������������

���������������������������������������������������

��������������������������������������������������������������������

��������������������� !�"��������!##$

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

REPORT

FIFTEENTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION

IN THE WESTERN PACIFIC REGION

Phnom Penh, Cambodia 1-2 December 2009

Manila, Philippines October 2010

(WP)/ICP/IVD/1.1/001-A Report series number: RS/2009/GE/56(CAM) English only

REPORT

FIFTEENTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION

IN THE WESTERN PACIFIC REGION

Phnom Penh, Cambodia 1-2 December 2009

Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Not for sale

Printed and distributed by:

World Health Organization Regional Office for the Western Pacific

Manila, Philippines

October 2010

NOTE

The views expressed in this report are those of the participants of the fifteenth meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization.

Keywords:

Immunization / Poliomyelitis – prevention and control / Certification

This report has been printed by the Regional Office for the Western Pacific of the World Health Organization for the participants of the fifteenth meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific Region, which was held in Phnom Penh, Cambodia, from 1 to 2 December 2009.

CONTENTS

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

1.1 Objectives ..................................................................................................................... 1 1.2 Organization ................................................................................................................. 1

2. PROCEEDINGS ................................................................................................................... 2

2.1 Global overview of poliomyelitis eradication (as of December 2009)......................... 2 2.2 Regional status of maintaining poliomyelitis-free status..............................................4

3. CONCLUSIONS................................................................................................................... 9

3.1 General ......................................................................................................................... 9 3.2 Country-specific conclusions and recommendations.................................................. 11

1. INTRODUCTION

The Regional Commission for the Certification of Poliomyelitis Eradication (RCC) in the Western Pacific Region continues to meet on an annual basis in order to review and support maintenance of poliomyelitis-free status and certification standard quality requirements and to fulfil its reporting mandate to the Global Certification Commission (GCC).

1.1 Objectives

The objectives of the RCC at its fifteenth meeting were:

(1) to review progress reports from all countries and areas on maintaining the poliomyelitis-free status, including poliovirus laboratory containment; and

(2) to make recommendations on required action for maintaining the Region's poliomyelitis-free status.

1.2 Organization

In order to have closer direct interactions with the National Certification Committees (NCC) in key countries and allow RCC members to observe activities for maintaining poliomyelitis-free status, the 15th RCC meeting was held in Phnom Penh, Cambodia. Field activities for a targeted review of the acute flaccid paralysis (AFP) surveillance system were conducted immediately after the meeting and the main conclusions and recommendations presented to the National Immunization Programme (NIP) by the RCC rapporteur. Holding the meeting in the country also presented advocacy opportunities for the significance of and requirements for maintaining the country's poliomyelitis-free status and subsequently support the NIP.

The meeting was attended by six of the seven commission members and a WHO secretariat. Annex 1 includes the meeting timetable, and Annex 2 contains a list of participants. The opening ceremony was attended by His Excellency, the Secretary of State, Professor Eng Huot, NCC members, officials of the Ministry of Health and the Regional Immunization Specialist of the United Nations Children's Fund (UNICEF) East Asia Pacific Regional Office, representing one of the key stakeholders in the Global Polio Eradication Initiative (GPEI).

1.3 Opening ceremony

Dr Michel Thieren, acting WHO Representative in Cambodia, presented the opening remarks of Dr Shin Young-soo, the WHO Regional Director in the Western Pacific.

Dr Shin recognized the important role the RCC has played in keeping the Western Pacific Region poliomyelitis-free and the invaluable support it provides to the surveillance and immunization efforts of Member States.

Dr Shin highlighted that it was only fitting to hold the RCC meeting in Cambodia, which eliminated poliomyelitis in 1997 and by October 2000 was officially certified as poliomyelitis-free, joining all other Member States in the Region in reaching that important milestone.

- 2 -

Dr Shin reminded how in the ensuing years, the WHO European Region was also certified as poliomyelitis-free, and many other countries achieved elimination. He highlighted that there are still areas where interruption of wild poliovirus transmission has proven to be much more challenging than expected, including the four remaining poliomyelitis-endemic countries: Afghanistan, India, Nigeria and Pakistan. He warned that wild poliovirus continues to find its way back to poliomyelitis-free countries and repeated regional and transcontinental transmission has occurred in several countries, originating particularly from Nigeria and India.

Dr Shin reiterated that the GPEI continues to pursue its goal with high levels of political support and new operational approaches that are improving coverage in endemic countries and reducing the risks and consequences of the international spread of poliovirus. He also felt encouraged by the recently completed independent evaluation of major barriers to the interruption of poliovirus transmission.

Despite the ongoing efforts, Dr Shin warned that it must be remembered that wild poliovirus importations had been confirmed quite recently in less-expected-places — in Kenya in 2009, in Nepal in 2008, in Australia and Myanmar in 2007, and in Singapore in 2006 — and that with increased international travel into the country and internal migration, it also could happen in Cambodia. Dr Shin commended Cambodia for devoting great attention and effort over the past 12 years to maintaining high-quality AFP surveillance and immunization, even as other pressing health issues competed for attention and resources. Evidence of this could be found in Cambodia's swift and comprehensive response to the detection in the country of circulating vaccine-derived poliovirus (cVDPV) in late 2005. That episode also highlighted the importance of maintaining a high level of surveillance, particularly among high-risk populations.

Dr Shin concluded that as it is likely to take a few more years before global poliomyelitis eradication and certification may occur, poliomyelitis surveillance and immunization systems need to be made as sustainable as possible. Areas of synergies with other disease-control efforts need to be identified in order to maximize resources. A wider circle of health care providers — public and private sectors — need to be kept well informed about the requirements to meeting the final goal. Continuing collaboration among partners need to be ensured— poliomyelitis eradication was jointly achieved in Cambodia and must be jointly maintained.

2. PROCEEDINGS

2.1 Global overview of poliomyelitis eradication (as of December 2009)

In 1988, the World Health Assembly (WHA) adopted resolution WHA41.28 on global eradication of poliomyelitis by the year 2000. By 2008, all but four countries had interrupted indigenous transmission of wild polioviruses (Afghanistan, India, Nigeria and Pakistan), and the annual number of cases had declined by more than 99%. However, case numbers were still fluctuating between 1000 and 2000 per year and 12 to 23 additional countries were experiencing cases of poliomyelitis due to imported polioviruses each year. In at least two of these latter countries (Angola and Chad) and possibly the Democratic Republic of the Congo and Sudan, the imported virus persisted for more than 12 months and led to further international spread. In 2008, the Health Assembly in resolution WHA61.1 called for a new strategy to eradicate poliomyelitis from the remaining affected countries. The 'Programme of Work 2009' of the GPEI was constructed in order to inform this new strategy by evaluating new tactical innovations in each disease-endemic area, conducting clinical trials of new oral poliovirus vaccine

- 3 -

formulations and facilitating an independent evaluation of major barriers to interrupting poliovirus transmission.

In India, new tactics increased oral poliovirus vaccination campaign coverage in 2009 among migrant and mobile populations, and enhanced campaign operations being undertaken in the disease-endemic districts of central Bihar and western Uttar Pradesh, raising the proportion of very young children with antibodies to type 1 poliovirus in the latter area from 85% in late 2007 to 96% in late 2009.

In Nigeria, comparing the last six months (May–October 2009) with the same period in 2008, the proportion of children who had never been immunized in the 10 endemic northern states (high-risk states) fell from close to 20% (19.5%) to less than 10% (9.6%) in 2009, after state governors signed the 'Abuja Commitments to Poliomyelitis Eradication' in February 2009 and traditional leaders formed a poliomyelitis eradication committee in June 2009. Both of these actions have resulted in greater accountability at the local level for the performance of the poliomyelitis campaigns.

In Pakistan, the Prime Minister launched a 'Polio Action Plan' in February 2009 that enhanced multisectoral support for the oral poliovirus vaccination campaigns in many areas, although coverage remained less than 80% in the disease-endemic districts in the north of both the North West Frontier Province and the Federally Administered Tribal Areas, Baluchistan and the greater Karachi area of Sindh.

In the two remaining disease-endemic provinces in Afghanistan (Kandahar and Helmand in the Southern Region), access to children improved in key security-compromised districts during recent oral poliovirus vaccination campaigns through the use of new tactics, which included an enhanced role for nongovernmental organizations, the recruitment of local “access negotiators”, and negotiations with the International Security Assistance Force and the Taliban for days of tranquillity. Although access in the Southern Region continues to fluctuate, the proportion of inaccessible children was reduced for the first time to 5% during the oral poliovirus vaccination campaigns in July and September 2009, down from more than 20% at the start of the year.

To improve the efficiency and impact of oral poliovirus vaccination campaigns against the last two remaining serotypes of wild poliovirus, clinical trial lots of a bivalent oral poliovirus vaccine (bOPV), containing type 1 and type 3 viruses, were produced. In 2009, the results of the clinical trial demonstrated that the protection conferred against disease due to both serotypes by this bivalent vaccine was superior to that provided by the trivalent oral poliovirus vaccine (tOPV)

and “non-inferior” to the respective monovalent oral poliovirus vaccines (mOPV).1 The

Advisory Committee on Poliomyelitis Eradication (ACPE) concluded that “the use of bivalent oral poliovirus vaccine in supplementary immunization activities constitutes an important new

tool for the Global Polio Eradication Initiative” and made recommendations for its use.2 This

product was first used in the GPEI in December 2009 with subsequent rapid scale up in order to meet full demand by mid-2010.

1 Advisory Committee on Poliomyelitis Eradication: recommendations on the use of

bivalent oral poliovirus vaccine types 1 and 3. Weekly Epidemiological Record, 2009, 29(84):289-300.

