12–14 November 2019Siem Reap, Cambodia

Meeting Report

25TH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION

OF POLIOMYELITIS ERADICATION IN THE WESTERN PACIFIC

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

RS/2019/GE/60(KHM) English only

MEETING REPORT

TWENTY-FIFTH MEETING OF THE REGIONAL COMMISSION FOR THE CERTIFICATION OF POLIOMYELITIS ERADICATION

IN THE WESTERN PACIFIC

Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Siem Reap, Cambodia 12–14 November 2019

Not for sale

Printed and distributed by:

World Health Organization Regional Office for the Western Pacific

Manila, Philippines

May 2020

NOTE

The views expressed in this report are those of the participants of the Twenty-fifth Meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific and do not necessarily reflect the policies of the conveners.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the Twenty-fifth Meeting of the Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific in Siem Reap, Cambodia from 12 to 14 November 2019.

CONTENTS

SUMMARY ............................................................................................................................................................... 1 

1. INTRODUCTION ................................................................................................................................................. 2 

1.1 Meeting organization ....................................................................................................................................... 2 

1.2 Meeting objectives ........................................................................................................................................... 2 

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

2.1 Opening session ............................................................................................................................................... 2 

2.2 Global update ................................................................................................................................................... 3 

2.3 Progress in the global certification process ..................................................................................................... 4 

2.4 Recommendations of the 2019 Technical Advisory Group on Immunization and Vaccine-Preventable Diseases .................................................................................................................................................................. 4 

2.5 Regional update ................................................................................................................................................ 4 

2.6 Implementation of polio laboratory containment GAPIII: global and regional update ................................. 5 

2.7 Global overview and analysis of cVDPV outbreaks ....................................................................................... 5 

2.8 Overview and analysis of cVDPV outbreaks in the WHO South-East Asia Region ..................................... 5 

2.9 Overview and analysis of cVDPV outbreaks in the WHO Western Pacific Region ..................................... 5 

2.10 Discussion on cVDPV risks and response in the WHO Western Pacific Region ........................................ 6 

2.11 Country/area presentations ............................................................................................................................ 6 

2.12 Closing remarks ........................................................................................................................................... 11 

3. CONCLUSIONS AND RECOMMENDATIONS .............................................................................................. 11 

3.1 Conclusions .................................................................................................................................................... 11 

3.1.1 General conclusions ................................................................................................................................ 11 

3.1.2 Country-specific conclusions ................................................................................................................. 12 

3.2 Recommendations .......................................................................................................................................... 16 

3.2.1 General recommendations ...................................................................................................................... 16 

3.2.2 Country-specific recommendations ........................................................................................................ 16 

3.2.3 Recommendations for WHO .................................................................................................................. 19 

ANNEXES ............................................................................................................................................................... 21 

Annex 1. List of participants 

Annex 2. Meeting timetable 

Keywords:

Immunization / Poliomyelitis / Poliovirus vaccines / Vaccination

ABBREVIATIONS

AFP acute flaccid paralysis

bOPV bivalent oral polio vaccine

cVDPV circulating vaccine-derived poliovirus

cVDPV1 circulating vaccine-derived poliovirus type 1

cVDPV2 circulating vaccine-derived poliovirus type 2

EPI Expanded Programme on Immunization

GAPIII WHO Global Action Plan to minimize poliovirus facility-associated risk after type-specific eradication of wild polioviruses and sequential cessation of oral polio vaccine use

GCC Global Commission for the Certification of Poliomyelitis Eradication

GPEI Global Polio Eradication Initiative

IPV inactivated polio vaccine

mOPV monovalent oral polio vaccine

NCC national certification committee

OPV oral polio vaccine

PEF poliovirus-essential facility

PIM potentially infectious material

RCC Regional Commission for the Certification of Poliomyelitis Eradication

SRCC Subregional Committee for the Certification of Poliomyelitis Eradication in Pacific Island Countries and Areas

TAG Technical Advisory Group on Immunization and Vaccine-Preventable Diseases

VDPV vaccine-derived poliovirus

VDPV 1 vaccine-derived poliovirus type 1

VDPV2 vaccine-derived poliovirus type 2

VPD vaccine-preventable disease

WPV wild poliovirus

WPV1 wild poliovirus type 1

WPV2 wild poliovirus type 2

WPV3 wild poliovirus type 3

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SUMMARY

The Twenty-fifth Meeting of the Regional Commission for the Certification of Poliomyelitis Eradication (RCC) in the Western Pacific was held in Siem Reap, Cambodia, on 12–14 November 2019. The RCC meets annually to review and evaluate progress reports on maintaining polio-free status submitted by the national certification committees (NCCs) and by the Subregional Committee for the Certification of Poliomyelitis Eradication in Pacific Island Countries and Areas (SRCC). The NCC and SRCC reports also include updated information on the status of implementing recommendations from the 2018 RCC meeting.

During the meeting, the RCC reviewed the status of each Member State’s poliomyelitis (polio) eradication programme in the context of the polio endgame strategy with special emphasis on achieving and maintaining sensitive acute flaccid paralysis (AFP) surveillance and high population immunity through routine and supplemental polio immunization activities.

The RCC commended Papua New Guinea and WHO for coordinating and implementing high-quality Global Polio Eradication Initiative (GPEI) partnership efforts to respond to the 2018 outbreak of vaccine-derived poliovirus type 1 (VDPV1). However, they expressed concern on the growing risk of circulating vaccine-derived poliovirus (cVDPV) emergence and subsequent outbreaks, such as in Papua New Guinea, the Philippines and China. The RCC remained greatly concerned about the parallel cVDPV type 1 and type 2 (cVDPV1 and cVDPV2) outbreaks detected in the Philippines. They commended the country, WHO and GPEI partners for initiating and coordinating large-scale outbreak response activities.

After thorough discussion and deliberation, the RCC concluded that the Region remains free of indigenous and imported wild poliovirus (WPVs) transmission. Key general recommendations to all Member States included the following:

Maintain high-quality surveillance for polioviruses and high population immunity.

Establish environmental surveillance for polioviruses in countries of the Western Pacific Region at high risk for WPV and VDPV circulation.

In consultation with WHO, consider initiating surveillance for immunodeficiency-related vaccine-derived poliovirus (iVDPV) among persons with primary immunodeficiency disorders (PID).

Complete national inventories of all biomedical facilities that may host potentially poliovirus-infectious materials (PV-PIM surveys) as soon as possible.

For all countries planning to designate a poliovirus-essential facility (PEF), include preparations for possible containment breaches in their national outbreak response plans.

Ensure the annual progress report is submitted by the requested deadline to provide the RCC with sufficient time for thorough review.

Undertake polio outbreak simulation exercises regularly and update their outbreak preparedness and response plans.

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1. INTRODUCTION

1.1 Meeting organization

The Twenty-fifth Meeting of the Regional Commission for the Certification of Poliomyelitis Eradication (RCC) in the Western Pacific was held in Siem Reap, Cambodia, on 12–14 November 2019. The RCC meets annually to review the maintenance of polio-free status, the quality of acute flaccid paralysis (AFP) surveillance against standard indicators, and population immunity based on coverage of routine and supplemental poliomyelitis (polio) vaccination. This annual meeting fulfils the RCC’s mandate to assess progress and achievements every year, which are then reported to the Global Commission for the Certification of Poliomyelitis Eradication (GCC).

In attendance were six members of the RCC, 16 chairpersons of national certification committees (NCCs) or delegates, and eight observers/representatives. The Chairman of the GCC also attended the meeting as a temporary adviser. The meeting was supported by staff from World Health Organization (WHO) headquarters, the WHO Regional Office for the Western Pacific and the WHO Country Office in Cambodia.

Dr Nobuhiko Okabe was appointed Chairperson, Dr Wang Yu served as Vice-Chairperson, and Dr Bruce Robinson Thorley served as Rapporteur. The list of participants and meeting timetable are available in Annexes 1 and 2, respectively.

