Final Report

2nd African Regional Conference on Immunization (ARCI)

Ouagadougou, Burkina Faso

06 - 08 December 2010

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Contents Page Abbreviations……………………………………………………………………………... 3 Executive Summary of Conference Outcomes…………………………………………..5 Summary of outcomes……………..……………………………………………………...5 Polio Eradication……………………………………………………………………. 5 Reaching Un/Under-Immunized Children in the African Region………………… 6 Accelerated Disease Control Initiatives in the African Region……………………... 7 Session 1: Opening Ceremony…........................................................................................ 9 Session 2: Polio Eradication……………………………………………………………… 11 Parallel session: Interrupting endemic & re-established transmission…………. 14 Parallel session: Preventing new international spread & outbreaks……………. 16 Session 3: Reducing number of un /under-immunized children ……………………… 20 Parallel session: Routine immunization………………………………………… 26 Parallel session: New vaccines…………………………………………………. 30 Parallel session: Immunization Financing……………………………………… 35 Session 4: Accelerated Disease Control Initiative in the African Region……………... 38 Session 5: Closing Ceremony…………………………………………………………….. 45 Annexes 1. List of Participants ……………………………………………………………………… 47

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    Abbreviations ACPE Advisory Committee on Poliomyelitis Eradication

AFP Acute Flaccid Paralysis

ARCC African Regional Certification Commission

ARCI Annual Regional Conference on Immunization

BMGF Bill and Melinda Gates Foundation

bOPV bivalent Oral Polio Vaccine

CDC Centers for Disease Control and Prevention

cVDP circulating Vaccine-Derived Poliovirus DoV Decade of Vaccines

EPI Expanded Programme on Immunization

EU European Union

FRR Financial Resource Requirements

GAP.III Third edition of the Global Action Plan to minimize post eradication poliovirus facility-associated risk

GIVS Global Immunization Vision and Strategy

GPEI Global Polio Eradication Initiative

GPLN Global Polio Laboratory Network

GPMT Global Polio Management Team

ICC Interagency Coordinating Committee

IPD Immunization Plus Day

IST Intercountry Support Team

iVDPV Immunodeficiency-Associated Vaccine-Derived Poliovirus

JSI John Snow Incorporated

LGA Local Government Area

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LQAS Lot Quality Assurance Sampling

MDGs Millennium Development Goals

mOPV Monovalent Oral Polio Vaccine

NGO Non Governmental Organization

NID National Immunization Day

OPV Oral Polio Vaccine PCV Pneumococcal Conjugate Vaccine

RED Reaching Every District

SAGE Strategic Advisory Group of Experts on Immunization

SIA Supplementary Immunization Activity

SIAD Short Interval Additional Dose

SNID Sub-National Immunization Day TAG Technical Advisory Group

tOPV trivalent Oral Polio Vaccine

UNICEF United Nations International Children Emergency Fund

VAPP Vaccine-Associated Paralytic Polio

VDPV Vaccine -Derived Poliovirus VPD Vaccine-Preventable Disease

WHA World Health Assembly

WHO World Health Organization WPV Wild Poliovirus

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Executive Summary of Conference Outcomes The second African Regional Conference on Immunisation was convened in Ouagadougou, Burkina Faso from 6 to 8 December 2010. The conference was officially opened by the Prime Minister His Excellency Mr. Tertius Zongo, in the presence of the chairman of the 60th Session of the Regional Committee the Honourable Minister of Health from Equatorial Guinea, the Minister of Health for Burkina Faso, WHO Director General, the President of the Global Health Program of the Bill and Melinda Gates Foundation, WHO Regional Director for Africa, the Acting CEO of GAVI, Parliamentarians from DR Congo and Cameroun, Traditional Leaders from Nigeria, National EPI programme managers, UN agencies, immunization partners, donors, and TFI members. Three core themes on immunization in Africa were thoroughly reviewed and discussed and the main outcomes are highlighted below: (1) Polio Eradication: The conference commended Nigeria for the significant progress made in reducing wild poliovirus (WPV) cases. The meeting also recognised the efforts made by Chad and the importation countries in West Africa in limiting the circulation of WPV. Concerns were however raised with continued circulation of WPV in DR Congo and Angola, the outbreak in Congo Brazzaville affecting mostly adults and the poor surveillance in Kenya/Uganda border and East DR Congo evidenced by missed circulation of WPV (orphan viruses). The conference proposed the following actions: 1. The conference commended the coordination efforts in West Africa by WHO, UNICEF and

countries and requested that this model be adopted in all countries and sub regions experiencing polio outbreaks.

2. The conference recognized the institutionalization of Independent Monitoring (IM) in Polio SIA and the use of the generated data in tracking progress towards achieving the global polio eradication milestones. The conference called upon WHO and partners to support countries fully implement corrective measures whenever shortcomings in SIA quality are identified through IM.

3. Recognizing the high level advocacy that lead to the development of the 6-months Polio

Emergency Plan currently being implemented, the conference called upon Angola to review and intensify implementation in 2011

4. The conference noted with concern the intense transmission of WPV in DR Congo and

urged the country to urgently develop and implement an Emergency Plan to address chronic SIA gaps and sub-national surveillance weaknesses. Additionally, WHO should provide technical assistance to improve the performance of the National Polio Laboratory in DR Congo

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5. Nigeria and Chad should develop and implement aggressive mop ups strategies to reach high risk areas, migrant and mobile populations in order to interrupt transmission in line with the set milestones.

6. Countries with the support from partners should develop a comprehensive package that

includes social economic and communication factors to address surveillance, SIA gaps and create demand for better delivery of immunization services. Communications indicators should be included in this package.

7. The risk assessment model presented to the conference offered an opportunity for the region

to predict polio outbreaks. However, changes in the intensity of polio transmission and data quality seem to affect the accuracy of predictability of the model. Efforts should be made to revise the model and address its limitations. There is also need to initiate consultations before its use.

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8. WHO and partners should promote social, operational and applied research in order to reach the unreached populations and also to address population immunity gaps including adults and migrant / mobile populations

9. WHO and UNICEF should ensure:

a) Adequate supply of appropriate types of OPV for use in polio outbreak response in the region.

b) Continued and enhanced support for pre-qualification and licensure of additional products to increase vaccine security in the market and at the country-level

(2) Reaching Un/Under- Immunized Children in the African Region- Progress, Challenges and Opportunities The Conference noted with satisfaction the progress that had been made in reducing the number of un/under immunized children in the African Region. New innovations had been implemented in some countries such as Ethiopia resulting in significant reduction in the number of unimmunised children in 2010. However, the conference expressed concern on the declining or stagnating performance of routine immunization in a number of countries. In addition, inadequate financing of immunization services in general and routine immunization in particular pose a threat to the maintenance or sustenance of coverage and the introduction of new vaccines. Discrepancies between WHO/UNICEF immunisation coverage estimates and those reported annually by countries were also highlighted. The conference welcomed efforts by countries and immunisation partners in supporting the introduction of new vaccines such as Pneumococcal and Rotavirus vaccines in the region. However there is urgent need to accelerate introduction so that progress towards MDG 4 attainment in the African region could be achieved.

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The conference proposed the following actions 10. Countries with support from partners should implement all components of RED and other

innovative strategies to reduce the number of unimmunized children, especially in the top ten countries with large number of un/under immunized children.

11. Countries should continue working to improve data quality and utilize fora such as EPI

managers and regional consultations meetings to identify and address the challenges. 12. The conference welcomed the “Decade of Vaccines” (DoV) and proposed active

consultation with the Regional Office and countries in the development and formulations of the delivery component of DoV.

13. Countries with the support of WHO and partners should adopt a holistic approach to

synergize immunization with the control of pneumonia and diarrhea within the primary health care context as elaborated in the Alma Ata and Ouagadougou Declarations to accelerate attainment of MDG 4.

14. WHO and partners should support countries to strengthen surveillance capacity for new

vaccines for advocacy and support decision making on new vaccines introduction 15. WHO and Partners should support countries to develop local mechanisms to increase

funding for immunization services and maintaining immunization as a public health priority. 16. To strengthen logistic and delivery of vaccines, the conference proposed that WHO and

partners should consider introducing for discussion a document on the creation of Logisticians for Health during the Regional Committee of Health Ministers

(3) Accelerated Disease Control Initiatives in African Region The conference was informed that improvement in the routine measles immunisation coverage was slow, and that only 14 countries in the African Region had maintained at least 80% measles coverage over the past 3 years. In addition, scheduled follow up SIAs could not be implemented on time in some countries due to the failure to mobilise adequate resources from governments and partners. The gaps in routine immunisation coverage and SIAs quality have contributed to the significant increase in the number of measles outbreaks. These outbreaks, due to low population immunity, undermine the progress made and endanger the prospects of meeting the measles pre-elimination targets for 2012.

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On Maternal and Neonatal Tetanus elimination (MNTE), the conference was informed that a good number of planned SIA activities by countries were not implemented which is affecting the progress towards MNTe. The conference was also informed that the Meningitis Vaccine Project (MVP) between WHO and PATH has resulted in the development of Meningitis A Conjugate Vaccine (MCV) that was pre-qualified in June 2010 and initially rolled out in 3 countries (Burkina Faso, Mali and Niger) but will eventually reach 14 targeted countries. The conference suggested the following actions: 17. In view of resurgence of measles outbreaks in the region, the African Regional Measles

TAG should assess the progress towards meeting measles pre-elimination targets and provide guidance to countries

18. The conference noted the efforts by some countries to mobilize resources from within and

encouraged all countries to continue mobilizing local resources for measles SIAs 19. In order to support Maternal and Neonatal Tetanus Elimination goals, the conference called

upon countries and partner to implement the planned activities to achieve elimination 20. The conference appreciated the recent launch of the Meningitis A Conjugate vaccine in

Burkina Faso and calls upon WHO, partners and targeted countries in the meningitis belt to ensure accelerated introduction.

21. The strategy for the control of Viral Hepatitis B in the African region was discussed and the

conference requested that this document be disseminated to countries

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Session 1: Opening Ceremony The Second Annual African Regional Conference on Immunization held in Ouagadougou, Burkina Faso, was officially opened by the Honourable Prime Minister of Burkina Faso, His Excellency Mr. Tertius Zongo. The Conference brought together about 200 participants including the Minister of Health of Burkina Faso, the Minister of Health of Equatorial Guinea who is also Chairman of the WHO Regional Committee, the WHO Director-General, the WHO Regional Director, the President of the Global Health Programme of the Bill and Melinda Gates Foundation and the interim Chief Executive of GAVI. Other participants included parliamentarians from Cameroon and DRC, traditional leaders from Nigeria, National Programme Managers of the Expanded Programme on Immunization, agencies of the United Nations system, partners and the Task Force on Immunization (TFI) which is a regional technical advisory body on immunization set up by the WHO Regional Director in 1989 and experts. The Conference opened with a call for intensification of priority interventions and investments to speed up progress towards achieving the Millennium Development Goals related to maternal and child health. Countries, with the support of WHO and partners, should strive to meet this challenge in order to avoid needless deaths from vaccine preventable diseases (VPDs) such as measles, polio and meningitis, to mention only a few. The Conference made this call through the theme “Reaching Every Child with Immunization”.

The five major addresses delivered at the opening ceremony included that of the Prime Minister of Burkina Faso, the WHO Director-General, the WHO Regional Director for Africa, partners and the Chairman of the Conference. The speakers unanimously commended the progress in the control of vaccine-preventable diseases and urged countries to redouble their efforts.

In his address, the Prime Minister of Burkina Faso, H.E. Mr Tertius Zongo, expressed optimism about the capacity of African countries to conquer these diseases. He recounted the milestones achieved over the years especially the victory over smallpox, the successful implementation of the Expanded Programme on Immunization and the development of new vaccines. Mr Zongo further invited countries to work out better vaccine procurement procedures, promote vaccine management and give special attention to the side effects of vaccines.

For his part, the Chairman of the Conference, Dr Sodiomon Sirima, emphasized the duties and obligations of each and everyone. “We should make all children benefit from the existing preventive facilities”, he said. He warmly congratulated his predecessor, Prof. Peter Ndumbe, on the progress made under his Chairmanship.

Addressing the gathering, the WHO Regional Director, Dr Luis Gomes Sambo, hailed the launch of MenAfriVac, the new vaccine against meningococcal meningitis A and underscored the personal commitment of the President of Burkina Faso, H.E. Mr. Blaise Compaore, as sponsor of the initiative to eliminate meningitis epidemics in Africa.

He called on countries and partners to make concerted efforts to mobilize additional financial resources in order to guarantee access to this vaccine to rid Africa of the terrible suffering of the past.

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Dr Sambo informed participants of the progress made in routine immunization with a 79% DPT3 immunization coverage and a spectacular reduction of about 97% of poliomyelitis cases in Nigeria.

“The challenge Nigeria now faces is to maintain this achievement” said the WHO Director-General, Dr Margaret Chan who proudly outlined the health benefits of immunization as the best life-saving weapon available. Three-to-five million lives are saved each year through immunization, she added.

The Director-General paid tribute to Africa for the Conference theme which, in her opinion, reflects Africa’s vision and commitment in regard to health.

Other partners especially GAVI and the Bill and Melinda Gates Foundation added their voices to those of the other speakers in commending the partnership without which no achievement was possible. Bill and Melinda Gates Foundation pledged US$ 10 million for the Decade.

GAVI was represented at the Conference by its current acting Chief Executive Officer, Ms Helen Evans, and Bill and Melinda Gates Foundation by Dr Tachi Yamada, President of the Global Health Programme.