2 Ibid.

- 4 -

An independent evaluation of major barriers to interrupting poliovirus transmission was chaired by Dr A.J. Mohamed (Oman), a vice-chairman of the Executive Board, and comprised five subteams with a total of 28 experts in relevant disciplines including public health, immunization programmes, vaccinology, social mobilization and security. These subteams collectively spent 24 person-months working on the evaluation in Afghanistan, Angola, India, Nigeria, Pakistan, Sudan, the WHO regional offices for Africa and the Eastern Mediterranean and WHO headquarters, with wide consultation with GPEI partners and stakeholders in each country. The evaluation team submitted its report to the WHO Director-General on 22 October 2009.

The results and impact of the GPEI's Programme of Work 2009 were reviewed by WHO’s Strategic Advisory Group of Experts (SAGE) on immunization on 29 October 2009, and by the ACPE on 18 and 19 November 2009 at a special consultation of this Group with poliomyelitis-affected countries and Global Polio Management Team (GPMT) partners. The SAGE on immunization urged the GPEI to rapidly consider the findings of the independent evaluation; it also supported an enhanced research agenda and agreed that bOPV vaccination constituted an important new tool. The Group recommended that the GPEI’s major indicators be internationally monitored with influential oversight by senior management in partner agencies and poliomyelitis-affected countries.

The ACPE stated that the challenges faced by the GPEI in 2009 should not be allowed to overshadow significant achievements, particularly in Nigeria, India and Afghanistan. Participants in the ACPE’s consultation concurred that the GPEI should establish a new three-year programme of work that focused on stopping transmission of wild poliovirus globally, based on the findings of the independent evaluation, and developed in a consultative process with countries and partners.

2.2 Regional status of maintaining poliomyelitis-free status

Certification aspects

All countries, except one, continue to have active NCCs in place which met at least one time in 2009; either face to face or in video conferences. Where countries have separate expert review panels (ERP) to classify AFP cases, NCC members participated in some of the ERP meetings. Following the RCC recommendation, at least seven NCCs have updated their terms of references (TOR) to reflect post-certification aspects and requirements of their work.

In nine countries, NCCs also serve as ERP while for the 20 Pacific island countries and areas (PIC) one Subregional Certification Committee (SRCC) is in place which also serves as ERP. In China, each province has an ERP; with varying meeting frequency (though there is a standard requirement of four times per year) and case review practices. The majority of ERP (9/17) review all AFP cases for final classification where the others review all cases with inadequate stool specimens who have residual paralysis, died or were lost to follow up and all cases with Sabin-like poliovirus isolates.

AFP/poliomyelitis surveillance

The majority of countries in the Western Pacific Region were able to maintain AFP/poliomyelitis surveillance quality during 2008 and in 2009 to date at the necessary level of sensitivity (or 'certification standard'); details are included in Annex 3. Notable performance improvements were observed in the Lao People's Democratic Republic and Papua New Guinea.

- 5 -

0

0.5

1

1.5

2

2.5

3

AUS CAM CHN HOK LAO MAA MON NEZ PIC PNG PHL SIN VTN

2007 2008 2009

Figure 1: Non-polio AFP rate by country in the Western Pacific Region, 2007-2009*

*dataset as of 9 November 2009

However, while overall quality levels have been maintained, detailed review of country performances revealed that gaps exist at subnational level in several countries like Cambodia, and the Philippines, and need to be addressed to ensure timely and reliable identification of circulating polioviruses.

In 2009, only one VDPV isolation was reported; from an AFP case in Shandong Province in China. The type 2 VDPV had a sequence diversion in the VP1 region of 1%. Similarly, early detection of VDPVs was observed in China in the previous years, supporting the good quality of the AFP surveillance system.

Table 1: Emergence of VDPVs (2006 – 2009)

Country Place Onset

paralysis Type VP1

divergence # AFP cases

Cambodia Near Phnom Penh Nov 05 / Jan 06 3 >2% 2

China Guangxi Province Mar-06 1 1.40% 1

China Shanghai None (Aug 06) 3 1% 0

China Shandong Province Feb/Mar 07 1 1.4% / 1% 2

China Shanxi Apr-07 1 1% 1

China Guangxi Jun-07 1 1% 1

China Shandong Province Feb-09 2 1% 1

- 6 -

Important activities in 2009 to keep focus on poliomyelitis surveillance include introduction of environmental surveillance at selected sites in Australia and China, conduct of targeted AFP surveillance reviews in Cambodia and China (planned), visit by Prof Anthony Adams (RCC chairperson) to Papua New Guinea in June for advocacy purposes with senior health officials and technical discussions and a special surveillance project in the PIC (CDC funded; also including rash and fever surveillance and re-establishment of the SRCC).

Important issues in 2009 included the need for continuous efforts to retrain and sensitize new surveillance staff and clinicians on AFP surveillance, particularly in public health offices and priority health facilities with high staff turnover and the special focus placed by all countries on H1N1 Pandemic 2009, often involving national and WHO Expanded Programme on Immunization staff to a significant extent (e.g. surveillance, preparedness plans future vaccine deployment).

Poliomyelitis laboratory network

The regional poliomyelitis laboratory network continued to function at a good quality level with all but one of the 43 laboratories (the provincial laboratory in Tibet/China) in operation under the main WHO accreditation criteria. A new algorithm for faster isolation of polioviruses (within 14 days of 28 days) was introduced in eight laboratories. Timeliness requirements for sequencing results were reduced from 14 to seven days. Challenges still existed for obtaining intratypic differentiation (ITD) results within 45 days of paralysis onset. Delays continued to occur in shipping AFP stool sample from the point of collection to the isolation laboratory and sending poliovirus isolates to the reference laboratories, mainly in China.

Table 2: Polio laboratory network performance*

% results w/in 28 days of

receipt (old algorithm)

% results w/in 14 days

of receipt (new

algorithm)

% ITD results w/in 14 days of receipt

% ITD results

w/in 7 days of receipt

% ITD results w/in 60 days of onset

% ITD results w/in 45 days of receipt

2007 96 58 52 12 2008 95 85 40 18 2009 96 86 93 78 45

*dataset as of 22 June 2010

Immunization against poliomyelitis

Data on immunization activities in 2008 indicated that, overall, countries were maintaining high levels of immunity against poliomyelitis, with some notable exceptions (e.g. Lao People's Democratic Republic, Papua New Guinea, some subnational areas in the Philippines); please see Figure 2 and Annex 4. Supplementary immunization activities (SIAs) were only conducted in China and the Lao People's Democratic Republic.

- 7 -

Figure 2: Poliomyelitis 3 coverage in the Western Pacific Region countries, 2008

Data source: JRF

Macao (China) has shifted from OPV to inactivated poliovirus vaccine (IPV) and Malaysia is piloting IPV use in eight states (DTaP-IPV/Hib to children at 2, 3, 5 months of age. A DTaP-IPV/Hib booster will be given from March 2010 onwards at age 18 months. Meanwhile, other states still use DTwP-HBV/Hib + OPV at age 2, 3 and 5 months. Brunei Darussalam is considering to shift from OPV to IPV in the near future. The current poliomyelitis immunization schedule by country can be found in Annex 4.

In Japan, the NCC recommended that the adoption of IPV for routine immunization is essential. For this, it is necessary to get national consensus to reduce the occurrence of vaccine associated paralytic poliomyelitis (VAPP), and in order to maintain high vaccine coverage rate, the NCC suggested to introduce a combined vaccine with DPT.

In the Lao People's Democratic Republic, based on the initial available resources (vaccine and operational costs), 59 priority districts in 12 provinces were selected (319 989 children under 5 years) for two rounds of OPV immunization, first in December 2008 with the Child Health Days (also providing vitamin A and mebendazole) and a second round in February 2009. After a donation from the Government of Italy, an additional 191 855 children were targeted in February and a final round was conducted in March/April 2009. In some difficult-to-reach areas, additional antigens such as measles vaccine were added. The government reported 463 839 children aged 0-59 months received OPV in February 2009. In the March/April 2009 campaign, the government reported 174 149 children 0-59 months being vaccinated (again 91% coverage). The remaining districts were covered during the first round of tetanus toxoid (TT) SIAs for child-bearing-age women and the next round will be held in January 2010.

China will continue to conduct its annual OPV SIAs in the winter season. Future planning should include carefully establishing risk criteria for areas/populations to be targeted, operational

- 8 -

aspects including external monitoring and innovative strategies for fund raising ('seed money'). The country is also planning to conduct serosurveys in six provinces. In Papua New Guinea, inclusion of OPV in the measles SIAs planned in 2010 is being discussed.

Wild poliovirus importation preparedness

One of the essential requirements for regional certification had been a national preparedness plan for wild poliovirus importation. In light of the large poliomyelitis outbreak in Indonesia in 2005, following an importation of wild poliovirus, and the introduction of the International Health Regulation (IHR) 2005 making a wild poliovirus case of the four reportable diseases, the RCC had previously already requested that all countries should update their national plans accordingly and regularly reiterated this recommendation.

At the end of 2009, current wild poliovirus importation response plans were in place in nine countries but the generic protocol of the PIC had been updated the last time only in 2005. Several large countries like Cambodia, China, Malaysia, the Philippines and Viet Nam, though, did not yet have updated preparedness plans in place.

Completion of Phase 1 wild poliovirus laboratory containment

Based on reviews of the final reports on Phase 1 wild poliovirus laboratory containment and findings from the external technical review panel, the RCC concluded in its meeting in December 2008 that the Phase 1 containment activities documented by China and Japan provided a complete and accurate national inventory of laboratories with wild poliovirus infectious and potentially infectious materials. With these final reports, the RCC declared Phase 1 wild poliovirus laboratory containment, laboratory surveys and national inventories, complete for the whole Western Pacific Region. A total of 77 260 laboratories were included; the number of laboratories storing relevant materials has been reduced from 107 in 2008 to 47 as of 16 November 2009; this is in Australia, China, Japan and the Republic of Korea.

With the data analysis from all the countries in the Region now completed, results have been shared with national containment coordinators and the RCC recommendation is being reinforced that all countries should maintain a national focal point. In order to protect the huge investments made into the exercise and facilitate the destruction of materials, maintenance plans have been established in China and in Japan. Similar work will be done with Australia, Mongolia and the Philippines and is planned for Cambodia.