1.2 Meeting objectives

The objectives of the meeting were:

1) to update the RCC members on the global status of polio eradication and recent activities in the Western Pacific Region;

2) to review and evaluate NCC progress reports, including the implementation status of 2018 RCC recommendations; and

3) to recommend actions for countries to sustain polio-free status and implement polio endgame activities.

2. PROCEEDINGS

2.1 Opening session

Dr Tigran Avagyan, Technical Officer, Vaccine-Preventable Diseases and Immunization unit, WHO Regional Office for the Western Pacific, delivered the opening remarks welcoming all participants to the meeting. He gave an update about the eradication of wild poliovirus type 3 (WPV3) by the GCC, mentioning that only wild poliovirus type 1 (WPV1) remains in circulation in two countries. He shared that in Africa, no type of wild poliovirus has been detected since September 2016, indicating that the African Region is eligible to be certified free of all wild poliovirus in June 2020. In the Western Pacific Region, it has been than one year since the last acute flaccid paralysis (AFP) case and the last environmental sample confirmed positive for circulating vaccine-derived poliovirus type 1 (cVDPV1) in Papua New Guinea. He expressed concern about the rising number of vaccine-derived poliovirus outbreaks, reporting that the global polio programme is currently responding to vaccine-derived poliovirus outbreaks in 18 countries, including in the Western Pacific Region: circulation was confirmed in China in July 2019, and outbreaks of vaccine-derived polioviruses type 1 and 2 are

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ongoing in the Philippines. He raised the question whether we can or should continue using oral polio vaccine (OPV) while there is no wild poliovirus transmission in most countries, but vaccination coverage with OPV is still low in several countries. He elaborated that the ultimate goal is to ensure no paralysis due to any type of poliovirus in the population. To achieve this goal, continuous efforts are required to reveal and close all immunity and surveillance gaps in communities and ensure use of proper polio vaccines in the routine immunization schedules to prevent possible emergence of vaccine-derived polioviruses in the future. He assured that the WHO Regional Office for the Western Pacific will continue working with the RCC and NCCs in providing support to the countries in addressing these challenges.

Dr Okabe welcomed the Chair of the GCC, Professor David Salisbury, to the meeting. He expressed his appreciation for the contributions of Dr Aida Salonga who has now resigned from the RCC and welcomed Dr Anna Lena Lopez from the Philippines as a new member of the RCC. He highlighted the global eradication of WPV3 as an important milestone for the global polio eradication programme and mentioned the challenges still faced by the programme regarding increases in WPV1 cases in both endemic countries: Afghanistan and Pakistan. He said that outbreaks due to vaccine-derived polioviruses (VDPVs) also remain a challenge globally and for the Western Pacific Region. He reported that the Government of Papua New Guinea, supported by partners, has effectively controlled the cVDPV1 outbreak, which is expected to be officially closed in November–December 2019. He also brought up the two outbreaks due to cVDPVs confirmed recently in the Region: cVDPV2 outbreak in China and cVDPV1 and cVDPV2 outbreaks in the Philippines.

He highlighted that the Western Pacific Region is approaching to its 20th year of being certified free from indigenous poliovirus. However, children are still paralysed by the virus derived from the vaccine. He advised countries to ensure that immunity levels and surveillance activities remain optimal, that regular risk assessments are sensitive enough to identify critical gaps and guide corrective actions, and that national and regional capacity is strong enough to mount a timely and comprehensive response to any polio events/outbreaks.

2.2 Global update

GPEI achieved several milestones in 2019: WPV3 was certified as eradicated; and more than three years have passed without detection of any WPV in the African Region. However, to date in 2019, the programme has experienced a growing number of paralytic cases of polio caused by WPV1 in the two endemic countries, with 100 cases reported (20 in Afghanistan, 80 in Pakistan), compared to 33 in 2018. In addition to paralytic cases, there is continued detection of WPV1 through environmental surveillance (ES) in the northern, central and southern corridors of transmission in Afghanistan and Pakistan. In addition, GPEI experienced an unprecedented increase of cVDPV2 outbreaks (more than 20 independent cases) throughout Africa but also in Pakistan, China and the Philippines.

GPEI continues to collaborate with several institutions in the Western Pacific Region on polio research. The projects include: polio antibody seroprevalence surveys in Viet Nam and Papua New Guinea; Sabin inactivated polio vaccine (sIPV) immunogenicity studies in China; an immunodeficiency-related vaccine-derived poliovirus (iVDPV) surveillance pilot project in China; development of micro array patches with inactivated polio vaccine (IPV) in Australia; and collaboration with the National Institute of Infectious Diseases (NIID) in Japan on the development and use of polio pseudovirus.

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2.3 Progress in the global certification process

The last human case of paralysis due to WPV3 was detected in November 2012. Since then, over 1 million AFP cases and environmental specimens have tested negative for WPV3. Modelling suggests well over 95% confidence of no undetected circulation of WPV3. Considering this evidence, the GCC agreed that WPV3 has been eradicated in that no transmission has been detected in any region in the last seven years since the last detection in November 2012. On 17 October 2019, the GCC certified global eradication of WPV3. The next steps for certification of global eradication of poliovirus include: interrupt transmission of WPV1, interrupt the current outbreaks due to cVDPVs, continue with containment in line with the WHO Global Action Plan to minimize poliovirus facility-associated risk after type-specific eradication of wild polioviruses and sequential cessation of oral polio vaccine use (GAPIII), and, depending on circumstances, certify absence of cVDPVs.

2.4 Recommendations of the 2019 Technical Advisory Group on Immunization and Vaccine-Preventable Diseases

In June 2018 at its 27th meeting, the Technical Advisory Group on Immunization and Vaccine-Preventable Diseases (TAG) recommended that all countries: achieve and maintain high levels of population immunity against poliovirus and certification-level performance of AFP surveillance; consider initiation of poliovirus surveillance among patients with primary immunodeficiency disorders (PIDs) to detect iVDPV, following the GPEI Guidelines for Implementing Poliovirus Surveillance among Patients with PIDs, and to consider establishment of a registry for patients with PIDs. The TAG also urged all Member States to continue activities in poliovirus laboratory containment in line with the global guidelines and time frames. The TAG encouraged the WHO Secretariat to support Member States in maintaining polio-free status and addressing gaps in AFP surveillance and population immunity, properly and comprehensively responding to the outbreaks of cVDPVs, developing national plans for environmental surveillance, implementing GAPIII, and initiating an expert consultation to guide preparation of Member States for OPV cessation prior to the global eradication of poliovirus.

2.5 Regional update

Most Member States in the Western Pacific Region maintain over 90% coverage with three doses of polio vaccines and quality surveillance for AFP achieving the regional targets for key performance indicators. In light of recent and ongoing outbreaks due to cVDPV in 2019, the WHO Secretariat revised the polio risk assessment model to consider the risk associated with susceptibility to poliovirus type 2. Based on this news model, the RCC classified 10 countries and areas as low risk for poliovirus circulation, two countries as medium risk and four countries as high risk. In 2019, to strengthen national capacity in polio outbreak preparedness and response, the WHO Regional Office conducted the first polio outbreak simulation exercise for Cambodia, China, the Lao People’s Democratic Republic and Viet Nam. The critical issues addressed during the exercise included:

revision of the national plan of action, in line with the current GPEI standard operating procedures;

identification of high-risk population groups (including travellers, nomads); and maintenance of high routine vaccination coverage and increase in vaccination coverage and

quality AFP and environmental surveillance.

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2.6 Implementation of polio laboratory containment GAPIII: global and regional update

Globally 25 countries plan to retain poliovirus type 2 materials in 70 designated poliovirus-essential facilities (PEFs). In the Western Pacific Region, five countries have designated a total of 17 PEFs that will handle and store WPV/VDPV/OPV/Sabin poliovirus type 2: Australia (1), China (8), Japan (6), Republic of Korea (1) and Viet Nam (1). Progress with the containment certification in the Region has been slow: the Republic of Korea (1) and Japan (2) received endorsement for certification of participation (CP) from the containment working group of the GCC, while it is expected that a PEF in Australia and the remaining four PEFs in Japan will submit certifications of participation by the end of the year.

