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IMMUNIZE AND PROTECT YOUR FAMILY Volume XXVIII, Number 6 December 2006 I N THIS ISSUE: PAN AMERICAN HEALTH ORGANIZATION 1 Ad-hoc Meeting of Experts for HPV Surveillance 1 SIGN and TechNet 21 Meetings 4 Presidential Leadership Award 5 Measles and Rubella Lab Network 6 The Paramaribo Declaration 7 Reported Cases of Selected Disease, 2004-2005 8 Recent Advances in Immunization Ad hoc Meeting of Experts on Surveillance of HPV-Associated Disease in the Americas In October 2006, the Immunization Unit of the Pan American Health Organization (PAHO) convened a two day Ad Hoc Meeting of Experts to discuss and advise on the most appropriate and effective strategies for the conduct of human papillomavirus (HPV) surveillance in Latin America and the Caribbean. The meeting’s purpose was to determine how HPV surveillance could be operationalized and what supporting information and laboratory systems would be required. Four PAHO Member States, Brazil, Chile, Costa Rica, and Mexico were represented at this meeting. Experts from McGill University in Canada, the Ludwig Institute in Brazil, the National Cancer Institute and the Centers for Disease Control and Prevention (CDC) in the United States, and the World Health Organization in Switzerland also participated. This abridged report focuses on the salient points emerging from the meeting. Dr. Carlos Castillo-Solórzano, Acting Chief, Immunization Unit, opened the meeting and Dr. Jon Andrus, Lead Technical Advisor on Immunization, chaired the proceedings. In his opening address, Dr. Castillo-Solórzano briefly summarized the key facts in relation to the epidemiology of cervical cancer in Latin America and the Caribbean and reviewed the important elements of PAHO’s technical cooperation activities with its Member States in relation to new vaccine introduction. He noted that HPV vaccine introduction presents multiple and unique challenges when compared with other vaccines currently used. Some of these included the following: (1) HPV vaccines are being targeted to non-traditional EPI age groups; (2) proposed HPV surveillance systems cannot be based on the observation of early clinical signs and symptoms, such as a fever and rash in the case of measles; (3) the vaccine impact will not be immediately observable; and (4) the need for consensus- building across a very wide spectrum of stakeholders. A Snapshot of Country Perspectives During this meeting, the CDC representative gave an outline of the developing US perspectives on HPV surveillance including its purposes, the endpoints being considered for monitoring vaccine impact, some identification of potential information sources and the associated challenges. The representatives from Brazil, Chile, Costa Rica, and Mexico shared some of their perspectives regarding HPV vaccine introduction. The Mexican representative indicated that they had already initiated internal discussions around the issue of HPV vaccine and had noted that vaccine cost would be a key determinant of their introduction plan. She emphasized that because reducing inequities in health was an important goal for Mexico, direct vaccination of most vulnerable groups with lowest human development index was being given priority consideration. It was envisaged that HPV vaccination could be initially introduced in the 50 poorest municipalities for adolescents up to age 17 years, with subsequent expansion to other poor regions. She also noted that the treatment and follow-up of cytologically screened positive women in the Social Security sector had become more focused as these services were now guaranteed free of charge. The Costa Rican representative indicated that the national cervical cancer screening program in that country was functioning effectively and that it had resulted in a reduction in the incidence and mortality of invasive See MEETINGS page 2 SIGN and TechNet21 Meetings The annual SIGN and the 9th TechNet21 meetings were held back to back in October 2006 in Mexico. Both events were organized by the World Health Organization, which serves as the global secretariat for both networks, and co-hosted by the Ministry of Health of Mexico and PAHO. With the assistance of Mexico’s National Center for Excellence in Health Technology (CENETEC), both meetings were webcasted for the first time. Partner agencies such as UNICEF and PATH also provided key assistance. Both meetings provided opportunities for the exchange of ideas between the public and private sectors. It also facilitated a closer collaboration toward the common goal of ensuring the quality, safety, and efficiency of new technologies related to immunization. SIGN Meeting The SIGN meeting took place from 24-26 October with participation from more than 51 countries. The objectives of the meeting were to promote injection safety, the protection of health workers, the rational use of injections, improved waste disposal, and the introduction of new technologies. Representatives from Bolivia, Brazil, Colombia, Honduras, and Mexico were present at the meeting. Bolivia presented its experience with See HPV SURVEILLANCE page 3
Transcript of SIGN and TechNet21 Ad hoc Meeting of Experts on ... · IMMUNIZE AND PROTECT YOUR FAMILY Volume...
IMMUNIZE AND PROTECT YOUR FAMILY
Volume XXVIII, Number 6 December 2006
In thIs Issue:
PAN�AMERICAN�HEALTH�ORGANIZATION
1 Ad-hoc MeetingofExpertsforHPVSurveillance
1 SIGNandTechNet21Meetings4 PresidentialLeadershipAward5 MeaslesandRubellaLabNetwork6 TheParamariboDeclaration7 ReportedCasesofSelected
Disease,2004-20058 Recent Advances in Immunization
Ad hoc Meeting of Experts on Surveillance of HPV-Associated Disease in the AmericasInOctober2006,theImmunizationUnitofthePanAmericanHealthOrganization(PAHO)convenedatwodayAd Hoc MeetingofExpertstodiscussandadviseonthemostappropriateandeffectivestrategiesfortheconductofhumanpapillomavirus(HPV)surveillanceinLatinAmericaandtheCaribbean.Themeeting’spurposewastodeterminehowHPVsurveillancecouldbeoperationalizedandwhatsupportinginformationandlaboratorysystemswouldberequired.