Post eradication activities

While several countries and areas have already shifted from OPV to IPV with their own financial and technical resources (Australia, Hong Kong/China, Macao/China, Malaysia/partially, New Zealand, Republic of Korea), others require increased technical support. Particularly in countries with large populations like China, there is a growing need to consider economic analysis of various aspects to establish the scientific evidence for decision-making on future poliomyelitis immunization options, including cost-effectiveness of different poliomyelitis immunization alternatives; in terms of preparations, schedules, health impact of OPV cessation in terms of VAPP and disability adjusted life years (DALYs) averted, cost of VDPV cases resulting from the continued use of OPV and bio-safety and population immunity requirements for domestic IPV production after global eradication. Phase II clinical trials have started for Sabin-based IPV production in China and work is also going on in Japan.

Furthermore, China and the Philippines participated in the WHO-led multicountry study on iVDPV detection in persons with primary immune deficiency (PID) while Australia is planning its own study for detection of chronic poliovirus infection in persons with a PID.

- 9 -

3. CONCLUSIONS

3.1 General

Overall conclusion

By the time of the 15th RCC meeting, update reports had been received from all countries. Based on the information received, the RCC was satisfied that the Region has remained free of poliomyelitis during 2009, despite the persisting risk of wild poliovirus importation from endemic areas, and despite the existence of subareas in the Region where insufficient immunity levels may allow wild poliovirus spread, subsequent to an importation. With only one VDPV isolation reported in 2008/2009, such an occurrence seem to be sporadic, without evidence for sustained circulation.

Maintaining the certification process

The majority of NCCs have remained very active in their oversight of national poliomyelitis programmes. Progress reports were generally comprehensive and, to a large extent, addressed previous RCC recommendations, including updating the NCCs' TOR.

The RCC thanked all NCCs and their secretariats for the timely preparation and submission of reports.

Maintenance of AFP/poliomyelitis surveillance

The RCC commended countries in the Western Pacific Region for generally upholding ‘certification standard’ AFP surveillance during 2009. However, some countries have AFP surveillance quality gaps, particularly subnationally, or deterioration in AFP surveillance sensitivity.

The RCC noted continued concern in the Region about the need for more precise guidelines on VDPV terminology, investigation and response and reporting requirements, and deemed further guidance in this area necessary from the GPEI.

The RCC highlighted how poliomyelitis eradication efforts have, particularly in surveillance, established baselines for reporting requirements, use of standardized surveillance indicators and linkages and collaboration between field and laboratory staff; to be used to promote the AFP surveillance platform for other vaccine preventable disease (VPD) control efforts as appropriate and support sustain poliomyelitis surveillance systems in return.

Polio laboratory network

The RCC was satisfied that the regional poliomyelitis laboratory network continued to provide valuable high-quality laboratory support to Member States, noting in particular the contribution of the Regional Reference Laboratories. The RCC commended that the Global Specialized Laboratory at the National Institute of Infectious Diseases (NIID) in Japan, in addition to its various support functions to countries in the Region, also continued in global capacity-building by conducting global poliomyelitis laboratory training courses which benefit countries in other WHO Regions as well (African and South East Asian Regions).

The RCC noted the progress achieved by the regional poliomyelitis laboratory network to introduce the new real-time polymerase chain reaction methodology to a) more precisely identify VDPVs and b) reduce the time needed for laboratory testing.

- 10 -

The RCC reiterated the recommendation by the Global poliomyelitis laboratory network for all network laboratories to report all wild polioviruses and viruses with discordant ITD results (i.e. potential VDPVs) to national authorities and WHO, including regional and global coordinators, within 24 hours of their detection. The RCC requested all poliomyelitis laboratories in the Region to adhere to this recommendation.

Maintaining high immunity levels

The RCC was impressed that available data on immunization activities indicated that most countries and areas maintained high levels of immunity against poliomyelitis, but noted the lack of uniformity of reported coverage at the district level. The RCC commended continued efforts to boost immunity against poliomyelitis in areas with relatively low performance of routine immunization; special approaches to enhance routine systems, i.e. through defaulter tracking or better utilization of fixed-site immunization service delivery, comprehensive outreach or targeted high quality SIAs.

The RCC appreciated that many progress reports included information on subnational immunization coverage. This approach should be used even more widely, and identified low-performing areas should be targeted for remedial activities.

Preparedness for wild poliovirus importation and cVDPV

The RCC continued to consider active and current preparedness plans for the detection of and response to wild poliovirus importation and VDPV emergence as essential in countries' efforts to stay poliomyelitis-free and requested the WHO Secretariat to work closely with all countries that do not yet have one. Each NIP should seriously review if their national plan still meets all requirements; to immediately activate an appropriate surveillance and immunization response as required. Particularly, IPV-using countries need to include in the plan the vaccine to be used in the event; considering all implications of securing adequate supplies.

With transmission of both type 1 and type 3 wild poliovirus continuing in the four endemic countries and wild poliovirus transmission ongoing in several previously poliomyelitis-free countries following importation from endemic/reinfected countries, the RCC remained very concerned that this situation would once again compel the shifting of the anticipated timeline of global eradication further into the future.

By implication, the threat of wild poliovirus importation for countries in the Region remains and all Member States and key partners need to continue vigorously implementing all relevant activities to maintain the poliomyelitis-free status. The RCC recommended to the WHO Secretariat to consider best means to strengthen coordination with other poliomyelitis-free Regions and interregional exchange; to widely share experiences in environmental and enterovirus surveillance, conduct of serosurveys and AFP surveillance reviews, preparing for and shifting to IPV, among others.

Laboratory containment of wild poliovirus infectious/potentially infectious materials

The RCC noted that several, but not all, countries indicated their current national focal point for laboratory containment as recommended in 2008 and requested the WHO Secretariat to ensure that all Member States were aware of the requirements. The RCC again encouraged all laboratories to consider destruction of materials that were no longer essentially required.

- 11 -

3.2 Country-specific conclusions and recommendations

Australia

The RCC commended Australia for comprehensively addressing its recommendations by updating the TORs of its NCC, updating the national inventory for wild poliovirus laboratory containment and resolving the discussions about AFP case classification at the Expert Review Committee (ERC).

The RCC appreciated several innovative efforts to identify ''all potential sources of poliovirus in Australia", including the initiation of enterovirus surveillance in two sites (which is in line with the Strategic Plan 2010-2012 of the GPEI) and the iVDPV study. The RCC wished to be kept informed about these activities. Furthermore, the RCC noted that the Paediatric Active Enhanced Disease Surveillance (PAEDS) system was working well and a helpful adjunct to routine AFP surveillance.

The RCC commended the continued outstanding support given by the Regional Reference Laboratory at VIDRL to the regional poliomyelitis laboratory network.

The RCC recognized that the wild poliovirus importation preparedness plan was endorsed by the Australian Health Protection Committee in December 2008. The RCC continued to consider the plan as comprehensive and adequate but recommended to follow discussions at the WHO Secretariat on the best vaccine of choice responding to evidence, possibly in an area of low IPV coverage/low immunity, of the importation and spread of a wild poliovirus.

Brunei Darussalam

The RCC commended the national poliomyelitis programme for maintaining surveillance and immunization performance at certification standards and acknowledged the continued leadership of the NCC.

The RCC noted that the NCC was considering to establish a separate Expert Review Panel (ERP); in view of the low number of AFP cases the country experienced, this might not be necessary. The RCC considered it important though that the NCC was otherwise not directly involved in the day-to-day operations of the programme. In general, an ERP requires TORs completely separate from the NCC TORs.

The RCC welcomed the review of the wild poliovirus importation contingency plan and related risk assessment. The RCC encouraged immediate collaboration with WHO and UNICEF in an event; also to meet the requirements under the IHR 2005.

Cambodia

The RCC expressed its sincere appreciation to the Government of Cambodia for hosting its 15th meeting.

The RCC congratulated Cambodia on the excellent report on maintaining its poliomyelitis-free status, which took a very thorough approach and identified and described all critically important issues.

The RCC appreciated that all recommendations made at the RCC's 14th meeting had been responded to, including the opportunity for the RCC members to participate in a targeted field review of AFP surveillance.

- 12 -

While the RCC agreed with the areas of concern identified by the NCC, the RCC still wanted to highlight the following points.

AFP surveillance

Overall surveillance indicators have been maintained at the required quality levels, such as a non-poliomyelitis AFP rate of 1.1/100 000 under age 15 in 2009 to date and stool specimen adequacy at 82%. However, there was a concern that the number of AFP identified each year continued to decrease. An increasing number of large provinces each year were either 'silent' (eight in 2009, including Kampong Thom and Bantay Meanchey) or were not reaching a rate of 1/100 000 (seven provinces in 2009, including Phnom Penh and Siam Reap).

The majority of cases in the whole country were still reported from Kunta Bhopa hospital in Phnom Penh, with a similar number of cases, compared to 2008, reported directly from provinces. In this context, the RCC acknowledged the major contribution made by Kunta Bhopa hospital to AFP surveillance in Cambodia.

The RCC expected that the outcomes of the targeted AFP review could help in better defining the reasons for which AFP reporting is declining and contribute to the development of an activity plan to strengthen AFP surveillance over the next two years, and to clarify the necessary resource requirements. The activity plan should focus also on identifying opportunities to integrate AFP surveillance with surveillance for other vaccine-preventable or other priority diseases. The RCC would appreciate a detailed report for its next meeting.

Immunization activities

The RCC found the overall reported third-dose oral poliovirus vaccine (OPV3) coverage (91%) satisfactory but noted that coverage levels continued to vary considerably at the district level (from 54% to "> 100%"). Also, the progress report correctly highlighted the continued problems to access and vaccinate important high-risk groups, such as migrant populations and slum-dwellers.

The RCC encouraged continued detailed subnational analysis, including use of surveys as planned for 2010, to identify coverage gaps.

