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Certification of
Poliomyelitis Eradication
EUROPEANREGIO
NDECLAREDPOLIO-FREE
Fifteenth meeting of the EuropeanRegional Certification
Commission
Copenhagen, 1921 June 2002
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Fifeenth meeting othe European Regional Commission
or the Certicationo Poliomyelitis Eradication
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KEYWORDS
POLIOMYELIIS prevention and controlCERIFICAIONEPIDEMIOLOGICAL
SURVEILLANCE standardsIMMUNIZAION PROGRAMMES
CONAINMEN POLIOVIRUSESNAIONAL HEALH PROGRAMMESEUROPE
World Health Organization 2005
All rights reserved. he Regional Oice or Europe o the World
Health Organizationwelcomes requests or permission to reproduce or
translate its publications, in part or inull.
he designations employed and the presentation o the material in
this publicationdo not imply the expression o any opinion
whatsoever on the part o the World HealthOrganization concerning
the legal status o any country, territory, city or area or o
itsauthorities, or concerning the delimitation o its rontiers or
boundaries. Where the
Address requests about publications o the WHO Regional Oice
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publications) [email protected] (or permission to reproduce
them) [email protected] (or permission to translate them)
by post Publications WHO Regional Oice or Europe Scherigsvej 8
DK-2100 Copenhagen , Denmark
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Fifeenth meeting othe European Regional Comm
or the Certicationo Poliomyelitis Eradicatio
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ABSTRACT
Te feenth meeting o the European Regional Commission or the
Certicao Poliomyelitis (RCC) was held at the World Health
Organization (WHO) REurope, Copenhagen, Denmark on 1921 June 2002.
In this unique meeting,
national documents prepared by all 51 Member States o the Region
in order decision: to certiy the European Region o WHO as
poliomyelitis ree. Temeeting were to assess progress made towards
certication o poliovirus eradRegion, to discuss ongoing activities
or the post-certication period (that is, immunization services,
polio surveillance and the regional polio laboratory nMember States
on the regional and global situation regarding polio
eradicatioconsisted o two plenary and our private sessions.
Certication was based on
detailed scientic data provided by each country and supplemented
by WHOwith an emphasis on national poliovirus surveillance. Each
National Certicaprovided an offi cial statement summarizing the
evidence that their country hindigenous wild poliovirus
transmission or the previous three years. In additspecial
presentations to the Commission during the meeting. Based on careuo
the evidence presented, the RCC concluded that the transmission o
wild pinterrupted in all 51 Member States o the European Region
and, on 21 June 2
certied the European Region to be poliomyelitis ree. Te RCC
emphasized eradication has been achieved, importation o wild
poliovirus rom polio-endand thereore each Member State and WHO must
sustain the highestlevels oand surveillance.
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Introduction
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Te ceremony o signing o the certicate at the Ny
CarlsbergGlyptotek
Statements o Dr Marc Danzon, Regional Director or Europe o
the World Health Organization; Sir Joseph Smith, Chairman o
thEuropean Regional Certication Commission; Mr Rudol Horndl
Representative o Rotary International; Mr Philip OBrien,
Region
Director or Europe o the United Nations Childrens Fund
(UNICEF); Dr David Fleming, Acting Director, Centres or
Disea
Control and Prevention, Atlanta, USA; Ellyn Ogden,
Representat
o US Agency or International Development; Dr Daniel aranto
Director, Department o Vaccines and Biologicals, WHO, GenevaDr
George Oblapenko, Medical Offi cer, WHO Regional Offi ce or
Europe
Te European Regional Certication Commission
Plenary Session o the European Regional Certication Commissi
on 20 June 2002
Plenary Session o the European Regional Certication Commission
21 June 2002
Private Sessions o the RCC
Contents
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I N T R O D U C T I O N
W O R L D H E A L T H O R G A N I Z A T I O NE U R O P E A N R E
G I O N
R E G I O N A L C O M M I S S I O N F O R T H E C E R T I F I C
A T I OO F P O L I O M Y E L I T I S E R A D I C AT I O N
SI R JOSEPH SM IT H CH AI R MA NSIR JOSEPH SMITH, CHAIRMAN DR G
E OR G E F DR EJE RDR GEORGE F. DREJER
CERTIFICATE
T H E C O M M I S S I O N C O N C L U D E ST H E C O M M I S S I
O N C O N C L U D E S
F R O M E V I D E N C E P R O V I D E DF R O M E V I D E N C E P
R O V I D E D
B Y T H E N AT I O NA LB Y T H E N AT I O N A L
C E R T I F I C AT I O N C O M M I T T E E SC E R T I F I C A T
I O N C O M M I T T E E S
O F T H E 5 1 M E M B E R S TAT E SO F T H E 5 1 M E M B E R S T
A T E S ,
T H AT T H E T R A N S M I S S I O NT H A T T H E T R A N S M I
S S I O N
O F I N D I G E N O U S W I L D P O L I O V I RO F I N D I G E N
O U S W I L D P O L I O V I R
H A S B E E N I N T E R RU P T E DH A S B E E N I N T E R R U P
T E D
I N A L L C O U N T R I E S O F T H E R E G II N A L L C O U N T
R I E S O F T H E R E G I
T H E C O M M I S S I O N O N T H I S D AT H E C O M M I S S I O
N O N T H I S D A
D E C L A R E S T H E E U R O P E A N R E G ID E C L A R E S T H
E E U R O P E A N R E G I
P O L I O M Y E L I T I S F R E E .P O L I O M Y E L I T I S - F
R E E .
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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D
I C A T I O N F I F T E E N T H M E E T I N G O F T H E E U R O P E
A N R E G I O N A L
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I N T R O D U C T I O N
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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D
I C A T I O N F I F T E E N T H M E E T I N G O F T H E E U R O P E
A N R E G I O N A L
Sir Joseph Smith, Chairman o the Regional Certication Commission
(RCCand Dr Roberto Bertollini, Director o echnical Support, gave an
opening adWHO Regional Director. Secretaries or the meeting were Dr
George Oblapenlu and Dr Steven Wassilak. Rapporteur or the meeting
was Dr Ray Sanders. Tis provided in Annex 1, and the list o
participants in Annex 5.
Tis report o the historic meeting begins with the ceremony o
signing the ceberg Glyptotek and then the RCC and the design o the
certication process iTe materials documenting the two plenary
sessions are presented and discusprivate meetings o the RCC are
also reected in this report.
SCOPE AND PURPOSE
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I N T R O D U C T I O N
L A C O M M I S S I O N C O N C L U TL A C O M M I S S I O N C O
N C L U T,
S U R L A B A S E D E S D O N N E SS U R L A B A S E D E S D O N
N E S
C O M M U N I Q U E S PA RC O M M U N I Q U E S P A R
L E S C O M M I S S I O N S N AT I O N A L E SL E S C O M M I S
S I O N S N AT I O N A L E S
D E C E R T I F I C AT I O ND E C E R T I F I C A T I O N
D E S 5 1 TAT S M E M B R E SD E S 5 1 T A T S M E M B R E S
,
Q U E L A T R A N S M I S S I O NQ U E L A T R A N S M I S S I O
N
D U P O L I O V I R U S S AU VA G ED U P O L I O V I R U S S A U
VA G E
I N D I G N E A T I N T E R R O M P U EI N D I G N E A T I N T E
R R O M P U E
D A N S T O U S L E S PAY S D E L A R G I OD A N S T O U S L E S
P AY S D E L A R G I O
L A C O M M I S S I O N D C L A R EL A C O M M I S S I O N D C L
A R E
A U J O U R D H U I L A R G I O N E U R O P EA U J O U R D H U I
L A R G I O N E U R O P E
I N D E M N E D E P O L I O M Y L I T E .I N D E M N E D E P O L
I O M Y L I T E .
O R G A N I S AT I O N M O N D I A L E D E L A S A N T R G I O N
E U R O P E N N E
C O M M I S S I O N R G I O N A L E P O U R L A C E R T I F I C
AT I O ND E L R A D I C AT I O N D E L A P O L I O M Y L I T E
CERTIFICAT
SI R JOSEPH SM IT H PR SI DEN TSIR JOSEPH SMITH, PRSIDENT DR G E
OR GE F DR EJE RDR GEORGE F. DREJER
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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D
I C A T I O N F I F T E E N T H M E E T I N G O F T H E E U R O P E
A N R E G I O N A L
A N H A N D D E R V O N D E N N AT I O NA N H A N D D E R V O N
D E N N AT I O N
Z E R T I F I K A T I O N S A U S S C H S SZ E R T I F I K A T I
O N S A U S S C H S S
D E R 5 1 M I TG L I E D S TA AT E ND E R 5 1 M I T G L I E D S
T A AT E N
V O R G E L E G T E N F A K T E N K O MV O R G E L E G T E N F A
K T E N K O M
D I E K O M M I S S I O N Z U D E M S C HD I E K O M M I S S I O
N Z U D E M S C H
D A S S D I E B E RT R A G U N G V OD A S S D I E B E R T R A G
U N G V O
E I N H E I M I S C H E M P O L I O W I L D VE I N H E I M I S C
H E M P O L I O - W I L D V
I N S M T L I C H E N L N D E R NI N S M T L I C H E N L N D E R
ND E R R E G I O N U N T E R B R O C H E N W O RD E R R E G I O N U
N T E R B R O C H E N W O R
D I E K O M M I S S I O N E R K L R TD I E K O M M I S S I O N E
R K L R T
D I E E U R O P I S C H E R E G I O N H ED I E E U R O P I S C H
E R E G I O N H E
Z U R P O L I O F R E I E N R E G I O NZ U R P O L I O F R E I E
N R E G I O N
ZERTIFIKATW E L T G E S U N D H E I T S O R G A N I S A T I O
N
E U R O P I S C H E R E G I O N
R E G I O N A L K O M M I S S I O N F R D I E B E S T T I G UD E
R P O L I O - E R A D I K A T I O N
SIR JOSEPH SMITH VORSITZENDERSIR JOSEPH SMITH, VORSITZENDER DR G
E OR G E F DR EJE RDR GEORGE F. DREJER
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I N T R O D U C T I O N
, ,
5 1 ,5 1 ,
, ,
. .