However, there are challenges: containment certification is delayed in Viet Nam due to the country’s lack of decision to designate a PEF and in China due to lack of designation of a national authority for containment, a responsible authority to carry out containment certification. Progress with completion of national inventories to identify poliovirus potentially infectious materials in biomedical facilities is also delayed since many countries have inadequate resources for this task. Only 14 of 37 countries have submitted complete reports to WHO.

2.7 Global overview and analysis of cVDPV outbreaks

Regarding cVDPVs, 93 cases have been reported in 2019 to date in Angola, Benin, the Central African Republic, Chad, China, Côte d’Ivoire, the Democratic Republic of the Congo, Ethiopia, Ghana, Myanmar, Nigeria, Niger, Pakistan, the Philippines, Somalia and Zambia. These were predominantly cVDPV2 outbreaks, which in the fourth year post switch from trivalent to bivalent OPV raises serious questions about the feasibility to control these outbreaks with vaccination campaigns with the monovalent OPV2 (mOPV2). Many new VDPV2 cases were reported from areas that had used mOPV2 to respond to previous cVDPV2 outbreaks but also from areas outside the original outbreak zone.

To avoid seeding new cVDPV2 outbreaks, GPEI has supported the development of a novel OPV2 or nOPV2 (as well as OPV1 and OPV3). This vaccine will reduce the risk of vaccine-associated paralytic poliomyelitis (VAPP) and cVDPV, because it is designed to improve genetic stability and decrease the risk of loss of attenuation relative to the parental Sabin 2 strain: current clinical data are supportive of further development. The latest plan is to make 100 million doses of nOPV2 available for GPEI in mid-2020.

2.8 Overview and analysis of cVDPV outbreaks in the WHO South-East Asia Region

The WHO South-East Asia Region has been polio free since 2014. The RCC and NCCs remain active and meet regularly to review the annual progress of the countries, using a more analytic approach based on risk assessment. One confirmed case and two healthy children samples of cVDPV1 were reported in 2018 from Indonesia; and six cases and 12 healthy children samples of cVDPV1 were reported in 2019 from Myanmar. In response to the outbreaks, supplementary immunization activity campaigns were conducted in Indonesia and Myanmar along with other integral outbreak response activities, including strengthening of routine immunization along with AFP and environmental surveillance.

2.9 Overview and analysis of cVDPV outbreaks in the WHO Western Pacific Region

As the world approaches eradication of WPV transmission, the circulation of cVDPVs continues to take on added significance. In 2018, the number of paralytic cases due to cVDPVs was three times higher

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than those due to WPV. Although efforts are under way to tackle both risk factors, the only and surest way to prevent cVDPVs in the future is to stop OPV use rapidly. Although the last indigenous WPV case in the Western Pacific Region was reported in 1997 and the Region was certified polio free in 2000, outbreaks due to cVDPV represent a continuous risk since certification. There are only two countries in the world with ongoing transmission of WPV (Afghanistan and Pakistan) and the risk of exportation of WPV to polio-free countries now is very low. The biggest current risk related to poliovirus in polio-free regions/countries still using OPV in their routine immunization schedules is emergence and circulation of VDPVs. The WHO Expanded Programme on Immunization in the Western Pacific Region is starting preparation for OPV use cessation in the Region and the switch to an IPV-only schedule in advance of global eradication of polio.

2.10 Discussion on cVDPV risks and response in the WHO Western Pacific Region

Dr Yoshihiro Takashima, Regional Adviser, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, initiated a discussion (participating through videoconference), with the RCC and Dr David Salisbury, GCC Chair, on key aspects of cVDPV detection and risk management. He noted that outbreaks due to cVDPV now represented the main polio risk faced in the Region. The number of cVDPV outbreaks, so far mainly type 1, occurring in known high-risk countries of the Western Pacific Region have actually increased over time (Lao People’s Democratic Republic, Papua New Guinea and now the Philippines).

A discussion had begun in the Western Pacific Region on the available options to mitigate or even eliminate the risk of further VDPV outbreaks. This included whether it may be possible to stop the use of any bivalent oral polio vaccine (bOPV) in the Region even before the planned global bOPV cessation, currently anticipated for one year after global WPV-free certification. In response, both Dr Salisbury and RCC members noted that technical advice on immunization policy was primarily the remit of the global Strategic Advisory Group of Experts (SAGE) and regional EPI TAGs. The GCC and RCC discussants appreciated the initiative of the WHO regional team, however, and agreed that all possible options to effectively eliminate VDPV risks should be considered. A Regionwide cessation of bOPV would certainly remove the risk of seeding new cVDPV cases within Member States and the Region.

However, countries in the Western Pacific Region neighbour 14 countries in four other WHO regions, including the two remaining WPV-endemic countries Afghanistan and Pakistan. Stopping bOPV in all Member States of the Region in advance of global bOPV cessation will entail the continued risk of outbreaks due to imported VDPV, particularly in the highest-risk countries of the Region, where one dose IPV coverage is not yet sufficiently high. The most likely way ahead, therefore, will be to plan for the discontinuation of bOPV country by country, as soon as current immunization coverage levels and questions of IPV cost and availability are resolved.

2.11 Country/area presentations

Papua New Guinea

Papua New Guinea experienced a cVDPV1 outbreak in 2018. A total of 26 confirmed cVDPV1 cases and 14 polio compatible cases were reported across the country, including environmental isolates from the National Capital District. The outbreak response included establishment of emergency operations centres (EOCs), eight supplementary immunization activities (SIAs) and enhanced surveillance activities (for both AFP and environmental surveillance). The sustained high vaccination coverage in supplementary immunization activities and enhanced surveillance activities have been assessed in the last poliovirus outbreak response assessment (OBRA), with the conclusion that the transmission has

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likely been interrupted (last case detected in November 2018). However, considerable gaps in population immunity and surveillance exist. There is now recognition for translating outbreak response gains into efforts to improve routine immunization ahead through better administrative management (retaining EOCs), microplanning for reaching high-risk populations through outreach and mobile immunization services, improving capacity of health staff, strengthening VPD surveillance, and restoring community confidence in immunization services. With regard to containment, poliovirus potentially infectious materials (PIM) surveys will be completed for all biomedical facilities.

China

China has maintained high immunization coverage, over 95% at the national level. In 2019, catch-up immunization activities with IPV were conducted for children born after the OPV switch. High performance of AFP surveillance was sustained in terms of detection rate and stool adequacy at national and subnational levels. Environmental surveillance is conducted in nine provinces. In 2019, two VDPV cases were detected through AFP surveillance.

One VDPV2 case was detected in Leibo county (Sichuan province); the virus was linked to VDPV isolated in Urumqi in 2018 and therefore classified as cVDPV. Similar viruses were detected in three local healthy children. The Chinese Center for Disease Control and Prevention launched a level 2 emergency response: a dynamic risk assessment was conducted, surveillance strengthened, two rounds of sIPV vaccination completed in Leibo county and catch-up vaccination in six surrounding prefectures. One VDPV3 case was detected in Changchun city (Jilin province), classified as VDPV but suspected as an immunodeficiency-related case.

As the supply of domestic IPV stabilizes, a second dose of IPV is planned to be introduced into the routine immunization schedule. Poliovirus type 2 containment has been completed successfully. The national inventory of laboratories/facilities was also completed, and 127 labs have been identified as having polioviruses type 2 to be transferred to PEFs.

Philippines

The country continues to record a decline in the non-polio AFP rate (0.98 in 2018; 0.32 as of mid-2019), and stool adequacy rate (73% in 2018; 53% as of mid-2019). Low immunization coverage (66% in 2018) and vaccine hesitancy partly accounted for the recent VDPV outbreak in 2019. In response to this outbreak, the Department of Health instituted several interventions: activation of central and regional incident management teams, activation of central and regional EOCs, assignment of technical and support teams, strengthened immunization, and synchronized polio vaccinations in affected areas. Surveillance, advocacy campaigns and partnerships were key areas of focus in the outbreak response activities. Government commitment to the outbreak response efforts is commendable; community acceptance and participation are remarkable. It is noted that efforts were insufficient to work on the previous RCC recommendations, including issues discussed at the side meeting. Sustainable plans for improving routine immunization and a more proactive (instead of reactive) outbreak preparedness and response approach are crucial.