The RCC strongly supported efforts in Cambodia to strengthen the routine immunization system, such as better utilization of fixed sites, and implementation of the 'coverage improvement plan' (CIP). However, in areas where coverage gaps cannot be quickly closed through routine vaccination, targeted preventive SIAs with OPV should be considered. Whenever possible, OPV should be added to other vaccination campaigns, or child health interventions, such as the measles catch-up SIAs planned for 2011 and the semi-annual vitamin A-supplementation campaigns.

The RCC requested regional and global poliomyelitis partners to provide the necessary resources for potential future SIAs.

Finally, the RCC noted that Cambodia had not yet submitted a specific preparedness and response plan for wild poliovirus importation and emergence of VDPV and considered that the development of such a plan has high priority.

China

As in previous years, the RCC appreciated the clear report from China which allowed to conclude that both surveillance and immunization activities generally remained at levels to assure the maintenance of poliomyelitis-free status.

- 13 -

The RCC encouraged continued identification of high-risk areas and population groups and, in coordination with the WHO Secretariat, to consider targeted AFP surveillance reviews and means to assess reported coverage.

The RCC recommended that the national programme should discuss with WHO the possible need for additional monitoring for poliovirus, such as environmental surveillance in low-performing areas that may bear risk factors such as suboptimal population immunity, high population density and frequent population movements.

The RCC commended the continued excellent support given by the Regional Reference Laboratory at the Chinese Center for Disease Control and Prevention to the regional poliomyelitis laboratory network, particularly the systematic work to identify emerging VDPVs.

The RCC noted that the national wild poliovirus importation contingency plan is under revision and strongly encouraged it finalization (in collaboration with WHO).

The RCC noted the various follow-up activities related to wild poliovirus laboratory containment, such as the development of a maintenance plan after completion of phase 1, and commended the Government of China for responding to recommendations the RCC made at its 14th meeting.

Hong Kong (China)

Overall, the RCC was satisfied that, based on the report submitted, both AFP surveillance and immunization activities had remained at certification quality in Hong Kong (China).

The RCC commended that additional activities had been undertaken to sensitize key physicians of public hospitals on the need for timely reporting of AFP and stool collection, and to remind research laboratory staff of the need to inform the national containment focal point when specimens are received from poliomyelitis-endemic areas (i.e. receipt of potentially infectious material).

The RCC noted that while the original importation preparedness plan for Hong Kong (China) had already been updated twice, it specifically mentioned that OPV (either tOPV and/or mOPV) should be used for outbreak response vaccination. Since routine vaccination in Hong Kong (China) was switched to use IPV exclusively in 2007, the RCC would appreciate to hear more from the NCC about the feasibility of using OPV for response immunization, i.e. whether OPV is still available/licensed in Hong Kong (China), and if yes, whether stockpiles of OPV have been created to use in an emergency situation. The RCC encouraged consultation with the WHO Secretariat about these matters.

Macao (China)

As in previous years, the RCC appreciated the clear report from Macau (China) which allowed to conclude that both surveillance and immunization activities remained at levels to assure the maintenance of poliomyelitis-free status.

The RCC noted that while the 'importation preparedness plan' was briefly discussed, the plan itself was not attached to the report. As Macau (China) switched to use IPV for routine infant immunization at the end of 2008, the RCC would like to know the vaccine to be used in responding to an importation, should that become necessary. If the plan calls for using OPV for that purpose (as in some other IPV-using countries), the RCC would appreciate to receive comments from the NCC on the feasibility of this approach, such as if a relatively large quantity of OPV could be available quickly, whether OPV is still licensed in Macau (China), and whether stockpiles of OPV (tOPV and mOPVs) have been created for use in an emergency situation.

- 14 -

Japan

The RCC noted the various follow-up activities related to wild poliovirus laboratory containment, i.e. development of a maintenance plan after completion of phase 1 - and commended the Government of Japan for responding to recommendations the RCC made at its 14th meeting.

The RCC commended the continued outstanding support given by the Global Specialized Laboratory at NIID to the regional and global poliomyelitis laboratory network.

The RCC appreciated the continued functioning of a large enterovirus laboratory network, which tests large numbers of stool specimens collected from children. The information collected through this network and other poliomyelitis surveillance activities allowed to conclude that Japan had maintained its poliomyelitis-free status.

The RCC noted that, so far, no wild poliovirus importation preparedness plan had been submitted with the annual reports and would appreciate to be briefed about related discussions; while recognizing that there is very low risk of spread following importation due to high population immunity levels. The RCC highlighted though that due to the biannual vaccination schedules, there is the possibility that relatively large proportion of young infants receive poliomyelitis vaccine during the second half of life only.

The RCC noted the ongoing discussions about a possible switch to IPV (Sabin-IPV), depending on the outcome of current clinical trials and recommended close collaboration with the WHO Secretariat for eventual decision-making.

Lao People's Democratic Republic

The RCC commended the Lao People's Democratic Republic for having completed two nationwide rounds of SIAs with OPV (two rounds from December 2008 to April 2009, covering around 67% of children under 5 years, with remaining districts covered in early 2010). The RCC noted that the reported coverage documented in the national report had been 91%, consistent with feedback from several external monitors who found coverage around 80% using small sample surveys.

The RCC was also impressed by the continued activities of the NCC, which met three times in 2009, had already adopted the new suggested terms of reference, continued to act as the Expert Review Group for final case classification, and facilitated and endorsed the new wild poliovirus importation preparedness plan for the country. The RCC concurred with the recommendations made by the NCC for maintaining the country's poliomyelitis-free status and encouraged the NCC to continue its active oversight and advocacy.

The RCC noted that AFP reporting in 2009 had decreased (non-poliomyelitis AFP rate 1.6/100 000 under age 15 for January - November) compared to 2008 (non-poliomyelitis AFP rate of 2.8 per 100 000 under age 15) and some large province like Vientiane Capital and Savannakhet were underreporting. The RCC assumed that, as in other countries, it was likely that the Pandemic H1N1 2009 response activities increasingly dominated the agenda of public health workers and reduced the person-time available for other public health tasks. To keep focus on the poliomyelitis-free status of the country, the RCC encouraged continuation of activities to search for missed cases and sensitize clinicians in low-reporting areas.

- 15 -

Malaysia

The RCC commended the national programme on the continued enterovirus surveillance to supplement AFP surveillance but was concerned that AFP reporting decreased in 2009 compared to 2008; with several large states including Kuala Lumpur, Sabah and Sarawak not achieving the minimum target. The RCC noted that the report did not contain any specific information which action had been taken in such low performing areas and would appreciate an update.

The RCC recommended that the national programme should discuss with WHO the possible need for additional monitoring, such as environmental surveillance in low-performing areas that may bear risk factors such as suboptimal population immunity, high population density and frequent population movements.

The RCC noted that the national wild poliovirus importation contingency plan was under revision and strongly encouraged its finalization (in collaboration with WHO). As Malaysia is already using IPV in eight states and will introduce the vaccine nationwide shortly, the importation preparedness plan will also need to spell out/be updated with details on vaccines used in an eventual poliomyelitis outbreak following importation.

Mongolia

The RCC commended the efforts in Mongolia to strengthen the NCC, which met twice in 2009.

The RCC noted that surveillance levels in 2009 appear lower than in previous years and encouraged continued specific efforts to sensitize clinicians and search for missed cases at hospitals; these activities should best be integrated with other disease surveillance and monitoring/supervision activities, wherever possible.

The RCC commended the updating of the national laboratory list for phase 1 wild poliovirus laboratory containment; this will be a good reference for future requirements.

The RCC noted that an importation preparedness plan had still not been prepared and strongly encouraged its finalization; in collaboration with the WHO Secretariat.

New Zealand

As in previous years, the RCC appreciated the clear report from New Zealand which allowed to conclude that both surveillance and immunization activities remained at levels to assure the maintenance of poliomyelitis-free status.

In the future, the RCC would appreciate if poliomyelitis coverage be presented for (at least) three doses and full calendar years.

The RCC recognized that the wild poliovirus importation preparedness plan was completed and published and welcomed that the designated National IHR Focal Point is also a member of the NCCEP. The RCC considered the plan as comprehensive and adequate but recommended to follow discussions with the WHO Secretariat on the best vaccine of choice responding to evidence, possibly in an area of low IPV coverage/low immunity, of the importation and spread of a wild poliovirus.

- 16 -

Pacific island countries and areas

The RCC appreciated that the recommendations made at its 14th meeting were fully addressed, including the re-establishing the PIC SRCC.

The RCC looked forward to receiving the workplan expected from the SRCC meeting in December 2009, to further strengthen surveillance and immunization activities to keep the PIC poliomyelitis free.

Papua New Guinea

The RCC appreciated the support given during Dr Adams' s visit in June 2009 and noted substantial improvements in surveillance, facilitated by the recruitment of new officers. The RCC urged to assure that all efforts should be made to retain these staff.

The RCC concurred with the assessment of the NCC that AFP surveillance performance must also be monitored at the subnational level and gaps subsequently be filled. This should be part of regular risk assessment (e.g. quarterly desk review), also immunization coverage, population movements and other aspects to be taken into consideration.

The RCC noted that the AFP line list in the report only included the cases meeting the standard case definition and recommended to include in the next annual progress report all AFP cases in the list, even those less likely to have been AFP.

The RCC appreciated the plan to include OPV during upcoming measles campaign and urged all poliomyelitis partners that the required resources would be provided. The RCC strongly encouraged that the reported coverage would be validated by external monitoring during this campaign and requested a summary to be included in the next annual report.

The RCC shared the NCC's concerns about the low immunization coverage, particularly in the National Capital Region with frequent international travel movements. As it is possible that the highest risk groups in Port Moresby area may be least well covered, the RCC requested an update on the current plans to close this immunity gap, in addition to the upcoming SIAs which will only be able to provide one dose of OPV.

Philippines

The RCC commended the Philippines for multiple continuing efforts to maintain its poliomyelitis-free status and noted that meetings of the ERP were used as a forum to convene the NCC, as well as a venue to discuss wider VPD-related activities.