FourPAHOMemberStates,Brazil,Chile,CostaRica,andMexicowererepresentedatthismeeting.ExpertsfromMcGillUniversityinCanada,theLudwigInstituteinBrazil,theNationalCancerInstituteandtheCentersforDiseaseControlandPrevention(CDC)intheUnitedStates,andtheWorldHealthOrganizationinSwitzerlandalsoparticipated.Thisabridgedreportfocusesonthesalientpointsemergingfromthemeeting.
Dr.CarlosCastillo-Solórzano,ActingChief,ImmunizationUnit,openedthemeetingandDr.JonAndrus,LeadTechnicalAdvisoronImmunization,chairedtheproceedings.Inhisopeningaddress,Dr.Castillo-SolórzanobrieflysummarizedthekeyfactsinrelationtotheepidemiologyofcervicalcancerinLatinAmericaandtheCaribbeanandreviewedtheimportantelementsofPAHO’stechnicalcooperationactivitieswithitsMemberStatesinrelationtonewvaccineintroduction.HenotedthatHPVvaccineintroductionpresentsmultipleanduniquechallengeswhencomparedwithothervaccinescurrentlyused.Someoftheseincludedthefollowing:(1)HPVvaccinesarebeingtargetedtonon-traditionalEPIagegroups;(2)proposedHPVsurveillancesystemscannotbebasedontheobservationofearlyclinicalsignsandsymptoms,suchasafeverandrashinthecaseofmeasles;(3)thevaccineimpactwillnotbeimmediatelyobservable;and(4)theneedforconsensus-buildingacrossaverywidespectrumofstakeholders.
A Snapshot of Country PerspectivesDuring this meeting, the CDC representative gave an outline of the developing US perspectives on HPVsurveillance including its purposes, the endpoints being considered for monitoring vaccine impact, someidentificationofpotentialinformationsourcesandtheassociatedchallenges.TherepresentativesfromBrazil,Chile,CostaRica,andMexicosharedsomeof theirperspectives regardingHPVvaccine introduction.TheMexican representative indicated that they had already initiated internal discussions around the issue ofHPVvaccineandhadnoted thatvaccinecostwouldbeakeydeterminantof their introductionplan.SheemphasizedthatbecausereducinginequitiesinhealthwasanimportantgoalforMexico,directvaccinationofmostvulnerablegroupswithlowesthumandevelopmentindexwasbeinggivenpriorityconsideration.ItwasenvisagedthatHPVvaccinationcouldbeinitiallyintroducedinthe50poorestmunicipalitiesforadolescentsuptoage17years,withsubsequentexpansiontootherpoorregions.Shealsonotedthatthetreatmentandfollow-upofcytologicallyscreenedpositivewomenintheSocialSecuritysectorhadbecomemorefocusedastheseserviceswerenowguaranteedfreeofcharge.
TheCostaRicanrepresentativeindicatedthatthenationalcervicalcancerscreeningprograminthatcountrywasfunctioningeffectivelyandthatithadresultedinareductionintheincidenceandmortalityofinvasive
See MEETINGS page 2
SIGN and TechNet21 Meetings
The annual SIGN and the 9thTechNet21meetingswereheldbackto back in October 2006 in Mexico.Both events were organized by theWorld Health Organization, whichserves as the global secretariat forboth networks, and co-hosted bytheMinistryofHealthofMexicoandPAHO.WiththeassistanceofMexico’sNational Center for Excellence inHealthTechnology (CENETEC),bothmeetings were webcasted for thefirst time. Partner agencies such asUNICEFandPATHalsoprovidedkeyassistance.
Bothmeetingsprovidedopportunitiesfor the exchange of ideas betweenthe public and private sectors. Italsofacilitatedaclosercollaborationtowardthecommongoalofensuringthe quality, safety, and efficiencyof new technologies related toimmunization.
SIGN MeetingThe SIGN meeting took place from24-26 October with participationfrom more than 51 countries. Theobjectives of the meeting wereto promote injection safety, theprotection of health workers, therational use of injections, improvedwastedisposal,andtheintroductionofnewtechnologies.
Representatives from Bolivia, Brazil,Colombia, Honduras, and Mexicowerepresentatthemeeting.Boliviapresented its experience with
See HPV SURVEILLANCE page 3
2 IMMUNIZATION NEWSLETTER Volume XXVIII, Number 6 December 2006 PAN AMERICAN HEALTH ORGANIZATION
Technical Network for Strengthening Immunization Services (TechNet21)
TheTechnicalNetworkforLogisticsinHealth(TechNet)wasfirstestablishedin1989toprovideupdatesintechnologytoaprofessionalnetworkoflogisticsexpertsandimmunizationprofes-sionalswhoare involvedinthemanagementof immunizationandotherprimaryhealthcareoperationsatthecountryandinternationallevels.In2001,itsnamewasupdatedtoTechnicalNetworkforStrengtheningImmunizationServices,toreflectitswideningaudience.ItsacronymwaschangedtoTechNet21.TechNet21servesasaforumforexpertstodiscusswaystoimproveimmunizationservices.Membersoftheforummeetevery18to24monthstosharetheirexperi-encesandinformation.Forfurtherinformation,seehttp://www.technet21.org/
The2006TechNet21meetingproducedanumberofrelevantrecommendationsintheareasofvaccinemanagement,equipmentmanagement,integrationofsupportsystems,andresearch.Afullcopyofthereportisavailableathttp://www.technet21.org/Mexico/TechNetMexicoMeet-ingReport2006.pdf.
