Subregional immunization programme managers' meeting

Subregional immunization programme managers’

meeting

Report on a WHO meeting, Antalya, Turkey, 15-17 November 2005

Keywords IMMUNIZATION PROGRAMS PROGRAM EVALUATION MEASLES - prevention and control POLIOMYELITIS - prevention and control RUBELLA - prevention and control RUBELLA SYNDROME, CONGENITAL - prevention and control EPIDEMIOLOGIC SURVEILLANCE VACCINES - standards SAFETY MANAGEMENT COMMUNICABLE DISEASE CONTROL EUROPE, EUROPE, EASTERN COMMONWEALTH OF INDEPENDENT STATES TURKEY

EUR/06/5073285

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CONTENTS

Page

ABBREVIATIONS ............................................................................................................... 1 EXECUTIVE SUMMARY........................................................................................................ 3 OPENING OF THE MEETING ................................................................................................. 3 SCOPE AND PURPOSE OF THE MEETING ................................................................................. 3 TOPIC 1: GLOBAL AND REGIONAL IMMUNIZATION PROGRAMME.............................................. 4

1.1 IMMUNIZATION IN THE GLOBAL CONTEXT - GLOBAL IMMUNIZATION VISION AND STRATEGIES (GIVS) (DR JEAN-MARIE OKWO-BELE)................................................................................ 4 1.2 IMMUNIZATION PROGRAMME IN THE EUROPEAN REGION; PROGRESS, CHALLENGES AND PRIORITIES IN THE CONTEXT OF GLOBAL IMMUNIZATION VISION AND STRATEGIES (GIVS) (DR NEDRET EMIROGLU).................................................................................................................... 5

TOPIC 2: ACCELERATED DISEASE CONTROL: POLIO ERADICATION, MEASLES AND RUBELLA ELIMINATION AND CONGENITAL RUBELLA INFECTION (CRI) PREVENTION ................................. 6

2.1 SUSTAINING POLIO-FREE STATUS IN THE EUROPEAN REGION, PREPARATION FOR THE POST-CERTIFICATION ERA AND CONTAINMENT OF WILD POLIOVIRUSES (DR GALINA LIPSKAYA).................. 6 2.2 MEASLES AND RUBELLA ELIMINATION AND CRI PREVENTION BY 2010 – PROGRESS AND CHALLENGES (DR JOHN SPIKA)........................................................................................... 6 2.3 ACCELERATED DISEASE CONTROL (ADC) WORKSHOP: STRENGTHENING SURVEILLANCE FOR MEASLES, RUBELLA AND CONGENITAL RUBELLA SYNDROME – PLANS FOR 2006 (DR JOHN SPIKA)........ 7

TOPIC 3: LABORATORY NETWORKS FOR ACCELERATED DISEASE CONTROL .......................................... 8 3.1 EUROPEAN REGIONAL LABORATORY NETWORK FOR POLIO AND MEASLES/RUBELLA; OPPORTUNITIES FOR EXPANSION TO OTHER DISEASE CONTROL INITIATIVES (DR EUGENE GAVRILIN AND DR MICK MULDERS) ........................................................................................................ 8 3.2 COUNTRY EXPERIENCE: MEASLES, RUBELLA AND CRS PLANS, PROGRESS AND CHALLENGES ......... 9

TOPIC 4: STRENGTHENING IMMUNIZATION SYSTEMS: UPDATED POLICIES, IMPROVED PLANNING, SURVEILLANCE AND MONITORING......................................................................................11

4.1 REGIONAL APPROACH FOR STRENGTHENING IMMUNIZATION SYSTEMS IN THE FRAMEWORK OF GLOBAL IMMUNIZATION VISION AND STRATEGIES (GIVS) (DR NEDRET EMIROGLU) ..................... 11

TOPIC 5: IMMUNIZATION QUALITY AND SAFETY ..................................................................13 5.1 SURVEILLANCE SYSTEM FOR ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI) (DR PHILIP DUCLOS)..................................................................................................................... 13 5.2 EXPERIENCE IN ESTABLISHING A NATIONAL “ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI) SURVEILLANCE SYSTEM” IN TURKEY (DR PERVIN OZELCI) ....................................................... 14 5.3 IMMUNIZATION QUALITY AND SAFETY IN THE EUROPEAN REGION: ACHIEVEMENTS AND SPECIAL FOCUS ON VACCINE SUPPLY AND MANAGEMENT (MR DENIS MAIRE) ........................................... 14 5.4 EXPERIENCE IN UPGRADING VACCINE REGULATIONS AND SUPPLY SYSTEM IN LATVIA (DR JURIJS PEREVOSCIKOVS) .......................................................................................................... 15

TOPIC 6: INTRODUCTION OF NEW VACCINES INTO NATIONAL IMMUNIZATION PROGRAMMES: PERSPECTIVES AND SUPPORT FOR DECISION MAKING ...........................................................15

6.1 NEW AND UNDERUTILIZED VACCINES; WHERE WE ARE AND THE WAY FORWARD (DR ANDREI LOBANOV) ................................................................................................................... 15 6.2 IMMUNIZATION AGAINST HIB IN THE CZECH REPUBLIC (DR JIRI WALLENFELS)...................... 15

6.3 HIB INITIATIVE: EVIDENCE BASED APPROACH FOR DECISION MAKING AND POLICY DEVELOPMENT (DR PATRICK ZUBER)..................................................................................................... 16 6.4 KEY ASPECTS OF AN EVIDENCE BASED DECISION FOR ROTAVIRUS VACCINE – SURVEILLANCE, DISEASE BURDEN, MONITORING (DR ROBIN BIELLIK)........................................................... 16 6.5 ROTAVIRUS EPIDEMIOLOGY IN UZBEKISTAN: REPORT FROM PILOT HOSPITAL BASED SURVEILLANCE SYSTEM (DR ERKIN MUSABAEV)........................................................................................ 16

TOPIC 7: ADVOCACY, COMMUNICATION AND PARTNERSHIP: ROLE IN IMPROVING IMMUNIZATION SERVICE DELIVERY AND THE EUROPEAN IMMUNIZATION WEEK..............................................17

7.1 EUROPEAN IMMUNIZATION WEEK – A TOOL FOR ENHANCING TARGETED ADVOCACY AND COMMUNICATION (MS ARAN CORRIGAN) ............................................................................ 17 7.2 PARTNERSHIP WITH EUROPEAN UNION (EU) AND EUROPEAN CENTRE FOR DISEASE PREVENTION AND CONTROL (ECDC) (DR PEET TULL) ............................................................................ 17 7.3 DEVELOPING INTEGRATED COMMUNICATION STRATEGY IN TURKEY (LILA PIETERS)................. 17