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Session 2: Eradication of Poliomyelitis in the African Region - Progress, Challenges and Opportunities

The Polio Eradication Initiative continues to be an important priority globally and in the African region in particular. Since its inception in 1988, following the WHA Resolution, significant progress has been made so far. However, continuing challenges have hampered the eventual attainment of the eradication goal. In this session, presenters and participants reviewed progress made over the past 12 months and discussed ways of sustaining the progress and subsequent interruption of transmission in the African region. Global Polio Eradication: Update Dr Bruce Aylward, Director Polio Eradication, WHO/HQ Summary of presentation: The presenter summarized the progress and challenges of the Global Polio Eradication Initiative (GPEI) in 2010. One of the major activities was the launch of the New Polio Strategic Plan 2010-12 in June 2010 which outlines new strategies and tools for the GPEI. The introduction of the bivalent OPV (bOPV) and improvements in SIAs quality have played significant roles in dramatically reducing WPV1 & 3 in endemic countries. Nigeria and India have reduced types 1 and 3 by close to 95% in 2010 compared to 2009. In Nigeria, laboratory data has confirmed that the progress was real with fewer virological clusters circulating in 2010. The reduction in the diversity of the clusters is evidence of immunization pressure on polio virus Furthermore, the impact in the past 6 months has been tremendous with:

• No WPV cases reported from 14 out of 15 African outbreak countries from 2009 • No WPV cases reported in 2 out of 4 re-established countries (Chad and Sudan) •

However, risks still remain in endemic countries with explosive outbreaks in Pakistan and Afghanistan due to chronic SIAs gaps, complicated by floods and spread to high risk insecure areas. In Nigeria, there are remaining reserviors for type 1 in the North Eastern axis of Borno state and type 3 in the North Western axis of Sokoto and Zamfara states.

In countries with re-established circulation, the biggest threats are in Angola and DRC. In Angola the virus is still widely spread since importation from India with international export to DRC and Congo. In DRC, WPV had been missed for more than 12 months in the Eastern part of the country with on-going explosive outbreak in Kasai Occidental. Recently, Congo has experienced an explosive type 1 polio outbreak among adults with more than 476 cases, of which 80% were were more than 15 years of age, and a high case fatality rate of about 50% . There is also an ongoing outbreak which had not been detected on time due to surveillance gaps (orphan viruses) at sub-national level on the Uganda/Kenya border

The presenter also narrated the reasons behind the creation of the Independent Monitoring Board (IMB) which will change, monitor and advise on how the GPEI carries out its business. In summary, the Board will monitor implementation of the New Strategic Plan, progress towards achieving the set milestones and advise countries and stakeholders on corrective actions.

Monitoring Milestones & Corrective Actions 

Public: MoHs, donors, advisory bodies Ministries, Tech 

Experts, etc. 

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Among the immediate priorities are to: • Conduct aggressive mop-ups focusing on migrant and mobile populations in India and

Nigeria • Develop and review Emergency Plans for Angola & DR Congo • Stop new outbreaks, especially in Chad, Uganda and Congo • Restructure the Pakistan program • Urgently close the financing gap for implementation of planned activities Discussion The conference participants welcomed the presentation and acknowledged the progress being made in Nigeria. However, they were concerned with the continued gaps in SIAs quality in some countries. For example, in Pakistan where huge proportions of children have been missed for almost 10 years, and in Angola where polio circulation has continued since the last importation from India. Also, the gaps identified in AFP surveillance as revealed by orphan viruses (missed circulation for more than one year) reported in countries like Uganda / Kenya were worrisome. The impact of bOPV was welcomed but WHO and UNICEF should ensure adequate availability of the vaccine by working more closely with manufacturers and also prioritizing its use. The conference also emphasized that social, communication, economic and environmental factors should be considered in planning and implementation phases of SIAs.

Independent Monitoring Board (IMB) 

U.S. CDC  surveillance & SIA risk assessment 

WHO & UNICEF milestone & major indicator data 

Heads of Agency WHO, UNICEF 

BMGF, Rotary, CDC 

Ministry of Health Corrective Action Plan  

(2 weeks) 

'off‐track' 

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Status of Polio Eradication in the African Region Dr Sam Okiror, WHO-AFRO Summary of Presentation The presentation highlighted the significant progress and challenges made in reducing wild poliovirus cases in Africa Notably, the Global Polio Eradication Strategic Plan 2010/12 milestones were disseminated to all countries in the Region and were being closely monitored. Independent Monitoring has been institutionalized in all countries that carried out OPV SIAs in 2010. There has been a significant reduction of WPV cases in Nigeria from 390 in 2009 to 13 in 2010, representing a 97% reduction which was a remarkable achievement in an endemic country. There has been a decrease in number of outbreak countries in the region from15 in 2009 to 8 in 2010. Seven out of the 10 countries in West Africa have achieved the first milestone and interruption of transmission was on track. In re-established transmission countries, there was a significant reduction in WPV3 transmission in Chad from 47 cases in 2009 to 14 cases as at 3 December 2010. However, in the other re-established transmission countries, persistence spread of WPV1 in Angola and intense transmission in DRC were noted. Despite the set-back experienced with the recent outbreak of WPV1 in Republic of Congo affecting more than 400 people, mostly adults, with 175 deaths in 2010, the Central Africa epidemiological block was still on track to achieving milestone one. On the way forward, the presenter outlined the actions to be taken to achieve the milestones that were in line with the ones described in the GPEI presentation. One of main actions in the region will be to ensure formation of Coordination Mechanisms, as experienced in West Africa, with Task Forces to mobilize resources as well as to timely monitor the preparations of SIAs to ensure high quality. Discussion The conference commended the progress in Nigeria but noted with concern the following set- backs related to interrupting transmission in the African region. It noted that the WPV outbreaks were directly related to low levels of routine immunization coverage and chronic campaign gaps. For example, the intense WPV1 transmission in DR Congo since May 2010 and the low quality of SIAs in Luanda, Angola after >30 campaigns, were not entirely due to the problem of accessibility. The failure to interrupt transmission in these countries have resulted inWPV1 outbreaks affecting mostly adults in DR Congo. The conference also noted the existing population immunity problems which were compounded by surveillance gaps shown by the finding of long chain transmission viruses in Uganda and DR Congo The conference urged AFRO and partners to quickly address the chronic SIAs gaps to achieve the set milestones in the region in 2011.

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Monitoring Global Polio Milestones Dr Brent Burkholder – Centers for Disease Prevention and Control (CDC-Atlanta) Summary of presentation The GPEI Strategic Plan 2010-12 outlined the role of CDC in helping to monitor the milestones by providing quarterly assessment for endemic, re-established, and ‘importation’ countries to determine the risk of failing to interrupt WPV. . The assessment methodology takes into account surveillance performance such as the risk of failing to timely detect WPV circulation and population immunity gaps using the OPV doses of non-polio AFP cases from surveillance data and reported routine immunization OPV coverage

Based on the global risk assessment, the primary areas of concern were:

o Pakistan and Afghanistan o Angola and DRC o Focal areas of Russian Federation o Uganda and Kenya borders of Sudan

Discussion The conference welcomed the presentations and appreciated the simple methodology of assessing the risk for timely interventions. However, they were concerned that the data provided by some countries to monitor milestones were of unknown and questionable quality, and in some cases inconsistent which may mislead the risk assessment. AFRO was, therefore, advised to continue taking the necessary steps to assist countries in ensuring acceptable quality of the data. PEI Parallel Session 1.1 Interrupting Endemic and Re-established Transmission in Africa Summary of the presentations Four presentations were delivered during the session (a) Sustaining the Gains in Polio Eradication in Nigeria by Dr E A Abanida, Director of Disease Control and Immunization, National Primary Health Care Development Agency (b) Innovative Approaches to interrupting WPV transmission in Chad by Dr Jabber, EPI Manager (c) Progress in the implementation of the Emergency Plan to interrupt WPV transmission in Angola by Dr Adelaide de Carvalho, National Director of Public Health (d) Interrupting WPV transmission in DR Congo by Dr Calembe, EPI Manager. The main progress reported included decline in wild poliovirus transmission in 2010 compared to same period in 2009 in Nigeria (97% decline) and Chad (71%), improved quality of polio eradication activities (Nigeria, Chad); increased engagement of Government leaders at national and sub-national level (Nigeria, Angola and Chad); strong partnership with religious, traditional and other civil society leaders (Nigeria, Angola); effective initiatives to enhance community participation (Chad) as well as innovative resource management mechanisms including payment for performance (Chad).

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Angola presented progress in the implementation of a six month emergency plan that included strengthening programme coordination and advocacy, resource mobilization, strengthening of partnership and social mobilization. Challenges identified included sub-optimal routine immunization performance in countries with endemic and re-established transmission, persistent poor quality of campaigns in several high risk areas, sub-optimal surveillance quality in hard-to-reach and insecure areas, risk of declining political commitment particularly in countries with elections in 2011 and inadequate funding for key programme operations and activities. Priorities identified for 2011 included continued advocacy to achieve and/or sustain high political commitment, implementation of special emergency plans in poor performing areas, intensification of routine immunization and surveillance, improving the quality of immunization campaigns in areas where significant number of children continue to be missed A summary of communication issues in Polio Eradication was presented by I Dincu, UNICEF/WCARO. Progress reported include implementation of KAP study and updating of communication strategies in several countries, strengthened capacity for communication with several UNICEF country offices, monitoring of global communication indicators and inclusion of communication indicators in independent monitoring. Revision of communication Standard Operating Procedures (SOPs), roll out of intensified communication activities in 8 priority counties as well as final adoption and regular reporting against global communication indicators were priorities identified for 2011. Discussion The resurgence of wild poliovirus transmission in DR Congo was highlighted as a concern. It was pointed out that every effort should be made to enhance political commitment and programme ownership at national and provincial level in DR Congo, rapidly prepare a targeted plan to address gaps in campaign quality and surveillance in the different infected provinces in the country. Routine Immunization coverage remains sub-optimal in countries with endemic and re-established transmission. Recent efforts to strengthen routine immunization should be further accelerated in order to ensure that recent gains in reducing wild poliovirus transmission are sustained. Best practices in engaging political leaders at national and sub-national levels as well as strengthening partnership with Traditional and Religious leaders should be documented and disseminated. Plans and strategies should be tailored to address remaining challenges in areas that continued to have sub-optimal campaign quality and surveillance gaps. Qualitative and ethnographic research should be prioritized and used to improve communication and community engagement strategies.

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Parallel Session 1.2: Preventing New International Spread & Outbreaks (Strategic Plan Milestone 1) Analysis of Poliomyelitis Outbreak in Re-infected Countries in Africa K. O’Reilly, Imperial College Summary of presentation To better understand the risk factors for outbreaks in re-infected countries and plan for timely interventions the GPEI requested Imperial College London to come up with a model that could assist in identifying the risk and where SIAs would be needed. It was recognized that SIAs were not occurring in some countries which were at high risk until after an occurrence of an outbreak, and SIAs may have been implemented in countries where there was sufficient population immunity to prevent an outbreak. Based on data analysis in Africa particularly with experience from West Africa, a Statistical model was presented that could predict outbreak risk in Africa. Utilizing AFP and polio cases surveillance data, the vaccination history of non-polio cases, intensity of previous polio outbreaks, particularly in the previous 6 months and inter-country migration patterns, the model had a predictive value of 82%. Among the variables with high correlation were • Poor population immunity

– low proportion of children aged 0-4 years reporting 3+ doses of OPV. Routine and SIAs coverage were not as significant factors in the model

• High force of infection and population movements e.g. – Countries bordering Nigeria – Population movement from Nigeria to each country in previous 6 months

Discussions Achievements in Nigeria since the analysis (Feb 2010) may have altered the predictive value of original model. Based on predictions for first half of 2010, 6 of 9 countries with outbreaks were in lowest risk category In addition, the low data quality may, to some extent, have limited the predictive value of the model. It was, therefore, suggested that inclusion of independent monitoring data could improve the predictive value of the model. Also, inclusion of community level data into the model should be considered. The conference advised that before the model is disseminated and used for prediction, it should be refined taking into account the suggestions of the meeting and consultations, before use.

Major Lessons in Coordinating International Outbreak Response Dr I. Kane, IST/West Summary of presentation It had been observed that there was significant variation in the quality of SIAs in West Africa which was hampering the efforts to interrupt WPV transmission in the epidemiological block. With the prolonged periods of WPV outbreaks in some countries, huge population movement among countries, inadequate immunization activities (low routine immunization coverage, sub-optimal SIA quality) and limited government ownership of polio response activities, unless a coordinated effort was carried out, it would be impossible to interrupt transmission in West

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Africa. To address these issues, WHO and UNICEF spearheaded implementation of a series of activities in a coordinated manner. Among the major activities of the Coordination Mechanism included weekly teleconferences, lead by IST West with AFRO, WHO/ HQ, UNICEF/ WCARO, UNICEF/HQ and Supply Division. Regular feedback through Daily Feedback bulletins and direct contact with country teams was provided. Once an outbreak was reported, investigations ensured full technical support to the country from WHO, UNICEF and partners with the development of a response plan immediately following the investigation, including SIA dates and resources identification / mobilization for a timely response of high quality. The implementation of the preparatory activities was closely monitored with immediate corrective action taken. The Coordination Mechanism resulted in high quality SIAs which have resulted in interruption WPV transmission in most West African countries. Discussion There was no question that the Coordination Mechanism had a positive impact in interrupting transmission in West Africa. The conference therefore recommended that the mechanism should be institutionalized in other epidemiological blocks in the African region. The conference also noted that while the coordination was mostly facilitated by WHO, UNICEF and partners, it was important to strengthen ownership and leadership of the coordination by countries for sustenance. Improving SIA Quality through Independent Monitoring in the African Region Dr M. Salla, IVD AFRO Summary of presentation Despite SIAs with reported high coverage rates, WPV circulation and importations still occurred in AFRO region. To help improve the quality of SIAs, Independent Monitoring (IM) was institutionalized in October 2009, with updated guidance distributed in March 2010. The objectives of IM were to identify any missed children, missed areas/communities and the reasons for the unvaccinated children. The information was used to rapidly identify SIA gaps and take appropriate corrective action during that round and subsequent ones. The emphasis was to conduct IM outside houses in areas where vaccination teams usually miss children such as transit areas, markets, playgrounds etc. The findings of the in-process monitoring (during campaigns implementation), were used to strengthened team supervision and scrutinize team performance. The end-process monitoring (post-campaign) data were used to direct teams to comb up / revisit areas where performance was sub-optimal Another experience in the Region was the Enhanced Independent Monitoring introduced in Nigeria in 2010. Enhanced IM-Nigeria (improving IM) was implemented with some changes to ensure high level monitoring by reducing work-load of monitors (reducing the number of monitoring days, less intra-campaign monitoring), improved sampling methodology of houses to be monitored, adequate training (from 1 to 2 days), intensified supervision, improved data management through data entry while a monitor was present. This approach resulted in more unvaccinated children being detected.