MEETINGS from page 1
waste management during the recent rubellaelimination campaign (May-June 2006). Brazilpresented on hepatitis B immunization amonghealth care workers. Colombia presented thestudy conducted on the reuse of single-usemedicaldevices.Hondurasshareditsexperienceonvaccinationsafety.Thedetailsofthesereportscanbefoundonthewebsite(seeboxabove).
PAHO gave an overview of its Regional Planfor Quality Control and Safety of Syringes, acollaborative activity between the EssentialMedicines, Vaccines, and Health TechnologyUnitandtheImmunizationUnit.Theplan’smainobjectiveisaretoensurethequalityandsafetyof products used by Regional immunizationprograms, from procurement to final disposal,includingstorage,distribution,anduse.(1)
TechNet21 MeetingThe TechNet21 meeting was held from 26-27October with 130 participants in attendancewho shared their experiences in the areas ofvaccinemanagement,equipmentmanagement,and integration of support systems. A sessionon research provided information on newtechnologies such as less heat/freeze sensitivevaccines, aerosol administration of measlesvaccine,andintra-dermaljetinjection.
PAHOmadetwopresentationsonbehalfoftheRegionoftheAmericas.Thefirstwasaregionaloverviewofcurrentpriorities.OnepriorityistoreviewthePAHORevolvingFund’ssupplychainanditsplanofactionenvisionedfor2007to“domorewithless”byreducingcostsandimprovingservicestomembercountries.Anotherpriorityis toexamine thecritical roleof thecoldchainin the supply chain in terms of warehousing,distribution,andutilization.
PAHO’ssecondpresentationwasanoverviewofthe impactof rotavirusvaccine introductionon
coldchainequipmentneeds inBrazil,Panama,andVenezueladuring2006.Thepresentationshighlighted the challenge of working withcountriesandsupplierstoanticipatetheimpactnewvaccineswillhaveoncoldchaincapacity.
ConclusionParticipantsintheSIGNandTechNet21meetingsrecommended that the “back-to-back” formatbe maintained as it encourages the exchangeof experience between both communities ofexperts.ParticipantsalsoacknowledgedthatthewidedistributionofinformationviatheInternetwasusefulandaskedthatitberepeatedinthe
future. In the case of the TechNet21 meeting,theinformationwassentviaitsnetworktomorethan1,000userswho,althoughtheycouldnotattend,wereabletobenefitfromthemeeting.
UNICEFandotherpartnersexpressedinterestinthe incident reporting system implemented byPAHO.Thesystemreportsproblemsrelatedtoqualityofsyringesandotherproductspurchasedthrough the PAHO Revolving Fund. Staff fromthe Immunization Unit and the EssentialMedicines, Vaccines, and Health TechnologyUnitprovidedashortbriefingaboutthesystemthat was created on PAHO’s SharePoint site.1Objectives of the incident reporting systemsite are toprovide a forum for informationonqualityandsafetyissues,conductfollow-upandmonitoringofincidents,disseminatealerts,andserveasarepositoryforproductinformationforthebenefitofEPIpersonnel.
Reference:1. Pan American Health Organization. Regional Plan for
Quality Control and Safety of Syringes. Immunization Newsletter2005;28(5).
1 Share Point is a tool designed to facilitate distancecollaborationandinformation-sharingthroughtheweb.
Safe Injection Global Network (SIGN)
Unsafeinjectionpracticesareincreasinglyrecognizedasamajorsourceofinfectionwithbloodbornepathogens.TheSIGNallianceisavoluntaryco-alitionofstakeholdersaimingtoachievesafeandappropriateuseofinjec-tions.FormoreinformationonSIGN,seehttp://www.who.int/injection_safety/sign/en/.
The 2006 SIGN meeting produced a number of relevant recommendations in the areas ofintegrated infectioncontrol strategies,health careworkers safety, injection safety,qualityandaccesstosafeinjectiondevices,andwastemanagement.Afullcopyofthereportwillbeavailableshortlyathttp://www.who.int/injection_safety/sign/meetings/en/index.html
PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXVIII, Number 6 December 2006 �
cervical cancer and in the increased detectionof pre-cancerous lesions. He noted that CostaRica was considering HPV vaccine introductionforwomenaged10-25yearsbeforeinitiationofsexualactivity.
BothBrazilandChileindicatedthatHPVvaccineintroduction was being considered in theirrespective countries and that cost-effectivenessstudies were being planned. The Brazilianrepresentative noted that although universalvaccinationcoverageisthepreferredgoalofthatcountry,HPVvaccinemayhavetobeconsideredasaspecialantigenforriskpopulationsgiventhecurrenthighvaccineprices.Shecommentedthatitwouldbeprohibitivelyexpensivetovaccinatethe 26 million women, aged 9-26 years, forwhomthevaccinehasbeenapprovedinBrazil.
HPV Surveillance1. ObjectivesThe main objectives of HPV surveillance weredefinedasfollows:
• To gather baseline data for assessing thepre-vaccine disease burden and compilingthe evidence for informed decision-makingregardingHPVvaccineintroduction;
• To monitor the impact and effectiveness ofHPVvaccineintroduction;and
• Todeterminewhetherornotpolicychangesmaybeindicated.