CONCLUSIONS AND RECOMMENDATIONS............................................................................18 TOPIC 1: GLOBAL AND REGIONAL IMMUNIZATION PROGRAMME................................................ 18 TOPIC 2: ACCELERATED DISEASE CONTROL: POLIO ERADICATION, MEASLES AND RUBELLA ELIMINATION AND CRI PREVENTION .................................................................................................... 18 TOPIC 3: LABORATORY NETWORKS FOR ACCELERATED DISEASE CONTROL.................................. 19 TOPIC 4: STRENGTHENING IMMUNIZATION SYSTEMS: UPDATED POLICIES, IMPROVED PLANNING, SURVEILLANCE AND MONITORING ...................................................................................... 20 TOPIC 5: IMMUNIZATION QUALITY AND SAFETY .................................................................... 20 TOPIC 6: INTRODUCTION OF NEW VACCINES INTO NATIONAL IMMUNIZATION PROGRAMMES: PERSPECTIVES AND SUPPORT FOR DECISION MAKING.............................................................. 21 TOPIC 7: ADVOCACY, COMMUNICATION AND PARTNERSHIP: ROLE IN IMPROVING IMMUNIZATION SERVICE DELIVERY AND THE EUROPEAN IMMUNIZATION WEEK ................................................. 21

Subregional immunization programme managers’ meeting page 1

Abbreviations

AEFI adverse events following immunization AFP acute flaccid paralysis CRI congenital rubella infection CRS congenital rubella syndrome DTaP diphtheria-tetanus-acellular pertussis vaccine DTwP diphtheria-tetanus-whole cell pertussis vaccine EPI Expanded Programme on Immunization EU European Union GAVI Global Alliance for Vaccines and Immunization GIVS Global Immunization Vision and Strategy Hep B hepatitis B Hib Haemophilus influenzae type b IPV inactivated polio vaccine MDG Millennium Development Goals MMR measles–mumps–rubella vaccine NRA National Regulatory Authority OPV oral polio vaccine SIA supplementary immunization activities UNICEF United Nations Children’s Fund USAID US Agency for International Development VDPV vaccine-derived poliovirus VPD vaccine-preventable disease VPI Vaccine-preventable Diseases and Immunization Programme WHO World Health Organization


Executive summary

A sub-regional meeting of National Immunization Programme Managers representing 22 of the 52 countries of the WHO European Region was held in Antalya, Turkey, from 15 to 17 November 2005. Issues discussed included the Global Immunization Vision and Strategy (GIVS) and its potential role in guiding regional policy, integration of surveillance and vaccine delivery systems, new approaches to immunization services planning, immunization quality and safety, introduction of new vaccines and the role of advocacy, partnerships and communication.

The European Region is highly diverse with regard to health systems and governance models; however, progress in the provision and maintenance of national immunization services has been notable. Average national vaccination coverage levels are high for the routine EPI antigens, but these statistics can mask much lower coverage in certain population groups. The new GIVS strategy provides an opportunity for countries to review and realign their policies, incorporating new approaches, where relevant. Greater efforts must be made to reach and incorporate vulnerable and hard to reach populations with routine immunization services.

Polio-free status has been maintained and good progress towards the 2010 goal of measles and rubella elimination is being made. However, political commitment, improved surveillance and strong advocacy for immunization, as well as appropriate funding, must be ensured if the Region is to see a further reduction in the incidence of vaccine-preventable diseases (VPDs) through strong and sustainable immunization systems.

The immunization programme infrastructure such as the laboratory network, surveillance system and the quality and safety structures are vital to support other areas of the health system. By further capacity building and better integrating immunization service delivery into other areas of the health sector, major and far reaching gains will be made. These gains will also contribute to global objectives for example, the achievement of the Millennium Development Goal (MDG) of reducing child mortality.

Opening of the meeting

Dr Nedret Emiroglu, Regional Adviser, Vaccine-preventable Diseases and Immunization Programme (VPI) opened the meeting. Dr Turan Buzgan provided a welcome on behalf of the Ministry of Health, Turkey. Dr Ray Sanders acted as rapporteur.

The programme and list of participants are provided in Annex 1 and 2 respectively.

Scope and purpose of the meeting

The scope and purpose of the meeting were to review and discuss the following subjects with participants and provide recommendations for future programme activities:

1. The current status of global and regional immunization programmes, including disease control targets, progress and future priorities for strengthening immunization systems in countries of the WHO European Region;


2. Programmatic areas of work and future priority areas for strengthening national immunization systems, within the concept of child and adolescent health with special focus on vulnerable groups:

Accelerated disease control, including integrated surveillance and laboratory support for polio eradication, measles and rubella elimination and CRI prevention;

1. Advocacy and communication, including its role in strengthening immunization service delivery and the European Immunization Week;

2. New Vaccines introduction into national immunization programmes, with perspectives and support for decision making;

3. Immunization quality and safety, with focus on vaccine supply and vaccine management and surveillance for AEFI (adverse events following immunization).

Topic 1: Global and Regional Immunization Programme

1.1 Immunization in the global context - Global Immunization Vision and Strategies (GIVS) (Dr Jean-Marie Okwo-Bele)

In response to the challenges of a rapidly changing and increasingly interdependent world, WHO and UNICEF have jointly drafted a global immunization vision and strategy for the years 2006–2015. Its goal is to protect more people against more diseases by expanding the reach of immunization to every eligible person, including those in age groups beyond infancy, within a context in which immunization is high on every health agenda. It aims to sustain existing levels of vaccine coverage, extend immunization services to those who are currently un-reached and to age groups beyond infancy, introduce new vaccines and technologies, and link immunization with the delivery of other health interventions and the overall development of the health sector.

The global strategy comprises four main areas with component strategies. The strategic approaches are:

1. Protecting more people in a changing world; 2. Introducing new vaccines and technologies; 3. Integrating immunization, other health interventions and surveillance in

the health systems context; and 4. Immunizing in the context of global interdependence.

Immunization and the other linked interventions described will contribute significantly to the achievement of the MDGs, the immunization-related goals set by the United Nations General Assembly Special Session on Children in 2002, and the goals set by the Global Alliance for Vaccines and Immunization (GAVI).

The document, adopted by the Member States at the World Health Assembly (WHA58.15) in 2005, sets out a unifying vision and strategies for 2006–2015 which are intended to stimulate collective action and to ensure commitment by governments and immunization partners. It establishes a common strategic platform for countries and immunization partners, supports a comprehensive approach to planning and urges a broader approach to immunization programmes. It is a vision that focuses not only on new vaccines and technologies for future introduction, but also on ways of strengthening the current immunization system so that it can maximise the delivery of currently available vaccines, as well as underutilized or new vaccines


and other technologies. The vision also focuses on the need to strengthen surveillance and other measurement and monitoring systems in order to identify high-risk and underserved populations where additional efforts are needed. In view of the marked differences between countries’ strengths and weaknesses, countries and their partners are encouraged to use this document to reflect on the policies and strategies most suited to their individual needs and circumstances.