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Discussions The conference welcomed IM as a process to identify gaps in SIA quality to be addressed through appropriate measures based on the country situation. The role of a coverage survey was noted to be different from IM. The survey validates coverage while IM identifies missed areas. It was also discussed that budgets for corrective action to revisit poorly done areas were often not planned for. However, it was agreed that if remuneration is tied to team performance, extra budget may not be needed to revisit the poorly done areas. Therefore, payment of supervisors/teams should be based on completion of task, and not on days worked It was also proposed that simple GPS technology can supplement independent monitoring to ensure all target areas are reached. cVDPVs and Research Related to Optimizing Control in the Short and Long Term Dr R. Sutter, WHO/HQ Summary of Presentation Efforts to eradicate polio require a balance of research and product development. The presentation focused on 3main areas: 1)how to accelerate polio eradication;2) assess and respond to the risks of VDPV following OPV cessation; and 3) efforts to secure eradication in the future. Among the issues on how to accelerate eradication, development and licensing of new vaccines (e.g. bOPV), enhancing immunogenicity of polio vaccine (higher potent vaccines e.g. mOPV, inclusion of some micro-nutrients e.g. vitamin A, zinc, were presented. It was also important that operational issues in improving quality of SIAs such as transmission in special populations (adults, adolescents, migrants), SIA monitoring , Rapid Response Initiative (RRI) - ensuring targets are met with monitoring, evaluation and corrective actions, use of GPS to supplement RRI and IM data, network analysis of non-compliant households and improvements in social mobilization activities should be considered. On assessing VDPV risk, it is important that VPDV surveillance should be fully integrated into AFP surveillance and cVDPV outbreak investigations. To secure eradication, there is need to evaluate the switch from OPV to IPV to assess Sabin circulation following cessation. Efforts to make IPV affordable should be made through fractional dosing, new formulations, safer production of IPV, expanding IPV production to developing countries, needless delivery device (for IPV), consider antiviral compounds for chronic WPV shedders and policy development for containment and IPV use. Discussion The conference expressed that the role of combination vaccines (which include IPV) was noted to be an unaffordable option at this time. In fact the introduction of IPV in Africa was discussed previously at the SAGE IPV Working Group and agreed that the eradication strategy with OPV should take precedence at this time, though some countries in Africa have introduced IPV. As for the other operational research issues to accelerate eradication, the conference welcomed the proposals to improve quality of the SIAs. It was also expressed that the social components of polio eradication were not always researched and that opportunities should be made available by WHO to support such activities

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Update on Global OPV Supply M. Shirey, UNICEF, Supply Division Summary of presentation The presentation provided background on the status of the global vaccine supply. UNICEF procures vaccine for the global polio program for over 80 countries. In 2010, UNICEF procured 1.9 billion doses of oral polio vaccine. Much of this vaccine (90%) in 2010 was utilized for polio SIAs. The presentation then summarized the availability of the various types of oral polio vaccine: • tOPV- Supply of tOPV is adequate under current global projections, but tight in quarters 1

&2, 2011 (based on planned campaigns) especially January and February 2011 SIAs. Global shortage of pre-qualified amounts of tOPV was possible if cVDPV-2 outbreaks occur

• bOPV - Supply of bOPV is very tight in first half of 2011 because it has become a favored vaccine for many SIA even in countries that have only one WPV type circulating. Previous demands have limited the ability to have buffer stocks. Distribution of bOPV is limited as endemic countries have licensed only a single manufacturer (except India which has 2 licenced manufacturers), limiting flexibility on availability.

• mOPV1 and mOPV3 –Because of decreased demand for both mOPV1 and mOPV3 due to preferential use of bOPV, there is an expected excess in the coming year. With fewer mOPV SIAs being planned and diminishing demand, the production of mOPV by manufacturers may be negatively affected in future.

Therefore, adequate planning is a critical component of vaccine production process, requiring at least 2 years to ensure enough production. The GPEI is required to prioritize vaccine allocations based on global programmatic requirements allocations. UNICEF ensures manufacturers produce quality vaccine by focusing on vaccine security. To ensure adequate vaccines are available, UNICEF utilizes multi-year tenders, multiple manufacturers and consultation with manufacturing. Since polio outbreak responses tend to strain the supply and delivery system, it was therefore requested that only urgent vaccine requests should be made, to reduce pressure on UNICEF Supply Division, as well as manufacturers and freight forwarders. The participants were reminded that to have appropriate orders (type and quantity) delivered from the Supply Division, a minimum of 6 weeks for planned activities is required while for emergency outbreak responses, requests have been delivered in 1-2 weeks in some cases, though some areas in West Africa have some limitations due to few flight options therefore more time may be required for delivery. Discussions The conference expressed the concern on supply limitations of bOPV and excess of mOPV. The participant’s proposal of changing excess stocks of mOPV to bOPV was unlikely due to manufacturer constraints. The conference also suggested that the possibility of extending the shelf life of excess mOPV should be considered by experts to advise the GPEI.

As for other possible vaccine sources to meet the shortage, the conference was informed that China does not yet have a NRA that meets WHO standards, and therefore Chinese vaccines are not pre-qualified Session 3: Reaching un/under Immunized Children in the African Region- Progress, Challenges and Opportunities Reaching the Unreached in AFR with Routine Immunization Services Dr Richard Mihigo, WHO/AFRO Summary of presentation An overview of the progress and challenges on RI performance, continued introduction of new vaccines in countries, successful launch of Meningitis A Conjugate Vaccine and plans for immunization financing in the African Region were presented. 2009 performance revealed disparities between and within countries in routine immunization coverage performance. For example, 10 countries accounted for 80% on unimmunized children in the Region in 2009. As a result, the goal for 2010 was to reduce the number of unimmunized children by 50% using innovative strategies. In 2010, there have been some improvements with 10 countries with the largest number of unimmunized children accounting for 71% compared to 80% in 2009. Three countries (Cote d’Ivoire, Cameroon and Chad) have moved out of the top 10 countries with largest numbers of unimmunized children and have been replaced by Mozambique, Zambia and Madagascar. Ethiopia with a 46% reduction in the number of unimmunized children in 2010 compared to 2009 has shifted from the second highest position to sixth.

Reaching the unreached with RI Services in AFR. 2nd ARCI, Ouagadougou /Burkina Faso, 7 Dec. 201011 |

Top 10 Countries with DTP3 underTop 10 Countries with DTP3 under--immunized children, Janimmunized children, Jan--Sept 2010Sept 2010

71%of All under

vaccinated in the Region

•3 New countries •3 Countries out of the top10 : Côte d’Ivoire, Cameroon and Chad

However, only Gambia and Burkina Faso have reached the GIVS goal of >90% DTP3 coverage.

20

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New Vaccines were introduced in many countries by 2010 with 44 countries having introduced Hib vaccine, 45 introduced HepB, 3 introduced PCV, with 11 more planning to introduce in 2011. Among the challenges with RI performance, included lack of community ownership and awareness leading to low demand for vaccines. It was also noted that National Strategic Health Development Plans still lack plans for immunization activities in many countries. In addition, improvements in data quality still require further efforts. An operational research capacity needs to be further developed to gather evidence to increase performance.

Meningitis A Conjugate vaccine was being rolled-out in 3 countries in 2010, and in the remaining countries from 2011-2015 targeting 1-29 years of age. Phase I introductions had high coverage: Burkina Faso (98%), Mali (97%), Niger (91%). Only one severe adverse event following immunization (AEFI) associated with the vaccine was reported while 8 deaths were determined to be coincidental. Immunization financing issues continued to persist. 41 countries have budget lines for vaccine, but funding remains inadequate with significant reliance on donor funding for new vaccines. Increasingly, the global health community was moving away from direct project assistance for health towards sectoral or general budget support based on MTEFs. Efforts need to be made to ensure the evidence base for introduction, adequate policy dialogue on priority setting, and to roll these resource requirements into annual or multi-year budgets. Several challenges were mentioned which require urgent prioritization by countries and partners: • identify sustainable ways to increase government immunization financing • expand supply and logistics capacity with the introduction of additional vaccines, • strengthen surveillance of VPDs for evidence based advocacy for funding • strengthen national regulatory capacity • Increase advocacy for activities including Africa Child Health Week • improve data quality

Discussions The conference stressed the need to show sub-national performance data which was not presented during this meeting. Also there was concern that data from countries like Algeria were not presented. In response, the presenter assured the participants that sub-national data was being monitored regularly and analyzed in a systematic manner by AFRO. Data from Algeria was not included in the presentation, as it was incomplete. The conference urged AFRO to ensure that data are collected from all countries and should be presented in the next ARCI. The conference noted that countries that had shown improvements such as Ethiopia, had immunization services linking within the Primary Health Care services delivery system. It was stressed that although this linkage seems to be a new innovation / strategy, it has actually been

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part of EPI from its inception supported by many PHC declarations such as Alma Alta, Ouagadougou etc. It was also noted that Governments and partners support to Civil Society Organizations (CSOs) was an important aspect of improving routine immunization coverage in African countries. There was also need to focus on socio-cultural research to increase demand and uptake of vaccines by communities. Overview of WHO/UNICEF Immunization Coverage Estimates

Martha Gacic Dobo, WHO/HQ Summary of presentation The presenter provided background on the different sources of coverage estimates, comparing administrative and survey data. The advantages and disadvantages of each estimate were noted, administrative data had the advantage of timely monitoring performance, but the disadvantage is that it heavily relies on accuracy of the denominator. Although surveys have an advantage of not being reliant on population estimates and include private health facility data, but the data are not continuous let alone being timely (>1 year intervals). WHO/UNICEF estimates have been distributed since 1999 for the 194 countries and territories. The estimates were not influenced by the countries and country’s approval of the estimates is not required. The methodology of coming up with estimates was distributed in 2009 and transparency has since increased with better acceptance by countries. In short, the estimate algorithm is based on submitted administrative coverage data and high quality surveys as well as additional information (stock-outs, Data Quality Audits) and local knowledge based on a set of pre-defined rules. Data for WHO/UNICEF Joint Reporting Forms (JRF) are due to HQ annually by 15 April for compilation and analysis with circulation to countries by the end of May. Countries are expected to submit comments and/or additional data by the end of June, with estimates published on websites the 2nd week of July. Data is then utilized by WHO/UNICEF in official reports, tracking progress for MDGs, funding agencies and for disease burden models. In the African region, the number of countries where reported JRF figures are similar to WHO/UNICEF estimates have increased since 2000 showing some improvement in data quality.

WHO/UNICEF Immunization Coverage Estimates|

Relation between reported and estimated DTP3 coverage in AFR region 2000, 2005 and 2009

0

5

10

15

20

25

2000 2005 2009

Num

ber o

f mem

ber s

tate

s

reported < estimated reprted = estimated reported > estimated

43%

26%

48%

Source: WHO/UNICEF coverage estimates, as of July 2010

To further improve coverage estimates several areas were noted which need to be addressed: 1) Improve data quality at sub-national and national levels to have reliable reported data from all countries using administrative systems or from surveys - preferably administrative data periodically confirmed by a survey, 2) Improve country consultation process utilizing more direct contact with regions / countries to review coverage estimates and use EPI managers meetings and other opportunities to work directly with countries using country experts, 3) Improve current estimation methods by improving current rules system for determining estimates. Discussions The conference expressed concern that although there has been improvement in data quality, the increase in the number of countries over-reporting needs to be given serious attention by WHO / UNICEF and countries. Some of the simple checks to improve data quality before submission at all levels could include monitoring unexplained coverage discrepancies of antigens that are scheduled to be administered at the same time e.g. DTP3 and OPV3 coverage discrepancies. The conference also advised that the quality of some survey findings should be taken into account during the estimate process. In addition, the evaluation of valid dose administered at correct intervals should be included when reporting coverage using administrative methods or surveys.

Decade of Vaccination Delivery Stream Dr J-M Okwo-Bele, Director – IVB, WHO/HQ Summary of presentation

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The Decade of Vaccines was announced by Mr Bill Gates in Davos in January 2010 with a pledge of 10 billion USD from the Bill and Melinda Gates Foundation. This announcement was supported by the WHO Director General at the WHA in May 2010. In September 2010, the Decade of Vaccine team started to develop structures and timelines using a collaborative process. The organo-gram currently included a leadership committee, steering committee and several working groups. WHO/UNICEF are co-chairing the delivery working group, and were directed by SAGE to develop a draft framework for review by mid-February 2011. Before final submission in June 2011, the framework will be circulated to the WHA, WHO / UNICEF Regional offices and countries.