Malaysia

There is a robust AFP surveillance system at the national level, combined with high national IPV coverage with recent catch-up vaccination in low coverage areas, including covering high-risk groups in Sabah state. Detailed analysis of surveillance indicators was conducted which revealed suboptimal stool adequacy and many 2019 AFP cases still pending final classification. Significant efforts have been made to improve routine immunization coverage in high-risk areas such those in close proximity to the

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Philippines. In view of the current cVDPV1 and cVDPV2 outbreaks in the Philippines, a memorandum of agreement was signed between the Philippines and Malaysia in July 2019 for vaccination of migrant Filipino children. Challenges remain with high numbers of foreign visitors, workers and students from polio-affected countries that represent a risk of importation, especially among the stateless population in Sabah where vaccination service delivery is a major challenge. Considerable progress has been achieved with polio containment by establishing an exhaustive list of the facilities that may have poliovirus PIM.

New Zealand

The country continues to achieve overall high coverage but with a slight decrease from 93.8% in 2017 to 92.7% in 2018 with three districts having coverage below 90%. Surveillance indicators were achieved and one notably greatly improved, reaching 100% of total AFP cases with adequate stool specimen. Continuous efforts are being made to improve performance of AFP surveillance by conducting supplemental enterovirus surveillance, through engagement with paediatric neurology nurse specialists at tertiary care centres and with electronic collection of surveillance data since January 2018. Efforts are sustained to ensure that all migrants and high-risk groups are vaccinated. The national inventory to identify poliovirus PIM have been completed in compliance with GAPIII requirements, and the national polio response plan has been updated.

Republic of Korea

The Republic of Korea continues to maintain very high performance in immunization, with all provinces reaching coverage for three doses of IPV between 96% and 98% in 2018. This is a result of multiple efforts: the Government is providing financial support to the private sector to increase accessibility to vaccination; there is a school entry vaccination requirement; the Immunization Week campaign increases routine immunization activities; and a national vaccine adverse event compensation programme supports in building confidence in the National Immunization Programme. The country implements AFP surveillance complemented by enterovirus surveillance. AFP surveillance performance indicators are reaching targets at the national level, but some provinces are underperforming in terms of the non-polio AFP rate. Activities are ongoing to inform and sensitize hospitals and medical practitioners about AFP surveillance. In 2018, 53 sites actively participated in enterovirus surveillance. A website is available for international travellers to search information about ongoing outbreaks of infectious diseases including polio and recommendations for vaccination, and the Korea Centers for Disease Control and Prevention (KCDC) informs travellers to countries with increased risk of polio through text message. The Republic of Korea has designated its National Poliovirus Containment Coordinator and established the National Authority for Containment in August 2018. A national survey of facilities retaining polioviruses was finalized, and the application for the certificate of participation was endorsed by the GCC.

Australia

No case of polio was detected during the reporting period, 1 January 2018 to 30 June 2019. The non-polio AFP rate for the country remains above the target (1.36 by mid-2019), but the stool adequacy rate is below the target (44% in 2018; 38% as of June 2019). To improve performance, Paediatric Active Enhanced Disease Surveillance (PAEDS) has developed an action plan identifying what contributes to successful stool specimen collection with standardized strategies across the network. A comprehensive risk assessment revealed that the risk of WPV or VDPV reintroduction, resultant outbreaks of poliovirus infection and sustained transmission occurring in Australia in the next five years (2019–2023) is very low. The country maintains a commitment to the goals of GAPIII and is currently exploring how to

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adopt and implement these principles in the Australian context. Additional environmental surveillance sites that were previously put on hold have resumed operations, but funding and inadequate human resources are challenges. Efforts are under way to address these challenges.

Brunei Darussalam

Brunei Darussalam retains high performance in its routine immunization programme and AFP surveillance system. High coverage of IPV3 immunization (> 95%) has been maintained in the last several years without any need of supplementary immunization activities. The integrated AFP and measles surveillance framework has been adopted since 2010, and required AFP surveillance benchmarks have been met for 2018 and 2019. The challenge of addressing public concerns about a recent polio outbreak in the Philippines was discussed. The issue of IPV vaccine procurement is being managed; a quotation from Sanofi pharmaceutical company has recently been secured. In conclusion, there is low overall risk for polio in the country.

Cambodia

Cambodia continues with overall good national coverage with OPV3, community outreach in high-risk provinces and catch-up immunization activities. The country is strengthening AFP surveillance with continued field activities to improve surveillance indicators such as training workshops for strengthening routine immunization and VPD surveillance and has initiated quarterly VPD surveillance reviews in four provinces. Despite such efforts, challenges remain: six provinces with < 90% OPV3 coverage in 2018, for instance 62% coverage in Svay Reng and 68% in Preah Vihear with suboptimal AFP surveillance in some of these provinces. Improvements can be achieved with more engagement and communication with different health administrative levels and working with private/nongovernmental hospitals especially in urban areas. The national inventory to identify poliovirus PIM has been completed in compliance with GAPIII requirement.

Hong Kong SAR (China)

The last polio case was reported in 1983, and AFP surveillance has been in place since 1997. IPV has been used in the routine immunization programme since 2007. At present, the routine immunization schedule includes a four-dose primary series followed by two booster doses given at primary 1 and primary 6. Coverage with at least three doses has been close to 100% since 2008. All AFP surveillance performance standards are being met. Hong Kong SAR (China) does not plan to establish PEFs. A survey was conducted in 2019: no laboratory had kept infectious materials of poliovirus type 2; three laboratories had kept infectious materials of other polioviruses but agreed to destroy them according to the GAPIII timeline. The biggest risk may come from heavy international travel with 65 million visitors in 2018, including almost 7927 visitors from polio-endemic countries. Due to heavy international travel and population movement, the possibility of WPV importation cannot be ruled out. In November 2018, the Centre for Health Protection (CHP) conducted a tabletop exercise named “Onyx” on poliovirus to assess the operability of the polio response plan. Future plans include: maintaining: a sensitive surveillance system, a high-quality and fully accredited laboratory, high population immunization coverage, and an up-to-date and implementable polio importation preparedness and response plan.

Japan

Routine immunization against polio remains high with four doses of DTP-IPV since 2012. A seroprevalence survey found that high population immunity against polio has been maintained after IPV introduction in the country. AFP surveillance has been ongoing since 2018, but improvements, including regular reporting to WHO, are needed. It was noted that the stool adequacy rate (8% in 2018;

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14% as of June 2019) and non-polio AFP rate (0.79 in 2018; 0.32 as of June 2019) were below the AFP surveillance performance target. An accidental release of Sabin type 3 infectious material into sewage by a vaccine manufacturing company was reported. The risk relating to this incident was assessed to be low, though efforts are in place to identify any cases of AFP within the affected area possibly related to this incident. The national environmental surveillance network in Japan has been in operation since 2013, while PEF certification and a PIM survey are ongoing as part of GAPIII requirements.

Lao People’s Democratic Republic

Overall programme performance continued to improve in 2018–2019. Coverage with three doses of OPV was reported at 84%. Core AFP surveillance indicators achieved recommended targets, except for timely case notification. Efforts also in place to improve EPI and surveillance data quality. Supportive supervision and on-the-job training are being reinforced, community engagement sessions continue, and there is close monitoring of routine immunization and AFP surveillance at the subnational levels.

Macao SAR (China)

Macao SAR (China) has maintained a high quality of AFP surveillance and established enterovirus surveillance in since 2008 when it started using IPV. The Macao Health Bureau has implemented annual random checks in selected pre-primary, primary and secondary schools to ensure both local and immigrant children have completed the vaccination record as well as required entry checks for all day-care and educational institutions. A new regulation has been launched to request all higher education institutions to check on the immunization status of students from countries with high polio risk upon their first entry. From 2017, the specified birth cohort coverage of residents (including local and non-local residents with long stay permits) has been used.