2. EndpointsofinterestforsurveillanceGiven thewide spectrumofdiseaseassociatedwithanHPVinfectionandtheexperienceusing
some of the endpoint indicators of vaccineefficacyintheclinicalvaccinetrials,itwasagreedthatthediscussiononendpointsforsurveillancewouldbe focusedon thesix variablesoutlinedinTable1.Giventhatbothvaccineswillcontainthehigh-riskoncogenicHPVtypes16and18,themost important common endpoints of interestfor monitoring vaccine impact would relateto cervical cancer and its precursor lesions. Inthosecountrieswherethequadrivalentvaccineisbeingused,monitoringofgenitalwartswouldbeimportantforanimpactassessment.Genitalwarts, however, were considered to be a softendpointbecausemanyaffectedindividualsarenotsufficiently inconveniencedtoseekmedicalcareand therealpopulationmagnitudeof thisproblemwouldbeunderestimated.Additionally,inmanycountriesgenitalwartsarenotincludedinanyobligatorynationalnotificationofsexually-transmittedinfections.
InadditiontotheendpointspresentedinTable1,itwasrecognizedthatanHPVsurveillancesystemcould also include pharyngeal papillomatosisandanogenitalcancer.However,adeluxeortop-of-the-linemodelHPVsurveillancesystemwouldbe too costly and too complex for developingcountries to sustain over the long term.Countrieswere thereforeadvised toadoptandimplement those surveillance strategies whichwere sustainable and affordable for them. Theexpertsreiteratedthatwherefinancialresourceswereconstrained, limited fundsshouldbestbeusedforenhancingHPVvaccinationcoverage.
3. PotentialimportantdatasourcesImportantdatasourcesforanyHPVsurveillance
systemwereidentifiedandincludedthefollow-ing:
• National, sub-regional, and regional labora-tories thatwillparticipate in theGlobalHPVlaboratorynetwork;
• Colposcopy and other hospital-based orclinicservicestowhichwomenarereferredfor diagnostic evaluation of an abnormalPapanicolaou smear (Pap smear) result andwherehistologicresultsaregenerated;
• Nationalregistrieswhichcaptureallcasesofhistologically-defined cervical intraepithelialneoplasiaGradeIII(CIN3);
• Cancerregistries,wheretheyexist,toprovidedata on the changing cervical cancer inci-dence;
• Nationalvitalregistrationsystemstoprovidefordataonchangingcervicalcancermortalitydata;and
• HPVvaccineregistersasameanstolinkvac-cinationstatustofuturediseaseoutcomes.
Becausecostsandcomplicated laboratorysup-portforcontinuousmonitoringofaslowlyevolv-ingconditionpresentedchallenges,case-controlstudy methodology is an important and viablealternativeforassessingvaccineeffectiveness.
Other important points emerging from thediscussionsarepresentedbelow:
• Given the potential complexity and costs ofimplementingafullrangeofHPVsurveillancestrategies, it will not be possible for everycountry to develop such an expanded com-plement of surveillance strategies. Instead,it was recommended that some countries,where the capability and infrastructure ex-isted,couldundertakesomeofthemoreso-phisticatedelementsofasurveillancesystem,forexample,type-specificHPVtestingofCIN3lesions,whileothersmaybeabletocontrib-utetoanotherendpoint.
• Neither abnormal Pap smears nor cervicalcancer and any of its precursor lesions arelegallynotifiableinanycountryintheAmeri-cas.
• Some assessment of HPV type-specificchanges would be warranted to confirmdeclines in HPV genotypes contained in thevaccines, as well as to ascertain whether ornotthevaccinegenotypesarebeingreplaced.Theteamrecommendedthatthisshouldbeaperiodicexerciseundertakeninafewselectedcountries.
• The performance characteristics of the Papsmeartest,particularly itspositivepredictivevalue, will change over time as vaccinationcoverageincreasesandthereisaconcomitantdeclineintheincidenceofcervicalcanceranditsprecursorlesions.Therefore,theuseofcy-
Table 1. Endpoints for HPV Surveillance and Measurement Indicators
Endpoints MeasurementIndicators
GenitalHPVinfections Changesinprevalence
Genitalwarts(dependsonvaccineproductbeingused)
Changesinprevalence
Cervicalcancerprecursors,specificallyCIN3*basedonhistologicaldetermination
Changesintheoverallprevalence
Invasivecervicalcancerbasedonhistologicaldetermination
Changesintheincidenceprofiles
Invasivecervicalcancermortality Changesinmortalityprofiles
HPVtype-specificchangesinhistologically-definedCIN3*lesions
Changesintype-specificincidenceinCIN3*precursorlesions
*CervicalIntraepithelialNeoplasiaGradeIII
HPV SURVEILLANCE from page 1
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tologically-definedendpointswasnotrecom-mended,eventhoughitwasrecognizedthatcytologyregistersexistedinmanycountries.
• It is critically important toachievehighHPVvaccinationcoveragerates in thoseareasorpopulations which are underserved with re-gardtoscreening. If this isnotattained,fur-therinequitieswillbecreatedasthesepopu-lationswillbenefitneitherfromscreeningnorfromvaccination.
• Serologicassessmentofcoverageisnotcur-rently recommended owing to its costs andthe absence of standardized commerciallyavailableVLP(vaccine-likeparticle)assays.