The kePublicensureaffordof newof straquality The fi

• • • •

y components to link the existing GIVS with the DoV included four area: Strengthening Support for vaccine use and financing; expanding the reach of Delivery programs to that all persons at risk, particularly children, benefit from the protection that vaccines can ; maintaining a strong pipeline of Research and Development to harness the cutting edge science to produce new vaccine solutions and associated technologies; exploring a variety tegies to ensure Global Access to sufficient supplies of affordable vaccines of assured .

nal framework involves several areas: Equitable access to immunization Protection against diseases in synergy with other related disease control initiatives Strengthening immunization systems performance and monitoring Costing

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Discussion: The conference welcomed the Decade of Vaccines and thanked Bill &Melinda Gates Foundation for the initiative that will protect beneficiaries from vaccine preventable diseases and contribute towards achieving MDG-4, in particular. The plan for gathering contributions for the development of the action plan was discussed and found not to be consultative enough. The conference proposed that consultations should be extended to beyond HQ and regional offices to include other regional immunization forums such TFI and countries. It was explained that with the prescribed timelines since declaration of DoV, there wasn’t adequate time to solicit contributions from countries but country contributions/ inputs should be taken into consideration before finalization of the action plan. The conference also expressed caution that some of the DoV targets may not be achievable within 10 years, and others may not be sustainable. The development of improving vaccinations cannot only be looked at within the next 10 years but should also be used for building foundation for further progress beyond the next 10 years.

Strategic Approaches to Protect, Prevent and Treat Children to Reduce Pneumonia and Diarrhea Mortality. Dr T. Cherian, IVB, WHO/HQ Summary of presentation The presenter emphasized the global community commitment to achieve the MDGs. Not reaching MDG4 will result in 30 million unnecessary child deaths of which a third will be due to pneumonia and diarrhea. Unfortunately, as of 2010, the progress was not on track. The 10 countries with the highest number of deaths from pneumonia are the same 10 countries with the highest deaths from diarrhea. Although existing public health and clinical tools to significantly reduce childhood mortality and reach these MDG goals are well-known, they are not being fully implemented in countries.

2577283238404343484953626978807930

0 20 40 60 80 100

IPTp for malariaChildren sleeping under ITNs

Exclusive breastfeeding Antibiotics for pneumonia

Diarrhoea treatmentMalaria treatment

Early initiation of breastfeedingImproved sanitation facilities Careseeking for pneumonia

4+ antenatal care visitsSkilled attendant at deliveryComplementary feeding (6‐9

Improved drinking water Vitamin A supplementation (2

Measles immunizationDPT3 immunizationHib3 immunization

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Planning to synergistically improve pneumonia and diarrhea control should be implemented to protect, prevent and treat these syndromes. By increasing coverage of these services to 90%, approximately 5.3 million deaths can be averted by 2015. In May 2010, the WHA Executive Board was presented the plan to accelerate coverage of the interventions and the Board directed that annual progress on pneumonia and diarrhea morbidity and mortality reduction should be reported to WHA, including country specific actions and required resources mobilized to reach these goals. Discussion The conference noted that the significant progress to reach MDG-4 in Africa has been mostly due to the reduction of measles mortality in the African region, however, these gains are still fragile. Therefore, a significant setback would occur if measles mortality reduction was not sustained due to shifting focus. Taking this observation into consideration, caution should be exercised when rolling-out additional interventions, especially those that are associated with significant cost. Nevertheless, the conference agreed that to reach the MDG goals and avert the unnecessary death of children, it is vital to accelerate implementation of the advocated strategies in countries.

Parallel Session 3.1: Routine Immunisation Reaching the Unreached Children: Country Experience - Burkina Faso Summary of presentations This country presentation was in 2 parts: firstly, an overview of the national EPI programme and the problem of unvaccinated children, despite reporting very good administrative coverage. The presenter described the use of corrective action based on the independent monitoring mechanism to ensure that all eligible children are reached with the polio vaccine. Secondly, the presentation centred around the use of community resources in ensuring the tracing and vaccination of children eligible for routine vaccination, the surveillance of vaccine-preventable diseases and basic health education of mothers. In a project pilot of 24 health areas in 3 regions of Burkina Faso, the focus was on community involvement for adherence and monitoring of vaccination of eligible children in their communities. In each village in the project area, 3 community health volunteers chosen by the community were trained and equipped with simple tools to i) record births, deaths and arrivals in the community of children eligible for routine EPI services; ii) undertake monthly contact with the family to follow up on each child’s vaccination record, iii) search for children who are lost to follow up as a strategy to reduce drop-out rates iv) sensitise mothers about the value of vaccination, and v) compile and analyse the data on a regular basis. These community volunteers made regular monthly contacts with the health centre staff and provided the community with periodic reports. The system put in place encouraged and used an active collaboration between health centre staff and the community.

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The project results were very encouraging and revealed a much higher target population compared to the estimated target population provided by the central level. In addition, there was a reduction of drop-out rates in the project areas. Discussion The conference was informed that the community health workers were actually volunteers and the question of motivation was discussed. Apart from their recognition by the community, these volunteers also get re-imbursement for their transport and refreshments whenever they attend the periodic meetings with the health centre staff. They may also be given preference for educational programmes in their respective communities. The conference noted that this kind of linking services delivery within the Primary Health Care context should be taken into account when designing and implementing routine EPI services. Reaching the Unreached Children: Country Experience - Benin Dr Marie Rose Nago, MoH Benin Summary of presentation The presenter outlined the profile of unvaccinated children, where they can be found and the likely reasons why they were not reached. Among factors contributing to this situation were budgetary constraints on the EPI programme, industrial action by health workers, and the lack of motivation of staff including the feeling of lack of advancement in their careers. The unimmunized children tend to be those living in remote and hard to reach areas, but also the children living in fringe settlements, slums in sub-urban areas, as well as in frontier settlements. Each region was provided with guidelines for the detection of non-vaccinated children and requested to plan special vaccination activities for 3-6 days. These plans were discussed with district staff who also identified the health areas in their districts for the execution of the plan. For the mobilisation of the communities, rural radio and town criers were used, while local NGOs and community volunteers were used to search for children in some health zones. Results obtained showed more than 90% of the number of children listed as unvaccinated were found and vaccinated with all antigens (DPT/HepB3/Hib3/MCV and YF). There was also a marked increase in the number of districts with reduced drop-out rates (= <10%) compared to the previous year. Among the lessons learnt to have good impact, were the need to involve and increase ownership of community leaders in planning and execution of the activity. Also, linking this activity with campaigns might lead to maximisation of resources and impact. Discussions The conference clearly noted the problem with governance in the context of the health system delivery in some African countries. While sectoral ministries have budgetary allocations, the discretion to finance planned activities may depend on individual preferences and not commonly perceived priorities that need attention. While the RED approach is being implemented in countries to reach the unreached populations, most of the time, children were still being missed particularly as a result of irregular implementation of scheduled immunizations due to lack of financing or industrial action by health worker staff. However, it was noted that if all the components of RED were correctly applied, there would be little or no need for these extra catch-up vaccination activities.

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Integrated Delivery of Services: Cameroon, Mali, Ethiopia Experiences. Dr T. Ryman, CDC Summary of presentation In the implementation of GIVS, there continues to be a push for using immunization systems as a platform for the integrated delivery of interventions. For improved efficiency, there is a need for a decision tool that will help countries determine their own integration package. The findings of the first phase of a study which aimed to provide the evidence for creating a decision tool to determine integration package for interventions was presented. The main objective of the study was to assess community and health worker perceptions of the benefits and concerns of integrated services as currently delivered. The study was carried out at peripheral (service provider) levels in Cameroon, Mali and Ethiopia through a series of interviews, focus group discussions and time observations. The main findings showed that EPI was widely accepted and that integration was viewed positively though concerns such as stock-outs of the integrated interventions were highlighted in all the sites in the study. Another concern was the retention of multiple messages for the packages to be delivered. Both, health workers and beneficiaries had similar perceptions in terms of concerns and benefits of integrated services. These findings suggest that in planning integration of interventions the following should be considered:

• Reducing beneficiaries’ waiting times • Vaccinator workload with staffing modifications to improve efficiency • Patient flow variations

Based on the findings, the next steps would be to create a generic decision tool, and test for application in several countries. Discussions The conference observed that the study was both qualitative and quantitative so strictly speaking comparisons cannot be made but similarities across countries can be examined. The time-observations and education of the mother were only in relation to vaccination visits and not other scenarios of integration. Vaccines and Supply Chain Mr P.Lydon, OPTIMIZE Summary of presentation The presentation introduced the joint WHO-PATH project OPTIMIZE which is a 5-year (2007-2012) project funded by the Bill and Melinda Gates Foundation and the main objective is to shape the future of technologies and supply chain/logistics systems for vaccination in low and middle income countries in view of the need to manage the future with the introduction of new vaccines (greater volumes), new delivery strategies and new emerging risks e.g. H1N1 that may affect vaccine management.

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The project is based on the 3 pillars of innovation, demonstration and facilitation in the use or adoption of new/improved technologies and logistics systems. There are currently 5 main activities in the African region, namely:

• Supporting the development of supply chain and logistics assessment tools and their roll-out – EVM (Effective Vaccine Management Assessment) in Nigeria, Sierra-Leone, Ghana, Chad and Cameroon) This involves an assessment of national supply chain systems at all levels of the chain (from national to service delivery level) composed of 9 criteria. This is a tool for diagnosing the current state of vaccine management and allows for future improvements and planning for the introduction of new vaccines in the best conditions

• Supply Chain Integration demonstration (Senegal) which focuses on storing and/or transporting vaccines with other health products that may or not require cold chain thus aiming for a better use of the existing cold chain system. It is also envisaged to reduce the overall number of parallel health commodity supply chains.

• Supply Chain Outsourcing study (South-Africa) • Controlled Temperature Chain analysis (Chad, Mali) with the focus of storing and

transporting vaccines outside the recommended temperatures ranges for a limited period of time.

• Inter-Country Warehouse and International Shipping of Vaccines (South-Africa) The presenter also indicated that OPTIMIZE envisages a global map of supply chain systems which is to be aligned to the Decade of Vaccine. Finally the presenter made an appeal to participants to disseminate OPTIMIZE areas of work in countries. Discussion The conference noted the experience from the DRC which showed that the integration of the supply chain with other health products was not always feasible and there is need for caution when institutionalizing the integration. There was also the issue of choice and availability of suitable transport systems which need to be taken into consideration However, the conference also expressed that certain bi-lateral agencies would like to support strengthening of the cold chain and an analysis of the tools would facilitate their interest. Towards the creation of a new health staff category called “Logistics for Health” Dr. Avocksouma, WHO-AFRO Summary of presentation The presenter made the case for the creation and institutionalisation of a cadre of staff to cover the logistic function within the health sector. He asserted that based on the findings of an evaluation conducted in 2005 in Benin, Burkina Faso, Chad, Madagascar and DRC, the logistician function is essential in health sector activity but is not formalized in MoH structures. The role of health logistics in strengthening health systems delivery was also defined, and noted as being very important in providing solutions to the logistical challenges for the implementation of Primary Health Care, and expressed the need for a formal training of Logisticians for Health. Consequently, he stressed that we have a collective responsibility to: Ensure the recruitment and retention of competent logisticians in the health sector Advocate among stakeholders for institutionalising logistics for health as a profession Harmonize approaches among stakeholders in reaching this goal

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An approach should be adopted for this purpose, consisting of an evaluation and an analysis of the institutional environment to find the best introduction strategy, and also monitor implementation. These activities could be supplemented by support to countries for advocacy, resource mobilisation and technology transfer. Discussions There was general consensus on the concept and participants were informed that there is already a Working Group looking at the issue of training of logisticians for health. The conference noted that an adequate number of health workers with correct skills-mix was very important as we aim to scale up implementation of immunization services, introduce new vaccines and integrate services delivery. It was also important that this issue be adequately addressed in many of the country comprehensive multi-year plans (cMYP). Parallel Session 3.2: New Vaccines Pneumococcal Conjugate Vaccines Introduction: An Opportunity for Reaching MDGs Dr. Chizoba Wondi, John Hopkins University, School of Public Health Summary of presentation The presentation covered five thematic areas, namely: pneumonia and pneumococcal disease’s contribution to childhood mortality; projected pace of PCV introduction in GAVI countries; pneumococcal vaccine pipeline; PCV supply outlook; financing for PCV; and advocacy to support and sustain vaccine programs. It was stated that Pneumonia was the second leading cause of under -5 mortality in Africa, killing more than 700,000 children annually and contributing about 18% to all-cause mortality based on the 2008 WHO estimates. Africa had the highest morbidity and mortality rates due to pneumococcal disease. 10 countries with most under 5s pneumococcal deaths in AFRO contribute at least 300,000 deaths /annum based on 2000 WHO estimates. Additionally, Pneumococcal and Hib infection together account for about 50% of all severe pneumonia. The presenter then addressed the integrated approach to pneumonia, GAPP, proposed by WHO/UNICEF. The good news was that Pneumococcal conjugate vaccines had demonstrated efficacy in Africa but the impact of PCV on MDG-4 by 2015 would depend on three things: speed of vaccine adoption; serotypes contained in vaccines; and routine immunization coverage. It was reported that if there will be no financial & supply constraints, 45 GAVI countries (26 in Africa) would introduce PCV by 2015. The three vaccines types available on the market, namely: Prevenar®-7 (7-valent), Synflorix™ (10-v with non-typeable H. influenzae carrier in1 or 2 dose vial presentation), and Prevenar 13 (13-valent, single dose vial). After considering invasive disease-causing serotypes in existing vaccines formulations, by region, it was reported that 10-valent and 13-valent coverage were statistically similar in Africa like in other regions. An adequate supply of vaccine was expected to be available to meet the pneumococcal vaccine demand of countries already approved by GAVI as well as to meet increases in future demand. It was estimated that the potential impact of PCV vaccination could range from 168,000 to 265,000 deaths averted per year among under-5 children in the top 10 pneumococcal mortality countries