Mongolia

AFP surveillance performance has been declining in terms of the non-polio AFP rate since 2014. However, efforts have been made to conduct supportive supervision and regional training, and 2019 data show significant improvement. Stool adequacy rates reached 100% in 2018. High national and subnational routine immunization coverage for three doses of OPV (more than 98% in 2018) was maintained. Removal of OPV birth dose (zero dose) from the routine immunization schedule has been delayed. Mongolia received IPV in late 2018 and developed an introduction plan. IPV was finally introduced on 1 April 2019 in the whole country to children aged 5 months. A vaccine-preventable diseases seroprevalence survey is being conducted and expected to be finalized in 2019, although support is needed for neutralization of testing for polio. A national survey of biomedical laboratories was launched in September 2018 and has identified two laboratories that may contain poliovirus PIM. An annual risk assessment is planned using a revised methodology in line with the regional tool.

Pacific island countries and areas (PICs)

The non-polio AFP rate for the PICs is quite good (1.1 in 2018), but the specimen adequacy rate is less than desired (38% in 2018; 53% by September 2019). Significant variability exists regarding quality of AFP surveillance in the PICs. In view of the recent cVDPV1 outbreak in Papua New Guinea, Solomon Islands has strengthened surveillance and improved cross-border collaboration with Papua New Guinea as recommended by the RCC in 2018. It was noted that American Samoa has not submitted reports for several years. Activities of Phase 1 of GAPIII have been completed and reports (Form 2) received from Fiji, Nauru, New Caledonia, Guam, Solomon Islands and the Commonwealth of the Northern Mariana Islands. None of these countries has retained PIM for poliovirus type 2. No report has been received yet from the remaining PICs on poliovirus containment. The latest risk assessment results for the PICs date

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back to 2013/14, but the risk assessment indicators were reviewed during the SRCC/SRVC meeting in May 2019 and are expected to be ready for use in 2020.

Singapore

Routine immunization coverage remained high. IPV is used for the three primary doses and first booster dose, while bOPV is used as a second booster. The AFP surveillance system is also functioning optimally: timeliness and completeness of reporting to national level remained 100%, the non-polio AFP rate met the required benchmark, and stool adequacy has improved from 77% in 2018 to 87% so far in 2019. The Ministry of Health is working closely with AFP surveillance coordinators to improve stool adequacy through sensitization and close coordination with healthcare providers. The 2011 version of the polio outbreak preparedness and response plan is currently under revision, and it will be finalized by 2020. The country has complied with poliovirus type 2 containment requirements.

Viet Nam

The membership of the NCC was changed recently with new members starting their five-year term in July 2019. The country is in the process of implementing recommendations of the 24th RCC meeting. As part of strengthening AFP surveillance, active surveillance was integrated with the national infectious diseases digital report. To track the vaccination status of children, the national immunization information system was developed and will be rolled out to more than 17 000 immunization stations and 12 000 health clinics in Viet Nam. Coverage with three doses of OPV remains high. In September 2018, the country introduced one dose of IPV. Training was conducted for health-care workers on management of adverse events following immunization, communication, planning routine vaccination and immunization campaigns, and supportive supervision, among others. However, the remaining challenges include: suboptimal vaccination coverage in remote/hard-to-reach areas, internal migration of population and the antivaccination movement.

2.12 Closing remarks

Dr Okabe delivered the closing remarks. He said that he appreciated the presence of essential capacities in the Region to quickly and effectively respond to the challenges, as was demonstrated by the rigorous response to the outbreaks of cVDPV type 1 in the Lao People’s Democratic Republic and Papua New Guinea – and now in the Philippines. Dr Okabe closed the meeting by acknowledging the commitment and dedication to polio eradication by all the ministries of health and the generous support of international partners.

3. CONCLUSIONS AND RECOMMENDATIONS

3.1 Conclusions

3.1.1 General conclusions

• The RCC concludes that the Western Pacific Region remained free of indigenous and imported wild poliovirus (WPV) transmission and congratulates all Member States of the Region for their continued dedication.

• The RCC expresses its gratitude to all laboratories in the regional polio laboratory network for their high-quality support to countries of the Region.

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• The RCC expresses concern, however, about the growing risk of circulating vaccine-derived poliovirus (cVDPV) emergence and subsequent outbreaks, such as in Papua New Guinea, the Philippines and China.

• The RCC remains greatly concerned about the parallel cVDPV1 and cVDPV2 outbreaks detected in the Philippines, and commends the country, WHO and Global Polio Eradication Initiative (GPEI) partners for initiating and coordinating large-scale outbreak response activities.

• The RCC commends Papua New Guinea and the WHO Country Office, the WHO Regional Office for the Western Pacific and WHO headquarters for coordinating and implementing high-quality GPEI partnership efforts to respond to the 2018 outbreak of vaccine-derived poliovirus type 1 (VDPV1) in Papua New Guinea.

• The RCC notes with satisfaction that immunization and poliovirus surveillance activities in most Member States of the Region continue to be implemented with high quality, which is essential for the Western Pacific to remain polio free.

• The RCC also notes the progress made towards implementing poliovirus containment, including establishing inventories of facilities storing poliovirus potentially infectious materials.

3.1.2 Country-specific conclusions

Australia

• The RCC commends the continued achievement of the non-polio acute flaccid paralysis (NPAFP) rate quality indicator, although stool adequacy remains below the expected level.

• The RCC also commends the efforts to improve stool adequacy:

– the acute flaccid paralysis (AFP) system (PAEDS) now has added a key performance indicator to require AFP stool adequacy of 80%

– action plan developed to improve timely collection of two stool samples.

• The RCC thanks the Polio Regional Reference Laboratory from the Victorian Infectious Diseases Reference Laboratory for their critical support in the context of the Papua New Guinea outbreak.

• The RCC notes the results of a detailed risk assessment, indicating that Australia remains at very low risk of poliovirus reintroduction and establishment.

Brunei Darussalam

• The RCC commends the country for maintaining a high-level performance in immunization and AFP surveillance.

Cambodia

• The RCC commends maintenance of AFP surveillance and high oral poliovirus vaccine type 3 (OPV3) coverage overall and appreciates continued field activities to improve AFP surveillance.

• The RCC notes continued “high-risk community outreach”, as well as catch-up immunization activities.

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• The RCC notes that the national inventory of biomedical facilities was reviewed and updated in April 2019.

China

• The RCC commends the country for maintaining overall high immunization coverage and sensitive AFP surveillance and notes the plans for expanding environmental surveillance and initiating primary immunodeficiency (PID) surveillance.

• The RCC appreciates the careful investigation of cVDPV2 detected in Xinjiang (environmental surveillance sample) and Sichuan (AFP case + three contacts), followed by a comprehensive outbreak response.

• The RCC notes that containment activities in China continue to lag behind:

– no official nomination of a national authority for containment (NAC)

– no official designation of poliovirus-essential facilities (PEFs)

– delay in completing national survey to identify poliovirus potentially infectious materials (PIM) in biomedical laboratories

– poliovirus type 2 (PV2) materials from provincial laboratories are not yet destroyed or transferred to PEF.

Hong Kong SAR (China)

• The RCC commends continued efforts to sustain high immunization coverage (for both Hong Kong and mainland-born children) and quality surveillance.

• The RCC appreciates the successful conduct of a polio outbreak simulation exercise (Onyx).

• The RCC notes the completion of the PIM survey (type 2) of biomedical facilities.

• The RCC notes initial discussions to implement immunodeficiency-related vaccine-derived poliovirus (iVDPV)/PID surveillance.

• The RCC appreciates the continued long-standing support for Macao SAR (China) provided by the polio laboratory in Hong Kong SAR (China).

Japan

• The RCC notes and commends continued efforts to conduct AFP surveillance.

• The RCC commends continuation of supplemental (environmental and enterovirus) surveillance strategies.

• The RCC thanks the Government of Japan and the National Institute of Infectious Diseases Global Specialized Polio Laboratory for continued support of surveillance activities in other Member States of the Western Pacific Region, including the recent outbreaks.

• The RCC notes the progress with the national inventory to identify poliovirus PIM.

• The RCC congratulates Japan on the successful submission and endorsement by the Global Commission for the Certification of the Eradication of Poliomyelitis (GCC) of certificates of participation for two of the six designated PEFs.