SI R JOSEPH SM IT H CH AI R MA NSIR JOSEPH SMITH, CHAIRMAN DR G
E OR GE F DR EJE RDR GEORGE F. DREJER
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he historic decision to certiy the European Region o the
WorldHealth Organization (WHO) poliomyelitis-ree was announced
thismorning at the meeting o the European Regional Commission orthe
Certiication o Poliomyelitis Eradication (RCC) in Copenhagen.his
decision is the most important public health milestone o the
newmillennium. It means there is no longer wild poliovirus
circulation inthe European Region. It means that some 873 million
people living inthe Regions 51 Member States do not need to ear
contracting endemic
wild poliovirus any more.he European Region has been ree o
indigenous poliomyelitis or
over three years. Europes last case o indigenous wild
poliomyelitis oc-
C H A P T E R 1 T H E C E R E M O N Y O F S I G N I N G O F T H
E C E R T I F I C A T E A T T H E N Y C A R L S B E R G G L Y P
T
curred in eastern urkey in 1998, when the virus paralysed a
two-year-old unvaccinpoliovirus imported rom poliomyelitis-endemic
countries remains a threat. As wein 2001 alone, there were three
poliomyelitis cases among Roma children in Bulgaralytic case in
Georgia all caused by poliovirus originating rom the Indian
subcon
remember a decade ago, imported poliovirus paralysed 71 people
and caused 2 deain the Netherlands that reused vaccination.
he path to a poliomyelitis-ree European Region began in 1988,
ollowing the cHealth Assembly to eradicate poliomyelitis. A
partnership was set up, spearheadedInternational, the US Centers or
Disease Control and Prevention (CDC) and UNI
Opening remarks by Dr Marc Danzon, Regional Director, WHO
Regional Offic
he ceremony o signingo the certiicate
at the Ny Carlsberg Glyptotek
PLENARY SESSION OF
HE EUROPEAN REGIONAL CERIFICAION COMMISSIOON 21 JUNE 2002
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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D
I C A T I O N F I F T E E N T H M E E T I N G O F T H E E U R O P E
A N R E G I O N A L
Commission in Paris in March 1996. It was an historic meeting,
where the Re
Commission was just starting this work and had questions to
clariy and deincedures and criteria or certiication. Six years have
elapsed since that meetinboth the eradication programme and
certiication activities have matured thrintensiied eorts to reach
the highest quality level possible, enabling the Regpoliomyelitis!
Since the Global Poliomyelitis Eradication Initiative was launched
in 1988,been certiied poliomyelitis-ree: the WHO Region o the
Americas in 1994 an
Paciic Region in 2000. Poliomyelitis cases have dropped rom an
estimated 31988 to just 480 reported cases in only 10
poliomyelitis-endemic countries in Success, which we are
celebrating today, is the result o a great collaborativber States,
the hard work o public health workers in the ield, and a solid
intecoordination with WHO, particularly with Rotary International,
CDC AtlantSeveral donor nations o the Region, as well as charities,
have contributed subbrating a truly international collaboration or
the beneit o our children in al
However, we cannot rest. Activities must continue to sustain
high levels o coverage, with supplementary immunization activities
where needed, and to ratory-based surveillance and containment o
polioviruses, until global eradiSo, polio-eradication work is not
over till its over globally! And it will continuknow, the Regional
Oice has received irm commitments rom all ministriesimmunization
and surveillance.
It is a great pleasure or me to congratulate you all on this
tremendous achiEuropean Region but also or the global eorts to
eradicate poliomyelitis. It is
open this historic meeting.
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C H A P T E R 1 T H E C E R E M O N Y O F S I G N I N G O F T H
E C E R T I F I C A T E A T T H E N Y C A R L S B E R G G L Y P
T
he WHO European Region stretches rom Greenland in the north-west
to the lthe east, and rom the northern shores o Europe and Asia to
the Greek island o CIts 873 million people live in 51 dierent
countries, which include urkey, Israel an
Statement by Sir Joseph Smith, Chairman, Regional Certification
Comm
republics. o certiy as polio-ree this large, disparatsound
evidence and careul scientiic judgement.
he Global Certiication Commission (GCC) setples and criteria or
certiication in 1995. he GCC the term eradication should apply only
to global ccommissions should initially certiy interruption
oindigenous wild poliovirus, a status that in brie maree. Guided by
the GCC recommendations, includto certiication, or a polio-ree
saety-margin o 3 ylance and testing to exclude any possible silent
transpean Regional Commission (RCC) irst met in 1996 Certiication
only becomes possible as a result o tion. hroughout its work, the
Commission has kepthe intensive immunization campaigns that have
led
o polio transmission in the Region. hese include not only
national programmes, vaccinations o the MECACAR and MECACAR-plus
operations, coordinated collaborating countries o the WHO European
Region and WHO Eastern Mediter
year, rom 1995 to the present.
Staging by epidemiological groups of countries
he Commission agreed that it would be essential to address its
task in a structuredmeeting in 1996 the RCC thereore accepted a WHO
proposal to review countries sive epidemiological groups. he irst
our groups comprised the western, nordic-and southern countries
thought to have been ree o polio or more than 8 years. N
would be the central/eastern, recently endemic countries
believed to have brought between 3 and 8 years earlier. he sixth
MECACAR group in the eastern part o seventh, the Russian
Federation, had all experienced endemic polio within the prevtook
part in the MECACAR operations.
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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D
I C A T I O N F I F T E E N T H M E E T I N G O F T H E E U R O P E
A N R E G I O N A L
or many years. his also proved to be the case in many western
European co
cians saw little need to prove what they perceived as the
sel-evident absence othe RCC and WHO gave much attention to the
value o other evidence.
Although AFP surveillance has been the single most important
tool, the Coployed a range o additional inormation including:
national health statistics;lance; environmental surveillance;
laboratory tests or poliovirus; risk groupsment; and Manuals o
Operations.
National health statisticsNational mortality and morbidity
statistics, polio vaccination rates throughouported poliomyelitis
cases year-by-year were documented, together with the nhead o
population. UN statistical data and a WHO Report in 2000 on
healthwere also taken into account. hese data were used
collectively as indicators ocessibility o health services, and
indirectly as indicators o the likelihood thatparalysis would, in
practice, be seen by doctors and appropriately investigated
Enterovirus surveillance
Enterovirus surveillance tests or poliovirus excretion by
inected persons, bysurveys or the use o routine diagnostic
laboratory tests. he value o such eages, numbers and national
distribution o the populations tested, and the nattested
patients.
Environmental surveillance
he culture o sewage samples or poliovirus is an indirect means o
detectingin the population sample rom which the sewage is derived.
his procedure, tsurveillance, has been developed and applied in
several countries and has prople, in Finland and in the
Netherlands, to monitor localities where groups whreligious reasons
live. he method has also been useul elsewhere, such as mo
Laboratory tests for poliovirus
hese tests underpin surveillance and it is thereore essential to
ensure that thWHO thereore established a regional network o
accredited reerence laborato meet appropriate perormance standards
and regularly to pass tests on blithe validity o their results.
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the preparation o national inventories o laboratories that may
hold stored sample
viruses. Documentation o the completion or near completion o
this irst phase orequirement or Regional certiication.
Manual of Operations
he Commission agreed a ormat o tables, inormation and comment in
which thsets should be provided, set out in a Manual o Operations.
he use o this uniorormat acilitated interpretation and analysis o
data and helped in identiying whe
missing.
The certification process
he health minister o each country was asked by the WHO Regional
Director to ependent National Certiication Committee (NCC), whose
members should be sentists not directly involved with eradication
activities. he NCCs task would be to cwhen appropriate approve,
inormation collected by national sta and documentedManual o
Operations or submission to the Commission or review. In this
way,eect, an independent judgement o the polio status o their own
countries. hrough successive meetings, held in dierent countries o
the Region, the Comthe national documentation sets. Prior to
meetings, all members studied the documaddition, two members took a
lead assessment role or each country. WHO oicerpendent evaluation.
he Commission then met to discuss and agree preliminary cthe NCC
chairpersons gave spoken presentations. he national representatives
coutioned in order to clariy uncertainties and, ater urther
deliberation in camera, th
were presented to the National Certiication Committees.