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in Africa. Advocacy was needed to support and sustain integrated pneumonia solutions and examples were given of events at the World Pneumonia Day 2009 and 2010. Discussion The conference expressed concern about the limited available amounts of the different formulations and that because of availability issues, some countries may be “forced” to introduce formulations based on current global availability and not the desired choice of the country. The participants were assured that there would be no problem with switching from PCV10 to PCV13 but it was more important to consider the reasons for the switch. Rotavirus Vaccines: Safety and Efficacy from Recent Clinical Trials in Africa Dr. Duncan Steele, PATH Summary of presentation The presentation re-emphasized that diarrhoea and pneumonia were the leading causes of child mortality, with pneumonia contributing 1.58 million and diarrhoea contributing 1.34 million deaths. Low resource countries in Asia and Africa carry the greatest rotavirus disease burden, with 9 out of 10 countries with highest rates of rotavirus mortality per capita being in Africa. Rotavirus is responsible for 40% of all severe gastroenteritis. It was reported that good efficacy data from Africa and Asia with excellent impact data from countries using the rotavirus vaccines in routine EPI were available. Regarding Rotavirus vaccine efficacy studies in Africa, the efficacy of Rotarix in Malawi and South Africa was 61.7% and Rotateq in Ghana, Kenya and Mali had an efficacy of 64.2%. Regarding reduction of all cause of severe gastroenteritis, vaccine efficacy against all-cause severe gastroenteritis was 30% (Rotarix™) and 23% (RotaTeq®). In Mexico, there was a 41% reduction in deaths due to diarrheal disease between 2002 and 2009 after the introduction of rotavirus vaccine. Looking at age-specific rotavirus hospitalization rate reduction and vaccine coverage, the biggest impact was in children aged 2 to less than 3 years. Regarding safety of the rotavirus vaccines, two aspects were reviewed, namely, safety of live attenuated rotavirus vaccine in HIV infected infants and incidence of intestinal intussusception with rotavirus vaccines. The reactogenicity and safety profile of the vaccine was similar to the placebo group for Rotarix™ in HIV-positive infants in South Africa. For intussusception which is uncommon, the aetiology was still not known but the peak incidence coincided with the age at vaccination in Brazil and Mexico. It was reported that following a SAGE recommendation, WHO had strongly recommended the inclusion of rotavirus vaccination into the national immunization programmes of all regions of the world. In addition, GACVS had recommended ongoing post-marketing surveillance when the vaccines are introduced. Discussion The conference noted that Merck was interested in monitoring intussusception and had established a hotline for reporting cases of intussusception. The conference also advised that national vaccination schedules should be adhered to when administering rotavirus vaccines. Also, work is being done by VPPAG in collaboration with countries to map out which vaccine characteristics were suitable to EPI programmes.

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Regional Surveillance for Paediatric Bacterial Meningitis (PBM) and Rotavirus in Support of New Vaccines Introduction in Africa Dr. Jason Mwenda, WHO/AFRO/IVD Summary of presentation The presenter covered the objectives of Paediatric Bacterial Meningitis (PBM) and Rotavirus Surveillance clarifying the pre-introduction and post introduction objectives. PBM and Rotavirus sentinel sites surveillance was conducted by MOH with support from WHO and partners and that it was established based on experience of surveillance of other Vaccine Preventable Diseases (VPDs). Sentinel surveillance sites were based in selected paediatric hospitals admitting about 250 children per year supported with acceptable bacteriology and virology laboratories. The six key indicators used in PBM surveillance were presented and performance for 2008-2010 reported. It was also stated that countries were monitoring serotypes for Streptococcal pneumonia, Neisseria meningitidis and Haemophilus influenza type b (Hib) since conjugate vaccines for these organisms were serotype/group specific. The presenter covered the commonest pneumococcal serotypes isolated in East Africa for the period 2004-2009 with 1, 14, 6B, 23F, 5 19F, 4, 9V and 18C being the commonest types with similar findings for West Africa for the period January to September 2010. In addition, for Rotavirus, the number of countries conducting surveillance had increased from 10 in 2008 to 15 in 2010. The circulating rotavirus strains for 2007-2009 were also presented, highlighting the 5 commonest serotypes. Numerous examples of the use of sentinel surveillance data were presented, including providing important data to guide informed decision making on new vaccines introduction, as well as contributing to national and global annual estimates of pneumonia & rotavirus associated mortality in under 5 children. Regarding the way forward, it was important to:

Continue efforts to encourage MOH to fully own new vaccine diseases’ surveillance and strengthen integration with other VPD surveillance as part of integrated disease surveillance

Improve reporting trends and quality of data from countries to Regional Office Contribute to strengthening of national laboratory capacity especially bacteriology

laboratory which are part of national public health laboratories Continue pneumococcal serotyping in Africa Continue efforts to mobilize resources for surveillance for VPD including invasive

bacterial disease and rotavirus Discussion The conference expressed the need to address challenges with generating data for invasive bacterial disease and collaborating with academic institutions. In addition, it was noted that laboratories in most African countries were not adequately equipped and should be strengthened by countries and partners. There is need to look for other possibilities to finance new vaccines surveillance including proper use of data as there may be no funds after two years.

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The conference also noted that there was an opportunity for countries to submit applications for PCV and Rotavirus introduction in the upcoming round of GAVI applications in May 2011 and WHO should provide technical support for application writing in countries. Human Papilloma Virus (HPV) Vaccine Introduction in Uganda: Lessons Learned from the PATH Demonstration Project Dr. Emmanuel Mugisha, PATH Uganda Summary of presentation The presentation reviewed the situation of Cervical Cancer Disease Burden in Africa, stating that Africa has about 268 million women aged 15 years or older who are at risk of developing cervical cancer. Available statistics showed that 78,897 women were diagnosed with cervical cancer while 61,671 died from the disease annually. It was recognized that cervical cancer was a major problem with HPV types 16 and 18 causing most of the cancer, especially in low-resource countries. Two HPV vaccines were currently available globally, that is, Cervarix® and Gardasil®. Following these developments, PATH was working in four low-resource countries to generate relevant data for HPV vaccine introduction. The main goal of the demonstration projects taking place in Peru, India, Uganda and Vietnam, was to generate and disseminate evidence for informed introduction of HPV vaccines. This was borne out of recognition that HPV has different characteristics from common vaccines, namely, age for vaccinations, gender issues, sexually transmitted diseases, and long delay of benefits. In Uganda, two delivery strategies were piloted, namely child days based delivery in Nakasongola and school-based delivery in Ibanda districts. The project had to primarily conductive formative research to come up with vaccine delivery strategies, advocacy and communication strategies. HPV vaccination coverage results for 2008-2009 based on the two different strategies using administrative data and coverage survey results were presented. Regarding cost estimates, it was found that the child-days strategy was cheaper; and the major cost driver for school-based strategy was personnel costs. The lessons learnt included:

• HPV vaccine is acceptable, as evidenced by high coverage. • School-based delivery was more feasible than the child days-based strategy • Education messages should build on prevention of cancer and vaccine safety among

others • Communication channels should include teachers in addition to health workers and

community leaders • Adequate preparation and well-coordinated efforts are essential

One of the key developments for accessibility has been the reduction of the price from USD100 per dose in 2007 to USD20 in 2010. Discussion The conference expressed caution on financial sustainability considering that there are also plans to introduce Pneumococcal and Rota vaccines. For example, there was an assumption that GAVI would have offered support for HPV but this has not happened except for a recent donation to the country which will prolong vaccination for a longer period

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The conference noted that contrary to assertions that cold chain capacity was adequate, the recent EPI review in Uganda found problems in cold chain, low routine immunisation coverage, and other areas so it is important to undertake these assessments / evaluations before new vaccine introduction. New Vaccine Introduction in Low Middle Income Countries Mrs. Bakanuki Nfila, EPI Manager, Ministry of Health, Botswana Summary of presentation The presentation covered the process of introduction of new vaccines in Botswana with particular focus on the Hib vaccine. Although, Botswana introduced the Hepatitis B vaccine in 1995, introduction of the Hib vaccine was discussed in 2004 but the idea was shelved due to the high cost of the vaccine, sustainability issues and competing priorities. The key constraint was lack of local data on disease burden as the Hib sentinel surveillance, set up in 2001, was not working optimally due to various reasons. The key factors leading to a decision being taken to introduce Hib vaccine was the formation of an Interagency Coordination Committee (ICC), its support for Hib introduction , the use of disease burden data from neighbouring countries, and the availability of country’s funds for procurement of the vaccine. Vaccines including Hib are line items in the MOH and national budgets. Key programmatic issues were also presented which included EPI performance and cold storage capacity among others. The activities undertaken to prepare for the introduction of the Hib vaccine in November 2010 were also highlighted. The presentation concluded with challenges that still remain after introduction and these included high cost of new vaccines, competing health priorities, financial sustainability and strengthening surveillance for Hib among others. Discussion The conference congratulated Botswana on the introduction of the Hib vaccine and stressed the importance of good surveillance data which can used internally to advocate for resources to ensure sustainability. Cholera Vaccine: An Investment Case Brian Maskery, International Vaccine Institute, Korea Summary of presentation The presentation started with an introduction of the International Vaccine Institute highlighting three arms, namely: vaccine discovery and design, vaccine development, and research to generate evidence for policy. The ultimate aim was to support rational and sustainable vaccine introduction. The presentation then focused on the aspect of generating evidence for policy. The justification for the global investment case was to provide a global evidence base for investing in oral cholera vaccines (OCVs) as part of a larger strategy that includes improvements to water and sanitation.

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It was reported that WHO annually estimated that there were 100,000 – 120,000 deaths globally. For 2009, a total of 203,444 cases and 4,828 deaths were reported from WHO African Region alone. A study estimated that treatment costs and productivity losses due to cholera in Africa were $43.3 – 72.7 million from 110,837 cases in 2007. WHO recommended in the 2010 Position Paper on Cholera that cholera vaccines should be considered in endemic areas (in collaboration with other prevention and control strategies). There were two vaccines on the market, namely, Dukoral and Shanchol vaccines with the former being WHO pre-qualified. It was reported that the efficacy and feasibility of Dukoral had been demonstrated in Africa in Mozambique and Zanzibar. The presentation covered the two types of vaccination strategies that are used in endemic cholera and epidemic cholera respectively. The costs of the vaccines were covered as well as potential sources of financing. The market landscape was presented for the period 2014-2020, with the number of countries potentially increasing on annual basis. The cost and storage assumptions were also presented in addition to projected programme impact based on endemic use. In conclusion, it was stated that the global investment case provided strong evidence for the feasibility of introduction of OCV. The next steps for OCV introduction were also outlined. Discussion The conference welcomed the presentation on the cholera vaccine and was very encouraged given the cholera disease burden in Africa. Parallel Session 3.3: Immunization Financing GAVI Update Dr Mercy Ahum, GAVI Secretariat Summary of Presentation: The presenter informed the participants that US$ 3.4 billion has been committed for AFRO from 2000-2015 which has 36 African countries (58%) out of 72 eligible countries globally. The 2011-15 Strategy retains key elements of the previous five-year strategy and introduces a new explicit goal of shaping vaccine markets, given the importance of reducing vaccine prices Beginning 2011, only countries with GNI per capita less than US$1,500 will be eligible for GAVI support and as such Angola & Congo will not be eligible. The new criteria for support will be as follows:

• Low Income Countries: 20 cents per dose for all vaccines. The main objective is to promote country ownership while maintaining almost same levels of support as current

• Intermediate Countries (>$995-$1,500): current levels or 20 cents per dose, increasing by 15% per annum with the objective of moving towards financial sustainability. Six (6) countries in Africa are in this category.

• Graduating Countries: ramp up over five years to reach financial sustainability after GAVI support ends. The main objective is to achieve financial sustainability while facilitating smooth transition to post-GAVI period

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Revision of Co-Financing Policy: In June 2010, GAVI endorsed a set of principles on co-financing and agreed that financial sustainability should be the overall policy objective of co-financing while acknowledging enhancing country ownership as an intermediate objective. In November 2010, the Board approved the revised Co-financing Policy. Discussion The conference noted that no economic modeling on the impact of price on immunization coverage has been done but that it should be done in future. In addition, current information on the cost of immunizing a child taking into consideration new vaccine introduction is not available but WHO is working on this. Nigeria indicated her willingness to seek GAVI support for introduction of new vaccines. Country Experience in Vaccine Co-financing (Ghana) Dr Kwadwo Odei Antwi-Agyei, MoH Ghana Summary of Presentation Routine EPI started in 1978 in Ghana with provision of traditional vaccines. GAVI support started in 2002 which led to the introduction of HepB and Hib. Ghana’s Financial Sustainability Plan decided to extend the 5-year support over a 10-year period (2002 -2011) with incremental payment by Country whilst GAVI support declined. As part of co-financing, by 2006, Ghana was paying 45% ($1.65) per dose of pentavalent vaccine and is now grouped among “Intermediate Countries”. However, some challenges in co-financing still remain and these include competing priorities on government budget, change in government budget systems from Direct Project Funding to Multi Donor Budget Support and lack of decreasing cost of new vaccines as was expected then. The implications on co-financing on the country as more new vaccines are being introduced to achieve MDGs are that:

• Co-financing by the country will increase • There is need to re-prioritize which new vaccines should be introduced and by when • Advocacy for financing through “Vaccination champions” should be intensified in the

country Discussion The conference noted that although budget-lines for immunization services delivery exist in many African countries, this does not translate into actual availability of funds for services. The presence and participation of associations and NGOs on the ICC help advocacy for improved immunization funding in countries. This financing problem is compounded by the lack of input and consultation into the budgetary process from the lower levels thus financial needs for these levels are develop after the budget is approved. The conference therefore encouraged the need for exhaustive consultations at all levels in the country while formulating health budgets.