1.2 Immunization Programme in the European Region; progress, challenges and priorities in the context of Global Immunization Vision and Strategies (GIVS) (Dr Nedret Emiroglu)

The WHO regional immunization goals for 2010 include: Increasing and sustaining immunization coverage to ≥95% nationally and ≥90% in all districts;

Strengthening immunization systems within the overall context of health systems;

Improving immunization service delivery, with a focus on district level management and capacity building;

Accelerating the appropriate use of new and underutilized vaccines; Ensuring immunization safety, covering all aspects of providing safe and

effective vaccination, including AEFI surveillance; Eliminating measles and rubella, and preventing CRI; Sustaining regional polio-free status; Maintaining progress in rolling back diphtheria; Ensuring adequate capacity for surveillance and monitoring, including

enhancing the laboratory network; Improving partnership, advocacy and communication.

Major challenges to achieving these goals include:

Unequal vaccination coverage particularly at sub national level and among high risk groups in many countries which results in outbreaks of VPDs, particularly measles;

Inequity in access to immunization services which means that vulnerable and hard-to-reach groups exist in each and every country;

Low VPD incidence which results in a decreased awareness of the importance of immunization;

Lack of financial sustainability which compromises immunization services and impedes the introduction of new vaccines;

Health sector reform in many countries which has a negative impact on service delivery, thus routine immunization services; and

Anti-vaccination group activities and media scare stories which result in vaccine refusal.

Several aspects of GIVS are already being implemented in the European Region. The core principles of the Regional immunization work plan 2006-2007 are to strengthen immunization systems through comprehensive and integrated approach with the overall aim of strengthening health systems, ensuring sustainability; build upon existing systems and infrastructure; integrate activities and link with other programmes; adapt to a changing environment and changing public demand; and increase country presence and partnership.

Subregional immunization programme managers’ meeting page 6 Topic 2: Accelerated Disease Control: Polio eradication, measles and rubella elimination and congenital rubella infection (CRI) prevention

2.1 Sustaining polio-free status in the European Region, preparation for the post-certification era and containment of wild polioviruses (Dr Galina Lipskaya)

From 2003 to 2005 the European Region has faced an increasing risk of importation of wild poliovirus. Recent importation of virus, originating in northern Nigeria, into several previously polio-free countries in Africa and into Yemen and Indonesia, underlines the risk the European Region faces. At the same time, decreased international funding for supplementary immunization activities (SIA) and surveillance has resulted in an increasing gap between the funding required and the funding available in the Region. Calls have been made on Member States to take greater responsibility for supporting their own polio activities and to pay greater attention to surveillance gaps at sub national levels. All Member States have national plans for maintaining polio-free status and WHO has prepared plans for rapid response to reported importations. The greatest concern is that surveillance quality is beginning to decline thereby allowing imported virus the opportunity for considerable spread before it is detected.

There has been a progressive shift in national immunization policies from OPV to IPV use. WHO has no recommendation to switch to IPV, but several countries have turned to WHO for advice, particularly where the incidence of VAPP is considered as a risk and a strong incentive for ceasing OPV use. The decision to switch must be made on a country-by-country basis, taking into account a number of factors including risk/benefit assessment, sustainability and vaccine coverage.

The first phase of laboratory containment of wild polio stocks has almost been completed in the Region. Laboratory survey and inventory activities have been completed in all Member States and quality assurance documentation collected from most. It is expected that all required activities will have been finalised by the beginning of 2006.

2.2 Measles and rubella elimination and CRI prevention by 2010 – progress and challenges (Dr John Spika)

Considerable progress has been made in the Region since 2002. All 52 Member States now have two or more doses of measles vaccine in their routine immunization schedule. Several Supplementary Immunization Activities (SIAs) for measles have been conducted and used as a tool to strengthen the national immunization programme. Regional rubella elimination is now considered a feasible goal, with 48 Member States including rubella vaccine (predominantly as MMR) in their routine immunization schedule.

The major challenges for measles elimination include improving vaccine coverage in susceptible cohorts and groups, and moving from aggregate case reporting to case-based reporting as the incidence of measles declines. The challenges for rubella elimination and CRI prevention lie in identifying and immunizing susceptible cohorts, which are not the same as the measles susceptible cohorts, and in establishing effective surveillance for congenital rubella syndrome (CRS).

Key action areas include: • National policy development

- Develop and implement national immunization plans


- Ensure plans for measles/ rubella/ CRIs - Establish national measles and rubella elimination committees

• Surveillance - Build capacity and infrastructure to monitor, measure and report on the regional elimination targets - Provide assessment and training tools - Revise surveillance guidelines

• Immunization quality and safety • Coordination and partnership • Communication/ advocacy

- Develop communication plans - Develop or maintain vaccine safety network - Implement European Immunization Week

• Certification process - Refine criteria used to assess achievement of national and regional elimination targets - Develop a regional certification process - Establish national certification committees - Develop national documentation

2.3 Accelerated Disease Control (ADC) workshop: Strengthening surveillance for measles, rubella and congenital rubella syndrome – plans for 2006 (Dr John Spika)

Surveillance for measles, rubella and CRS has been very successful. However, a number of areas now require strengthening; progression to measles case-based reporting, monthly rubella reporting and production of Regional CRS surveillance guidelines and implementation of CRS reporting.

The meeting participants were divided into 2 groups to discuss policy-level-specific issues relating to the implementation of case-based surveillance (including the linking of laboratory and epidemiologic data), monthly reporting, outbreak investigations, areas for collaboration and WHO assistance for the strengthening of national surveillance activities to monitor progress towards the disease elimination targets.

Conclusions of Group 1The following problems in moving to case-based surveillance were identified:

Logistics – the potential number of cases requiring sample transportation and testing, and funding support for these activities;

Sample collection – difficult to convince parents of the need to take a blood sample;

Laboratory confirmation – availability of ELISA (enzyme-linked immunosorbent assay) kits for testing;

National capacity – weak case investigation and data analysis capabilities; Training – needed at many levels, especially local level.

In response to the problems, the following recommendations were made:

Sustainable funding should be considered a core function of immunization;

SIAs should be used to trigger case-based reporting.

Subregional immunization programme managers’ meeting page 8 The following problems were identified with the epidemiology/laboratory links:

Discrepancies in data exist; Laboratories are not involved in programme development.

In response to the problems, the following recommendations were made:

Where appropriate, laboratory and epidemiology services should be integrated;

There should be regular interaction between the two groups; Use of unique case ID numbers should be standard practice;

Despite extensive discussion the problem of outbreak definition was not resolved. An area for WHO assistance for case-based surveillance would be to facilitate exchange of information and visits between countries. Conclusions of Group 2Case-based reporting should be possible next year.