HPV Vaccination and Cervical Cancer ScreeningDuringthemeeting,itwasrepeatedlyrecognizedthatsurveillanceofHPV-associateddiseasewasintimatelylinkedtothenationalcervicalcancerscreening programs in countries and that theintroductionofHPVvaccineinvariablyrequiredare-assessmentofexistingscreeningalgorithmsgiven issues of costs, cost-effectiveness, andoverallprogramefficiency.
Inordertomaximizetheeffectofvaccinationandscreening for improvedcervical cancer control,theexpertteamrecommendedtheintroductionof HPV vaccination approximately three yearspriortothemedianageofsexualdebuttogetherwith at least two cervical screenings during awoman’slifetime,preferablyat35and40yearsof age. HPV DNA assays are recommended asprimaryscreening tools,given thatviralpersis-tenceinolderwomenisabettermarkeroftheriskfordevelopingcervicalcancer.Inexpensive,rapid HPV DNA assays will become availablewithinthenext2-3yearsandwillgreatlyrevolu-tionizethecervicalcancerscreeningalgorithmscurrentlyused.Primaryandsecondarypreven-tiveinterventionsforcervicalcanceroverthelife
Figure 1. Integration of HPV Vaccination with Screening
ExistingStrategy
ProposedStrategy
Source: SchiffmanM,CastlePE.ThePromiseofGlobalCervical-CancerPrevention.N Engl J Med2005;353;20:2101-2104.Copyright©2005MassachusettsMedicalSociety.Allrightsreserved.Adaptedwithpermission,2006.
The Natural History of HPV Infection and Cervical Cancer. ThepeakprevalenceoftransientinfectionswithcarcinogenictypesofHPV(blueline)occursamongwomenduringtheirteensand20s,aftertheinitiationofsexualactivity.Thepeakprevalenceofcervicalprecancerousconditionsoccursapproximately10yearslater(greenline)andthepeakprevalenceofinvasivecancersat40to50yearsofage(redline).(Thepeaksofthecurvesarenotdrawntoscale.)Theconventionalmodel of cervical-cancer prevention is based on repeated rounds of cytologic examination,includingPapanicolaousmears,andcolposcopy(smallbluearrows).AlternativestrategiesincludeHPVvaccinationofadolescents(largebeigearrow),oneortworoundsofHPVscreeningatthepeakagesoftreatableprecancerousconditionsandearlycancer(largereddish-brownarrows),orboth.
coursearedepictedinFigure1.
Basedonthisconsultation,PAHO’sImmunizationUnitwillcontinuetodevelopandpilot-testsome
prototype HPV surveillance systems for use inLatinAmericaandtheCaribbean.
On 18 November, Women in Government, anorganization of women state legislators in theUnitedStates,presenteditsPresidentialLeader-shipAwards to individualsandgroups thatareadvancing efforts to eliminate cervical cancerworldwide.TheceremonywasheldinWashing-ton, D.C., during the Women in Government’ssummitoncervicalcancerandHPVvaccine.
Asoneof theawardrecipients, thePanAmeri-canHealthOrganization(PAHO)wasrecognized
becauseof itsworkintheAmericas,whichhashelped improvecervical cancer screening ratesand increase access to lifesaving technologiessuchasHPVvaccines.Inadditiontoeightdistin-guishedindividuals,WomeninGovernmentalsorecognized theBillandMelindaGatesFounda-tionandtheNationalBreastandCervicalCancerEarly Detection Program, a program affiliatedwith the U.S. Centers for Disease Control andPrevention.
AcceptingtheawardonbehalfofPAHO,Dr.JonAndrus,theleadtechnicaladvisoroftheImmu-nizationUnit, said “It’snot justabouthavingavaccine that can prevent cervical cancer. Thechallenge of national immunization programsaroundtheworldistodeploythisimportantlife-savingtechnologytothosewomenwhoneeditmost.Theproblemisthat80percentofwomenwho die of cervical cancer are generally poorand live in underserved areas, and will be theonestobenefitmostasweworkhardtocreateaffordablepricesandaccess to thisvaccine forthem.”The InternationalAgency forResearchonCan-cerestimatesthatmorethan37,600deathsdue
Presidential Leadership Award from Women in Government
PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXVIII, Number 6 December 2006 �
analysesincludeIgMandIgGantibodydetection,virusisolation,detectionofviralnucleicacid,andmolecularcharacterization.TheMeasles/RubellaLaboratoryNetworkiscomposedof21nationallaboratories, 124 sub-national laboratories,2 regional reference centers, and 1 globalspecialized laboratory (Figure 1). The mainactivityofnationalandsub-nationallaboratories
The Measles/Rubella Laboratory Networkcontinues to be fully functional in support ofmeasles and rubella surveillance in the RegionoftheAmericas.Thenetworkwasestablishedin1995andhasbeenprovidingcrucialinformationto confirm or discard suspect cases, identifycirculating virus strains, and evaluate theimpactofmasscampaignsactivities.Laboratory
istotestspecimensfromsuspectmeasles/rubellacasesbyIgMELISA.Somenationallaboratoriesare also responsible for virus isolation andqualitycontrolofsub-nationallaboratories.