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Decentralization as an Entry Point for Instituting National Immunization Trust Funds (DR Congo and Cameroon) & Peer Exchanges to Disseminate Performance-Based Budgeting Practices (Sierra Leone) Dr Raymond Musamba Cambele, DRC MoH Mr Sylvain Brice Bamela Belinga, Cameroon Mr Peter Sam-Kpakra, Sierra Leone Summary of presentations DRC has a federal system with financial allocations to provinces in the country. The resources are allocated to different levels based on provincial priorities. Previously, the provinces did not have budget line for EPI. However following advocacy with the assistance from SABIN Institute and partners to the National Assembly, Senate and different government levels, 6 provinces out of 11 now have a budget line Before the advocacy in 2009, the total allocation to EPI was less that US$1million against the need of US$91 million. This has increased in 2010 with national government contributing US$6.4 million. Furthermore, the National Assembly will be discussing the establishment of National Immunization Trust Fund to mobilize internal resources for EPI. In addition, DRC benefited from peer exchanges in immunization financing (visit to Cameroon leading to the Yaoundé Appeal) As for Cameroon, the process started with a meeting held in Nov 2008 leading to the creation of an institutional platform for discussing with the Legislature (Parliamentarians) and Executives. The result was a creation of a National Commission for Vaccination with Civil Society Oganizations involvement. With the establishment of this Commission, several sources of financing including those from State and contribution from the private sector were identified. The focus of the Commission was to mobilize funds in the country while avoiding duplication of efforts.

Through this Commission, political visibility to support immunization will be given attention. In Sierra Leone, a peer study tour was conducted to Uganda to understudy performance based incentive system for financing services. Upon return, using the experience, the participants advocated to Parliament which has approved a budget for EPI. Every 3 months funds are released to support implementation of activities including EPI. Discussion The conference welcomed the SABIN initiative to support countries in bringing the awareness of immunization to political leaders for increased sustainable financing. The conference also noted that advocacy to politicians can help formulate and pass laws which could make immunization compulsory to increase coverage in countries.

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Session 4: Accelerated Disease Initiative in African Region Measles Pre-elimination in the African Region Dr Balcha Masresha, WHO/AFRO Summary of Presentation Targets for Measles Pre-Elimination have been set and were reviewed including 98% measles mortality reduction by 2012 (relative to 2000), with a decrease of measles incidence to <5 cases per 100,000 population per year by implementing various measles control measures. Coverage of first measles dose through routine has continued to increase and has been associated with decreases in measles cases. The decrease in cases has been supported by both routine activities and SIAs. In addition, 12 countries have had MCV1 coverage>80% for 3 years, indicating readiness for introduction of MCV2 to the routine schedule. These countries should apply for GAVI support for second dose measles vaccine opportunity by May 2011. SIAs providing a second opportunity for measles vaccination have reached 452 million children since 2001. In 2010, it was noted that 14 countries planned SIAs targeting approximately 60 million children, however only 9 countries implemented (approximately 25 million children), 3 countries rescheduled for early 2011, and 2 countries postponed the SIAs due to a lack of funds. Outbreak response SIAs in 2010 were implemented in 5 countries (targeting about 22.6 million children). Thirteen (13) countries mobilized US$21million out of the planned US$41 million in operational costs. Measles Case-Based Surveillance has reported an increase in measles incidence, in part due to large outbreaks in several countries with more than 203,000 reported cases and 1,436 reported deaths in 2010. Some outbreaks occurred in countries soon after the SIAs. This is in part due to the poor timing of SIAs very close to the measles high transmission season. Based on several presented country experiences, many outbreaks occurred due to a large number of susceptibles in populations outside the target age group range of recent follow-up SIAs. In addition, in some areas, outbreaks occurred in non-compliant populations opposing vaccinations due to faith beliefs. Some outbreaks also occurred due to extended periods between SIAs because of delays in implementation.. In African Region, the majority of measles cases were genotypeB3 with a few D strains. An important next step for measles elimination in the African Region will be for the Regional TAG to convene to provide further guidance on the way forward. Discussion The conference noted with concern the funding gap for planned SIAs which have made the implementation of large measles follow-up SIAs difficult and urged countries to mobilize 50% of operational costs locally. It was noted that postponing of SIAs may compromise achieving measles elimination targets. Strategic plans should be developed for measles control and elimination, especially in large countries, such as Nigeria and DRC, and these plans should address the resource requirements.

The conference also noted that there is need to take into account the changing epidemiology of measles to cover younger and older age groups which will require aggressive resource

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mobilization by seeking new donors, increased local contributions and reinvigorate existing partnerships including linking Polio eradication efforts with measles pre-elimination activities. The conference welcomed the proposal to convene the Measles TAG meeting.

The Médecins Sans Frontières (MSF) Experience in Measles Outbreak Response Rebecca Grais, MSF/EpiCentre Summary of presentation MSF supports primary care, outbreak response and case management through missions in 32 countries. It was presented that there are reports of long duration outbreaks, with large magnitude, and late interventions. Many of these areas where outbreaks happened had large birth cohorts, were hard to reach, with low RI coverage and often underestimated morbidity / mortality estimates. The potential impact of late outbreak intervention was evaluated through a modeling exercise, recreating the epidemic mathematically based on outbreaks with good data. The timing of outbreak response SIAs was evaluated for different age-groups. Although WHO Guidelines stipulate vaccination targeting 6m-5years during outbreaks, District Level Outbreak Response Management Teams make decision about response including target age groups based on surveillance data. For example in Maroura, Cameroon an outbreak response with a wide age range vaccination campaign was conducted. A post-SIA coverage survey revealed that 7% of the targeted children were unvaccinated, with a large percentage receiving their first dose. The experience in Chad was presented which excluded older children resulting in a build up of susceptibles. Available data of 118,000 cases from Malawi was presented and indicated a low reported case-fatality rate. Coverage surveys done in four districts in the country indicated that a large number of susceptibles had accumulated in the 12 last years since the last outbreak. The possibility of waning immunity in the absence of wild measles virus and presence of vaccination non-compliant populations (e.g. apostolic faith communities) were contributing factors to the large epidemic. In summary, to increase population immunity, additional measles vaccine doses should be provided through routine immunizations to children >11 months. In addition, measles SIAs should have flexible age ranges and less intervals between planned measles follow-up SIAs depending on previous SIAs and routine immunization coverage. Outbreak investigations and SIAs response should be of high quality through provision of new guidelines to ensure appropriate and prompt responses. Discussion The conference stressed that prevention of outbreaks is a critical strategy and where it does not succeed, the outbreak investigation and response should be of high quality considering early timing of the response, geographical size and age group range of affected measles cases.

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Additionally modeling tools should be disseminated for review and consultation before wide use to evaluate the ability to predict outbreaks. Countries must report their experience with the tool to AFRO to further refine the model.

Implementing Best Practices in Measles SIAs: Ethiopia Experience Dr Neghist Tesfaye, FMoH / Ethiopia The presenter demonstrated that EPI coverage had improved in Ethiopia over the past years. However, outbreaks occurred in some regions in Ethiopia, with most cases below five years of age and unvaccinated. Ethiopia was implementing a phased Integrated Measles SIA in two phases (October 2010 and February 2011) targeting 8.5 million children, aged 9-47 months. Four interventions were integrated into the campaign including OPV, Vitamin A, de-worming and nutritional screening. Over 50% of the operational costs were raised by the country through local resources mobilization. From the onset, there was a high level Government ownership and leadership of the campaign. As part of the preparations, a consultative meeting was held with all stakeholders to identify best practices in the key areas of logistic, planning, training, social mobilization and opportunities for strengthening routine immunizations. Senior government officials and partners were timely deployed to regions to advocate for the important of the SIAs and the need to mobilize resources locally for the campaign. A KAP study was done to identify gaps to address during training and social mobilization messages. Technical staff and consultants from the central level were deployed to the regions to support micro- planning, training etc. Micro-planning was done at the lowest level with a focus on hard to reach populations (e.g. mobile populations). Logistics requirements based on the micro-plans were available at the central level 3 -4 weeks prior to SIA implementation and were distribution directly to most woredas more than a week before implementation. Further advocacy including high-level political involvement with evidence based messaging and mobilization through multiple channels of communication (media, Paediatric and Medical associations, Women’s Federations, schools, house-to-house canvassing etc.) were conducted. During implementation, identification of eligible children, monitoring and evaluation were done using a screening card designed for the campaign. Realizing that to sustain the gains from the SIAs, it was important to strengthen routine immunization, efforts to strengthen routine immunization were incorporated from the outset. Gaps in routine immunization were identified pre-SIAs including the capacity of Health Extension Workers to intensify routine immunization implementation. Therefore, capacity building for routine immunization planning, logistics and vaccine management and social mobilization activities were conducted during pre-SIAs, during SIAs, and post SIAs review. The overall SIAs coverage for measles vaccination was 107% (despite the planned age-group range, some older children may have been vaccinated due to the high demand for the measles vaccine because of experienced outbreaks); and 97% coverage for polio. To some extent, Independent Monitoring was challenged by the poor quality of finger markers. Factors that may have contributed to the success of the SIAs included high level ownership and leadership by the Government, formation of a National Task force at central level and Task Forces at lower levels, conduction of the consultative meeting with stakeholders to identify best practices more than 6 months before the SIAs, improved micro-planning processes from lowest levels, high level training and intensified social mobilization. Early deployment of facilitators to supervise and monitor preparations was also key to the success of the SIAs.

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The observed gaps were the delay in deployment of translated social mobilization messages, translated reference materials and data collection tools; delayed disbursement of operational funds in some regions; challenges of accurate screening of target age group; shortages of vaccine were experienced in some zones particularly for OPV; and poor quality finger-markers for independent monitoring. The next steps involve preparations for the second phase of the 2011 SIAs based on lessons learned from the first phase and maximizing the opportunity of the SIA to further strengthen delivery of routine immunization services. Discussion The conference welcomed the Measles SIAs Best Practice conducted in Ethiopia and encouraged the primary health care approach in providing integrated interventions during SIAs. The Ethiopian Best Practice experience and SIA evaluation should be documented and shared with other countries in the Region to improve quality of SIAs.

Progress in Maternal and Neonatal Tetanus Elimination (MNTE) in Africa Dr. Yodit Sahlemariam, UNICEF / ESARO Summary of presentation The goal is to eliminate MNT (less than one case per 1,000 live births) as a cause of preventable morbidity and mortality by 2015. A 92% reduction of MNTE deaths had occurred from 1980 to 2008. Thirty-nine countries globally and 24 in Africa are the focus of elimination activities through promoting clean delivery, TT vaccination in high-risk districts and improving MNTE surveillance. The methodology used for MNTE in countries was also outlined to the participants. The current action plan for MNTE includes maintaining elimination in the 13 countries already validated. In these countries, those with TT coverage <70% need re-validation studies to re-confirm elimination. 14 countries need to complete implementation of MNTE activities with 10 requiring validation. Since 1999, successes in MNTE were achieved through US$190 million funding, but a gap of US$110 million exists to implement the action plan for the next 5 years. Therefore, the greatest challenge to TT elimination is the funding gap, partially due to competing priorities of donors. Other challenges include need to improve SIAs quality in some countries, better integration of NT surveillance into AFP surveillance and maintaining TT SIAs in countries after validation. The presenter identified several areas where WHO and UNICEF can support MNTE: 1) Closing the funding shortfall to support remaining 24 countries, 2) Ensuring planned MNTE activities are not postponed due to other EPI activities, 3) Strengthening NT surveillance, 4) Support coordination of elimination activities between government and partners Discussion

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The conference noted the need for countries and partners to prioritize planned MNTE activities despite competing priorities to avoid further postponement; and the urgent need to fill the funding gap. The conference expressed the need to use other SIAs opportunities, such as measles SIAs, to have TT campaigns integrated to reduce costs other than advocating for TT stand-alone SIAs. The integration would require high quality planning well in advance. To support MNTE goals, efforts should be made to identify the weaknesses of clean delivery especially through qualitative anthropological studies The conference also noted that the Meningitis A conjugate vaccine is a tetanus toxoid conjugate and studies indicate that it acts as a Tetanus booster dose and this should offer an opportunity to the control of both meningitis and MNTE in the Men A conjugate vaccine targeted countries

Taking Epidemic Meningitis in the African Region with the African Health Agenda

Dr B. Toure, WHO/AFRO/IST-West Coordinator Summary of presentation In addition to the severe morbidity and mortality from epidemic meningitis in the African Meningitis Belt, meningitis exerts economic pressure on developing countries with treatment of a case estimated at US$116. The negative economic impact on a household was estimated at about $90 per case (in Burkina Faso), as well as other socio-economic impacts on the family due to the devastating sequelae. The presenter explained that significant meningitis control efforts started followed large outbreaks in 1995, ultimately leading to the adoption of further strategies including IDSR adopted at the 48th Regional Committee Meeting. The Meningitis Vaccine Project (MVP), between WHO and PATH, was started with the objective to develop affordable vaccines to eliminate epidemic meningitis as a public health problem in the meningitis belt. The other strategies for meningitis control include establishing strong surveillance, pre-positioning of drugs and vaccines, regular outbreak reporting network, availability of sample collection kits, and establishment of Epidemic Management Committees. From 2006- 2010, Enhanced Meningitis Surveillance was implemented with improved case detection and control. This resulted in an increase in reported meningitis cases due to Meningococcal A in 2009 and W135 in 2010. The MVP has developed an affordable Meningitis A Conjugate vaccine, initially rolled out in 3 countries, but will eventually reach 14 targeted countries. The MenA vaccine was prequalified in June 2010, after development by Serum Institute of India, at a cost of $0.40/dose. The vaccine was found to be safe and immunogenic with no significant safety issues identified during trials. The vaccine was also noted to develop longer-lasting immunity compared to the polysaccharide vaccine. Herd immunity could be induced through large scale campaigns (targeting people 1-29 years of age) reaching at least 90% coverage, and inclusion of the vaccine into the EPI schedule.