Appropriate information is present at the local level, but a consistent approach is needed to bring that information to the national level;

There is a need for clear case definitions for use at the lowest level. Training will be required in applying the case definitions;

There is a need to convince clinicians that laboratory testing of every case is required;

Concern was expressed about the use of case-based surveillance during outbreaks.

More testing kits will be required;

In response to the problems of epidemiology/laboratory data links the following recommendations were made:

A format for resolving data discrepancies is needed, for example the formation of a National Review Committee, but the exact mechanism will be country specific.

An area for WHO assistance would be to Resolve differences between WHO and EU case definitions; Provide financial support for testing and sample transport.

Topic 3: Laboratory Networks for Accelerated Disease Control

3.1 European Regional Laboratory Network for polio and measles/rubella; opportunities for expansion to other disease control initiatives (Dr Eugene Gavrilin and Dr Mick Mulders)

Within the WHO European Region there are 48 polio laboratories located in 37 countries. All passed their annual proficiency testing and accreditation assessment. These laboratories form a key component in the protection of the Region against the re-establishment of circulation of imported viruses and have demonstrated their effectiveness many times over the past 5 years. They have also played a central role in the detection and characterization of vaccine-derived polioviruses (VDPVs). As the risk posed from VDPVs and epidemic polio following importation exists, Member States are being encouraged to extend their polio laboratory capacity beyond


testing of samples from AFP (acute flaccid paralysis) cases to include broader enterovirus surveillance and environmental surveillance where appropriate, in line with WHO guidelines. The lessons learned in establishing and maintaining the polio laboratory network should also be extended to the establishment of laboratory networks for other infectious diseases.

The European Region currently has 47 nominated national measles laboratories, 3 Regional Reference Laboratories and 1 Global Specialized Laboratory. Laboratory diagnosis is based on IgM (immunoglobulin M) and virus detection. The majority of these laboratories also test for rubella, with IgM detection being the predominant method used. Current activities to strengthen the Regional network are focussed on improving the quality of testing and timeliness of reporting. General proficiency of the laboratories is high, with 93% passing the proficiency test in 2005.

One of the most significant challenges to the measles/rubella laboratory network is lack of sufficient funding to support laboratories in greatest need, the provision of appropriate training and coordination of network activities. This may become even more acute as measles incidence declines and the Region moves towards case-based reporting. The testing of serum samples remains the recommended procedure, but adoption of alternative sampling methods, including saliva and dried blood spots has been investigated and may go some way to overcoming problems associated with specimen collection and transportation to the laboratory.

3.2 Country experience: measles, rubella and CRS plans, progress and challenges

Experience from implementing enhanced surveillance protocol for measles in the Russian Federation (Dr Albina Melnikova)

The Russian Federation adopted the 2010 measles elimination goal in 2002 and established a national measles laboratory network based on experience gained from their polio laboratory network. In 2004, approximately 85% of the entire country was reporting a measles incidence of >1/100,000. The situation in 2005 showed further improvement. There have been a total of 219 measles outbreaks detected to date, mostly as single cases or as outbreaks among students and staff at universities. Approximately 90% of cases are laboratory confirmed. Less than 15% of confirmed cases are now ≤15 years of age and 40% are in the 20-29 years age group. In 2005, approximately 65% of detected measles cases had no history of measles immunization.

To improve surveillance the enhanced surveillance protocol for measles and rubella was piloted in 11 selected locations. Surveillance for rash and fever in children detected 27 measles cases and 366 rubella cases, values close to those expected, and was considered to have improved case detection in the younger age group. Results from the pilot suggested that a measles/rubella confirmation rate of 5/100,000 rash and fever patients was a reasonable surveillance target. Although effective, enhanced surveillance is expensive and additional funding support must be identified. It also increases the requirement for staff training.

Plans for enhancing surveillance after measles Supplementary Immunization Activity (SIA) in Turkey (Dr Mehmet Ali Torunoglu)

In the face of relatively low (<85%) measles coverage figures, Turkey adopted a 4-point plan to improve coverage and implement case-based surveillance. Measles School Vaccination Days were used to reach between 9.5 and 9.9 million primary school children, achieving >90% coverage in all districts. Immunization of pre-school children and those <15 years not at school

Subregional immunization programme managers’ meeting page 10 was undertaken between 25 April and 20 May 2005, using a door-to-door strategy in urban areas, reaching 8.6 million children.

Following this SIA in 2006 Turkey plans to implement active weekly, case-based surveillance for measles integrated into the AFP surveillance system. Plans are in hand for improving data quality, improving hospital-based surveillance and strengthening laboratory capacity.

Successes and challenges after measles and rubella Supplementary Immunization Activity (SIA) in Kyrgyzstan (Dr Ludmila Shteinke)

Kyrgyzstan implemented an SIA for measles and rubella in 2001, achieving immunization of 1.8 million (>98%) in the 7-25 year old target group. In 2002 Immunization of women of child-bearing age with rubella vaccine reached 400,000 (>97%). MMR was introduced into the routine immunization schedule in 2002.

Following the SIAs Kyrgyzstan introduced integrated surveillance for measles, rubella and CRS. This required political support, additional training, monitoring and supervision, and technical and financial support. The country adopted a suspected measles/rubella sensitivity indicator of 5/100,000 population, giving an expected 250 suspected cases per year. In 2005 to date 227 suspected cases have been detected, of these 52 have been confirmed measles (of which 45 are suspected to have been imported) and 1 has been confirmed as rubella. CRS surveillance has presented a very heavy workload, with only 1 case confirmed to date (in 2004). Many of the surveillance performance criteria show steady improvement since 2005, but there are still significant problems with timeliness of reporting and specimen transportation.

The main challenges include adapting surveillance management to accommodate changes brought about by healthcare reform; improving routine analysis of surveillance data at lower levels and ensuring active surveillance is fully implemented throughout the country. There is a need to revise the national measles and rubella case definitions to improve surveillance quality and to reduce the current surveillance sensitivity indicator to a more reasonable level.

Successes and challenges after measles Supplementary Immunization Activity (SIA) in Romania (Dr Adriana Pistol)

Health care in Romania has been in transition since 1999, with a progressive shift from a centralized to a decentralized system. Measles SIAs were conducted in 1998/99 targeting the 7-18 year old age group; a rubella catch-up campaign for 15-18 year old school girls was also conducted in 1998. Rash and fever surveillance was implemented from 1999. In 2003 it was considered this was too expensive for case-based reporting and a system for selective testing was adopted.

In 2005 an outbreak of measles occurred, with 2148 measles cases detected, many in paediatric hospitals. Many cases were <1 year of age, symptoms were not typical of measles and clinicians were not initially experienced in diagnosing the cases as measles. These factors allowed the outbreak to spread; of the measles-confirmed cases in the 1-4 year old age group, >50% had no record of measles immunization. Health-care reforms appear to have erected barriers to full immunization in Romania, and these should be assessed as a matter of urgency.