Toimprovevirologicsurveillance,ninenationallaboratoriesweretrainedonvirusisolationanddetection in 2005. This was done by conduct-ing supervisory visits and holding a regionalworkshop.For2007,thegoalistoincreasethenumber of laboratories performing virus isola-tion/detectionintheRegionfrom11laboratoriesto18.Theregionalreferencelaboratoriesarere-sponsible for thevalidationof IgM tests resultsofthenationallaboratories.Regionalreferencelaboratories also assist in ruling out measles/rubella cases with possible false-positive or in-determinate results by using additional testsforotherfebrilerashillness,virusisolationandgenotyping. In addition to tasks performed byregionallaboratories,theglobalspecializedlab-oratorydistributestheproficiencypanelstothenationallaboratoriesandvalidatesnewmethodsfor network capacity-building through trainingandcourses.Theglobalreferencelaboratoryisalsoresponsibleforthebankofmeasles/rubellavirusstrainsisolatedintheRegion.
False Positive ResultsCurrently, the main challenge for the Measles/Rubella Laboratory Network is dealing withsporadic cases of “false positive results”,particularly for suspect cases with no travel orvaccine history. As the disease becomes lesscommon due to high vaccine coverage andactive surveillance for rash illness and fever,the positive predictive value of laboratory test
Measles and Rubella Laboratory Network in the Region of the Americas
Figure 1. Measles / Rubella Laboratory Network
Source:ImmunizationUnit,PAHO.
tocervicalcanceroccurannuallyintheRegion.The organization has therefore developed anHPVvaccineintroductionplanthatincludesthefollowingsteps:
• Buildingpoliticalwillthroughadvocacy;• Disseminating relevant information and
knowledge in order to support evidence-baseddecision-making;
• Encouragingorconductingrelevantresearch,suchaseconomicanalysesandacceptabilitystudies;
• Designingsurveillancesystemsandtools;• Mobilizingcross-sectionalsupportthroughef-
fectivesocialmarketingandcommunication;and
• Mobilizingtheessentialfinancialandtechni-cal resources to facilitateHPV vaccine intro-duction.
Photo: Marty Lavor
Dr.AndrusandDr.MerleLewis,RegionalAdvisor,ImmunizationUnit,receivingthePresidentialLeadershipAwardonbehalfofPAHO.StandingtotheleftisDr.DonnicaMoore,awomen’shealthexpertwhoservedastheevent’semcee.StandingtotherightisSusanCrosby,PresidentofWomeninGovernment.
6 IMMUNIZATION NEWSLETTER Volume XXVIII, Number 6 December 2006 PAN AMERICAN HEALTH ORGANIZATION
The Paramaribo DeclarationAttheir23rdAnnualMeetinginSurinamefrom13-17 November 2006, the Caribbean EPIManagers:
Acknowledgingthatthe2007CricketWorldCupisahighly importantevent for theCaribbeancountries;
Recognizing the tremendous progress madein the subregion in immunization and theimportance of protecting the achievements,including theeradicationofpoliomyelitis andthe elimination of indigenous measles, andrubella,andcongenitalrubellasyndrome;
Acknowledging that poliomyelitis, measlesand/or other vaccine-preventable diseasesare endemic in other Regions of the worldandarestillendemicinmanyofthecountriesparticipatinginthe2007CricketWorldCup;
Realizing thehealth implicationsof thiseventandthehighriskofpoliomyelitis,measles,andrubella virus importations into the Caribbeansubregion;
Recognizing that vulnerable high-risk groupsstillremaininthesubregionandthatnationalimmunization programmes face many chal-lengesduetothisevent;
Acknowledgingthathighlyeffectivetools,suchas surveillance and vaccination, exist andshould be enhanced prior, during, and afterthisevent;and
Recognizing that the host countries of theCaribbean have developed preparednessplans for disease surveillance and outbreakcontainment, focusingonvaccine-preventablediseases,
1.Accordinglydeclarethat:a)It is critical to intensify epidemiological
surveillance and appropriate vaccinationactivities forall susceptible localpopula-tions;
b)Political commitment is necessary andshould be translated into tangible re-sourcestoguaranteetheimplementationofsurveillanceplansandmaintenanceofhighvaccinationcoverage;
c)Health care workers in the public andprivatesectorsatall levelsof thesystemshould be alerted to the possibilityof importation of measles, rubella,poliomyelitis,andotherinfectiousdiseasesnotcommonlyseeninthesubregion;
d)Personnelandvolunteersfromthehealth,tourism,sports,andtransportationsectorsshould be immune to poliomyelitis,measles, and rubella before the arrivalofcricketworldcupparticipantsbecause,in the event of an importation, suchpersonnel, if susceptible, may serve astransmission agents because of theirfrequentcontactwiththegeneralpublic.
2. In this context, the Caribbean EPI Managersacknowledge the excellent support providedby PAHO to Member States and gratefullyrequestthat:a)PAHOacceleratecommunicationswithWHO
andotherpartnerstohelpadvisethateveryvisitor coming from outside the Region toparticipateinthe2007CricketWorldCup:i.Beimmuneagainstpoliomyelitis,measles,
andrubellapriortoarrivalattheCricketWorld Cup in the Caribbean; and, whenappropriate,
ii.Beadvisedtoreceivepoliomyelitis-and/ormeasles/rubella-containing vaccines, ide-allyat least twoweeksbeforedeparturefromtheircountry if there isnovaccina-tioncardavailableorwrittenproofofvac-cination.Thistimeisrequiredforanewlyvaccinatedpersontodevelopprotection.
b)Effective coordination and commitment beprovided by all levels of society, includingthelocal,national,subregional,regional,andglobal levels to maintain the achievementsoftheAmericas,whichisahighpriorityforallcountriesoftheRegion;and
c)This declaration be further referred to as“TheParamariboDeclaration.”