Following its 14th meeting in 2008, the RCC had requested to be informed in more detail about membership, current set-up and meetings of the NCC. The RCC noted, however, that the 2009 report, again, did not provide the necessary details. The RCC was convinced that an active, independent NCC remains very important for the Philippines to assure the necessary advocacy and oversight for maintaining the country's poliomyelitis-free status and urged the Department of Health to revive this important group as soon as possible.

While AFP reporting remained at a satisfactory level, critical gaps remained again in the reporting of AFP at the subnational level. Of even more concern than last year, there were four densely populated regions with non-poliomyelitis AFP rates significantly below the expected 1/100 000; these include the greater Manila area (NCR) and several large regions in Luzon (Regions 1, 5 and half of Region 4). The RCC was concerned that these densely populated adjacent regions, including Manila (the main entry point for international travellers) form a large

- 17 -

joint 'blind' area which is currently unlikely to detect either imported wild poliovirus or emerging circulating vaccine derived poliovirus (cVDPV).

The RCC noted that stool specimen adequacy in 2009 had been below target at around 70%. Unfortunately, the report did not clarify the main reasons causing this problem. Since 86% of AFP cases were reported within 14 days of onset of paralysis, and 97% of cases were investigated within two days of reporting, the problem may be mainly related to problems in specimen transport and the RCC requested further discussion in the next annual report, should the problems persist.

The RCC was satisfied that OPV3 coverage seemed to have further increased, as confirmed by the National Demographic and Health Survey (85%; DHS 2008) and noted that the DHS survey indicated that OPV3 coverage was much more homogenous.

The RCC missed again updates on wild poliovirus laboratory containment and encouraged the Department of Health to create/maintain a permanent focal point or office within/under the department to:

a. maintain and update the national database and national inventory and provide institutional memory;

b. maintain communications with institutions listed on the inventory to keep them informed of progress in poliomyelitis eradication and changes in national laws or regulations relating to poliovirus containment;

c. serve as the technical resource for the Department of Health on poliovirus containment and the focal point for technical liaison with WHO; and

d. prepare the country for Phase 2 and implementation of containment requirements one year after detection of wild poliovirus anywhere in the world.

Republic of Korea

As in previous years, the RCC appreciated the clear report from the Republic of Korea which allowed to conclude that both surveillance and immunization activities remained at levels to assure the maintenance of poliomyelitis-free status.

The RCC appreciated the continued functioning of a large enterovirus laboratory network, which tests large numbers of stool specimens collected from children. The information collected through this network is likely to largely compensate for the relatively low performance of the AFP surveillance system in the country.

The RCC also appreciated the discussion on the national wild poliovirus importation preparedness plan. The RCC considered the plan as comprehensive and adequate but recommended to follow discussions with the WHO Secretariat on the best vaccine of choice responding to evidence, possibly in an area of low IPV coverage/low immunity, of the importation and spread of a wild poliovirus.

Singapore

As in previous years, the RCC appreciated the clear report from Singapore which allowed to conclude that both surveillance and immunization activities remained at levels to assure the maintenance of poliomyelitis-free status.

- 18 -

Viet Nam

The RCC commended the national poliomyelitis programme for maintaining general surveillance and immunization performance at certification standards and acknowledged the continued leadership of the NCC.

The RCC concurred with the conclusions of the NCC how the Ministry of Health and all poliomyelitis partners need to continue prioritizing poliomyelitis activities, particularly AFP surveillance, and provide the necessary financial and human resources.

The RCC appreciated the outline strategy and action plan to maintain the poliomyelitis eradication achievement in Viet Nam from 2005 to 2010 but did not consider it as an active and detailed wild poliovirus importation preparedness plan which is also required. The RCC encouraged the national poliomyelitis programme to collaborate with the WHO Secretariat to ensure that also global, regional and IHR 2005 requirements are addressed.

FIFTEENTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF 14 October 2009 POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION

Phnom Penh, Cambodia 1-2 December 2009 ENGLISH ONLY

TENTATIVE TIMETABLE

Time Tuesday, 1 December 2009

Time Wednesday, 2 December 2009

0800-0830 Registration

0830-0930

1. Opening ceremony

• Welcome remarks by the Responsible Officer • Opening remarks by the Regional Director (to be given by WR, Cambodia) • Welcome remarks by the Government of Cambodia • Self-introduction, Election of Officers (Chair, Vice-Chair, Rapporteur) • Remarks by the Regional Certification Commission (RCC) Chairperson • Administrative announcements; Group photo

0800-1000

7. Review of country reports on maintaining poliomyelitis-free status (contd.) a) Australia b) Brunei Darussalam c) Cambodia d) China e) Hong Kong (China) f) Japan g) Lao People's Democratic Republic h) Macao (China) i) Malaysia j) Mongolia

0930-1000

COFFEE BREAK 1000-1030

COFFEE BREAK

1000-1020

2. Maintaining poliomyelitis-free status in Cambodia: achievements and challenges

1030-1200

Continuation of country report review: k) New Zealand l) Pacific island countries and areas m) Papua New Guinea n) Philippines o) Republic of Korea p) Singapore q) Viet Nam

1020-1050

3. Global overview of the poliomyelitis eradication programme including outcomes of the Advisory Committee for Polio Eradication (ACPE) - November 2009 1200-

1330 LUNCH BREAK

1050-1100

4. Summary of conclusions and recommendations of the 14th RCC Meeting

1330-1500

Discussion on draft conclusions and recommendations

1100-1130

5. Regional overview of maintaining poliomyelitis-free status, including performance of regional poliomyelitis laboratory network

1500-1530 8. Presentation of draft conclusions and recommendations on maintaining

poliomyelitis-free status

1130-1200

6. Reviewing and evaluating the risks for maintaining poliomyelitis-free status in the Western Pacific Region

1530-1600

COFFEE BREAK

1200-1330

LUNCH BREAK 1600-

1630 9. Closing ceremony

1300-1500

Individual review of country reports on maintaining poliomyelitis-free status

1500-1530 COFFEE BREAK

1530-1700

Individual review of country reports on maintaining poliomyelitis-free status (contd.)

AN

NE

X 1

ANNEX 2

W O R L D H E A L T H

ORGANIZATION

ORGANISATION MONDIALE

DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

FIFTEENTH MEETING OF THE REGIONAL WPR/2008/DCC/04/EPI(9)/2009/IB2 COMMISSION FOR THE CERTIFICATION 16 October 2009 OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC REGION Phnom Penh, Cambodia ENGLISH ONLY 1-2 December 2009

INFORMATION BULLETIN NO. 2

PROVISIONAL LIST OF REGIONAL CERTIFICATION COMMISSION (RCC) MEMBERS AND SECRETARIAT

1. REGIONAL CERTIFICATION COMMISSION

Dr Anthony I. Adams Chairman, Regional Certification Commission No. 6/2-4 Chapman Crescent, Avoca Beach New South Wales 2251 Australia Tel: (612) 4382 6516 Fax: n/a E-mail: aarr@netspeed.com.au Dr Nobuhiko Okabe (Vice-Chairman, Regional Certification Commission) Director Infectious Disease Surveillance Center National Institute of Infectious Diseases 1-23-1 Toyama Shinjuku Tokyo 162-8640 Japan Tel: (813) 5285 1111 (Ext 2501) Fax:(813) 5285 1129 E-mail: okabenob@nih.go.jp; okabenob@aol.com

WPR/DCC/04/EPI(9)/2009/IB 2 Page 2

Dr Olen M. Kew Molecular Virology Section MSG-10 Respiratory and Enterovirus Branch National Centre for Infectious Diseases Centers for Disease Control and Prevention 1600 Clifton Road N.E. Atlanta, Georgia 30333 United States of America Tel: (1 404) 639 1341 Fax:(1 404) 639 4011 E-mail: omk1@cdc.gov Professor Nguyen Dinh Huong Health Policy Adviser Viet Nam Red Cross Society 104 C10 Giang Vo. Badinh Ha Noi Viet Nam Tel: (844) 846 3601 / 4376 Fax: (844) 771 6608 E-mail: ngdhuonghn@yahoo.com.vn Dr Aida M. Salonga** Head, Neurology Section Department of Neurosciences University of the Philippines-Philippine General Hospital Taft Avenue Manila Philippines Tel: (632) 521 8450, local 2405 Fax: (632) 525 4996 E-mail: neuromom@yahoo.com.; rms_md@pldtdsl.net Dr Steven Gary Fite Wassilak Medical Epidemiologist Global Immunization Division Centers for Disease Control & Prevention Mailstop MS-E05 Clifton Road Atlanta, Georgia 30333 United States of Amercia Tel: (1 404) 639 1867 Fax: (1 404) 639 8573 E-mail: sgw1@cdc.gov ________ **unable to attend

WPR/2008/DCC/04/EPI(3)/2008/IB/2 page 3

Dr Hui Zhuang Professor, Department of Microbiology Beijing Medical University 38 Xue-Yuan Road Haidian District Beijing 100083 People's Republic of China Tel: (8610) 8280 2221 Fax: (8610) 8280 1617 E-mail: zhuangbmu@126.com

2. SECRETARIAT

WHO Western Pacific Dr Yang Baoping Regional Office Regional Adviser Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) 528 9741 Fax: (632) 526 0279 E-mail: yangb@wpro.who.int

Dr Sigrun Roesel Medical Officer Expanded Programme on Immunization World Health Organization Regional Office for the Western Pacific United Nations Avenue 1000 Manila Philippines Tel: (632) 528 9741 Fax: (632) 526 0279 E-mail: roesels@wpro.who.int