Topic 4: Strengthening immunization systems: Updated policies, improved planning, surveillance and monitoring

4.1 Regional approach for strengthening immunization systems in the framework of Global Immunization Vision and Strategies (GIVS) (Dr Nedret Emiroglu)

Regional policies for strengthening immunization systems are based on the principles of strengthening systems in the context of health care, thus protecting more people, improving service delivery, integrating immunization and surveillance, introducing new vaccines and technologies, and promoting action at regional and national levels. Policies for strengthening systems in the context of health care include:

Building on existing health care infrastructures; Planning activities and interventions tailored to country needs; Building local capacity for improved management; Promoting use of high quality data to support problem solving programme

management; Improving access and utilization of services; Improving immunization quality and safety.

Specific actions include the introduction of national multi-year plans which should be incorporated into the broad sector-wide policies, improvement in the planning and management of human resources, provision for supportive supervision and integrated training, and advice on motivation and incentives.

Immunization systems strengthening: tools to build capacity through assessment and training (Dr Francois X. Hanon)

The strategy proposed for national immunization programme capacity building entails aligning the national requirements with the capacity to deliver. The first step is to conduct an initial assessment of country activities, to gather information for policy making, study the impact of an intervention, and provide a training tool. More than 15 assessment packages are now available for use globally, implementation requiring between 5-10 days and providing both quantitative and qualitative evaluation. The packages are based largely on either external assessment and/or review, using international consultants together with a national team, or a self-assessment exercise.

The aim of training is to develop and improve technical skills in immunization and to improve immunization services management. There are more than 25 training packages available. Training sessions require 5 days to implement and are often modular in structure allowing different combinations, depending on the needs. The methodology is to provide training by international consultants for a core group. The core group subsequently train others at national and sub-national level. There is also inter-country training through consultant briefings and country visits provided through international training programmes such as the Global Training Network.

The main challenges to providing effective training lie in keeping the courses as short as possible (immunization staff are taken away from their important daily work), and achieving the correct balance of theory and practice. In order to improve the impact of training, the training package must be implemented several times to achieve a cumulative effect and monitoring must be conducted to ensure that the correct information is being appropriately given at the lowest levels.

Subregional immunization programme managers’ meeting page 12 Training must be linked to funding availability and a balance must be struck between preventive and curative services and between short- and long-term investments.

Lessons learned from the implementation of monitoring immunization programme performance and immunization systems strengthening (Dr Chinara Aidyralieva)

A number of countries in the Region continue to operate immunization systems designed to function in very different social, economic and environmental conditions. These systems are characterised by time-consuming data collection methods, with information feed-forward, but no feed-back mechanism, and permitting very limited data analysis at the lowest level. Vaccination coverage data is analyzed only once a year, infant immunization information is relevant only to the children born during the reporting year and cumulative monitoring does not allow analysis of age-appropriate immunization.

The timeliness of vaccination is not monitored and the vaccine target population is often underestimated. Disease surveillance is largely based on clinical diagnosis, often with unclear or inappropriate case definitions, with rare laboratory confirmation of cases, often using non-standard methods. Supervisory visits require tedious screening of individual records to detect any problems and all decision making is restricted to higher level managers.

Internationally supported projects in Ukraine, Belarus, Moldova and Bulgaria have highlighted these problems and pointed the way forward. The projects have been used to review data collection, analysis and utilization needs at each level; promote WHO recommended monitoring tools and standards; achieve national consensus on the minimum essential set of surveillance data for effective monitoring and analysis; provide technical assistance in development and introduction of country-specific monitoring tools; and increase management and supervisory capacity.

Data Quality Self-Assessment in Bulgaria: results and future plans to improve performance monitoring (Dr Angel Kunchev)

A joint project between WHO, USAID and the Ministry of Health was conducted to strengthen the immunization monitoring system within the context of ongoing health care reform in the country, namely the switch to general practitioners and to introduce new indicators for improved analysis of immunization performance, including timeliness of vaccination. The project used the Data Quality Self-assessment (DQS) tool to assess services and found that although information on vaccinations is well recorded there is too much duplication of data due to different requirements of the different bodies involved. Definitions for vaccine eligibility are not standardised, with many GPs excluding children with contraindications and those that do not present, from the denominator. Monitoring requires improvement as GPs do not calculate drop out and wastage rates, and most GPs only track defaulters at follow-up on the regular check-ups for children under one year of age.

Key recommendations are to reduce the number of immunization records maintained to avoid duplication; to develop clear national guidelines on report submission and stock management; to introduce the WHO recommended definition of immunization coverage based on the age cohort; and to strengthen the analysis of immunization programme performance through monitoring of immunization coverage, timeliness and drop-out rates. The intention is also to improve the search for children not registered with the Health Insurance Fund or changing their GP; to design specific and more proactive strategies to reach high risk areas; and to explore the opportunities to change the current reporting form or to establish joint reporting based on the GPs electronic database.


Multi-Year Plan (MYP): a tool for incorporating Global Immunization Vision and Strategies (GIVS) into national policies (Dr Niyazi Cakmak)

Multi-Year Planning (MYP), based on the principles outlined in GIVS, presents an opportunity to strengthen strategic planning at country level, to streamline the immunization planning process and requirements, to streamline fundraising at country level, to optimize the links with broader health sector planning, and to improve country ownership. A new planning module for MYP has been prepared as part of the MLM (mid level management training) materials. MYP provides national goals, objectives and strategies, where appropriate makes linkages between various initiatives, integrates activities common to related initiatives and routine immunization, includes financial planning and costing, encourages links with other programmes, and includes scenarios and strategies for promoting financial sustainability.

Lessons learned through development of a Multi-Year Plan (MYP) in Kyrgyzstan (Dr Joldosh Kalilov)

With the end of the second National Immunization plan (2001-2005), and the need to synchronize activities with development of a new Health Sector plan, it was decided to attempt implementation of MYP according to specifications provided by WHO. It was found that the guide was quite practical and clear for technical staff, but that staff at policy making level found it less useful as they were used to have plans in text format. It was useful in orienting team members for the planning process. The costing and financing tool required expertise in costing, of which there is limited national capacity, and a familiarity with Microsoft Excel to use the tool. This resulted in limited utilization among planners. The dependence on external assistance for the set-up may be a problem when updating becomes necessary. Overall the process was found to be useful in predicting and comparing costs for different strategies.

Topic 5: Immunization quality and safety

5.1 Surveillance system for Adverse Events Following Immunization (AEFI) (Dr Philip Duclos)

AEFI monitoring and management requires continued improvement with countries making continued efforts to develop and sustain AEFI detection and investigation capabilities and to take subsequent appropriate action. WHO facilitates the development of capacity to monitor adverse events at the global level through mechanisms such as linked databases, but the global capacity for rapid response to safety issues of potential global importance must be enhanced.