Paramaribo, Suriname, 17 November 2006.
willdiminish,resulting inan increasednumberoffalsepositiveresults.ParvovirusB19,humanherpes virus 6 and 7, and cytomegalovirusmaybeclinicallymisdiagnosedasmeaslesandrubellaandtheirantibodiescancross-reactwithmeasles/rubella IgM tests, giving false-positiveresults.
Anin-depthdiscussioncanbefoundinthesecondeditionofRecent Advances in Immunization,inthe chapter entitled Interpretation of Measles and Rubella Serology. A key message in thischapter is that the clinical, epidemiologic, andlaboratorydataareequallyimportanttodecidethefinalcaseclassification.
Quality AssuranceIn theRegionof theAmericas,anaccreditationprocess was implemented at the end of 2005.Theprocessrequiresannualevaluationofalab-oratory,usingtimelinessandquality indicators.
The accreditation is essential for documentingthequalityofthelaboratorynetwork.Anannualproficiency test is administered to ensure thereliability and quality of serological work per-formedinthenationalandregionallaboratories.In2005,theoverallproficiencytestscoreofthenetworkwas100%.For2006,20out23labora-toriesreachedthescoreof100%.In2006,70%ofnationallaboratoriesreceivedanon-sitevisitandfulfilledthecriterianeededtoforaccredita-tion.
Astandardized,wellvalidatedassayforIgMde-tectionisusedinallnationalandregionallabo-ratories since 2005, ensuring data quality andcomparisonofresultswithinthenetwork.PAHOisprovidingsupporttoensurethatthelaboratorynetworkhasadequatesuppliesandequipment.PAHOalsopromotestrainingactivities,research,quality assurance, accreditation, data manage-ment,andtheuseoflaboratoryindicators.
RecommendationsAlthoughconsiderableprogresshasbeenmadeinensuringaccesstoqualityservicesthroughoutthelaboratorynetwork,furthereffortsareneededto improve virologic surveillance. Logisticalproblemsduetoshippingofinfectioussamplesmust also be resolved since they represent amajor obstacle for transporting the specimento regional laboratories or the specializedlaboratory.
Geneticdata for rubellaviruscirculation in theRegion needs continued support. Samples forvirus isolation must be obtained from everychain of transmission and from all congenitalrubellasyndromecasesinthefirstsixmonthsoflife. If genetic information regardingcirculatinggenotypesisenhanced,molecularepidemiologicdata will help to document viral transmissionpathway, classify cases, and confirm theeliminationofendemictransmission.
PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXVIII, Number 6 December 2006 �
Reported Cases of Selected Diseases, 2004-2005Number of reported cases of measles, rubella, congenital rubella syndrome (CRS), poliomyelitis, tetanus,
diphtheria, and whooping cough
CountryMeasles Rubella
CRS PoliomyelitisTetanus
DiphtheriaWhooping
CoughConfirmed Confirmed Non-Neonatal Neonatal2004 2005 2004 2005 2004 2005 2004 2005 2004 2005 2004 2005 2004 2005 2004 2005
Anguilla 0 0 0 0 ... ... 0 0 ... ... ... ... ... ... ... ...Antigua&Barbuda 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ... 0Argentina 0 0 6 0 0 0 0 0 25 14 0 0 0 0 976 2060Aruba ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...Bahamas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Barbados 0 0 0 0 ... ... 0 0 0 ... 0 ... ... ... ... ...Belize 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Bermuda 0 0 0 0 ... ... 0 0 0 ... 0 ... 0 0 0 ...Bolivia 0 0 12 8 0 0 0 0 29 15 4 5 2 0 6 1Brazil 0 6** 319 233 16 4 0 0 463 420 14 10 15 27 1146 1328Canada 7* 6** ... 320 1 1 0 0 2 4 0 0 1 0 2697 2231CaymanIslands 0 0 ... ... ... ... 0 0 0 ... 0 ... ... ... ... ...Chile 0 0 3 47 0 0 0 0 10 8 0 0 0 0 1059 1213Colombia 0 0 45 85 0 5 0 0 ... 72 8 9 ... 1 25 139CostaRica 0 1 0 0 0 0 0 0 0 0 0 0 0 0 13 7Cuba 0 0 18 0 0 0 0 0 0 0 0 0 0 0 0 0Dominica 0 0 0 0 0 ... 0 0 0 ... 0 ... ... ... ... ...DominicanRepublic 0 0 7 6 ... ... 0 0 49 54 5 4 122 39 53 63Ecuador 0 0 79 0 0 0 0 0 4 16 12 6 0 0 0 ...ElSalvador 0 0 1 0 0 0 0 0 7 7 1 1 0 0 1 5FrenchGuiana ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...Grenada 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Guadeloupe 0 0 ... ... ... ... ... ... ... ... ... ... ... ... ... ...Guatemala 0 0 36 4 2 1 0 0 3 6 1 0 0 0 391 0Guyana 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Haiti 0 0 3 0 ... 0 0 0 0 119 33 71 37 204 44 496Honduras 0 0 1 0 0 0 0 0 13 19 1 0 0 0 104 134Jamaica 0 0 0 0 0 0 0 0 11 12 0 0 0 0 5 8Martinique ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...Mexico 64 6** 699 38 5 1 0 0 68 71 4 1 0 0 137 349Montserrat 0 0 ... ... ... ... 