WHO/Cambodia Dr Michel Thieren Acting WHO Representative Programme Management World Health Organization No. 177-179 corner Pasteur (51) and 254 Phnom Penh Cambodia Tel: (855) 23 216610 Fax: (855) 23 216211 E-mail: thierenm@wpro.who.int WHO/Cambodia Dr Pal Niklas Danielsson Medical Officer Diarrhoeal & Acute Respiratory Disease Control World Health Organization No. 177-179 corner Pasteur (51) and 254 Phnom Penh Cambodia Tel: (855) 23 216610 Fax: (855) 23 216211 E-mail: danielssonn@wpro.who.int WHO Headquarters Dr Rudolf Tangermann Geneva Medical Officer Strategy Implementation Oversight and Monitoring World Health Organization CH-1211 Geneva 27 Switzerland Tel: (4122) 791 4358 Fax: (4122) 791 0746 E-mail: tangermannr@who.int

Date of onset of last indigenous wild polio virus case: 19 March 1997AFP cases investigated since: 79,823

Table 1: Classification of AFP cases with onset in 2008 and key surveillance indicators

Confirmed Polio

Polio-compatible

Non-polio (Discarded)

PendingNon-polio AFP

Rate/ 100,000 < 15 yrs

% with 2 Specimens w/n

14 Days of Onset

% Reported Within 14 Days

of Onset

% With Follow-up

% Inadequate Stools With Follow-up

Pending Classification > 90 Days After Onset

Australia 35 41 62 0 0 62 0 1.51 34% 52% 0%* 0% 0 24-Jun-09Brunei Darussalam 4 1 4 0 0 4 0 4.00 75% 75% 100% 100% 0 07-Mar-09Cambodia 94 54 76 0 0 76 0 1.41 83% 89% 100% 100% 0 12-May-09China 4,985 2,794 5,154 0 3 5,151 0 1.84 90% 93% 97% 94% 0 12-Jun-09Hong Kong, SAR, China 14 9 12 0 0 12 0 1.33 92% 92% 100% 100% 0 30-Mar-09Japan 0 171 0 - - - - - - - - - - -Korea, Republic of 26 84 8 0 0 8 0 0.10 100% 88% 100% - 0 02-Feb-09Lao PDR 19 23 58 0 0 58 0 2.52 69% 81% 71% 83% 0 21-Feb-09Macao, SAR, China 0 1 1 0 0 1 0 1.00 100% 100% 100% - 0 07-Jan-09Malaysia 106 95 122 0 0 122 0 1.28 67% 85% 55% 100% 0 06-Mar-09Mongolia 8 8 7 0 0 7 0 0.88 71% 71% 100% 100% 0 18-Feb-09New Zealand 4 9 7 0 0 7 0 0.78 57% 57% 100% 100% 0 19-Mar-09Pacific Island Countries 13 10 10 0 0 10 0 1.00 40% 10% 100% 100% 0 15-Jun-09Papua New Guinea 25 26 12 0 2 10 0 0.46 17% 92% 100% 100% 0 18-Mar-09Philippines 509 335 494 0 1 493 0 1.47 73% 87% 92% 99% 0 22-Apr-09Singapore 12 7 8 0 0 8 0 1.14 75% 75% 100% 100% 0 24-Apr-09Vietnam 391 330 384 0 0 384 0 1.16 94% 85% 99% 100% 0 13-Apr-09Western Pacific Region 6,245 3,998 6,419 0 6 6,413 0 1.61 88% 91% 95% 91% 0

* Follow-up is not required by the Polio Expert Committee if a case can be classified as non-polio AFP on the information available.

More Than 12 Years Without Indigenous Wild Polio Virus!

Latest Report Date

Reported AFP 2007

Indicators

Poliomyelitis Surveillance - Report for Polio Week 52, ending December 28, 2008(as of 04 Aug 2009)

ClassificationExpected AFP

2008Reported AFP

2008

0%

20%

40%

60%

80%

100%

CAM CHN LAO MAA MOG PNG PHL VTN

adequate stools (2006)

adequate stools (2007)

adequate stools (2008)0

0.5

1

1.5

2

2.5

3

CAM CHN LAO MAA MOG PNG PHL VTN

non-polio AFP rate (2006)

non-polio AFP rate (2007)

non-polio AFP rate (2008) AN

NE

X 3

Table 2: Laboratory investigation of AFP cases with onset in 2008

P1 P2 P3 Polio Mix Polio/NPEV

Australia VIDRL* 44 0 0 0 0 0 0 10% 100% 03-Feb-09Brunei Darussalam VIDRL* 4 0 0 0 0 0 0 0% 100% 05-Jan-09Cambodia NIID 76 0 0 0 0 1 0 29% 100% 12-Feb-09China, Anhui Prov. Lab 230 0 2 3 1 1 0 7% 93% 12-Jun-09China, Beijing Prov. Lab 45 1 0 0 0 0 0 13% 100% 12-Jun-09China, Chongqing Prov. Lab 75 0 2 0 0 0 0 6% 97% 12-Jun-09China, Fujian Prov. Lab 110 0 0 1 1 0 0 11% 97% 12-Jun-09China, Gansu Prov. Lab 115 0 1 2 0 0 0 3% 99% 12-Jun-09China, Guangdong Prov. Lab 294 0 3 1 5 1 0 11% 89% 12-Jun-09China, Guangxi Prov. Lab 297 4 0 1 1 0 0 12% 99% 12-Jun-09China, Guizhou Prov. Lab 196 1 5 3 2 0 0 10% 98% 12-Jun-09China, Hainan Prov. Lab 39 2 0 0 0 0 0 15% 100% 12-Jun-09China, Hebei Prov. Lab 396 2 5 4 10 3 0 14% 97% 12-Jun-09China, Heilongjiang Prov. Lab 81 0 0 0 2 0 0 5% 99% 12-Jun-09China, Henan Prov. Lab 494 3 2 4 6 0 0 10% 90% 12-Jun-09China, Hubei Prov. Lab 237 0 2 1 0 0 0 11% 87% 12-Jun-09China, Hunan Prov. Lab 258 0 3 0 1 0 0 15% 98% 12-Jun-09China, Jiangsu Prov. Lab 269 0 2 2 1 0 0 6% 99% 12-Jun-09China, Jiangxi Prov. Lab 178 1 6 5 1 0 0 12% 97% 12-Jun-09China, Jilin Prov. Lab 58 0 0 0 1 1 0 13% 100% 12-Jun-09China, Liaoning Prov. Lab 97 0 1 0 1 0 0 10% 87% 12-Jun-09China, Neimongol Prov. Lab 67 0 0 0 0 0 0 5% 97% 12-Jun-09China, Ningxia Prov. Lab 30 0 1 0 0 0 0 7% 98% 12-Jun-09China, Qinghai Prov. Lab 38 0 0 0 0 0 0 3% 97% 12-Jun-09China, Shaanxi Prov. Lab 102 0 3 2 1 2 0 12% 98% 12-Jun-09China, Shandong Prov. Lab 346 2 15 8 5 2 0 13% 90% 12-Jun-09China, Shanghai Prov. Lab 28 0 2 0 1 0 0 4% 100% 12-Jun-09China, Shanxi Prov. Lab 207 0 3 2 1 1 0 10% 96% 12-Jun-09China, Sichuan Prov. Lab 326 0 2 0 1 1 0 9% 97% 12-Jun-09China, Tianjin Prov. Lab 24 0 0 0 0 0 0 17% 98% 12-Jun-09China, Tibet Prov. Lab 9 0 0 0 0 0 0 0% 22% 12-Jun-09China, Xinjiang Prov. Lab 61 0 1 0 0 0 0 3% 99% 12-Jun-09China, Yunnan Prov. Lab 216 1 6 2 1 1 0 8% 98% 12-Jun-09China, Zhejiang Prov. Lab 148 2 2 2 0 0 0 6% 87% 12-Jun-09Hong Kong2, SAR, China PHLC 13 0 0 0 0 0 0 8% 96% 07-Feb-09Korea, Rep. Of NIH 8 0 0 0 0 0 0 0% 88% 02-Feb-09Lao PDR NIID 57 0 1 0 0 0 0 26% 100% 31-Jul-09Malaysia IMR, KL 127 1 0 0 2 0 0 0% 98% 10-Apr-09Mongolia PHI 7 1 0 0 0 0 0 0% 100% 02-Mar-09New Zealand IESR 4 0 0 0 0 0 0 25% 100% 02-Feb-09Pacific Island Countries VIDRL* 8 0 0 0 0 0 0 7% 100% 03-Feb-09Papua New Guinea VIDRL* 9 0 0 0 0 0 0 0% 100% 02-Apr-09Philippines RITM 506 0 0 0 3 0 0 5% 90% 22-Apr-09Singapore SGH 7 0 0 0 0 0 0 8% 100% 06-Feb-09Vietnam, North NIHE 192 0 0 1 1 0 0 11% 98% 16-Mar-09Vietnam, South PI 195 0 0 1 0 0 0 13% 100% 04-May-09Total 6,328 21 70 45 49 14 0 10% 95%

* Specimen test reports are under the guidelines of the June 2006 test algorithm.