C H A P T E R 1 T H E C E R E M O N Y O F S I G N I N G O F T H
E C E R T I F I C A T E A T T H E N Y C A R L S B E R G G L Y P
T
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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D
I C A T I O N F I F T E E N T H M E E T I N G O F T H E E U R O P E
A N R E G I O N A L
In due course, NCCs provided updated inormation, including the
responses
and recommendations o the RCC reviews. his iterative process was
supplemselected key areas by Commission members, including parts o
the Region wipolio, such as Albania, Azerbaijan, Bulgaria, Georgia,
the Kosovo area, UzbekRCCs work was urther supported by the reports
o technical visits to countrand consultant experts to assess the
quality o surveillance. Prior to Regional certiication, each NCC
was asked to sign a statement o believed their country to have been
ree rom indigenous wild poliovirus tran
3 years. Such a ormal statement, signed by senior proessionals
who know thvalued by the RCC.
WHO Eastern Mediterranean Region (EMR)
EMR has made great progress in polio eradication despite marked
socioeconcountries, as well as protracted conlicts. Nevertheless,
in 2002 endemic polioparts o the EMR, and people moving illegally
across borders might carry wiltries o the European Region. he two
WHO regions have thereore collaborathe MECACAR operations. Members
o the two commissions have attendeand a report on EMR has eatured
in most RCC meetings.
Wild poliovirus importation
Until wild poliovirus has been eradicated globally, recently
inected travellerstries may carry the virus to other parts o the
world. Consequent outbreaks amgroups must be prevented by
maintaining high immunization rates and by su
detect and respond to importations quickly. Provided there is
convincing evidis rapidly stopped, the Global Commission has
concluded that importation evstatus o a region already certiied by
its Commission.
he RCC evaluated reports on the two importation events identiied
in theperiod ollowing the detection o the last case o indigenous
inection in urkhe irst importation event, in March 2000, was among
the Roma people o Bcultured rom two aected children and a urther
two who remained well. h
single isolate rom a child with meningoencephalitis in Georgia
in Septembermolecular genotyping showed the strains to have
originated in the Indian subtries undertook appropriate
investigations and vigorous immunization campplace in neighbouring
countries, with special attention to Roma in the case oExtensive
sampling subsequently ound no evidence o continued transmissio
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Presentations by the NCCs o 16 key countries were also heard at
this meeting.
or various reasons, such as a need to clariy the extent to which
surveillance had rriods o conlict, or to evaluate urther the
progress made in containment. O partiwere presentations rom
Bulgaria and Georgia on their recent importations o wildIndian
subcontinent. he RCC concluded in March 2002 that it probably could
in June 2002 certiy thlio-ree provided certain missing items o
inormation were supplied and ound to and provided no new imported
virus transmission episodes occurred beore then.
emphasized that, until wild virus was eradicated globally, polio
outbreaks due to viremained possible, especially among at-risk
groups. It was thereore essential that atained high levels o polio
immunization and surveillance. In the event, at its iteenth meeting
on 21 June 2002, ater consideration o the provided, including
reports o assessment missions to key countries by CommissioWHO
teams, the Regional Commission declared that indigenous wild
poliovirus tbeen interrupted in the WHO European Region, and the
Region was declared poli
The future
Immunization and surveillance
In view o the risk rom imported wild viruses, the WHO Regional
Committee or 2000 a resolution to maintain high levels o polio
immunization and surveillance ucation has been achieved.
Underlining the continuing importance o this resolutioDirector in
2002 asked all ministers o health to provide inormation on their
uturtaining polio immunization and surveillance, including an
action plan or dealing w
tion o wild virus.
Containment
he WHO Global Action Plan on Laboratory Containment proceeds in
phases. Fothe Region, countries addressed the irst, laboratory
inventory phase o this actionthrough the subsequent phases now
becomes necessary. By the time o global certipoliovirus samples
must have been destroyed or conined in biosaety level 3 conta
Annual Updates
he RCC intends to meet annually in the uture to consider concise
updates rom ewill include ongoing surveillance and immunization
data, as well as progress reporwhich will also be monitored by
means o validation exercises and consultant repo
C H A P T E R 1 T H E C E R E M O N Y O F S I G N I N G O F T H
E C E R T I F I C A T E A T T H E N Y C A R L S B E R G G L Y P
T
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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D
I C A T I O N F I F T E E N T H M E E T I N G O F T H E E U R O P E
A N R E G I O N A L
sion o indigenous wild poliovirus has been interrupted
throughout the Regio
he Commission greatly appreciates the work o the chairpersons
and memRegions 51 countries, who have invariably answered the
Commissions questiresponded willingly to recommendations.
he RCC would like to record thanks to its Secretary, Dr David
Salisbury, band expertise he brought to our assessments and or his
excellent work as rapo our meetings. We also thank Dr Nikolaj
Chaika and Dr Ray Sanders, who wthe remaining meetings.
here are many others to whom thanks are due, including the
experts whthe RCC, and the WHO ield oicers who work in the
countries o the Regionlio eradication Rotary International, CDC
Atlanta, UNICEF and USAID hparticipants in the eradication
programme, but their representatives have alsotors to our meetings.
he RCC especially appreciates the work o the members o the WHO
poliOice, Copenhagen. It is a particular pleasure to recognize the
outstanding leOblapenko, and the ine contributions o his senior
colleagues, Dr Galina LipWassilak. Among those upon whose work the
RCC depends are the secretariMs Johanna Kehler and Ms atiana
Michaelson, whose unailing and ever helinvaluable.
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hank you or that kind introduction. As a European citizen, I am
very proud, hto be able to witness this historic event. But
speaking on behal o the more than 1.2o Rotary in 163 countries and
especially on behal o the more than 250 000 Europ
Statement by Mr Rudolf Horndler, representative of Rotary
Internatio
can also express our happiness and pride in having remilestone
and I can assure you that we will do everyt
ensure that nothing derails our dream o a polio-reeto invite you
to ollow me on a short review o Rotaryour ight against Polio. In
1979, Rotarians in the Philippines, with the helpFoundation,
carried out the irst nationwide immunitries ollowed. Encouraged by
the success o these nacampaigns, Rotary International in 1985
started its ihumanitarian activity: the ight against polio.
Contrary to a widely held belie, even among Rotawhen Rotary
International irst turned its attention acrippling disease, Rotary
did not intend, plan or prompolio. All we planned and promised in
1985 was to ra
then calculated at US$ 120 million, to provide ree, oral
poliovirus vaccine to immuo the world by 2005, Rotarys 100th
anniversary. But instead o the goal o US$ 120 million, more than
US$ 220 million was reach
pledges, where European countries were among the top achievers.
hrough additiinterest, by the year 2005, Rotarys inancial
contribution to the global ight against Pwill have reached US$ 500
million. And besides the money, Rotary International covolunteer
eort o its huge membership and others they could mobilize, helping
emobilization and the logistics o the immunization campaign.
hereore, when in May 1988 the World Health Assembly committed its
Membto the global eradication o polio, Rotary International was
ready and willing to
coalition o partners to achieve this high goal, spearheaded by
WHO, Rotary InterUNICEF and joined by the health authorities o all
polio-endemic countries. his diately highly successul example o
public and private sector cooperation. Rotarys primary roles within
the coalition were to provide vaccines, mobilize voimmunization
campaigns, coordinate eorts among coalition partners, advocate
o
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A very special challenge arose when the Kosovo Albanians reused
vaccina
authorities. Again, Rotarians could convince them o the beneits
o the immlenges arose and were also overcome in other
central/eastern European count he WHO European Region consists not
only o geographic Europe, but, sUnion belonged to it as a whole,
the Region now extends not only over all o tbut also the Newly
Independent States. It thereore extends rom the Atlantic rom the
Polar Sea to the Himalayas and the Black Sea, and shares borders
wcountries like Aghanistan, Iran, Iraq and Pakistan, belonging to
the WHO E
Region.But not until 1995 were coordinated immunization
activities between thesegions developed, and with the decisive help
o my predecessor as Chairman oPolioPlus Committee, past Rotary
International Director, Mario Grassi, Operstarted.Operation MECACAR
stands or the coordinated poliomyelitis eradication eCaucasus and
central Asian republics. his is a crucial area or polio
eradicatisome o the last countries where wild poliovirus is still
circulating. Without Operation MECACAR, we would probably not be
able to celebrattoday. It is a pity that my good riend Mario
Grassi, who worked so hard to acnot live to join in this
celebration.
Yet, in spite o this success and todays extraordinary
achievement, our greagainst polio worldwide is a unding gap o US$
275 million. his could threanate every child by 2005. Eradicating
polio is Rotarys top priority. o help ill the US$ 275 million u
launch its second membership undraising drive with the goal o
raising US$ 2002 and July 2003.