• The RCC notes the report by a vaccine manufacturer of a recent accidental release into sewage of Sabin type 3 infectious material.

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Lao People’s Democratic Republic

• The RCC appreciates that national-level AFP indicators are well above the required cut-off but is concerned that subnational AFP quality gaps remain – such as in the urban centres of Vientiane and Savannakhet.

• The RCC acknowledges ongoing efforts to maintain and improve AFP quality, targeting low-performing areas.

• The RCC is concerned that important immunization coverage gaps remain.

• The RCC commends the updating of the national risk assessment tool to reflect the Western Pacific Region standard methodology.

Macao SAR (China)

• The RCC commends continued good-quality AFP surveillance and use of enterovirus surveillance.

• The RCC notes high vaccination coverage achieved among the resident population, and systematic efforts to ensure vaccination of all arriving and resident migrant children.

Malaysia

• The RCC commends the country for conducting catch-up vaccination in low-coverage areas, including covering high-risk groups in Sabah state.

• The RCC appreciates that environmental surveillance sites in Sabah state were reviewed and new sites added and that plans exist for the expansion of environmental surveillance.

• The RCC commends the detailed analysis of surveillance indicators but noted that stool adequacy is suboptimal and that many 2019 AFP cases are pending final classification.

Mongolia

• The RCC notes the efforts to improve AFP reporting, with high stool adequacy.

• The RCC appreciates the successful introduction of one dose of inactivated polio vaccine (IPV) in April 2019, following delays in introduction due to the global vaccine shortage.

New Zealand

• The RCC commends efforts to improve AFP surveillance and maintenance of supplementary enterovirus surveillance, including engagement with the Paediatric Society, the International Classification of Diseases (ICD) code audit and liaising with the neurology unit of STARSHIP Hospital.

• The RCC commends continued focus on vaccinating migrants and other high-risk groups.

• The RCC acknowledges the 2019 update of the national polio response plan.

Pacific island countries and areas

• The RCC notes the increasing trend in AFP reporting and stool adequacy in 2019 compared to 2018.

• The RCC commends the leadership of the SRCC for the Pacific island countries and areas, past and present, for striving to have countries adequately address the RCC recommendations.

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• The RCC notes with concern that several small island nations continue to have low-performing immunization programmes (< 70% coverage).

• The RCC notes progress in conducting the PIM survey (to find laboratories keeping poliovirus potentially infectious materials); results are available from six countries.

Papua New Guinea

• The RCC commends the country and supporting GPEI partners for conducting a comprehensive response to the nationwide 2018 cVDPV1 outbreak, with no cVDPV1 detected since November 2018.

• The RCC appreciates that outbreak response supplementary immunization activities were used to provide vitamin A and other Expanded Programme on Immunization (EPI) antigens (measles and rubella on the last National Immunization Days).

• The RCC commends that AFP surveillance greatly improved and environmental surveillance was established.

• The RCC notes that specimen adequacy is still below 80%, and routine coverage remains very low, particularly coverage with IPV.

Philippines

• The RCC notes with regret that the predicted cVDPV outbreak scenario has occurred: parallel type 1 and type 2 cVDPV emergence and outbreaks were detected in Luzon and Mindanao due to persistently low routine coverage with polio vaccines.

• The RCC remains highly concerned that both AFP surveillance performance and routine immunization coverage have declined further and that a high risk of further spread and of new outbreaks elsewhere remained.

• The RCC appreciates that national and local health authorities took outbreak response measures, in close coordination with GPEI partners:

– activating the Incident Management System, national and in Metro Manila and Mindanao

– implementing a series of response supplementary immunization activities (bivalent OPV in Metro Manila, monovalent OPV2 in Mindanao) and expanding environmental surveillance.

• The RCC commends the support and sustained strong performance of the national polio laboratory even with the increased workload due to the outbreaks in the Philippines and Papua New Guinea.

Republic of Korea

• The RCC commends the programme for consistent high immunization coverage and activities to further improve coverage (Immunization Week, financial incentive for the private sector, school entry requirement).

• The RCC appreciates continued high performance of the AFP surveillance system, meeting indicators since 2012, and continued supplementary enterovirus surveillance.

• The RCC commends the country for being the first in the Region to submit the certificate of participation for the designated PEF, and to receive GCC endorsement.

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Singapore

• The RCC commends the country for maintaining quality AFP surveillance.

• The RCC appreciates that immunization coverage remains high.

• The RCC commends the country for conducting a comprehensive poliovirus PIM survey.

Viet Nam

• The RCC notes the continued maintenance of high routine immunization at national and province levels, although district-level gaps remain.

• The RCC commends the continued high-quality AFP surveillance overall but noted subnational AFP quality gaps.

• The RCC notes that POLYVAC has still not been designated officially as a PEF, delaying the facility certification process.

3.2 Recommendations

3.2.1 General recommendations

Member States are encouraged to consider the following:

1) Maintain a high quality of surveillance for polioviruses and high population immunity in all Member States.

2) Establish environmental surveillance for polioviruses in countries of the Western Pacific Region at high risk for WPV and VDPV circulation.

3) In consultation with WHO, initiate surveillance for iVDPV among persons with primary immunodeficiency disorders (PID).

4) Complete national inventories of all biomedical facilities which may host poliovirus potentially infectious materials (PIM surveys) as soon as possible in all Member States of the Region.

5) For all countries planning to designate a PEF, include preparations for possible containment breaches in their national outbreak response plans.

6) Ensure the annual progress report is submitted by the requested deadline to provide the RCC with sufficient time for thorough review.

7) Undertake polio outbreak simulation exercises to regularly update their outbreak preparedness and response plans.

3.2.2 Country-specific recommendations

Australia

1) Urgently start the PEF certification process and submit the certificate of participation by the end of 2019.

2) Initiate the national inventory of biomedical facilities to identify poliovirus potentially infectious materials (PIM survey) as soon as possible.

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Brunei Darussalam

1) Maintain high-quality immunization and AFP surveillance activities to contribute to the regional polio-free status.

Cambodia

1) Continue addressing the reasons for low AFP surveillance indicators in underperforming provinces and take corrective actions, such as increasing private health sector involvement in surveillance, particularly in large urban settings.

2) Continue to implement the high-risk community immunization strategies, as well as catch-up immunization outreach services, to achieve uniformly high levels of coverage.

3) Establish environmental surveillance with WHO support.

China

1) Continue enhanced AFP surveillance and environmental surveillance in the outbreak areas to monitor for potential virus transmission; surveillance results should be promptly shared with WHO.

2) In consultation with WHO, update the outbreak preparedness plan for potential use of mOPV2 (supply and scope).

3) Expedite containment activities:

– nominate and establish a functional national authority for containment, to allow designated PEFs to submit applications to the National Authority for Containment by the end of 2019

– officially designate PEFs that will be retaining poliovirus type 2 materials

– elevate priority within the government to urgently destroy all type 2 materials remaining in provincial labs or transfer such material to a designated PEF, and document this process

– complete a national inventory to identify poliovirus PIM in all biomedical facilities and describe the risk assessment process.

Hong Kong SAR (China)

1) Continue to maintain high-quality immunization and surveillance activities.

Japan

1) Collaborate with local health authorities on improving AFP surveillance sensitivity and stool adequacy.

2) Consult with WHO on adapting current AFP recommended practices (case classification, monitoring performance), and ensure AFP results are regularly submitted.

3) Urgently progress with certification of the remaining four designated PEFs, submitting the required certificate of participation by the end of 2019.

4) Work with WHO to provide the risk assessment process used to identify poliovirus PIM.

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Lao People’s Democratic Republic

1) Continue to implement the action plan to improve AFP surveillance (including to conduct training, improve awareness and provide more supervision).

2) Revise and update the polio outbreak response plan, incorporating the 2015/16 VDPV1 outbreak experience.

3) Collaborate with WHO to prepare for establishing environmental surveillance.

Macao SAR (China)

1) Maintain high-quality AFP surveillance, supplemented by enterovirus surveillance.