1 Acronyms:

VIDRL - Victorian Infectious Diseases Reference Laboratory, Australia IMR, KL - Institute of Medical Research, Kuala Lumpur PHI - Public Health Institute, Mongolia

NIID - National Institute of Infectious Diseases, Japan IMR, PNG - Institute of Medical Research, Papua New Guinea NIH - National Institute of Health, Seoul

PHLC - Public Health Laboratory Centre, Hong Kong IESR - Institute of Environmental Science and Research, New Zealand NIHE - National Institute of Hygiene and Epidemiology, Hanoi

SGH - Singapore General Hospital RITM - Research Institute for Tropical Medicine, Philippines PI - Pasteur Institute, Ho Chi Minh2 Includes cases from Macao, SAR, China

CountryNational

Lab1

AFP Cases with

Specimens

AFP Cases Positive For:Pending

% Positive for NPEV

% Results Reported

w/n 28 Days

Latest Report Date

Table 3: Intratypic differentiation of polio isolates from AFP cases with onset in 2008

P1S P1W P2S P2W P3S P3W Pending3 Discordant4 VDPV Not VDPV Pending

China CCDC 204 53 0 119 0 90 0 0 0 - - - 83% 38%Hong Kong, SAR, China PHLC 0 - - - - - - - - - - - - -New Zealand IESR 0 - - - - - - - - - - - - -Singapore SGH 0 - - - - - - - - - - - - -Australia VIDRL 0 - - - - - - - - - - - - -Malaysia VIDRL 3 1 0 2 0 3 0 0 0 - - - 100% 75%Pacific Island Countries VIDRL 0 - - - - - - - - - - - - -Papua New Guinea VIDRL 0 - - - - - - - - - - - - -Philippines VIDRL 3 3 0 7 0 6 0 0 0 - - - 100% 100%Japan NIID 0 - - - - - - - - - - - - -Cambodia NIID 1 0 0 1 0 0 0 0 0 - - - 100% 100%Korea, Rep. Of NIID 0 - - - - - - - - - - - - -Lao PDR NIID 1 0 0 2 0 0 0 0 0 - - - 100% 100%Mongolia NIID 1 1 0 0 0 0 0 0 0 - - - 100% 0%Vietnam NIID 3 2 0 2 0 4 0 0 0 - - - 100% 33%Total 216 60 0 133 0 103 0 0 0 0 0 0 85% 40%

Table 4: Laboratory investigation of polio isolates from non-AFP cases in 2008 5

P1S P1W P2S P2W P3S P3W Pending Discordant VDPV Pending

China CCDC 58 25 0 11 0 22 0 0 0 - -Hong Kong, SAR, China* PHLC 5 1 0 4 0 0 0 0 0 - -New Zealand IESR 0 - - - - - - - - - -Singapore SGH 3 0 0 0 0 3 0 0 0 - -Australia VIDRL 0 - - - - - - - - - -Malaysia VIDRL 16 10 0 5 0 5 0 0 0 - -Pacific Island Countries VIDRL 0 - - - - - - - - - -Papua New Guinea VIDRL 0 - - - - - - - - - -Philippines VIDRL 0 - - - - - - - - - -Cambodia NIID 0 - - - - - - - - - -Japan NIID 0 - - - - - - - - - -Korea, Rep. Of NIID 0 - - - - - - - - - -Lao PDR NIID 0 - - - - - - - - - -Mongolia NIID 0 - - - - - - - - - -Vietnam NIID 1 1 0 0 0 0 0 0 0 - -Total 83 37 0 20 0 30 0 0 0 0 0

* Includes isolates from Macao, SAR, China.

1 Acronyms:

2 ITD Results:

4 Antigenic ITD <> Molecular ITD for all serotypes. Cases with discordant ITD results

CCDC - Chinese Center for Disease Control and Prevention S - Sabin; W - Wild may be counted more than once under "ITD results", ie. as "discordant" and "S" or "W",

VIDRL - Victorian Infectious Diseases Reference Laboratory, Australia depending on the results of sequencing.

NIID - National Institute of Infectious Diseases, Japan 3 Pending ITD = Pending Antigenic ITD and/or Pending Molecular ITD

PHLC - Public Health Laboratory Centre, Hong Kong Total Pending Cases = Pending ITD + Pending Sequencing5

Based on year of collection of sample, if available. Otherwise, based on year of receipt

SGH - Singapore General Hospital at reference laboratory.

SequencingCountry

Regional Reference

Lab

Polio Isolates

ITD Results

CountryRegional

Reference Lab1

AFP Cases w/ Polio Isolates

ITD Results w/n 60 Days of

Onset

ITD Results2 ITD Results w/n 14 Days of

Receipt

Sequencing

Table 1: Classification of AFP cases with onset in 2009 and key surveillance indicators2008

Confirmed Polio

Polio-compatible

Non-polio (Discarded)

Pending

Non-polio AFP rate*

per 100,000 < 15 yrs

% cases with 2 specimens

within 14 days of onset

% reported within 14

days of onset

% with follow-up

% inadequate stools with follow-up

Pending classification > 90 days after onset

Australia 62 41 34 0 0 34 0 0.96 41% 79% 0%** 0% 0 22-Oct-09

Brunei Darussalam 4 1 0 - - - - - - - - - - 13-Oct-09

Cambodia 76 54 57 0 0 44 0 1.22 81% 93% 77% 55% 0 28-Oct-09

China 5,154 2,794 3,472 0 3 3,281 188 1.44 90% 94% 73% 69% 158 26-Oct-09

Hong Kong (China) 12 9 8 0 0 6 2 1.03 63% 75% 100% 100% 2 28-Oct-09

Japan 0 171 0 - - - - - - - - - - -

Lao PDR 58 23 34 0 0 27 7 1.71 74% 82% 41% 78% 3 15-Oct-09

Macao (China) 1 1 1 0 0 1 0 1.16 100% 100% 100% - 0 21-Oct-09

Malaysia 122 95 63 0 0 55 8 0.77 73% 94% 22% 76% 8 26-Oct-09

Mongolia 7 8 4 0 0 4 0 0.58 100% 100% 100% - 0 28-Oct-09

New Zealand 7 9 7 0 0 6 1 0.90 43% 43% 29% 25% 1 28-Aug-09

Pacific island countries 10 10 15 0 0 8 7 1.73 60% 53% 80% 67% 5 27-Oct-09

Papua New Guinea 12 26 31 0 0 31 0 1.38 39% 65% 16% 26% 0 05-Nov-09

Philippines 494 335 460 0 0 242 218 1.59 65% 80% 38% 29% 88 02-Nov-09

Republic of Korea 8 82 13 0 0 13 0 0.18 100% 54% 100% - 0 21-Oct-09

Singapore 8 7 4 0 0 4 0 0.66 100% 100% 100% - 0 29-Sep-09

Viet Nam 384 330 240 0 0 210 30 0.84 95% 85% 68% 82% 6 14-Oct-09

Western Pacific Region 6,419 3,996 4,443 0 3 3,966 461 1.28 86% 91% 67% 55% 271* AFP rate is annualized based on current week, and thus, may be underestimated depending on country's data submission.

** Follow-up is not required by the Polio Expert Committee if a case can be classified as non-polio AFP on the information available.

Reported number of

cases

Polio BulletinWeek 45, 2009, ending 08 November 2009 (as of 09 Nov 2009)

Classification Indicators

Latest report date

2009

Reported number of

cases

Expected number of

cases

0.0

0.5

1.0

1.5

2.0

2.5

3.0

CAM CHN LAO MAA MOG PNG PHL VTN

Non

-pol

io A

FP r

ate

2007 2008 2009

0%

20%

40%

60%

80%

100%

CAM CHN LAO MAA MOG PNG PHL VTN

% c

ases

with

ade

quat

e sp

ecim

ens

2007 2008 2009

Chart 1. Non-polio AFP rate per country, 2007-2009 Chart 2. Percent cases with adequate specimens, 2007-2009

Table 2. Laboratory investigation of AFP cases with onset in 2009

P1 P2 P3 Polio Mix Polio/NPEV NPEV only Negative ≤ 28 days > 28 days L20B+L20B+ +NPEV