Rotary is also continuing
In addition, Rotary is continuing its eorts to convince national
governmentsinvest in a polio-ree world. Special public and private
sector advocacy task oand still are, active and also quite
successul. Donor governments have alread
US$ 1 billion to polio eradication. hese donor governments
include the Netdonations in Europe, and also our host country
Denmark and my own countr Already, Rotary is quite oten asked, What
comes ater polio?. o this tpossible answer: he question o whether
Rotary will ever join a new healthdecided upon the completion o
polio eradication. Until we inish this job, we
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I am delighted, on behal o UNICEF, to participate in todays
historic announcemo the European Region as polio ree is themajor
public health success story or theRegion and a giant step toward
global achievement o polio eradication. his goal w
Statement by Mr Philip OBrien, Regional Director for Europe,
UNIC
the recent UN Special Session or Children:A World which the
worlds nations re-committed to achieving
tion o poliomyelitis by the end o 2005. he certiication o Europe
as polio ree is a testamnerships, which over the last 14 years have
worked soacross the 51 countries o the Region to reach this
minership that enabled us to support the routine vaccina
partnership that allowed us to run successul NationDays, but also
one which has helped to provide vacciconlict zones, diicult
territories and to carry out amder immunization activities. Great
progress has been ing the Regions most hard-to-reach children:
minoriisolated by conlict, as well as reugee and internally d
UNICEF echoes the tributes we have heard today tgovernments and
individuals that have collectively created a polio-ree Europe.
hdeserved, and we in UNICEF are pleased that we have been able to
play a part in thas well as the global campaign.
Last year, with unds rom Rotary International, the American
Government, theDisease Control and Prevention, and other donors, we
were able to procure and dedoses o oral polio vaccine (OPV). In the
past 3 years, UNICEF procured and delivlion doses o OPV, worth over
US$ 10 million, to countries in the WHO Europeancountry oices have
worked with a range o partners to secure the cold chain, moband
advocate with political leaders to ensure polio eradication
activities. We must not be complacent. In 2001, we had polio cases
in Bulgaria and Georg
children o the minority Roma community were inected with
poliovirus o Indianchildren had not been vaccinated. We need to
attainand maintainhigh levels o rotion coverage, including against
polio, doing everything in our power to protect alcan do this
together, I do not doubt. Witness the excellence o the work WHO has
dto do in support o improved immunization and surveillance
systems.
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A N R E G I O N A L
I t is my great honour and a distinct pleasure to represent the
Centers or Dition (CDC), and the Government o the United States o
America to celebrateregion o eradicating polio orever rom the ace o
the earth. his work has b
Statement by Dr David Fleming, Acting Director, US Centers for
Disease Control
Member States o the WHO European Region, uthe World Health
Organization. It is indeed an historic accomplishment or wlaboured
so long and hard should be proud. I beeradicate polio can serve as
a model or uture pthe European Region and elsewhere, demonstrawhen
there is vision, leadership and a common he story o polio
eradication in this Region he groundwork or the initiative was laid
in 19into being o creating a coordinated action invo
tries in this Region and in the WHO Eastern Mstamp out the last
vestiges o polio. his new intion MECACAR, aimed to reach every
child witsynchronized National Immunization Days to s
sion across major portions o the continents o Europe and Asia.
he eort hathe lessons learned, in particular the collaboration
among national governmecause, have inluenced the approach to polio
eradication worldwide.
Poliomyelitis eradication is the model or building close
linkages between mence and public health implementation on a global
scale. he challenge beorextend all o the lessons in cooperation
learned rom Operation MECACAR iareas. We are also challenged to
complete the inal phase o polio eradication wide, thus preserving
orever the legacy o Operation MECACAR. CDC takes this opportunity
to thank the member countries o the EuropeaInternational, UNICEF,
USAID and all the other partners involved in this ini
nity CDC has had to participate in, contribute to and learn rom
this historic I would like to end my remarks on a personal note. he
sta at CDC will athe good memories o the many riends and colleagues
in the European Regiohad the pleasure o working. Many o you are
here today, so I take this opportyour historic work on this
triumphant occasion. he experience CDC has ha
d l l d h k l d b h h d
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O n behal o USAID Director Andrew Natsios, I would like to thank
the Certision or inviting USAID to participate in this auspicious
event. I congratulate all Mthe WHO European Region on this occasion
or achieving your goal o certiicatio
Statement by Ms Ellyn Ogden, Representative of the US Agency for
International
Perhaps more than any other public health programme, polio
eradication releclic health proessionals and humanitarians to leave
no child behind. Polio-eradicatopened our eyes to marginalized
groups and un-reached children: those most vuln
and disability. We must not orget them, or the other health
conditions they conroeradication as a oundation or strengthening
all health services, and as a bridge to Although we are here to
celebrate the European Regions polio-ree status, we mjust how
ragile that status is. here is still a long road ahead beore we can
ultimator polio altogether, and maintainingpolio-ree status until
that day may be more dterruption o wild virus transmission. In the
absence o disease, it becomes harder high and to detect low levels
o transmission. In addition, inishing containment is
Europe is not the same as when we started polio eradication in
1988, and it contWe must be prepared to meet the public health
challenges o the changing environmovements and political crises
warrant ongoing attention and revisions to plans ascontinue to
monitor routine immunization coverage at the subnational level in
thewith particular attention to high-risk groups, which may require
supplemental imm
progress in other aspects o your immunization provery proud o
the hard work done by vaccinators, vo
o health and all the organizations working in partnthis goal,
including Rotary International. he leadership provided by WHO in
both Europdle East has been strong and steady, including the
uMECACAR collaboration. his has helped to meet lenges in a
transparent and proessional way, and ovproblems as they have
arisen. I want to give special tOblapenko it is a joy and a
privilege to work with nizes the great dedication o all WHO
Regional Oito assure that the integrity o polio eradication data is
greatly valued by all donor agencies and sets a higprogramme.
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rom the region, donors and partners will wash their hands and
walk away ro
that the job is done. Nothing could be urther rom the truth. In
order to protbillion investment in polio eradication worldwide, it
is incumbent on all o usindeed, to identiy new partners. here is
also an opportunity to build on the the hallmark o the polio
programme, to strengthen routine immunization andiseases o public
health importance. We would like to see broader
ownershipease-control initiatives, including all donors in the
Region. USAID hopes you share this vision o the uture and that all
countries in thmeet the challenges o the post-certiication era. We
believe our money has bRegion and that it has been very well
utilized or the best o all goals: the prevdeath o children. We also
know that the job is not over until its over the Ammains committed
to polio eradication through USAID and CDC. USAID conthe global
polio-eradication programme. Our investment o over $US 240 mito
support supplemental immunization campaigns, the laboratory
network, stions and research or polio eradication. In the past
year, we have expanded suSudan and Somalia, in addition to
maintaining our inancial and technical su
countries in Arica, South Asia and the Near East. Most o our aid
is channellcies such as WHO, UNICEF, the Core Group o NGOs and
other USAID techBASICS. But apart rom the technical aspects o polio
eradication, what is remarkabindividual lives are changed in
unoreseeable ways by this dreadul virus. Whomany lives would be
touched by the virus that passed child to child rom Iwere some
children paralysed and others not? hese are some o the mysterie
As a child, my grandather told me that I should be proud that I
am the desand princesses. I dont know i this is true or just amily
olklore, but I do knodren are Roma or not, on whichever shore or in
whichever country they live, one step closer to being polio-ree
orever, because o your eorts. You, the vohealth workers in your
countries, are the real heroes o this story. I am sure thdren rom
your own countries, were here today, they would thank you. Again,
we extend our heartelt congratulations to you all.
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I am here today to speak rom the perspective o the Global Polio
Eradication Inlike to begin by expressing my thanks to you, the
European Region and congratulamental achievement. he European
Region has made a great contribution to the g
Statement by Dr Daniel Tarantola, Director, Department of
Vaccines and Biological
cate poliomyelitis. You have done your job very neagreat thanks
rom the regions where polio is still a r
ight goes on. he Global Initiative also thanks donors in the
Euthe support you have given to polio-eradication pronomically
deprived countries o polio-endemic regicontinue to ace the great
costs o polio eradication,ing the very lives o health-care workers
as they reacwho need to be immunized. We still have a long way to
go. Untilglobaleradicatis has been certiied, we need to continue to
immunneed to maintain the surveillance system. We need tso that it
remains saely stored in secure laboratorieagain. o do this we need
people, like the many thou
workers around the world who have been trained, mobilized and
inspired by the port. And we also need people like the Rotary and
Red Cross volunteers who, in onalone, vaccinated 125 million
children in just a ew days. We need people and we n
he expenses incurred in the Global Polio Eradication Initiative
are high. For this a unding gap o US$ 60 million. his sounds
enormous, but it is small compared wbeneits o the eradication
campaign, a campaign that continues to contribute to mreduction o
death and disability caused by one disease. In our global vision o
polio eradication, the monumental achievement we are cbut one step
into the uture o public health. he Polio Eradication Initiative
will lelegacy, beginning with its strengthening o routine health
services. Stronger routin
strengthen human development, and stronger human development can
help alleviawill urther reduce human illness and suering. From the
global perspective, thereing something even more wonderul than
Polio-Free Europe today. We are celebrathat has brought together
health-care workers, volunteers, donors and others into agreater
uture or all o our children.