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The introduction plan for MenA conjugate vaccine has been successfully launched, first in Burkina Faso, Mali and Niger in 2010-11 with high coverage. However, there was a USD11million funding gap to reach the target population in these countries. Additional countries identified through a high risk analysis based on epidemiological criteria and outbreak history will be reached after 2011. Surveillance was noted to be critical to ensure documentation of the impact of the introduction activities to advocate for resources to meet the funding gap. Discussion In the event of a meningitis outbreak, Nigeria, because of her large population, can have large numbers of cases and deaths and should, therefore, be considered for earlier introduction prior to the planned 2013. The conference also noted that some countries, such as Sierra Leone, were not included as priority countries, but still have Meningococcal A outbreaks. The conference expressed concern that countries currently not included may have increased risk in the future associated with climate change. Therefore, as scientific and epidemiological changes evolve, roll-out plans may have to be re-evaluated. The role of polysaccharide vaccine during outbreak control was still considered to be significant when there are still supply constraints for Men A, and the existence of other strains (including C, Y and W135). The need to develop W135 conjugate vaccine should be considered, especially given the 2010 outbreaks.

Prevention & Control of Viral Hepatitis Infection in the African Region Dr R. Mihigo, WHO/AFRO Summary of presentation Most countries in the African Region have a high prevalence of Hepatitis B disease as evidenced by routine hospital blood screening and sero-surveys. Hepatitis B vaccination was first recommended for inclusion in country immunization schedules in 1997, however, it was not until 2000, when GAVI resources were made available allowing introduction of the vaccine on a wide scale. As of 2010, 45 out of 46 countries have introduced, HepB vaccination into their immunization schedules. A document was developed by AFRO and endorsed by TFI to propose hepatitis control plans for the African region. The plan includes two targets: The first target is that by 2012, all countries should implement a comprehensive advocacy plan to inform the general public, high-risk groups and health care workers of the dangers of HBV infection, how to avoid it, and the value of being protected by HepB vaccine. The second target is that by 2018, hepatitis infection (as measured by HBsAg prevalence) be reduced to less than 1% in under-5 children born after routine immunization activities have started. 70% of countries should measure their progress towards achieving this target at least once by 2015. The presenter mentioned the strategies required to reach these targets which include:

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• Immunization strategies: 1) Raising routine coverage; 2) Introducing a birth dose for facility and home deliveries; 3) Multi-antigen campaigns; 4) Immunizing high risk groups; 5) Catch-up campaigns.

• Reducing the risk of transmission in health care settings through strengthening Infection control , safe injection practices , safe blood transfusion

• Strengthening health services by linkage with other health care initiatives (PHC, HIV/AIDS, MCH),

• Informing the public through health education • Improve disease treatment through guideline development and strengthening treatment

centers Several issues need to be considered for the control plan such as the introduction of the birth dose which has a significant impact on Hep B prevalence including maternal to child transmission, and protection of older age groups such as health care workers and other adults at high-risk. Hepatitis control will require monitoring which cannot be addressed by routine surveillance alone. Special sero-survey studies are needed for HBsAg testing. Discussion The conference noted that in many countries health workers and those at high risk of exposure were requesting the vaccine, but it was not made available. The current status-quo should be changed to allow access of vaccine to high-risk individuals (e.g. health workers, military).

The conference also noted that a birth dose has not been introduced in most countries in the region which have introduced Hepatitis B vaccine in their EPI schedule. It was clear that additional resources for the introduction of monovalent Hepatitis B vaccine will require efforts to plan and mobilize resources for sustainability.

The conference recommended that the Hepatitis control plan should be finalized and distributed to all countries as soon as possible.

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Session V: Closing Ceremony The closing ceremony was presided over by the Assistant Regional Director, Dr Matshidiso

Moeti, on behalf of the WHO-AFRO Regional Director, Dr Sambo. The Regional Director’s

message assured the conference that the dream of having every child protected against vaccine-

preventable diseases can and should be a reality. Countries were called upon to undertake actions

focused on innovation and consolidation of achievements.

Poliomyelitis eradication

The number of countries that reported poliomyelitis epidemics decreased from 15 in 2009 to 9 in

2010 because of high quality supplementary immunizations activities. However, the weakness of

health systems and the low coverage of routine immunization have considerably slowed down

the process of polio eradication.

It is imperative that all countries and sub-regions exposed to outbreaks of the epidemic should

adopt the coordination model developed in West Africa by countries of the sub-region, WHO

and UNICEF. In Central Africa, Angola was urged to review and intensify the implementation of

the Polio Emergency Plan while the Democratic Republic of the Congo should develop and

implement an Emergency Plan to tackle, among other things, the weakness of the wild poliovirus

surveillance system. Countries should also develop a package comprising components focused

on social and economic aspects and on communication in order to promote disease surveillance

and create demand for enhanced provision of immunization services.

Reaching hardly accessible children

Countries have succeeded in reducing the number of un-immunized children through innovative

measures especially the introduction of new community-based approaches. This major

achievement should be consolidated. Countries were requested to strengthen surveillance

capacities for introduction of new vaccines, develop mechanisms for financing immunization

activities, build a new category of health personnel (logistician) and organize consultations with

the WHO Regional Office to ensure adequate preparation for the Decade of Vaccines.

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Accelerating disease control

Measles, neonatal tetanus, viral hepatitis and meningitis are diseases for which control activities

should be scaled up considering the recurrent outbreaks of epidemics especially of measles,

thereby undermining measles control. In the past three years, only 14 countries have been able to

maintain at least 80% immunization coverage. In addition, there are difficulties in monitoring

supplementary immunization activities. The Regional Measles Technical Advisory Group is

requested to assess progress towards achieving the measles pre-elimination targets and mobilize

resources for supplementary immunization activities. The best practices in measles mortality

reduction should be documented and disseminated.

Maternal and Neonatal Tetanus elimination calls for implementation of planned SIAs and

validation of elimination status. Factors contributing to poor conditions of hygiene during

childbirth should also be tackled. Concerning meningitis, countries and partners should speed up

the introduction of the MENAFRIVAC vaccine. In regard to viral hepatitis B, the dissemination

of the strategy for its control is an absolute priority.

“Routine immunization remains the cornerstone of all initiatives to control these diseases”

stressed the WHO Regional Director for Africa, in his closing statement at the Conference. He

stated that operationalization of the “Reaching Every District” approach is a priority in

strengthening routine immunization and revitalizing primary health care.

The Regional Director mentioned other priorities especially communication with communities

and involving them in disease control, effective mobilization of resources to speed up the

introduction of the new vaccine against meningitis, as well as partnership.

Dr Sambo thanked development partners, ministers of health and civil society for their support to

immunization. He invited the African Region to join the other regions in 2011 to commemorate

the first-ever immunization week.

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Annexes List of Participants

Name Organization Country Contact Address Dr Margaret Chan

WHO / HQ Switzerland 20 Avenue de l'Appia, 1211

Geneva 27, Switzerland Dr L. Sambo

WHO / AFRO Congo BP 06 Brazzaville, Congo

Dr Matshidiso Moeti

” ” ” ” ” ”

Dr D. Nshimirimana

” ” ” ” ” ”

Dr Francis Kasolo

” ” ” ” ” ”

Dr Olga Agbodjan

” ” ” ” ” ”

Dr Dicky Akanmori

” ” ” ” ” ”

Dr Balcha Masresha

” ” ” ” ” ”

Mr Collins Boakye-Agyemang

” ” ” ” ” ”

Mme Flavienne Issembe

” ” ” ” ” ”

Dr Evariste Mutabaruka

” ” ” ” ” ”

Dr Sam Okiror

” ” ” ” ” ”

Dr Jason Mwenda

” ” ” ” ” ”

Ms Helena O'Malley

” ” ” ” ” ”

Dr Mbaye Salla

” ” ” ” ” ”

Ms Gloria Mouhouanou

” ” ” ” ” ”

Ms Debra D. Townes

” ” ” ” ” ”

Mr Alain Nyembo Poy

” ” ” ” ” ”

Mr Keith Shaba

” ” ” ” ” ”

Dr Kasonde Mwinga ” ” ” ” ” ”

Dr Djamila Cabral

WHO Representative Burkina Faso

158, Av. de l'Independence, 03 Ouagadougou, PO Box 7019 Ouagadougou

48

Dr Ma Ouattara

WHO/Burkina Faso ” ” ” ”

Mr Clement Lingani

” ” ” ” ” ”

Dr Bokar Toure

WHO / IST/ West ” ” ” ”

Mr Bernard Ntsama

” ” ” ” ” ”

Dr Fenella Avokey

” ” ” ” ” ”

Mr Hilaire Dadjo

” ” ” ” ” ”

Dr Fabien Diomande

” ” ” ” ” ”

Dr Nehemie Mbakuliyemo

” ” ” ” ” ”

Dr Mamoudou Harouna Djingarey

” ” ” ” ” ”

Mary Traore

” ” ” ” ” ”

Dr Denis Kandolo

” ” ” ” ” ”

Dr Ibrahima Kane

” ” ” ” ” ”

Mr Alexis Satoulou

” ” ” ” ” ”

Dr Annick Dosseh

” ” ” ” ” ”

Dr Chantal Kambire

” ” ” ” ” ”

Dr Lucile Imboua

WHO /IST / Central Gabon B.P. 820, Libreville, Gabon

Dr Jean-Marie Kipela

” ” ” ” ” ”

Dr Norbert Ngendabanyikwa

” ” ” ” ” ”

Dr Oladapo Walker WHO / IST / ESA Zimbabwe P.O.Box 5160, 166, P. Amarnock way, Ryelands, Harare, Zimbabwe

Dr Nestor Shivute

” ” ” ” ” ”

Dr Mutale Mumba

” ” ” ” ” ”

Dr. L. Vaz WHO Representative Angola

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Dr. Jean-Marie Yameogo

WHO/Angola ”

Dr Matthieu Kamwa

WHO Representative DR Congo 42, av des Cliniques, Ceombe, Kinshasa, RD Congo

Dr Koffi Tsogbe

WHO/Congo ” ” ” ”

Dr Dah Ould Cheikh

WHO Chad Chad C/O WHO Chad

Dr Alex Gasasira

WHO Nigeria Nigeria C/O WHO Nigeria

Dr Pascal Mkanda

WHO Ethiopia Ethiopia UNECA Compoond, POBox 3069, Addis Ababa, Ethiopia

Dr Gavin Grant

” ” ” ” ” ”

Ms Meseret Fikru

” ” ” ” ” ”

Dr Jean-Marie Okwo-Bele

WHO / HQ Switzerland 20 Avenue de l'Appia, 1211 Geneva 27, Switzerland

Dr Bruce Aylward

” ” ” ” ” ”

Dr Maria-Teresa Aguado de Ros

” ” ” ” ” ”

Dr Thomas Cherian

” ” ” ” ” ”

Ms Alison Brunier

” ” ” ” ” ”

Dr William Perea

” ” ” ” ” ”

Dr Roland Sutter

” ” ” ” ” ”

Dr Carol Tevi Benissan

” ” ” ” ” ”

Mr Simon Wreford-Howard

” ” ” ” ” ”

Mr Simon Wreford-Howard

” ” ” ” ” ”

Ms Fiona Doyle

” ” ” ” ” ”

Ms Altanzul Sainjargal

” ” ” ” ” ”

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Ms Marta Gacic-Dobo

” ” ” ” ” ”

Dr Marie-Paule Kieny

” ” ” ” ” ”

Mr Patrick Lydon

” ” ” ” ” ”

Dr Marie-Pierre Preziozi

” ” ” ” ” ”

Dr Olivier Ronveaux

” ” ” ” ” ”

Dr Carsten Mantel

” ” ” ” ” ”

Roger Bavuwu

UNICEF DR Congo 87, Boulevard du 30 Juin, Kinshasa, RD Congo

Dr Brandao Co

” ” Angola R. Canhangulo 197, UN Building, Luanda, Angola

Ms Irina Dincu

UNICEF/WCARO idincu@unicef.org

Mr Yalda Momeni

UNICEF Denmark UNICEF Supply Division, UNICEF plads, Freeport, 2100 Copenhagen, Denmark

Ms Meredith Shirey

UNICEF Denmark UNICEF Supply Division, UNICEF plads, Freeport, 2100 Copenhagen, Denmark