0 0 0 ... ... ... ... ... ... ...NetherlandAntilles ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...Nicaragua 0 0 6 47 0 ... 0 0 5 8 0 1 0 0 0 0Panama 0 0 0 0 0 0 0 0 2 1 1 0 0 0 12 28Paraguay 0 0 1 2 1 0 0 0 12 17 5 2 4 0 40 13Peru 0 0 1759 3672 1 7*** 0 0 52 44 4 2 0 0 201 127PuertoRico ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...SaintKitts&Nevis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0SaintLucia 0 0 0 0 0 ... 0 0 0 ... 0 ... ... ... ... ...St.Vincent/Grenadines 0 0 ... ... ... ... 0 0 0 0 0 0 0 0 0 0Suriname 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0Trinidad&Tobago 0 0 0 0 ... 0 0 0 0 0 0 0 0 0 0 0TurksandCaicos 0 0 0 0 0 ... 0 0 0 0 0 0 ... 0 ... 0UnitedStatesofAmerica 37† 66** 10 11 1 1 0 0 34 30 ... 0 0 0 25827 25616Uruguay 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0Venezuela 0 0 96 823 ... ... 0 0 35 33 0 2 0 1 715 836VirginIslands(US) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...VirginIslands(UK) 0 0 0 0 ... ... 0 0 0 ... ... ... ... ... ... ...RegionalTotal 108 85 3102 5296 27 20 0 0 825 972 93 114 181 272 33452 34654
*Duetoimportation **2005imported/relatedtoimportation:Brazil,6cases;Canada,4cases;Mexico,6cases;USA,25cases.***plus10congenitalrubellainfection …nodata †23importedcases
Source:CountryReportstoImmunizationUnit,PAHO. Updated:14December2006
� IMMUNIZATION NEWSLETTER Volume XXVIII, Number 6 December 2006 PAN AMERICAN HEALTH ORGANIZATION
The Immunization Newsletterispublishedeverytwomonths,inEnglish,Spanish,andFrenchbytheImmunizationUnitofthePanAmericanHealthOrganization(PAHO),RegionalOfficefortheAmericasoftheWorldHealthOrganization(WHO).ThepurposeoftheImmunization NewsletteristofacilitatetheexchangeofideasandinformationconcerningimmunizationprogramsintheRegion,inordertopromotegreaterknowledgeoftheproblemsfacedandpossiblesolutionstothoseproblems.
ReferencestocommercialproductsandthepublicationofsignedarticlesinthisNewsletterdonotconstituteendorsementbyPAHO/WHO,nordotheynecessarilyrepresentthepolicyoftheOrganization.
ISSN1814-6244
VolumeXXVIII,Number6•December2006
Editor:JonAndrusAssociateEditors:BéatriceCarpanoandCarolinaDanovaro
Immunization Unit525Twenty-thirdStreet,N.W.Washington,D.C.20037U.S.A.http://www.paho.org/immunization
Recent Advances in ImmunizationThe second edition of Recent Advances in Im-munization was launched this month duringa press conference held at the National PressClub inWashington,D.C. Thenewpublication“provides the strategies and tactics to help usreachthegoalsofsustainingour immunizationachievementsandreachingthepeoplewhohavenotbenefited fromexistingandnewvaccines,”according toDr. JonK.Andrus,LeadTechnicalAdvisorwiththeImmunizationUnitandoneofthebook’stwoeditors.
Dr. Ciro de Quadros, Director of InternationalProgramsattheSabinVaccineInstituteandtheothereditor,addsthatthepublication“isaverytimelybookwithdetailsonsomenewvaccinesthat haven’t been introduced yet. We are wit-nessinggreatadvances in scienceand technol-ogybutnotallmankindisbenefitingfromthem.We hope this book will help make these newtechnologiesavailable.”
Theprogressof immunization in theRegionoftheAmericashasbeenextraordinary.Howeverit has also been uneven. While diseases havebeen eradicated or eliminated, some countries
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dvancesinImmunization,
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stillhaveasignificantproportionoftheirpopula-tions living indistrictswherecoverage remainsbelow95%,puttingthematriskforoutbreaks.Inaddition, countriesmust consider the introduc-tion of new or underutilized vaccines (againstpneumococcus, human papillomavirus, rotavi-rus,and influenza). Indeed,challengesremainthataredrivingimmunizationprogramstomovefromchildtofamilyimmunization.
Recent Advances in Immunizationisintendedtobeareferencefornational immunizationman-agers and other health professionals such aspublic health, medicine, and nursing students,epidemiologists, and surveillance experts. Thetopicscoveredrangefromadolescentandadultimmunizationtocombinationvaccinesforchild-hoodimmunization,optimaluseofBCGvaccine,vaccinationsafety,interpretationofmeaslesandrubella serology, preparing for the influenzaepidemic,introductionofnewandunderutilizedvaccines, and prophylactic human papillomavi-rusvaccines.
ThepublicationwaspublishedinEnglishbutwillalsobetranslatedintoFrench,Portuguese,and
Spanish.Formoreinformationonhowtoobtainacopy,pleasevisit thePAHOPublicationweb-page at www.paho.org/english/DD/PUB/pub-Home.asp.