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A N R E G I O N A L
I could not sleep last night ater I learned the Commission would
declare three. I was wondering how dierent it is to live in
Polio-Free Europe? I must aany dierent, and I realized that it will
take some time or us to truly understaevent, the meaning o the
words: POLIO-FREE EUROPE. his is a great day he road to
poliomyelitis-ree Europe was long and hard, and there are magreat
thanks. I would like to begin by thanking everyone who contributed
thesouls to our common goal: the eradication o poliomyelitis in the
European Rbe proud o this great success. he Certiication o Europe
as polio-ree is a wnership successul cooperation o many dierent
countries, organizations, i
Statement by Dr George Oblapenko, Medical Officer, WHO Regional
O
good will. It is an excellent example o successmake a new
generation the children o the 21and wealthy! hanks to all o us!
here are many individuals who must get sptraordinary
contribution to this success. I wouing Dr Ralph Henderson,Director
o the WHon Immunization, who irst presented the casethe World
Health Assembly, which endorsed ttion Initiative on 13 May 1988,
and called all cthis humanitarian work.
he key to the success o polio eradication inwas Operation
MECACAR, which was a uniqution. Eighteen countries o the European
and E
Regions joined orces and coordinated polio-eradication
activities between 19hard work to deliver polio vaccines to
children in the most remote corners o a success and high levels o
immunization coverage and surveillance were maMECACAR was not just
the cooperative eort o governments and ministries
nary dedication and hard work o many people. I recall an
encounter back in the irst round o Operation MECACAR. It was in
Kazakhstan, close to the bolocal district health authority, the
Chie Oblast Medical Oicer and I were goo National Immunization Day
(NID) activities in a remote settlement. On ouman he was an
ophthalmologist returning rom that remote village, where h
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also would like to express our great thanks and appreciation to
Dr Marc Danzon,t
Director, who has continued to actively and strongly support
this important prograhis time, energy and ull trust. And, as we
give thanks and recognition on this very bright and beautiul day, I
wour partners and riends who have departed and could not celebrate
with us today
Dr Mario Grassi,the irst chairperson o Rotarys European
PolioPlus Committpromoted polio eradication and supported
implementation o appropriate strateRegion, particularly in the
ormer Yugoslavia.
Dr Bruno Martainwas the UNICEF Coordinator or Immunizations,
includingin our Region during our most diicult years, 19931997.
Bruno was particularimplementation Operation MECACAR in Caucasian
republics.
Dr Henrik Zoffmann,ormer director o WHOs Expanded Programme or
Immprovided strong support to the European Regional programme.
Dr Ko Kejarom the core o the Expanded Programme on Immunization
(EPI)ters, who practically initiated polio eradication eorts in
urkey.
Dr Ivan Masar,who was coordinator o EPI in Slovakia. Ivan
contributed a lot to the Regional immunization and
polio-eradication programmes; he was the chEuropean Advisory Group
and we have gained rom his epidemiological expertexperience.
I particularly would like to recall the name o Dr Mirzobalie
Jacheev,Chie MedVachshskiy district, in ajikistan. He was assessing
the quality o NIDs in 1995, in ajikistan. UNICEF was able to stop
ighting or a week o tranquillity. Howev
visit, an armed group rom Aghani territory targeted Dr Jacheevs
car and Dr Ja
he Polio eam thanks and salutes all o our riends and colleagues
or the roles ththis great achievement. We know quite well that one
o most important strategies ieorts is high-quality surveillance,
and in Europe, the Regional Polio Laboratory Nsential in assuring
quality polio surveillance. I would like to express great cordial
thgists and sta o all o the laboratories that have played such a
key role in our succe
have worked very hard to provide the programme with
investigation results in a timvery oten worked through nights and
weekends. It is also very important to recogpean Polio LabNet is
highly proessional and reliable, thanks to the hard work o Dthe
Regional Coordinator, who is both a great virologist and manager.
Partnership! It would be diicult to over-estimate the role o
partnership in this
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In the spirit o this great partnership, I eel strongly that I
have to name some
not able to attend this historic ceremony, colleagues who worked
all these yeathe irst Coordinator o the Global Polio Eradication
Initiative; Dr Mark Pallvirologists rom the CDC/Atlanta; Mr Bob
Keegan,Public Health Manager, CTangermann,WHO headquarters; Dr Mary
Agocs,CDC/Atlanta and Dr Brtor o the Global Polio Eradication
Initiative, WHO headquarters. I do not have the words to express my
great appreciation and my deep thaneam. For many years, this team
has worked hard and under great pressure, topolio-ree Europe a
reality. I recall many midnight work sessions to inalize edocuments
and how, during the 1996 polio outbreak in Albania, Dr Steve Wasend
e-mails at three in the morning. he spirit o the European Regional
Polhighly motivated and target-oriented just what was needed to get
the job douse this unique chance to cordially thank the WHO
Regional Oice Polio eaconstant support you gave me. Finally, it is
a great pleasure to thank the European Regional Certiication
Ccation Commission is highly competent and since our irst meeting,
in March
elegant style o working in a spirit o trust, balanced with
critical scientiic inq So, let us enjoy this celebration! We all
worked hard and we can be proud. Htain our victory until all
transmission o polio has been stopped, worldwide, abeen contained.
Wild polioviruses are still around the corner and high levels
coverage and high-quality AFP surveillance are the key elements in
sustaininIts not over until its over!
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he ollowing terms o reerence were approved:
to validate the plan o action and timetable or certiication or
polio eradicRegion; to ratiy or change the proposed quality o
surveillance or certiication in t
endemic and endemic countries o the Region;
to state the documentation that will be needed rom each country
o the Retion;
to approve and update as necessary the protocol or collection o
national i
veillance data or certiication and polio eradication; to
develop, i needed, innovative methods or veriying polio eradication
inor high-risk areas in recently endemic and endemic countries,
where thecriteria or certiication have not been met;
to conduct site visits, i required, to review or veriy the
status o polio-eradvidual countries;
to review the polio-eradication documentation o each
country/zone on an
port the indings and required actions to the Regional Director
and approp to bring unresolved certiication issues to the attention
o the Global Commtion o Eradication o Poliomyelitis or
discussion;
to certiy, i and when appropriate, the eradication o circulating
wild poliopean Region o the World Health Organization, and to
provide the Global documentation necessary to endorse Regional
certiication.
he Commission considered the relevance to the European Region o
the g
mended at the First Meeting o the Global Certiication Commission
in 1995
The design of the Regional certification process
he health minister o each country was asked by the WHO Regional
Directopendent National Certiication Committee (NCC), whose members
should btists not directly involved with eradication activities. he
NCCs task would bwhen appropriate approve, inormation collected by
national sta and docum
Manual o Operations or submission to the Commission or review.
In thiseect, an independent judgement o the polio status o their
own countries. hrough successive meetings, held in dierent
countries o the Region, thethe national documentation sets. Prior
to meetings, all members studied the daddition, two members took a
lead assessment role or each country. WHO o
d t l ti h C i i th t t di d li i
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he stage was inally reached in 2001 when no indigenous wild
poliovirus inec
ported in the region or the past three years and certiication
might soon become mission decided to undertake this task in two
stages, and to address not only the evrom polio and progress in
laboratory containment, but also the capacity o countrrespond to
virus importation, and their plans or sustaining polio control ater
cert
A penultimate review was made, or which inormation in an
approved ormat wall countries. Commission members studied these
documents and then met to discteenth meeting in March 2002. he RCCs
assessment was greatly helped by a comtion prepared by the WHO
Regional Oice.
Presentations by the NCCs o 16 key countries were also heard at
this meeting. or various reasons, such as a need to clariy the
extent to which surveillance had rriods o conlict, or to evaluate
urther progress made in containment. O particulathose presentations
rom Bulgaria and Georgia on their recent importations o wilIndian
subcontinent. he RCC concluded in March 2002 that it could
probably, in June 2002, certiy tree, provided certain missing items
o inormation were supplied and ound to be
provided no new imported virus transmission episodes occurred
beore then.Prior to Regional certiication, each NCC was asked to
sign a statement o the re
believed their country to have been ree rom indigenous wild
poliovirus transmissthree years. Such a ormal statement, signed by
senior proessionals who know thebeen valued by the RCC. On the
evening o 20 June 2002, the RCC unanimously concluded to declare
thethe World Health Organization as Region POLIOMYELIIS-FREE.
he Commission emphasized that, until wild virus was eradicated
globally, polivirus importation remained possible, especially among
at-risk groups. It was therecountries sustained high levels o polio
immunization and surveillance.
C H A P T E R 2 T H E E U R O P E A N R E G I O N A L C E R T I
F I C A T I O N C O M M I S S I O N
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A N R E G I O N A L
T H E C H A I R P E R S O N O F T H E R E G I O N A L C E R T I
F I C A T I O N
SIR JOSEPH SMITHJoseph Smith qualiied in medicine at the
University oior hospital appointments and national service in
thjoined the Public Health Laboratory Service to train aFrom 1960
to 1965 he was Lecturer and Senior Lectureology and immunology at
the London School o Hygie(LSHM), and researched upon the
pathogenesis and1965 he became Consultant Bacteriologist to the
RadclLecturer in Bacteriology to the University o Oxord, ctetanus.