The main weaknesses and challenges for AEFI surveillance at present are the lack of sensitivity of current systems, the absence of clear definitions and instructions for reporting, the weak analysis capability that exists, the limited investigation capability in many countries, the absence of causality assessment, insufficient collaboration between partners and insufficient use of country resources, lack of involvement of the private sector and lack of concern for non EPI vaccines.

WHO provides support to countries for AEFI monitoring and management, including reference materials (Aides-Mémoire on investigation, causality assessment), and NRA (national regulatory authority) assessments. Training is provided through the Global Training Network on AEFI (at regional training centres) and national training and technical support is provided through

Subregional immunization programme managers’ meeting page 14 consultant briefings and support for investigations. WHO support for improving global monitoring and investigative capacity includes:

Proposed project for Network of Sentinel Countries for the monitoring of efficacy and safety of newly introduced vaccines (novel vaccines);

International drug monitoring Programme, Uppsala, Sweden; Global consultation; The Brighton collaboration; CIOMS (the Council for International Organizations of Medical Sciences)

vaccine working group; Global Advisory Committee on Vaccine Safety; Vaccine safety net; Vaccine safety data links.

5.2 Experience in establishing a national “Adverse Events Following Immunization (AEFI) surveillance system” in Turkey (Dr Pervin Ozelci)

The current AEFI surveillance system was initiated in November 2003. Clear definitions and causality assessments were incorporated from the outset. Different functions were allocated to different levels of the health system, with a reporting system clearly defined. The system appears to be working well, with timely investigation of reported events and appropriate assessment of the causality of events, particularly for sever events, even though improvement is required to be able detect estimated number of mild and moderate adverse events.

5.3 Immunization quality and safety in the European Region: achievements and special focus on vaccine supply and management (Mr Denis Maire)

The aim of immunization quality and safety (IQS) is to ensure the quality and safety of immunization services by establishing quality assurance and quality control systems at each step of the immunization process from vaccine procurement to the point of use. IQS priorities for 2005 were for every country to adopt vaccine regulations to ensure quality, institute quality-assurance system to eliminate vaccine freezing, set up effective stock-management system to monitor consumption and wastage of vaccines and avoid shortage and increase compliance with best injection practices, and to render AEFI Surveillance system functional.

Main challenges to effective vaccine procurement include lack of synchronisation between the procurement and the budgeting/funding cycles, and the fact that most forecasting is done on the basis of historical use and administrative norms and not on actual wastage and requirements. There is limited competition in procurement due to vaccine licensing requirements and arrangements suppliers, lack of information about the world vaccine market, and reliance only on traditional suppliers. The entities involved in procurement need stronger coordination, and regular performance evaluation needs to be implemented.

The priority concern in the area of vaccine management is to evaluate the capacity of vaccine storage and distribution systems in maintaining temperature, to identify weaknesses and to take appropriate action. Assessments conducted in 9 countries have shown a range of capacities measured over 7 key areas, with vaccine deliveries and minimizing damage being the most challenging area.


5.4 Experience in upgrading vaccine regulations and supply system in Latvia (Dr Jurijs Perevoscikovs)

A number of problems and gaps in the vaccine procurement system in Latvia were identified. These included a very generic 5-year immunization plan for 2001-2005 that stated the main directions but lacked detail. There were problems in maintaining a reserve vaccine stock of 25% as desired. No long term contracts with suppliers could be established and vaccine lot release had not yet been implemented. As there were only 2 vaccine suppliers there was no competition and vaccine volumes were exactly determined. There was no convenient tool for assessment of quotations, no account being made for quality or ease of use, the only criterion used being price. Furthermore, there was no direct contact with the vaccine manufacturers, all vaccines being purchased through wholesalers.

Identified solutions to these problems included the establishment of two-year agreements with suppliers; expanding the evaluation criteria to include not only the price but also efficiency; adverse event ratio and other factors; and establishing arrangements for variable volumes of vaccine to be purchased, provided through a range of deliveries from a minimum up to a maximum. The minimal volume of purchases will be guaranteed, and opportunities will be sought to conduct purchases directly from the manufacturers rather than going through wholesalers. Joint procurements with other countries in the Region could be beneficial in allowing better prices through more competition and more choice, reducing the staff costs and the time taken.

Topic 6: Introduction of new vaccines into national immunization programmes: perspectives and support for decision making

6.1 New and underutilized vaccines; where we are and the way forward (Dr Andrei Lobanov)

Introducing new vaccines and technologies is one of the four key strategic areas of GIVS. The WHO Vaccine Introduction Guidelines is a new tool to aid decision making at a national level. Questions remain, however, on the capacity of many countries to effectively introduce new vaccines. The role of the Global Alliance for Vaccines and Immunization (GAVI) is to expedite and sustain evidence-based decisions at the global, regional and country levels regarding the use of new vaccines to prevent childhood deaths and illness. GAVI supports the introduction of Hib (Haemophilus influenzae type b), pneumococcal, rotavirus and meningococcal vaccines in appropriate eligible countries. Future areas for country support include gathering further evidence on disease burden and cost benefit analysis, technical support with decision-making and vaccine introduction, sustainability of immunization and monitoring of implementation and impact of immunization with new vaccines. Support is also necessary to strengthen surveillance, particularly with regard to increasing laboratory capacity.

6.2 Immunization against Hib in the Czech Republic (Dr Jiri Wallenfels)

In 1999 enhanced surveillance of Hib invasive disease was implemented, covering the entire population of 10.3 million people. The total incidence rates of Hib invasive disease was observed as approximately 1/100 000 at this time. In 2001 routine Hib vaccination of infants was introduced, using the tetravalent vaccine DiTePe+Hib. In 2002 enhanced surveillance of Hib

Subregional immunization programme managers’ meeting page 16 invasive disease was extended to include reporting of Hib vaccination failure. Disease incidence decreased after the introduction of routine Hib vaccination of infants and reached 0.5/100 000 and 0.2/100 000 in 2003 and 2004, respectively. Only six vaccine failures were observed in the period 2001-2004 out of about 360 000 vaccinees. The most noticeable decrease in Hib-related disease has been seen for meningitis. Neither Hib incidence in the age groups above 5 years, nor frequency of 'non-b' haemophilus invasive disease was seen to increase after introduction of routine Hib vaccination.

6.3 Hib Initiative: evidence based approach for decision making and policy development (Dr Patrick Zuber)

The mission of the Hib initiative is to expedite and sustain evidence-informed decisions at the global, regional and country levels regarding the use of Hib vaccination to prevent childhood meningitis and pneumonia. The initiative is country driven, focused on evidence-based decision making and dedicated to health system integration. The goals are to amplify the impact of Hib disease prevention through country consultation and support, regional information sharing, and global coordination; to assist GAVI eligible countries that have introduced Hib vaccine to make evidence-based decisions about the continuation of routine Hib vaccination; and to support evidence-based decision making about vaccine introduction in countries that have not introduced Hib vaccine.