2) Maintain uniformly high immunization coverage of both Macao-born and immigrant children.

3) Consult with WHO on the appropriate testing for polio serosurveys.

Malaysia

1) Strengthen AFP surveillance in all low-performing states and areas, particularly in view of the risk of importation from neighbouring countries.

2) Ensure regular meetings of the expert panel for timely classification of AFP cases.

3) Expand environmental surveillance as planned, and report results using the environmental surveillance data reporting system, in consultation with WHO.

4) Continue efforts to identify and vaccinate migrants and other high-risk groups with all EPI antigens.

Mongolia

1) Continue activities to strengthen AFP surveillance, particularly to use active surveillance at high-priority surveillance sites.

2) Finalize the national risk assessment tool, adopting the regional risk assessment methodology.

3) Consult with WHO regarding polio seroprevalence surveys.

New Zealand

1) Sustain AFP surveillance at required quality level and continue enterovirus surveillance.

2) Maintain high-quality immunization coverage, with a focus on vaccinating high-risk groups.

3) Consult with WHO on appropriate risk management for a sample collection of potentially WPV/VDPV-infectious materials from an international pneumonia etiology study (Canterbury Health Laboratories).

Pacific island countries and areas

1) Sustain AFP surveillance at the required quality level and continue enterovirus surveillance.

2) Maintain high-quality immunization coverage, with a focus on vaccinating high-risk groups.

3) Consult with WHO on appropriate risk management for a sample collection of potentially WPV/VDPV-infectious materials from an international pneumonia etiology study (Canterbury Health Laboratories).

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Papua New Guinea

1) Sustain AFP surveillance at the required quality level and continue enterovirus surveillance.

2) Maintain high-quality immunization coverage, with a focus on vaccinating high-risk groups.

3) Consult with WHO on appropriate risk management for a sample collection of potentially WPV/VDPV-infectious materials from an international pneumonia etiology study (Canterbury Health Laboratories).

Philippines

1) The Department of Health to critically review the impediments to effective programme management, which allows repeated VPD outbreaks, and strongly emphasize disease prevention through improving the quality of immunization services.

2) The national response team to urgently strengthen the implementation of high-quality outbreak response activities, including surveillance focusing on lowest-performing areas, including in Metro Manila.

3) Ensure all mOPV2 procured for outbreak response is accounted for by maintaining an accurate inventory and documenting the destruction of remaining stock, as per GPEI guidelines.

4) Government leaders at national and provincial levels to build on the visibility of the outbreak to increase programmatic momentum, and sustain any gains made towards strengthening routine immunization and surveillance.

Republic of Korea

1) Work with WHO to provide more information on the risk assessment process to identify poliovirus PIM.

2) Maintain high immunization coverage, including for migrants.

3) Maintain high AFP surveillance performance and strengthen subnational areas not meeting indicators.

Singapore

1) Review the polio risk assessment to take into account cVDPV outbreaks.

Viet Nam

1) Close immunity gaps in underserved populations.

2) Destroy all poliovirus type 2 materials in the National Institute for Control of Vaccines and Biologicals and report officially to WHO.

3) Ensure that a national authority for containment is officially designated and made functional, to expedite the POLYVAC certificate of participation application before the end of 2019.

3.2.3 Recommendations for WHO

WHO is requested to consider the following:

1) Lead in raising awareness of the continuing risks of poliovirus outbreaks and ensure long-term commitment of national authorities to sustain high immunization coverage and surveillance to remain polio free.

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2) Continue discussions with technical advisory groups on how to mitigate the risk of cVDPV emergence and outbreaks.

3) Continue to provide technical support to countries for immunization and surveillance activities, and to implement the requirements of the WHO Global Action Plan to minimize poliovirus facility-associated risk after type-specific eradication of wild polioviruses and sequential cessation of oral polio vaccine use (GAPIII).

4) Continue to provide technical support to countries for preparation and implementation of polio outbreak simulation exercise.

5) Whenever possible, consider subnational risk assessments accounting for neighbouring countries outside the Western Pacific Region to assess the risk of potential cross-border transmission.

6) Assist countries in assessing the need for serosurveys and, if necessary, facilitate appropriate testing.

7) Ensure continuous WHO technical support for EPI in the Pacific islands.

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ANNEXES

Annex 1. List of participants

1. Regional Certification Commission Members

Dr Nobuhiko Okabe, (Chairman, Regional Certification Commission), Director General, Kawasaki City Institute for Public Health, Life Science and Environment Research, 2F 3-25-3 Tono-Machi Kawasaki-ku, Kawasaki City, Kanagawa 210-0834, Japan Tel no.: +81 4 4 2444985, Fax no.: +81 4 2462602, Email: okabe-n@city.kawasaki.jp okabenobu46@gmail.com

Dr Wang Yu, Distinguished Profressor, Health City Research Center, Institute for China Sustainable Urbanization, Tsinghua University, Beijing, People's Republic of China, Tel no.: +86-10-58900216, Fax no.: +86-10-58900240, Email: wangyu@chinacdc.cn

Dr Steven Wassilak, Medical Epidemiologist, Global Immunization Division, Centers for Disease Control and Prevention, 1600 Clifton Road N.E., Atlanta, Georgia 30333, United States of America, Tel no.: +1 404 639 1867, Fax no.: +1 404 639 8573, Email: sgw1@cdc.gov

Dr Olen M. Kew, Coordinator, National Poliovirus Containment Coordinator, 270 North Peak Drive, Alpharetta, Georgia 30022, United States of America, Tel no.: +1 770 993 3069, Fax no.: +1 404 639 4011, Email: omk1@cdc.gov; omk1@bellsouth.net

Dr Anna Lena Lopez, Director and Research, Associate Professor, Institute of Child Health and Human Development, University of the Philippines, 623 Pedro Gil Street Ermita, Manila, Philippines, Tel no.: +63 2 525 5405, Fax no.: +63 2 525 4996 Email: allopez2@up.edu.ph

Dr Bruce Robinson Thorley, Senior Medical Scientist, Head, WHO Polio Regional Reference Laboratory, Victorian Infectious Diseases Reference Laboratory, The Doherty Institute, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia, Tel no.: (613) 9342 9607, Fax no.: (613) 9342 9665, Email: bruce.thorley@vidrl.org.au bruce.thorley@mh.org.au

2. Temporary Adviser

Professor David Salisbury, (Chairman, Global Certification Commission), Associate Fellow, Centre on Global Health Security, Chathan House, London, United Kingdom, Tel no.: +44 7799 860986, Email: david.salisbury@btinternet.com

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3. Participants (National Certification Committee Members – Designates)

AUSTRALIA Dr Meryta May, Microbiologist, Sullivan Nicolaides Pathology, 24 Hurworth St Bowen Hills, Queensland 4006 Tel no. : + 61 412925383, Fax no.: + 61 02 49246215 Email : merytam@bigpond.com

BRUNEI DARUSSALAM Dr Anie Haryani Abdun Rahman, Director, Environmental Health Service, Public Health Services, Ministry of Health, Commonwealth Drive, Bandar Seri Begawan 3910, Tel no. : +67 3 2381470, Email : anie.rahman@moh.gov.bn

CAMBODIA Dr Ly Sovann, Director, Department of Communicable Disease Control, Ministry of Health, #80, Samdech Penn Nouth, Phnom Penh, Cambodia, Tel no.: +855 12 825424 Fax no.: +855 23 880441, Email: sovann_ly@online.com.kh

MACAO SAR (CHINA) Dr Wong Fong Ian, Consultant Pediatrician, Centro Hospitaler Conde de Sao Januario, Estrada de Visconde de Sao Januario, Macao, Tel no.: +853 6686 6678 Email: wongfongian@gmail.com

HONG KONG SAR (CHINA) Professor Yu-Lung Lau, Doris Zimmern Professor in Community Child Health, Chair Professor of Paediatrics, Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Telephone : +852 2255 4481, Facsimile: +852 2855 1523, Email: lauylung@hku.hk

JAPAN Dr Takaji Wakita, Director General, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, Tokyo 162-8640, Japan, Tel no.: +81 3 5285 1111, Fax no.: +81 3 5285 1193, Email: wakita@nih.niid.jp