Ater appointments as Head o Bacteriology Laboratories, and as a
amily doctor in inner London, hDirector o the Epidemiological
Research Laboratory oratory Service [PHLS]. His research interests
there in
and immunoprophylaxis o inluenza, diphtheria and pthor or joint
author o some 140 scientiic publicationsDirector o the National
Institute or Biological Standar1985 to become Director o the Public
Health LaboratoWales, rom which appointment he retired 1993. He sto
the University o Nottingham, 1989-94. He was knig
Sir Joseph Smith has served on a range o oicial commKingdom
Department o Health, many relecting his cmunisationimmunization,
including: Committee on Sman, Biological Subcommittee); Joint
Committee on Vnization (chairman, Subcommittees on inluenza and
Joint Sub-committee on Adverse Reactions to Vaccineon AIDS; and
British Pharmacopoea Commission (ch
Committee). He has been a member o the Medical Rechairman o
several o its advisory bodies, including thDevelopment, ropical
Medicine Research Board, SimAIDS Vaccine Clinical Studies
Committee, Working GEncephalopathies, and as a member o its
Biological R
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M E M B E R S O F T H E R E G I O N A L C E R T I F I C A T I O
N C O M M I S
PROFESSOR MARGARETA BTTIGERMargareta Bttiger qualied in medicine
at the Karolinska holm in 1954. Afer training in paediatrics at
Bellevue HospCity and in both paediatrics and bacteriology at the
KarolinStockholm, she began working at the polio and virological
National Bacteriological Laboratory, Stockholm, in 1957. F
she conducted extensive research on live and inactivated poing
in her doctoral thesis and dissertation at the KarolinskaFrom 1967
to 1971, she was an associate proessor at the Kaand held a research
ellowship rom the Swedish Medical R1971, she returned to the
National Bacteriological LaboratoDepartment o Epidemiology, with
access to laboratory acher studies on vaccines. In 1976, she was
appointed Full Proo the Epidemiology Department. Proessor Bttiger
was co
National Epidemiologist o Sweden, a position that she heldment
in 1993.
During this time, Proessor Bttiger continued to do
bothenvironmental studies o polio in addition to research in
epidemiological interest. Evaluations o the introductions
vaccinations against measles (rom 1971 onwards), rubella ((since
1978) and MMR (since 1982) were perormed. Vacc
diseases were also studied (diphtheria, tetanus, BCG, pertuslio
always held a central place in Proessor Bttigers work a
Proessor Bttiger has been involved in the analysis o all ease
outbreaks in Sweden since 1971. From 1983 on, AIDS nant research
area. She is the author or co-author o 250 been a member o a number
o Swedish and European coBttiger was an expert adviser to both the
global and Eur
Organization advisory groups or the Expanded Programma member o
the Board o the Swedish Medical Research CData Inspection Board. In
addition, she worked with the Epin AIDS Research o the European
Union, was a member oo the Swedish National Board o Health, the
Swedish Foodth AIDS C i i th S di h G t
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DOCTOR WALTER R. DOWDLEDr Walter Dowdle is a member o he ask
Force or Childopment, Atlanta, Georgia, where he serves as
Director, PoliContainment Preparedness, US Department o Health and
consultant to WHO on the Global Poliomyelitis Eradication
Prior to joining he ask Force, Dr Dowdle was Deputy DirDisease
Control and Prevention (CDC), Atlanta, 19871994tor, CDC, 19891990
and 1993. He was Director o the WH
Center or Inluenza, 19681979; Associate Proessor,
SchooUniversity o North Carolina, 19641984; and Honorary FeSchool
or Medical Research, he Australian National Univ19721973.
A doctoral graduate o the University o Maryland, College joined
CDC as a virologist and served as Chie, Respiratory
Director, Virology Division; Assistant Director or Science;
Inectious Diseases; and Associate Director or HIV/AIDS. sive
experience in virus research, vaccine development/evallation o
immunization policy. Dr Dowdles current active sinclude polio,
inluenza, HIV and malaria.
He has received wide recognition during his career and is a
proessional societies. He received the Sigma Xi Lietime Acor
Public Health Science in 1995, CDCs Champion o Prev1993, and the
Surgeon Generals Exemplary Service Award ithe US Presidential
Distinguished Executive Award in 1982President o the Armed Forces
Epidemiologic Board rom 1President o the American Society or
Microbiology rom 1served on numerous scientiic and editorial
boards.
Dr Dowdle received his undergraduate and masters degreeso
Alabama. He is married to Mabel Irene Dowdle. hey haHe served in
the US Army/US Air Force Medical Corps in Grom 1948 to 1952.
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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D
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A N R E G I O N A L
DOCTOR GEORGE F. DREJERDr Drejer qualied in medicine at the
Leyden Univeresidencies in obstetrics and paediatrics and a course
iRoyal ropical Institute in Amsterdam.
From 1967 to 1975, Dr Drejer was superintendent anhospitals in
the Cameroons. It was here that he becamaspects o poliomyelitis,
through direct experience. Btrained as a general paediatrician in
the Juliana ChildreDr Drejer served the next 20 years as a general
paediatrseveral hospitals in the Hague beore becoming a senioogy
and head o the neonatal intensive care unit at thetal. Afer he
nished his clinical career in the Hague hor two years or the
Kilimanjaro Christian Medical Cepaediatric education in rural
hospitals in northern anappointed as a senior consultant and
lecturer in paedbeth Central Hospital and the College o Medicine
o
in Blantyre, with a special interest in perinatology.Dr Drejer
has served on a number o committees adifferent missions reecting
his interest in internatiograduate education in Europe and Arica,
including: liomyelitis afer 10 years o immunization in
Burkinpaediatrics in Angola, Mdecins Sans Frontires (MSworkgroup o
MSF or continuing the education o m
mania in the Netherlands.
Since 1996, Dr Dreyer has been a member o the WHor the
Certication o Eradication o Poliomyelitis.
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PROFESSOR SERGEI DROZDOVSergei Drozdov qualiied in medicine at
the Kuban State Krasnodar, Russia, in 1952. hat year, he joined the
InstituAcademy o Medical Sciences o the USSR, in Moscow, or In
1956, Dr Drozdov graduated with the degree o Candiences in
virology. In 1955, he was appointed to be a Junior Sestablished
Institute o Poliomyelitis and Viral EncephalitidMedical Sciences o
the USSR. In 1958, Dr Drozdov was ption o Senior Scientist and, in
1959, he became Head o th
demiology o Poliomyelitis. In 1965, Dr Drozdov received o
Medical Sciences (DMSci) in virology and epidemiologyDr Drozdov was
a Medical Oicer in the Viral Diseases Uneva, Switzerland. In 1971,
he was appointed Deputy DirecPoliomyelitis and Viral
Encephalitides. Since 1972, ProessDirector o the Institute.
In 1978, Proessor Drozdov was elected as a CorrespondingAcademy
o Medical Sciences o the USSR, and in 1984, he bber o the Academy
(FM RAMS).
Proessor Drozdovs research interests and ields o proessiclude
the virology, epidemiology, prevention and eradicatiotick-borne
encephalitis; hemorrhagic evers; rotavirus gastr
mental virology; and biological saety in virological
laboratactivities o Proessor Drozdov are presented in more than 3in
scientiic journals and bulletins, our monographs and seproessional
manuals. In addition, the Institute o Poliomyecephalitides conducts
research in basic science and medicalpoliomyelitis, enteroviral
diseases, tick-born encephalitis, harenaviral diseases, hepatitis
and rabies. he Production De
stitute, which was established in 1957, manuactures poliovas
vaccines or tick-borne encephalitis, rabies and yellow ev
Since 1995, Proessor Drozdov has been a member o the mission or
the Certiication o Eradication o Poliomyeliti
C H A P T E R 2 T H E E U R O P E A N R E G I O N A L C E R T I
F I C A T I O N C O M M I S S I O N
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C E R T I F I C A T I O N O F P O L I O M Y E L I T I S E R A D
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A N R E G I O N A L
DOCTOR DONATO GRECODonato Greco was born in Naples, Italy, in
1947. He remedicine and surgery rom the University o Naples
intraining in medicine and public health, earning speciatious,
ropical and Subtropical Diseases rom the UnivPreventive Medicine
and Hygiene rom the UniversityMedical Statistics rom the University
o Rome in 1982public health at the London School o Hygiene and
roCenters or Disease Control and Prevention, in Atlanta
panded Programme on Immunizations course in Mosas a physician in
the clinical wards o the D. Cotugno HDisease in Naples or 9 years
beore moving to the Instin Rome to establish the Laboratory o
Epidemiology a
In 2004, ater 26 years at the Laboratory o Epidemioloprimarily
on inectious disease epidemiology, he assum
ties o Director General o Disease Prevention o the Itand
director o the newly ounded National Center orDuring this time, Dr
Greco has been an author o morlications.
For more than 20 years, Dr Greco has strengthened glohis
participation in committees, commissions and adv
European Union and the World Health Organization. been the
director o the WHO Collaborating Centre oSurveillance, Instituto
Superiore di Sanit, Rome.
Since 1996, Dr Greco has been a member o the WHOor the
Certiication o Eradication o Poliomyelitis.
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PROFESSOR BURGHARD STCKBurghard Stck did his medical training at
the Freie Universny, rom which he obtained his MD degree in 1955.