6.4 Key aspects of an evidence based decision for Rotavirus vaccine – surveillance, disease burden, monitoring (Dr Robin Biellik)

Rotavirus infection is estimated to cause 440,000 deaths and 2 million hospitalizations globally each year. There are now 2 rotavirus vaccines entering the market, one manufactured by Glaxo-SmithKline (RotarixTM), the other by Merck (RotaTeqTM).

GSK has submitted Rotarix® for licensure with European Regulatory Authority (EMEA) and >60 countries worldwide, with 20 approved to date. Merck has submitted RotaTeqTM for licensure with EMEA, US FDA, and several countries in Asia and the Americas, though none have been approved to date.

The WHO Generic Protocol provides guidelines for rotavirus disease surveillance. The Guidelines recommend hospital-based surveillance with 1-3 sentinel sites per country collecting information on all children <5 years of age with severe diarrhoea and using a simple ELISA technology for testing. These guidelines are recommended for conducting studies to determine the cost-effectiveness and suitability for introduction of rotavirus vaccine into routine immunization systems.

6.5 Rotavirus epidemiology in Uzbekistan: report from pilot hospital based surveillance system (Dr Erkin Musabaev)

A study was established to determine the disease burden associated with rotavirus infection in Uzbekistan. A total of 817 children <5 years of age hospitalized with acute diarrhoea at 2 sites were enrolled in the study. A rotavirus antigen ELISA was used to test stool samples, with virus genotyping by PCR on selected positives. As an integral part of the study an economic burden assessment of hospitalized cases of rotavirus diarrhoea was made. The study found that rotavirus infection is one of the leading causes of acute diarrhea in Uzbekistan, with a substantial


economic burden to public health system and families. Rotavirus vaccine will reduce disease burden and health care costs.

It is estimated that rotavirus immunization will avert 1,500 deaths, 4,800 hospitalizations and $370,000 in hospitalization costs.

Topic 7: Advocacy, communication and partnership: Role in improving immunization service delivery and the European Immunization Week

7.1 European Immunization week – a tool for enhancing targeted advocacy and communication (Ms Aran Corrigan)

The goal of the European Immunization Week (EIW) is to increase vaccination coverage by drawing attention to and increasing awareness of the importance of every child’s need and right to be protected from VPDs, with special focus placed on activities to reach vulnerable groups. Lessons learned from the pilot activities in 2005 include:

The EIW provides a platform for regular communication activities or new initiatives;

It can be used to reach a wide variety of target audiences; It can be leveraged to gain access to top-level decision makers and media; It is an opportunity to work with both regular and new partners; There is strong potential for sharing of resources from country to country; Planning should commence early to allow time for production of

materials; Target audience research is critical to understanding key barriers and

developing an effective communications strategy.

7.2 Partnership with European Union (EU) and European Centre for Disease Prevention and Control (ECDC) (Dr Peet Tull)

The ECDC became operational in May 2005. Its mandate includes: Surveillance Risk identification and risk assessment Preparedness planning Response to health threats and events Training Communication Scientific opinions and guidance

ECDC has no legal powers, but its role is to coordinate concerted actions in the Region, initiate technical activities when needed and give technical support to EC Member States in implementation of Council recommendations.

7.3 Developing integrated communication strategy in Turkey (Lila Pieters)

An integrated communication strategy is being developed to increase awareness, skills and knowledge; improve practices and in the long term change behaviour. Analysis of existing services highlighted insufficient coordination amongst services providers, lack of knowledge of parents especially amongst the poor, limited awareness amongst policy and decisions makers

Subregional immunization programme managers’ meeting page 18 resulting in limited financial and human investment, and limited skills amongst services providers. Priority areas for communication intervention were identified as parent education, breastfeeding promotion, nutritional education with a focus on IDD and iron deficiency, and immunization.

Conclusions and Recommendations

Topic 1: Global and Regional Immunization Programme

The WHO European Region is very diverse with regard to health systems and health governance models used in Member States. Progress in provision and maintenance of immunization services has been notable and most countries in the Region are achieving greater than 95% coverage with routine EPI vaccines, through high quality and safe vaccines and good delivery practices. Immunization programmes in most of the countries are well established and mature, requiring a much sophisticated and advanced technical and financial support. While the Global Immunization Vision and Strategy (GIVS) provides a new framework within which immunization programmes can be strengthened and sustained in the future, many of the strategies identified are already being implemented in the European Region. GIVS provides Member States with the opportunity to review their national immunization policies and incorporate additional strategies that meet their country-specific needs and priorities, with special focus to integration with other health interventions, where appropriate, and health system strengthening. One of the major challenges is continued commitment and prioritization to ensure sustainability of the programme, particularly during health care system reforms ongoing in many countries of the Region.

1. Member States are urged to develop plans for strengthening and broadening national immunization services within the GIVS framework, and seek further political commitment and prioritization for their implementation, especially in the context of health care reforms, with sustainable resources;

2. WHO is requested to continue to provide and develop technical support and tools for implementation of activities within the GIVS framework and in line with the Regional Plan of Action;

Topic 2: Accelerated Disease Control: Polio eradication, measles and rubella elimination and CRI prevention

The Region is maintaining its polio-free status, but delays in achieving the global polio eradication goal, a recent increase in the spread of wild poliovirus from remaining endemic foci and reduced levels of funding support for Regional polio eradication activities, places the Region at increasing risk of importation of wild polioviruses and re-establishment of virus circulation in areas with low immunization coverage. Laboratory containment of wild poliovirus stocks, infectious and/or potentially infectious materials is proceeding well, and all Members States have completed the Survey and Inventory phase.

Regional goals of measles and rubella elimination and prevention of CRI by 2010 were endorsed by the Regional Committee in September 2005, and considerable progress has been made towards achieving these goals. All Member States use routine two dose measles vaccine and 48 use rubella vaccines. However, further work is needed in Member States with regard to ensuring political commitment, strengthening surveillance capacity and improving advocacy for and communication on the benefits of immunization.


3. Member States are urged to: • Maintain high routine immunization coverage and high quality surveillance for AFP and

polioviruses, targeting particularly high-risk areas, to prevent the spread of imported wild polioviruses and circulating vaccine-derived polioviruses (cVDPVs);

• Implement polio laboratory containment activities required for global certification of polio eradication;

• Report case-based data on measles and rubella when the incidence of disease reaches a level at which most cases can be laboratory confirmed and single case data entry is feasible;

• Initiate monthly reporting of rubella cases and quarterly reporting of CRS cases from January 2006:

• Make use of the work undertaken during the SIAs as an opportunity to build national capacity and have a long term impact on strengthening routine immunization services, immunization quality and safety and AEFI surveillance.