NPEV only Negative ≤ 14 days > 14 days

Australia VIDRL 25 - - - - - - - - - - - 25 0 0 1 23 1 0 87% 3% 02-Nov-09Brunei Darussalam VIDRL 0 - - - - - - - - - - - - - - - - - - - - 02-Nov-09Cambodia NIID 52 52 0 0 0 0 0 20 32 0 0 96% - - - - - - - - 37% 06-Nov-09China, Anhui Prov. Lab 139 139 0 2 0 0 0 21 101 0 14 95% - - - - - - - - 12% 26-Oct-09China, Beijing Prov. Lab 21 21 0 0 0 0 0 2 17 0 2 100% - - - - - - - - 8% 26-Oct-09China, Chongqing Prov. Lab 54 54 0 2 1 0 0 6 41 1 1 97% - - - - - - - - 7% 26-Oct-09China, Fujian Prov. Lab 71 71 0 0 0 2 0 8 57 1 2 99% - - - - - - - - 10% 26-Oct-09China, Gansu Prov. Lab 87 87 0 0 0 3 0 2 73 1 7 97% - - - - - - - - 1% 26-Oct-09China, Guangdong Prov. Lab 178 178 0 2 2 5 1 33 127 0 6 89% - - - - - - - - 18% 26-Oct-09China, Guangxi Prov. Lab 215 215 1 2 2 0 0 26 167 0 14 93% - - - - - - - - 11% 26-Oct-09China, Guizhou Prov. Lab 170 170 0 2 3 1 0 13 144 2 5 100% - - - - - - - - 6% 26-Oct-09China, Hainan Prov. Lab 20 20 0 0 0 1 0 2 15 0 2 100% - - - - - - - - 11% 26-Oct-09China, Hebei Prov. Lab 264 264 3 1 5 4 0 34 191 2 21 98% - - - - - - - - 12% 26-Oct-09China, Heilongjiang Prov. Lab 48 48 0 0 1 1 0 5 40 0 1 97% - - - - - - - - 7% 26-Oct-09China, Henan Prov. Lab 363 363 1 3 0 2 1 65 272 0 12 96% - - - - - - - - 13% 26-Oct-09China, Hubei Prov. Lab 144 144 1 0 1 1 0 13 124 0 4 94% - - - - - - - - 9% 26-Oct-09China, Hunan Prov. Lab 183 183 1 4 1 0 0 31 130 1 13 98% - - - - - - - - 15% 26-Oct-09China, Jiangsu Prov. Lab 184 184 0 1 3 0 0 12 147 0 21 98% - - - - - - - - 7% 26-Oct-09China, Jiangxi Prov. Lab 146 146 1 1 2 2 0 25 107 0 8 96% - - - - - - - - 14% 26-Oct-09China, Jilin Prov. Lab 41 41 1 0 0 0 0 1 31 0 8 91% - - - - - - - - 3% 26-Oct-09China, Liaoning Prov. Lab 90 90 0 1 1 0 0 17 65 0 4 100% - - - - - - - - 19% 26-Oct-09China, Neimongol Prov. Lab 38 38 0 0 0 0 0 1 34 0 1 99% - - - - - - - - 3% 26-Oct-09China, Ningxia Prov. Lab 17 17 0 2 0 0 0 1 11 1 2 93% - - - - - - - - 10% 26-Oct-09China, Qinghai Prov. Lab 28 28 0 0 0 0 0 0 26 0 1 94% - - - - - - - - 0% 26-Oct-09China, Shaanxi Prov. Lab 83 83 0 1 0 0 0 5 66 1 8 94% - - - - - - - - 6% 26-Oct-09China, Shandong Prov. Lab 152 152 2 4 0 3 0 3 122 0 18 97% - - - - - - - - 1% 26-Oct-09China, Shanghai Prov. Lab 21 21 0 0 0 0 0 2 19 0 0 100% - - - - - - - - 10% 26-Oct-09China, Shanxi Prov. Lab 155 155 0 0 1 0 0 26 118 0 10 99% - - - - - - - - 16% 26-Oct-09China, Sichuan Prov. Lab 192 192 0 4 1 0 0 20 145 0 20 94% - - - - - - - - 10% 26-Oct-09China, Tianjin Prov. Lab 18 18 0 0 0 0 0 1 17 0 0 100% - - - - - - - - 6% 26-Oct-09China, Tibet Prov. Lab 1 1 0 0 0 0 0 0 1 0 0 0% - - - - - - - - 0% 26-Oct-09China, Xinjiang Prov. Lab 26 26 0 0 1 4 0 0 14 0 6 100% - - - - - - - - 0% 26-Oct-09China, Yunnan Prov. Lab 174 174 1 1 0 0 0 9 153 2 6 99% - - - - - - - - 5% 26-Oct-09China, Zhejiang Prov. Lab 94 94 0 1 0 0 0 8 79 0 6 98% - - - - - - - - 7% 26-Oct-09Hong Kong (China) PHLC 7 - - - - - - - - - - - 7 0 0 0 7 0 0 85% 0% 04-Nov-09Lao PDR NIID 34 34 0 0 0 1 0 5 28 0 0 94% - - - - - - - - 15% 02-Nov-09Macao (China) PHLC 1 - - - - - - - - - - - 1 0 0 0 1 0 0 50% 0% 11-May-09Malaysia IMR, KL 21 - - - - - - - - - - - 21 0 0 0 22 0 0 98% 0% 20-May-09Mongolia PHI 6 6 0 0 0 0 0 2 4 0 0 100% - - - - - - - - 25% 27-Oct-09New Zealand IESR 3 - - - - - - - - - - - 3 0 0 0 3 0 0 100% 0% 03-Jul-09Pacific island countries VIDRL 18 - - - - - - - - - - - 18 0 0 4 14 0 0 82% 18% 02-Nov-09Papua New Guinea VIDRL 36 - - - - - - - - - - - 36 0 0 5 24 0 7 37% 20% 05-Oct-09Philippines RITM 431 - - - - - - - - - - - 431 5 0 33 370 0 27 90% 7% 30-Oct-09Republic of Korea NIH 13 13 0 0 0 0 0 0 13 0 0 100% - - - - - - - - 0% 21-Oct-09Singapore SGH 4 - - - - - - - - - - - 4 0 0 0 4 0 0 100% 0% 22-Sep-09Viet Nam, North NIHE 126 126 0 0 1 0 0 17 107 4 0 100% - - - - - - - - 12% 05-Nov-09Viet Nam, South PI 153 153 0 1 0 0 0 24 113 15 0 100% - - - - - - - - 16% 02-Nov-09Total 4,347 3,801 12 35 26 30 2 460 2,951 31 223 97% 546 5 0 43 468 1 34 88% 10%

% positive for NPEV

Lab resultsCountry

National reference lab

Total no. of AFP cases

with specimens

Processed by old algorithm

AFP cases with

specimens

Latest report date

Polio BulletinWeek 45, 2009, ending 08 November 2009 (as of 09 Nov 2009)

Processed by new algorithm

AFP cases with

specimens

Pending results % results reported within 14

days

Lab results% results reported within 28

days

Pending results

Acronyms:IESR - Institute of Environmental Research, New ZealandIMR, KL - Institute of Medical Research, Kuala Lumpur, MalaysiaIMR, PNG - Institute of Medical Research, Papua New Guinea

NIH - National Institute of Health, Seoul, KoreaNIHE - National Institute of Hygiene and Epidemiology, Hanoi, Viet NamNIID - National Institute of Infectious Diseases, Japan

PHI - Public Health Institute, MongoliaPHLC - Public Health Laboratory Center, Hong Kong (China)PI - Pasteur Institute, Ho Chi Minh, Viet Nam

RITM - Research Institute for Tropical Medicine, PhilippinesSGH - Singapore General Hospital, SingaporeVIDRL - Victorian Infectious Diseases Reference Laboratory, Australia

Table 3. Intratypic differentiation of polio isolates from AFP cases with onset in 2009

P1S P1W P2S P2W P3S P3W Pending3 VDPV Not VDPV Pending

China CCDC 119 29 0 66 0 58 0 3 1 1 0 0 93% 40% 79%Hong Kong (China) PHLC 0 - - - - - - - - - - - - - -New Zealand IESR 0 - - - - - - - - - - - - - -Singapore SGH 0 - - - - - - - - - - - - - -Australia VIDRL 0 - - - - - - - - - - - - - -Malaysia VIDRL 0 - - - - - - - - - - - - - -Pacific island countries VIDRL 0 - - - - - - - - - - - - - -Papua New Guinea VIDRL 0 - - - - - - - - - - - - - -Philippines VIDRL 5 1 0 1 0 3 0 0 0 - - - 100% 78% 78%Japan NIID 0 - - - - - - - - - - - - - -Cambodia NIID 0 - - - - - - - - - - - - - -Lao PDR NIID 1 1 0 0 0 1 0 0 0 - - - 100% 0% 0%Mongolia NIID 0 - - - - - - - - - - - - - -Republic of Korea NIID 0 - - - - - - - - - - - - - -Viet Nam NIID 1 0 0 0 0 2 0 0 0 - - - 100% 0% 0%Total 126 31 0 67 0 64 0 3 1 1 0 0 93% 42% 77%

Table 4. Laboratory investigation of polio isolates from non-AFP cases in 20095

P1S P1W P2S P2W P3S P3W Pending Discordant VDPV Pending

China CCDC 41 15 0 10 0 16 0 0 0 - -Hong Kong (China) PHLC 2 2 0 0 0 0 0 0 0 - -New Zealand IESR 0 - - - - - - - - - -Singapore SGH 0 - - - - - - - - - -Australia VIDRL 0 - - - - - - - - - -Malaysia VIDRL 9 4 0 1 0 4 0 0 0 - -Pacific island countries VIDRL 0 - - - - - - - - - -Papua New Guinea VIDRL 0 - - - - - - - - - -Philippines VIDRL 0 - - - - - - - - - -Japan NIID 0 - - - - - - - - - -Cambodia NIID 0 - - - - - - - - - -Lao PDR NIID 0 - - - - - - - - - -Mongolia NIID 0 - - - - - - - - - -Republic of Korea NIID 0 - - - - - - - - - -Viet Nam NIID 0 - - - - - - - - - -Total 52 21 0 11 0 20 0 0 0 0 0

% ITD results within 45 days

of onset

% ITD results within 60 days

of onset

Polio BulletinWeek 45, 2009, ending 08 November 2009 (as of 09 Nov 2009)

% ITD results within 7 days

of receiptCountry

Regional reference

lab1

Discordant4

ITD

ITD results2AFP cases with polio isolates

Sequencing results

Sequencing resultsCountry

Regional reference lab

Polio isolatesITD results

1 Acronyms:CCDC - Chinese Center for Disease Control and Prevention, ChinaNIID - National Institute of Infectious Diseases, JapanPHLC - Public Health Laboratory Center, Hong Kong (China)SGH - Singapore General Hospital, SingaporeVIDRL - Victorian Infectious Diseases Reference Laboratory, Australia

2 ITD Results:S - Sabin; W - Wild

3 Pending ITD = Pending antigenic ITD and/or pending molecular ITD; Total pending cases = Pending ITD + pending sequencing

4 Antigenic ITD <> molecular ITD for all serotypes. Cases with discordant ITD results may be counted more than once under "ITD results", ie. as "discordant" and "S" or "W", depending on the results of sequencing.

5 Based on year of collection of sample, if available. Otherwise, based on year of receipt at reference laboratory.

Poliomyelitis vaccine immunization schedules in the Pacific island countries and areas, 2009

# doses OPV IPV DTaPIPV dTapIPV DTaPHepIPV DTaPHibIPV DTaPHep HibIPV

American Samoa 4 2, 4, 6m; 4y

Cook Islands 3 6w, 3, 5m

Fiji 4 B, 6, 10, 14w

French Polynesia 5 11y 2, 3, 4, 16m

Guam 5 2, 4, 6, 12-18m, 4-6y 2, 4, 6, 15-18m

Kiribati 3 6, 10, 14w

Mariannas 4 6w, 4, 6m, 4y 6w; 6m

Marshall Islands 4 2, 4, 6m, 4-6y

Micronesia 5 2, 4, 6, 12m; 4y

Nauru 5 6, 10, 14w, 18m, 4y

New Caledonia 7 6, 16y 11y 2, 3, 4, 16m

Niue 4 6w, 3, 5m, 4y

Palau 4 4-6y 6w, 4, 6m

Samoa 3 6, 10, 14w

Solomon Islands 4 6, 10, 14w, 5y

Tokelau 3 6, 10, 14w

Tonga 3 6, 10, 14w

Tuvalu 3 6, 10, 14w

Vanuatu 5 6, 10, 14w; 6, 12y

Wallis and Futuna 6 2, 3, 4, 16m, 6, 11y

(data source: JRF)

AN

NE

X 4