From 1did an internship and residencies in neurology, internal
medat the University Hospital, Freie Universitt Berlin. A NAOto New
York to work at the Sloan-Kettering Institute or Cao umour
Immunology rom 1962 to 1964. In 1966, Dr Doctor o Medical Science
degree and, until 1974, he was anat the Childrens Hospital o the
Freie Universitt Berlin. H
o Paediatrics in 1971. For twenty years, rom 1974 to 1994,Head o
the Paediatric Department, University-Hospital Berlin.Proessor Stck
was a Member o the National Advisory Conization, Robert
Koch-Institut, Berlin, rom 1977 to 1998. Hber o the
Immunization-Committee o the German AssociDiseases (DVV) rom 1975
to 2002.
Since 1996, Dr Stck has been a member o the WHO Euroor the
Certiication o Eradication o Poliomyelitis.
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C H A P T E R 3 P L E N A R Y S E S S I O N 1
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Current situation in the European Rin the Eastern Mediterranean
Reg
and globally
PLENARY SESSION OFHE EUROPEAN REGIONAL CERIFICAION COMMISSIO
ON 20 JUNE 2002
From let to right: Dr Ray Sanders, Dr Nedret Emiroglu,
Dr Donato Greco, Sir Joseph Smith,
Dr George Oblapenko and Dr Daniel arantola.
EUROPEAN SUBREGIONAL OVERVIEWIn 1996, the RCC recommended
splitting the Region into six subregional zones to sis o a large
and complex Region. hese subregions are:
1. Nordic/Baltic
2. Western
3. Central
4. Southern
5. Central/eastern
6. MECACAR, Russian Federation
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coverage is very good; with most countries either using
inactivated poliovirusin combination with oral poliovirus vaccine
(OPV). here are no indicationscinated populations in the subregion.
Surveillance quality in the subregion is good. Although only
Estonia, Latvihave acute laccid paralysis (AFP) surveillance
systems, almost all countries hrus surveillance systems and several
have environmental surveillance to provLaboratory quality control
systems or enterovirus laboratories exist in DenmIceland, Latvia
and Sweden. Laboratory containment activities are progressing well
in almost all countr
ing only slow progress. Within the subregion there are a limited
number o lapoliovirus, and these are all operating under biosaety
level 2 (BSL-2)/polio c he likelihood o indigenous wild polio
circulation is judged to be very lowtablished health systems with
the capacity to provide good immunization covlance. he countries
are also judged to have a strong capacity to detect any powild
poliovirus.
2. WESTERN SUBREGION(Austria, Belgium, France, Germany, Ireland,
Luxemburg, Monaco, NetherlanKingdom)
All countries in the subregion have good or very good
health-care systems proservices. However, immunization coverage
data is not available or several o thcurrently have no systems to
collect this data. Despite this lack o data, routine
are generally believed to be strong with more than 90% o
children reaching schmunized. A vulnerable subpopulation o
approximately 300 000 individuals wreligious reasons exists in the
Netherlands, and strong anti-immunization lobbcountries. All
countries in the subregion, with the exception o the United Kin
Only 50% o the countries had established AFP surveillance systems
in 200o these was not impressive, particularly with regard to
adequate stool collectsurveillance, several countries rely on data
rom enterovirus surveillance netw
surveillance systems are well established, but the data they
generate is complerize. Generally, countries lack data collection
and management systems capabdata in a manner required or the
polio-eradication initiative. In addition to eat least two o the
countries, France and the Netherlands, have well-developedlance
systems.
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3. CENTRAL SUBREGION(Belarus, Bulgaria, Czech Republic, Hungary,
Poland, Slovakia, Slovenia)
Health-care reorm is progressing in most o the countries o the
subregion, and hare either good or very good. he population has
good access to immunization sersystems are believed to have the
capacity to detect, diagnose and respond to paralymanner. Routine
immunization coverage is very good in all countries, and all use
OPV intion schedules, although several have now switched to a
combined OPV/IPV regim
poliovirus importation into Bulgaria in 2001, extensive
supplementary immunizatconducted in the country, and supplementary
immunization o high-risk groups invakia were also undertaken. AFP
surveillance quality is good in hal o the countries and moderate in
the othcarry out enterovirus surveillance in support o AFP
surveillance activities, and twcarry out environmental
surveillance. In general, the level o supplementary surveater the
importation into Bulgaria.
Good progress has been made with implementation o containment
requiremenlaboratories have been identiied in the subregion as
having wild poliovirus inectioperate under BSL-2/polio conditions.
here is no indication o continued poliovirus transmission in
Bulgaria or neighall evidence suggests that successul immunization
campaigns prevented extendedvirus. he likelihood o continued
transmission o indigenous wild poliovirus in thlow, due to good
surveillance and high immunization rates.
4. SOUTHERN SUBREGION(Andorra, Croatia, Greece, Israel, Italy,
Malta, Portugal, San Marino, Spain)
he countries in this subregion all have good or very good health
services, with gonization and preventive health care. Immunization
coverage levels are high, with cOPV alone or in combination with
IPV.
Only seven o the nine countries have established AFP
surveillance, and perormpoor, with particularly low stool
collection rates. However, six o the countries havsurveillance with
enterovirus surveillance o good quality, and three o the countrital
surveillance programmes.
Containment requirements have been implemented in all countries
except Port
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Health-care reorm is in a transition phase in this subregion;
health services awith the population having reasonably good access
to health care and immuncountries use OPV exclusively in their
immunization schedules and coveragehere have been concerns,
however, regarding under-vaccinated subgroups io Yugoslavia, and
particularly in Bosnia and Herzegovina. Reports on recentnization
campaigns carried out in these areas suggest that at least 90% o
the treceived OPV. All countries have good AFP surveillance systems
with good national indicgood subnational indicators. he only
exception has been Bosnia and Herzeg
have recently been made to enhance surveillance and signiicant
improvemen2002. he Republic o Moldova and the Federal Republic o
Yugoslavia also henterovirus surveillance systems. Albania conducts
annual stool surveys o he15 years o age, as well as diagnosis o
children with diarrhoea. he Ukraine ho enterovirus surveillance,
but the system ails to meet WHO quality assuranalso runs an
environmental surveillance system. Containment requirements have
been implemented in all countries o this
three national laboratories retaining wild poliovirus inectious
materials in B No wild poliovirus circulation has been detected in
this subregion since thto an importation o wild poliovirus into
Albania and the Federal Republic orelatively good health systems
that can detect cases o polio, the good immungood surveillance
systems, it is considered that the likelihood o wild
poliovirsubregion is very low.
6. MECACAR COUNTRIES AND RUSSIAN FEDERATION(Armenia, Azerbaijan,
Georgia, Kazakhstan, Kyrgyzstan, Russian Federation,urkmenistan,
Uzbekistan)
Countries in this subregion have 33% o the population o the
Region, the leaservices and the highest inant mortality rates. hese
countries represent a reczone, and had the last indigenous wild
poliovirus and the last importation. Htransition period, but health
services are generally satisactory and immunizacal services are
adequate. All countries use OPV exclusively in their immunizhave
relied on extensive supplementary immunization campaigns in the
past maintain high immunization coverage. All countries use AFP
surveillance or polio detection, although, as the ide
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tion o wild poliovirus through importation. hese countries
include the Russian FCaucasus region), ajikistan, urkey (south
east), Azerbaijan, Georgia and Uzbeki
IMPORTATIONS OF WILD POLIOVIRUS INTO COUNTRIES IN THE
REGION:LESSONS LEARNTwo wild poliovirus importations were detected
in the Region in 2001, in Bulgariaavailable evidence suggests
transmission was very limited in both instances. With etransmission
continuing in Pakistan/Aghanistan and northern India, the Region
rtinued risk o importation. For this reason, the National Plans o
Action or mainta
status, which all countries in the Region have been requested to
prepare, are o the tance. All countries must be able to detect
importation and act eectively to preveno circulation. Establishing
a system to ensure eective action in preventing urtheimportations
is the key to maintaining the Regions polio-ree status. Experience
with other importations, into the Netherlands, the United States o
ACanada in 1978; into the Netherlands and Canada in 1992; into
China in 1999; andhave demonstrated that a rapid and extensive
response to detection o wild poliovi
limiting transmission, preventing urther spread and maintaining
public conidenceradication initiative. hese instances have also
demonstrated that importation intis a relatively common event. O
the two importations into the European Region in 2001, response in
Bulgariaand eective. Intratypic dierentiation (ID) results were
available within 10 daysvirus isolation, the surveillance system
was enhanced within 3 days and National I(NIDs) were implemented
within 30 days. All neighbouring countries undertook p
lowing the importation by enhancing surveillance and identiying
and immunizinMolecular sequence data suggests that the virus
originated in northern India, and evidence exists to support the
conclusion that India is the most likely source. he stion, into
Georgia, close to the border with Armenia and Azerbaijan, was
detectedAn Azeri child with suspected meningitis was ound to be
excreting wild poliovirubecause the case was not considered to be
AFP, there were delays in sending the poID. here was also a slower
response to the importation than in Bulgaria, althougenhanced, and
supplementary immunization carried out. he origin o the virus
isnorthern India, but in this case there is no clear supporting
epidemiological eviden he principal lesson learned rom experience
to date is to expect another imporcountries in the Region,
particularly those neighbouring endemic areas, with closecultural
ties with endemic areas or with under-vaccinated subpopulations,
must im
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lem or the Region is that three o the endemic or recently
endemic countriesand Sudan, are conlict areas and access to the
children requiring immunizati
AFP surveillance perormance is now good in almost all countries
in the Rtries having a case detection rate o 1 and 83% o cases
having 2 stools in 200collection rate in Somalia in 2001 has been
improved in 2002. In 2001, there wassociated cases in the Region:
116 in Pakistan, 11 in Aghanistan, 7 in SomalSudan. o date in 2002
there have been 23 conirmed cases: 19 in Pakistan, 2 iSomalia.