4. WHO is requested to: • Continue to provide technical support to complete polio laboratory containment

activities; • Develop clear criteria and guidelines for surveillance and reporting of measles, rubella

and CRS cases and outbreaks; • Provide technical support and training to Member States to enable electronic data transfer

and/or online data entry of surveillance data; • Explore the possibility of establishing a platform to exchange and share experiences on

best practices between national disease control staff.

Topic 3: Laboratory Networks for Accelerated Disease Control

Early detection of circulating polioviruses through high quality, laboratory-based polio surveillance is critical for sustaining the polio-free status of the European Region. The WHO Polio laboratory network provides a successful model for improving national standards of laboratory investigation and opportunity to expand to other communicable disease control initiatives.

The WHO measles laboratory network is now well established in the Region, and many laboratories are providing laboratory diagnosis of rubella as well. Surveillance capacity, however, requires strengthening and the network remains under funded and additional resources are required to meet the demands of laboratory-confirmed case-based investigation.

5. Member States are urged to: • Maintain and increase the level of financial, technical and administrative support

provided to polio and measles/rubella laboratories; • Sustain high-quality laboratory-based AFP surveillance, complementing it, where

appropriate, with enterovirus and environmental surveillance using WHO recommended procedures and standards defined in WHO guidelines;

• Ensure the timely transport of good quality samples (including alternative samples like enterovirus or environmental samples for polio or dry blood for measles and rubella, where appropriate) to laboratories;

• Maintain and improve the completeness and timeliness of laboratory data reporting;


• Facilitate timely genotyping and characterization of representative virus isolates; • Use existing laboratory infrastructure to expand to other communicable diseases like

influenza, rotavirus, Hepatitis etc. where feasible and appropriate. 6. WHO is requested to: • Ensure continued support with supplies and equipment to selected regional, national and

sub-national laboratories; • Ensure high level of expertise in the laboratory networks by offering training

opportunities.

Topic 4: Strengthening immunization systems: Updated policies, improved planning, surveillance and monitoring

Strengthening routine immunization systems and targeting vulnerable and hard-to-reach groups, remains a priority within the Region. New tools are available within the Region for strengthening immunization systems, including the use of integrated work plans including advocacy and communication, integrated assessments and training for surveillance, multi-year planning (MYP), Reach Every District (RED) strategy and improving information management systems. These can assist Member States in linking immunization to broader health sector planning and financing.

Some Member States have improved their immunization programme monitoring systems allowing for better data use and programme management. WHO has developed integrated surveillance assessment, training and monitoring tools to further strengthen national capacity, particularly at district level.

7. Member States are urged to: • Review tools developed for strengthening immunization services and adopt them where

appropriate; • Use WHO recommended immunization coverage and VPD surveillance indicators; • Use a combination of strategies and activities to reach vulnerable and difficult to reach

groups; • Advocate for immunization services actively and ensure community participation; • Coordinate training for immunization services provided through the national educational

system and stakeholders to ensure that they are complementary rather than parallel; 8. WHO is requested to: • Finalise the integrated assessment and training tools and support their use in Member

States; • Facilitate coordination of multinational and synchronised activities targeted at vulnerable

groups.

Topic 5: Immunization quality and safety

Substantial progress has been made in quality and safety of immunization services through training and assessment of vaccine regulation, vaccine procurement and systems for cold chain and logistics. Further improvement in these key areas is required in several countries of the Region. Significant progress has been made in establishing AEFI surveillance and all Member States now report the existence of national AEFI surveillance systems. However, the sensitivity of AEFI detection and capacity for analysis of data is still weak in many countries.


9. Member States are urged to: • Strengthen AEFI surveillance system and improve data management and analysis; • Continue to improve vaccine procurement procedures; • Eliminate problems associated with vaccine freezing following a comprehensive

evaluation of the national vaccine store management situation; • Ensure that recommended injection safety procedures are universally implemented; • Continue training of national and local staff on immunization quality and safety. 10. WHO is requested to continue to provide training and technical assistance in key immunization quality and safety areas, including vaccine regulation, vaccine procurement, vaccine management, (including cold chain and logistics), injection safety and AEFI surveillance systems.

Topic 6: Introduction of new vaccines into national immunization programmes: perspectives and support for decision making

Many countries of the Region have demonstrated the ability to successfully introduce new vaccines into routine immunization schedules. Introducing surveillance for diseases preventable with these new vaccines is essential for assessing the impact and cost benefit of adopting these new vaccines. WHO has recently developed “Vaccine Introduction Guidelines” outlining the decision-making process for introduction of new vaccines. Maintaining and strengthening collaboration between Member States, WHO and other partners such as the GAVI, Hib Initiative and ADIPs is critical for effective evidence-based policies on the introduction of new vaccines.

11. Member States are urged to: • Familiarise, adjust and use the WHO Vaccine Introduction Guidelines for evidence based

decision making for introduction of new vaccines; • Collect information and evidence through disease burden and cost effectiveness studies

and/or establishing/strengthening surveillance for new VPDs for which vaccines exist or will be available in the near future; such as Hib, pneumo, meningo, rotavirus, Human Papilloma Virus and Hepatitis A;

12. WHO is requested to: • Continue to provide Member States with technical support and advice for collection of

national evidence on disease burden and cost benefit for decision making on potential introduction of new vaccines;

• Assist countries in the exchange of technical resources, expertise and information for evidence-based decision making on the introduction of new vaccines.

Topic 7: Advocacy, communication and partnership: Role in improving immunization service delivery and the European Immunization Week

Several countries have developed and implemented effective advocacy initiatives, and there is a great potential to share experiences and further develop advocacy and communication strategies tailored to the needs of countries through valuable lessons learned within the Region. The first European Immunization Week, held in October 2005, has been heralded as a very successful event in raising the profile of the immunization programme both within national authorities and the community. No negative repercussions of the heightened publicity for immunization have been observed.

Subregional immunization programme managers’ meeting page 22 Funding shortage and limited external partner support for immunization and VPD control programmes both at the regional and national level is a major restriction for further success in strengthening and broadening implementation. Collaboration with newly established European Centre for Disease Prevention and Control provides a great opportunity to broaden partnership for immunization programme in the Region. The ECDC has expressed interest in technical collaboration with WHO not only for Member States of the European Union, but also for neighbouring countries.

13. Member States are urged to: • Develop and implement strategies for proactively addressing advocacy and

communications issues integrated into their national immunization plans; • Strengthen coordination and communication among partners and mobilize resources

through the National Immunization Coordination Committees (NICC) led by the Ministries of Health;

• Start the planning process for participation in the European Immunization Week to be held in October 2006.

14. WHO, in collaboration with Member States and partners should: • Continue to place high priority on strong coordination and effective communication

between all partners engaged in supporting immunization systems; • Continue to seek out and engage new relevant partners; • Maintain and strengthen links with existing partners, particularly the European Union and

ECDC; • Support countries in developing strategies and plan of action for implementation of

European Immunization Week in 2006.

Subregional immunization programme managers' meeting

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