Dr Marcelline Ntabikirora

UNICEF/WCARO Senegal Dakar, Senegal C4D

Dr Yodit Yeshineh Sahlemariam

UNICEF / ESARO Kenya P.O.Box 44145-00100, Nairobi, Kenya

Jonathan Shadid

UNICEF/WCARO Senegal Dakar, Senegal C4D

Dr Garba Abdul

USAID Nigeria 7-9, Mamila Street, Mattama, Abuja, Nigeria

Ms Lindizgya Banda

” ” USA 1300, Pennsylvania Av. 5-O6y, Washington DC, 20523, USA

Dr Susan McKinney

” ” USA 1300, Pennsylvania Av. 5-O6y, Washington DC, 20523, USA

Dr Ellyn Ogden

” ” USA 1300, Pennsylvania Av. 5-O6y, Washington DC, 20523, USA

Ms Lina Astrid Piripiri

” ” DR Congo Mobil Building, Avenue Isiro 198, Gare Centrale, Kinshasa, Gombe, DR Congo

51

Dr. Benjamin Djoudalbayae

AU Commission Ethiopia P.O.Box 3243, Addis Ababa, Ethiopia

Dr Richard Adegbola

BMGF USA P.O.Box 23350 Seattle, WA 98102, USA

Ms Karen Lowry Miller

” ” ” ” ” ”

Dr Walt Orenstein

” ” ” ” ” ”

Jerame Ostrom

” ” ” ” ” ”

Mr Tim Petersen

” ” ” ” ” ”

Dr Regina Rabinovich ” ” ” ” ” ” Joseph D. Van Note

” ” ” ” ” ”

Dr Gregory William Widmye

” ” ” ” ” ”

Dr Tachi Yamada

” ” ” ” ” ”

Dr Alfred da Silva

Agence de Medecene Preventive

France 25-28, Rue du Docteur Rous, Campus Institut Pasteur, 7505 Paris, France

Mr Robert Davis

American Red Cross Kenya Box 41775, Nairobi, Kenya

Prof. Rose Gawa Fomban Leke

ARCC Cameroun Faculty of Medecine, University of Yaounde 1, Cameroon

Dr Sodiomon Bienvenu Sirima

ARCI Chairman Burkina Faso

01 BP2208 Ouagadougou, Burkina Faso

Jennifer Sequeira

ARISE /JSI

jsequeira@jsi.com

Dr Brent Burkholder

CDC USA 1600, Clifton Road, MSC-25, Atlanta, GA 30333, USA

Dr Rana Hajjeh

” ” ” ” ” ”

Dr Katrina Kretsinger

” ” ” ” ” ”

Dr Robert Wilson Linkins

” ” ” ” ” ”

Ms Tove Ryman

” ” ” ” ” ”

Dr Hardeep Singh Sandhu

” ” ” ” ” ”

52

Mr Jim Yuan Ting

” ” ” 4705, Wouderind way, Va Beach, VA 23455, USA

Dr Richard Luce

” ” Ethiopia Addis Ababa, c/o US Embassy, Entoto road, Ethiopia

Ms Judith Kallenberg

CLINTON FOUNDATION

Kenya CHAI, Timau Playa 3rd floor, Argwings Kodkek Road, Nairobi, Kenya

Dr Asnakew Tsega Yigzaw

” ” Ethiopia Addis Ababa, Ethiopia

Dr Filimona Semunigus Bisrat

CORE GROUP Ethiopia P.O.Box 5674, c/o CCRDA, Debre Ziet Road, Kality, Addis Ababa, Ethiopia

Dr Peter Njofon Wirsiy

” ” Angola Rua Dr Jose Cordeira Damata 53, Malanga, Luanda, Angola

Alexis Bagoro DIRECTION GENERAL DE L’ECONOMIE ET DE LA PL.

Burkina Faso

01 BP 396, Ouagadougou 01, DGEP (MWF), Burkina Faso

Lorraine Gallagher EUROPEAN UNION Burkina Faso

lorraine.gallagher@ec.europa

.eu

Ms. Rachel Mary Feilden

FDA United Kingdom

Tellisford Mill, Tellisford, Bath BA2 7RL, United Kingdom

Dr. Mercy Ahun GAVI ALLIANCE Geneva 2, chemin des Mines, Geneva 1209

Dr. Helen Evans ” ” ” ” ” ”

Dr. Jean Kaseya ” ” ” ” ” ”

Dr. Sanjoy Kumar Datta

GLAXOMSMITHKLINE BIOLOGICALS

Belgium Odyssey Building, Avenue Felming 20, 1300 Wavne, Belgium

Ms. Osaretin Earnestina Jaiyeola

” ” Ghana 5th Floor, GNAT Heights, 30 Independence Avenue, Accra, Ghana

Dr. Oladehin Olasile Olakunle

” ” Nigeria I, Industrial Avenue, Ilupeju Legos, Nigeria

Dr. Kathleen O’Reilly IMPERIAL COLLAGE, UK

United Kingdom

St Mary’s Campus, Norfolk Place, London W2 IPG, United Kingdom

Dr. Andre Savadogo INSTITUT BIOFORCE

savadogo.bioforce@gmail.com

Dr. Benoit Silve ” ” France 41, avenue du 8 Mai 1945,

53

69694-Venissieux, France Mr. Oscar Hounsou INTERPRETER Mr. Herve Songre ” ”

Ms. Bedarida-Gaveh Sroda

” ”

Mr. Stephen Tettey ” ”

Dr. Chizoba Wonodi JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH

USA 855, N. Wolfe Street, Suite 600, Baltimore, MD 21205, USA

Dr Patrick Kayembe

KINSHASA SCHOOL OF PUBLIC HEALTH

DR Congo

BP 11850, Kinshasa I, DR Congo

Dr Evans Nyasimi MCHIP

Kenya PO Box 66119-00800, Reponi Road, Westlands, Nairobi, Kenya

Mr Michel Othepa

” ” USA 1776 Massachusetts Avenue NW, Washington DC 20036, USA

Dr Florence Fermon

MEDECINS SANS FRONTIERES

France 8, rue Saint Sabin, 75011 Paris, France

Dr Franck Joncret

” ” ” ” ” ”

Margarita Riera

” ” ” ” ” ”

Dr Martin Antonio

MEDICAL RESEARCH COUNCIL

Gambia

Dr Jules Millogo

MERCK

USA 770 Sumney Town Pike, West Point, PA 19486, USA

Mr Andre Bona Kabamba

MINISTRY OF FINANCE, DR CONGO

DR Congo Kinshasa, 2610 Q/Baboma Matete, DR Congo

Mr Peter Sam-Kpakra

MINISTRY OF FINANCE, SIERRA LEONE

Sierra Leone

Dr Adelaide Carvalho

MINISTRY OF HEALTH, ANGOLA

Angola Direccao Nacional de Saude, Publica, Rua 1, Congresso de MPLA 67, Luanda, Angola

Dr Marie Rose Nago

MINISTRY OF HEALTH, BENIN

Benin 03 BP 621, Cotonou, Bénin

Ms Flora Bakanuki Nfila

MINISTRY OF HEALTH, BOTSWANA

Botswana Private Bag 0038, Gaborone, Botswana

Sylvestre Roger Marie MINISTRY OF Burkina 07 BP 5153 Ouagadougou 07,

54

Tiendrebeogo

HEALTH, BURKINA FASO

Faso Burkina Faso

Dr Hamid Djabar

MINISTRY OF HEALTH, CHAD

Chad Ndjamena, BP 440, Chad

Dr Raymond Musamba Cambele

MINISTRY OF HEALTH, DRCONGO

DR Congo Kinshasa, 2610 Q/Baboma Matete, DR Congo

Dr Neghist Tesfaye Belayneh

MINISTRY OF HEALTH, ETHIOPIA

Ethiopia P.O. Box 1234, Addis Ababa, Ethiopia

Dr Kwadwo Odei Antwi-Agyei

MINISTRY OF HEALTH, GHANA

Ghana Ghana Health Service, Disease Control Department, Box Kb 493, Korle-BU Accra, Ghana

Dr Mete Bonkoungou

MINISTRY OF HEALTH/BURKINA FASO

Burkina Faso

03 BP2109, Ouagadougou, Burkina Faso

Dr Souleymane Sanou

” ” ” ” ” ”

Mr Rene Sebgo

” ” ” ” ” ”

Mr Prosper Tapsoba

” ” ” ” ” ”

Mr Marcelino Edu Micha

MINISTRY OF HEATLH, EQUATORIAL GUINEA

Equatorial Guinea

Dr Francisco Pascual Obama Asue

” ” ” ”

Mme Consuelo Ondo

” ” ” ”

Mr Sylvain Brice Bamela Belinga

MINISTRY OF PUBLIC HEALTH, CAMEROON

Cameroon bamelabrice@yahoo.fr

Hon. Gaston Komba

NATIONAL ASSEMBLY, CAMEROON

” Bp 2565, Yaounde, Cameroun

Sheick Oumar Coulibaly

NATIONAL PUBLIC HELATH LABORATORY OF BURKINA

Burkina Faso

09 BP24, Ouagodougou 09, Burkina Faso

Dr Carine Dochez

NESI

Belgium University of Antwerp. Department of Epidemiology and Social Medicine, Universiteitsplein 1, Belgium

55

Prof. Andre Meheus

” ” ” University of Antwerp. Department of Epidemiology and Social Medicine, Universiteitsplein 1, Belgium

Dr Emmanuel A. Abanida

NPHCDA

Nigeria Area Eleven, Garky, Abuja

Kayode Akinyemi

” ” ” PO Box 460, Ijebu-Ode, Ogun State, Nigeria

Dr. Toyer Mojeed Alatishe

” ” ” PO Box 460, Ijebu-Ode, Ogun State, Nigeria

Dr Alhaji Mustapha Jumare

” ” ” 681/682 Port-Harcourt Crescent, Off Gimbiya Street, Garvi Area 11, Abuja FCT, Nigeria

Dr Mustafa Zubairu Mahmud

” ” ” PO Box 460, Ijebu-Ode, Ogun State, Nigeria

Dr Ndanusa Haliru Yahaya

” ” ” PO Box 460, Ijebu-Ode, Ogun State, Nigeria

Dr Antoinette Ba-Nguz

PATH

Kenya ACS Plaza, Lenena Road, Nairobi, Kenya

Ms Carla Ann Botting

” ” USA 7500, Old Georgetown road, Bethesda, MD 20274-3987

Dr Christopher Elias

” ”

Dr Marc LaForce

” ” USA 1800, K Street NW, Suite 800, Washington DC 20006, USA

Dr Stefano Malvolti ” ” France Bldg Avant Centre, 13 CHemin du Levant 01210 Fernez Voltaire, France

Ms Lisa Menning

” ” France Ferney Voltaire, 01210 France

Dr Emmanuel Mugisha

” ” Uganda P.O.Box 24578, Kampala, Uganda

Dr Bob Scott

ROTARY INTERNATIONAL

bobscott@eagle.ca

Dr Olubusuyi Aina Onabolu

” ” Nigeria 8, Ladoke Akintola st, Gra Ikeja, Nigeria

Dr Kasongo Ambroise Tshimbalanga

” ” DR Congo 131, Av Kasavubu, Kinshasa/Gombe, DR Congo

Sambo Paul Nikiema

” ” Burkina Faso

01 BP.5189 Ouagadougou, Burkina Faso

Dr Clifford Wurie Kamara

SABIN VACCINE INSTITUTE

Sierra Leone 3 Wukam Close, Sierra Leone

56

Dr Diana Kizza

” ” Uganda diana.kizza@sabin.org

Dr Helene Mambu-ma-Disu

” ” helene.mambu@sabin.org; heledisu@yahoo.fr

Dr Jonas Mbwangue

” ” USA 2000 Pennsylvania Avenue. NW, Suite 7100, Washington DC 2006, USA

Dr Helen Rees SAGE CHAIRPERSON

33, Escombe Avenue Paratown West, JHB 2193

Dr Said-Homayoun Madjrouh

SANOFI PASTEUR

homayoum.madjrouh@saofipasteur.com

Dr Pascal Perrin

” ” France 2, Av. Pont Pasteur 69007, Nyon, France

Dr Dizolele Foko Liliane Diatezulw

SANRU

DR Congo

75, Avenue de la Justice, Commune de la Gourbe, Kinshasa, RD Congo

Dr Adrien N'Siala Kumbi

” ” ” ” ” ”

Dr Suresh Jadhart

SERUM INSITUTE

India

Dr Alan Richard Hinman

TASK FORCE FOR GLOBAL HEALTH

USA 329 Swanton Way, Decateur, Georgia 30030, USA

Dr Lyova Arevshatyan

TFI

Zimbabwe 39 Moorgate road, Mount Measant, Harare, Zimbabwe

Dr Jean-Baptiste Sakatolo Zambeze Kakoma

” ” jbkakoma@nur.ac.rw

Dr Frederick Kaona

” ” Zambia 12, Kafipi road Northride, PO Box 73693, Nadla, Zambia

Dr John Peter Andrea Lusingu

” ” Tanzania Tanzna Medical Research Center, PO Box 5004, Tangna, Tanzania

Prof. Helder Fernando Brigido Martins

” ” Mozambique

C.P. 3646, 00310 Maputo, Mozambique

Dr Aziza J. Mwisongo

” ” aziza.mwisongo@indepth-network.org

Prof. Cheikh Ibrahima Niang

” ” niang1@yahoo.fr

57

Dr Kelguebsom Sondo

” ” sondoblaise@yahoo.fr

Dr Fatima Luisa Valente

” ” Angola Rua 1, Congresso 67, BP1201, Luande, Angola