Poliovirus type 1 and 3 continue to circulate in Pakistan and
Aghanhas been detected recently in Somalia.
Although Pakistan continues to have widespread circulation, the
number oreduced dramatically over the past 2 years, with only 13
districts with wild po2002. he major endemic oci now span the
border areas between Pakistan anlia, with two cases detected to
date in 2002, AFP surveillance is good but stooat 62% and need to
be improved. Egypt had ive cases detected in 2001, in two2002, no
cases have been detected, but wild poliovirus has been isolated
romat ive dierent sites along the Nile. he last wild poliovirus
positive sample w
Great progress has been made in polio eradication in the Eastern
Mediterrpast 2 years. he challenge now is to maintain the progress
that has been madpolio eradication.
REGIONAL OVERVIEW: ARE WE READY FOR CERTIFICATION?At its
ourteenth meeting, in March 2002, the RCC reviewed the
documentatdeined the additional documentation required and set the
ollowing precond
provision o strong evidence that the importation o wild
poliovirus into Bbeen appropriately controlled; demonstration that
Member States have achieved substantial progress tow
containment o wild poliovirus;
receipt rom all 51 Member States o high-quality updated
documentation together with Plans o Action to maintain polio-ree
status post-certiicatio
he governments o Bulgaria and Georgia have both submitted
documentatio
the importation o wild poliovirus in 2001, and their assessments
that the impully controlled. In addition, members o the RCC have
visited both countrieslogical situation and review the activities
undertaken. he response in both copositive, with rapid
implementation o supplementary immunization activitie
d i i d ill d i d t ti i i ti
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he quality o surveillance or wild poliovirus has shown a steady
improvementyears, with the Regional average non-polio AFP rate in
2001 at 1.15 and 81% o rep
two stools. his level o quality has been maintained in the irst
quarter o 2002. Msamples rom AFP cases, and an additional 3000
samples rom contacts o cases, arnually in the Regional polio
laboratory network, with more than 75% o results bei28 days o the
samples being received in the laboratory. AFP surveillance is
strongmany countries o the Region by enterovirus surveillance and
environmental survethe network o laboratories involved in
enterovirus surveillance more than 158 000investigated or
poliovirus between 1999 and 2001. No indigenous wild poliovirus
detected in the past 3 years.
Attempts have also been made to assess the likelihood o
circulation o indigenoususing a composite surveillance index.
Criteria or this index include quality o healsurveillance
activities and duration o polio-ree status. Based on this
assessment, astrongly suggests that all countries in the Region
have good capability to detect in acase o paralytic
poliomyelitis.
Assessments have also been made o the potential risk o
re-establishing circulatvirus ollowing an importation. Six main
criteria have been used or this assessmencoverage; the population
immunity proile; the proportion o high-risk subpopulatsurveillance;
the quality o epidemiological or public health services; and the
level this assessment, the only countries that can be considered at
high risk or re-establtion are Bosnia and Herzegovina, the
Netherlands, the north Caucasus region o thtion, ajikistan and the
south-eastern regions o urkey. At lower risk are Azerbaij
and Uzbekistan. he WHO Regional Oice has developed and
distributed a template or proposo Action or maintaining polio-ree
status. he plan should address actions requirlevels o routine
immunization coverage, with supplementary immunization activiate,
actions to sustain high-quality laboratory-based surveillance and
actions to coo wild poliovirus. Comprehensive plans have been
received rom 45 o the 51 Memstatements o strong commitment together
with highlights o key actions to be undreceived rom the remaining 6
countries.
In summary, the preconditions or certiication set by the RCC
have all been mehas been presented to the RCC or consideration. he
WHO Secretariat strongly bgion is now ready or certiication.
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rom coverage surveys. here is also greater scrutiny o data at a
subnational aggregated national data suggesting high coverage may
hide signiicant deici
or subnational populations. here is also greater emphasis on
timeliness o detion services, rather than on simple coverage
igures. Concern also exists overreported-disease incidence may be
due to under-detection or under-reportino disease. Overall, there
is now greater emphasis on the quality o inormatiocompleteness,
timeliness and accuracy. Countries in the Region are now being
encouraged to improve immunizatito increase coverage and reach all
eligible individuals in their populations. o
improved access to their populations by using innovative
approaches, such aspulse campaigns. hey need to improve the level o
utilization o the services ing the level o vaccination dropouts and
dissuading the use o alse contraindCountries are being encouraged
to adopt strategies that are target oriented, aigroups in their
populations: the urban poor, remote rural areas, minority grotions.
o provide immunization services to these diicult-to-reach groups,
stlevel will be required, together with capacity building to
improve local manag
Other areas o the immunization programme that are gaining
renewed attelogistics and saety o immunizations. Although o high
priority there are, antations in the national resources available
to ensure that requirements in theseIt is essential that capacity
exist at local levels, that the inrastructure is maintand
maintenance o equipment, and that local management is adequate or
th Vaccine Vial Monitors (VVMs) have been introduced and accepted
and aran increased use o auto-disable (AD) syringes and saety
boxes, and adverse
munization (AEFI) surveillance systems have been established in
many counstrengthened, however, to be ully unctional. Countries are
being encouragedment o vaccine supplies, particularly through
monitoring at each level, and tments o capacity at subnational
levels. Saety o immunizations is now o mao both saety o injections
and waste disposal management. Assessments are there is strong
Regional promotion o AD syringes and the use o saety boxes he
Global Alliance or Vaccines and Immunization (GAVI) is an
internatpartners, including national governments, international
organizations such aChildrens Fund (UNICEF), the World Health
Organization (WHO), the Woro philanthropic institutions. GAVI
provides unding support or new and unas hepatitis B,
Haemophilusinluenzaetype B (Hib) and yellow ever. It also
pimmunization services and or injection saety. An algorithm is used
to assess
C H A P T E R 3 P L E N A R Y S E S S I O N 1
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with GAVI has also had an impact on strengthening immunization
services througo programme assessments, development o multi-year
immunization plans, resou
and coordination, and an emphasis on injection saety. It has
provided an opportuimmunization inrastructure and capacity, and to
apply the lessons learnt to other Region. In general, countries in
the Region have strong, unctional immunization prograexisting
inrastructures are operating under stress. here is oten a lack o
politicalthe long-term goals o immunization, relected in the
paucity o resources allocatedtion services. he sustainability o
established systems must be ensured, by mainta
that has been made, by improving the inrastructure and by better
monitoring o aimproved quality and eiciency. he establishment o
multi-year national immunisential to this process, ideally
providing a clear analysis o the national situation, idand setting
clear priorities and uture directions or the immunization services.
he Region is actively pursuing disease control initiatives in polio
eradication, dmeasles elimination and congenital rubella syndrome
(CRS) prevention. Polio eradhugely successul, and much can be
learnt rom this success. Diphtheria now appea
control, with a very low level o transmission ater the outbreak
in 1994. he incidhas dropped in the past 20 years, with most
countries using the combined measles(MMR) vaccine. he incidence o
rubella, however, continues to be high in the Rushe Strategic Plan
or Measles and CRI calls or the interruption o measles
transmtogether with the prevention o CRI (to a level o less than 1
case per 100 000 live bthese goals, six key strategies have been
identiied:
achieve and sustain very high coverage with two doses o measles
vaccine
provide a second opportunity or measles immunization target
populations susceptible to rubella ensure protection o women o
childbearing age strengthen surveillance systems improve
availability o inormation on immunization.Critical components o
these strategies include ensuring social and political
suppomobilization o resources, strengthening routine immunization
programmes and s
veillance, in particular the adevelopment o an appropriate
laboratory network. Future work o WHO includes ocusing on the
national level, by assessing natioorities, supporting country-level
activities, mobilizing technical and inancial resonational capacity
and providing guidance in line with Regional priorities. Regionab i
d th h b tt h i ti d i ti
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Aspectso post-certiication
activities
POLIOMYELITIS ERADICATION: GLOBAL PROGRESS,POST CERTIFICATION
STRATEGIES AND PLANShe past eighteen months have seen a dramatic
all in the number o reported polirom 2 971 in 2000, to 498 in 2001.
Less than 200 cases o poliomyelitis were repormonths o 2002. he
drop in reported cases is very signiicant, especially given the
o acute laccid paralysis (AFP) surveillance worldwide. Between
the years 2000 ano polio-endemic countries has dropped rom 20