella eradication, and a vastly increased mobilization of resources and expertise in support of this goal, to protect the PICs against the continued threat of measles and rubella importation from endemic areas.

PROCEEDINGS OF THE SRCC Conclusions and recommendations Conclusions The SRCC noted that reporting of coverage data through the WHO–UNICEF Joint Reporting Form is continuously lacking by American Samoa.

The SRCC reviewed and classified four out of five AFP cases reported in 2019 and 2020. Further information on the fifth AFP case reported from Solomon Islands in 2020 is required for the SRCC to make a final classification of the case. The SRCC, having reviewed programme performance in implementing surveillance for AFP and ensuring population immunity against poliovirus, concluded that PICs have continued to maintain polio-free status.

The SRCC concluded the following: • Immunity gaps against polio remain in Guam, the Marshall Islands, the Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Samoa, Solomon Islands and Vanuatu.

26 • The risk of outbreaks remains high due to emergence or importation of cVDPVs in countries with suboptimal population immunity against poliovirus and underperforming AFP surveillance. This is evidenced by ongoing multiple outbreaks of cVDPVs in the Western Pacific Region. • The supply of one dose of IPV in 2021 is confirmed for PICs using OPV. • Countries using OPV will be able to introduce a second dose of IPV starting in 2021. • Performance of AFP surveillance remains variable in the subregion with persisting suboptimal performance in several PICs. • Further advocacy with PICs is required to raise awareness of clinical staff on reporting AFP cases and taking stool specimens for further testing in the respective reference laboratories. • The timely shipment of stool specimens to the respective reference laboratories might be affected by restricted national and international travel due to the COVID-19 pandemic.

Recommendations for Member States The SRCC encouraged Member States to consider the following: 1) All PICs to achieve and maintain more than 90% of coverage with three doses of polio vaccine at the national level. 2) Countries using OPV: a. to achieve and maintain more than 90% coverage with one dose of IPV in preparation for introduction of the second dose; and b. to assess the possibility of switching to an IPV-only schedule considering the availability of vaccine supply, affordability and other programmatic aspects. 3) SRCC members to continue advocacy efforts in their respective countries to raise awareness among clinical staff on the importance of AFP surveillance. 4) SRCC members to consider conducting retrospective reviews of medical records to identify possible missed/unreported AFP cases. 5) Irrespective of the current national and international travel restrictions, to continue collection of stool specimens from AFP cases. 6) For stool specimens that are collected, to contact the WHO Division of Pacific Technical Support in Fiji and the Regional Office for the Western Pacific in Manila, Philippines, to assist with sample shipment to the regional reference laboratory in Australia. 7) If a delay is expected in the shipment of stool specimens to the regional reference laboratories, to store the specimens at least below –20 °C temperature (if –70 °C is not available) until shipment becomes possible. 8) PICs to plan and implement actions to strengthen performance of AFP surveillance. 9) PICs to develop polio outbreak preparedness and response national plans. 10) For the 14 PICs that have not yet completed Form 2 of the Guidance to Minimize Risks for Facilities Collecting, Handling or Storing Materials Potentially Infectious for Polioviruses (PIM Guidance) to prepare a list of country focal points for completing the national inventory to identify potentially infectious materials and share it with WHO (Division of Pacific Technical Support and Vaccine-Preventable Diseases and Immunization unit) by the end of June 2020. 11) The remaining 14 PICs to complete Form 2 of the PIM Guidance and submit it to the subregional containment coordinator (SRCC secretariat at WHO in Fiji) by the end of August 2020.

27 12) The SRCC to submit the Form 2 PIM report to WHO by 1 September 2020.

Recommendations for WHO The SRCC also requested that WHO fill an EPI vacancy in the WHO Representative Office in the South Pacific in Fiji to ensure continuous technical support to the PICs, which is critical for the subregion in addressing immunity and AFP surveillance gaps.

The SRCC requested that WHO consider the following: 1) Support PICs using OPV in preparing for the introduction of the second dose of IPV. 2) Develop and provide a schedule of country visits and teleconferences to support completing containment reports. 3) Develop a template for the polio outbreak preparedness and response plan (in consultation with the SRCC) and support the countries in developing national plans.

28 www.wpro.who.int