LAO PEOPLE'S DEMOCRATIC REPUBLIC

Dr Khamla Choumlivong, Deputy Director, Setthathirath Hospital, Donekoy Village, Sisattanak District, Vientiane Capital, Telephone: + 856 20 2222 6104, Fax no.: + 856 21 351160, Email: khamla_choumlivong@yahoo.fr

MALAYSIA Dr Norhayati Binti Rusli, Director Control Division, Ministry of Health Malaysia, Level 2, Block E10, Complex E, 62590 Putrajaya, Tel no.: +603 8883 4419, Fax no.: +603 8888 0643, Email:dr_norhayati@moh.gov.my

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MONGOLIA Dr Janchiv Oyunbileg, Consultant, Leading Scientist, National Center for Public Health, Peace Avenue - 17 Ulaanbaatar, Tel no.: +99762000, Email: jobileg@gmail.com

PACIFIC ISLAND COUNTRIES AND AREAS

Dr Ilisapeci Tuibeqa, Head Department of Paediatrics, Colonial War Memorial Hospital, Box 115, Suva, Republic of Fiji, Tel no.: +67 7522778, Email: beth.vereti@gmail.com

PAPUA NEW GUINEA Professor John Vince, Deputy Dean (Academic), Director of Postgraduate and Research, School of Medicine and Health Sciences, University of Papua New Guinea P.O. Box 5255, Boroko, Tel no.: +67 5 73260185, Email: johndvince@gmail.com

PHILIPPINES Dr Nina G. Gloriani, Consultant, Clinical Microbiology Section, Institute of Pathology, St. Luke’s Medical Center, 279 E. Rodriguez Sr. Avenue, Quezon City, Tel no.: +63 917 865 5353, Fax no.: +63 2 521 1394 Email: ninagloriani@gmail.com

REPUBLIC OF KOREA Dr Youngmee Jee, Director, Center for Infectious Disease Research, Infectious Disease Surveillance Division, Korea Centers for Disease Control and Prevention, 182 Osongsaengmyeong2-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28160, Tel no.: +82 43 719 8402, Email: jeey62@gmail.com

SINGAPORE Mr Yuske Kita, Senior Public Health Officer, Strategy and Prevention, Ministry of Health, College of Medicine Building16 College Road, Singapore 1698854, Tel no.: +65 6221 5528, Email: yuske_kita@moh.gov.sg

VIET NAM Dr Pham Quang Thai, Vice head of Epidemiology Department, Deputy EPI Manager Northern Region, National Institute of Hygiene and Epidemiology, 1 Yersin Street, Hai Ba Trung district, Hanoi, Tel no.: +84 4 38211634, Email: phamquangthai@gmail.com

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4. Observers/Representatives

Chinese Centers for Disease Control and Prevention

Mr Fan Chunxiang, Medical Officer, National Immunization Program, Chinese Center for Disease Control and Prevention, No.27,Nanwei Road, Xicheng District, Beijing 100050, People’s Republic of China Email: fancx@chinacdc.cn

Centers for Disease Control and Prevention Macao SAR (China)

Dr Lou Ou Lei, Senior Technical Officer, Unit For Communicable Disease Prevention and, Diseases Surveillance, CDC-NDIV, Health Bureau, P.O. Box 3002, Macao, Tel no.: +853 2853 3525 Fax no.: +853 2853 3524, Email: lououlei@ssm.gov.mo

Department Of Health, Hong Kong SAR (China)

Dr Wong Miu-Ling, Senior Medical Officer (Surveillance Section), Department of Health, 21/F, Wu Chung House, 213 Queen's Road East, Wan Chai, Hong Kong, Tel no.: +852 2125 2230, Fax no.: +852 2711 0927 Email: smo_ss3@dh.gov.hk

National Institute of Health Dr Shin Nari, Staff Scientist, OHTAC 200, Osongsaengmyeong 2-ro, Osong-eup, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do 28160, Republic of Korea Tel no.: + 82-43-719-8392, Fax no.: +82-43-719-8379 Email: shinnari@korea.kr

National Institute of Infectious Diseases

Dr Hiroyuki Shimizu, Chief, Laboratory of Enteroviruses, Department of Virology II, National Institute of Infectious Diseases, Tokyo 208-0011, Japan, Tel no.: + 82-43-719-8392Fax no.: +82-43-719-8379, Email: hshimizu@nih.go.jp

Ministry of Health, Cambodia Dr Ork Vichit, Deputy Director, National Maternal and Child Health Center, Manager National Immunization Program, Ministry of Health, National Road No. 6, Kien Khlang, Prek Leap, Chroy Changya, Phnom Penh, Telephone : +855 12 830 548, Facsimile : +855 23 426 257 Email : orkvichit@yahoo.com

Dr Thriep Chanthan, Deputy Manager National Immunization Program, Ministry of Health, National Road No. 6, Kien Khlang, Prek Leap, Chroy Changya, Phnom Penh Telephone : +855 12 944 776, Facsimile : +855 23 426 257 Email : thiepchanthan@gmail.com

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Ministry of Health, Brunei Darussalam

Dr Martina Kifrawi, Medical Officer, Disease Control Division, Ministry of Health, Commonwealth Drive, Bandar Seri Begawan 3910, Tel no. +67 3 8727533, Email : martina.kifrawi@moh.gov.bn

5. Secretariat

WHO Regional Office for the Western Pacific (WPRO)

Dr Tigran Avagyan, Technical Officer, Vaccine-Preventable Diseases and Immunization, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines, Tel no.: +63 2 8528 9737, Fax no.: +63 2 8526 0279, Email: avagyant@who.int

Ms Varja Grabovac, Scientist, Vaccine-Preventable Diseases and Immunization, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines, Tel no.:+632 85289747,Fax no.:+632 85211036, Email: grabovacv@who.int

Dr Roberta Pastore, Technical Officer, Vaccine-Preventable Diseases and Immunization, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines, Tel no.: +632 85289018, Fax no.: +632 85211036, Email: pastorep@who.int

Dr Rudolf Tangermann, Short-term Consultant, Vaccine-Preventable Diseases and Immunization, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila Philippines, Tel no.: +632 85288001, Fax no.:+632 85211036, Email:rudi.tangermann@gmail.com

Dr Syeda Kanwal Aslam, Short-term Consultant, Vaccine-Preventable Diseases and Immunization World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines, Tel no.: +632 5288001, Fax no.: 632 5211036, Email: saslam@who.int

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WHO Regional Office for the Western Pacific (WPRO)

Mr Damian Akapoeh Nsoh, Intern, Vaccine-Preventable Diseases and Immunization, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines, Tel no.: +632 85288001, Fax no.: +632 85211036, Email: nsohd@who.int

WHO CAMBODIA Dr Md. Shafiqul Hossain, Technical Officer, Vaccine-Preventable Diseases and Immunization, WHO Representative Office in Cambodia, No. 61-64, Preah Norodom Blvd. Sangkat Boeung Keng Kang I, Khan Chamkamorn, Phnom Penh Tel no. : +855 23-216610, Fax no. : +855 23-216211, Email: hossains@who.int

WHO Headquarters, Geneva Dr Ondrej Mach, Team Lead, Clinical Trials and Research,World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland, Tel no.: +41 22 791 1863, Email: macho@who.int

Ms Liliane Dalila Boualam, Technical Officer, Research Policy and Containment, World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland, Tel no.: +41 22 791 2163, Email: boualaml@who.int

1

Annex 2. Meeting timetable

Time Tuesday, 12 November 2019 Time Wednesday, 13 November 2019 Time Thursday, 14 November 2019

08:00–08:30 08:30–09:00 09:00–09:20 09:20–09:40

Registration Opening ceremony Welcome remarks by the Responsible Officer Self-introduction, Election of Officers

(Chair, Vice-Chair, Rapporteur) Remarks by the Regional Certification Commission (RCC) Chairperson Administrative announcements Global Update Progress in the global certification process

08:30–10:00

Country presentations (continuation) New Zealand The Republic of Korea Australia Brunei Darussalam)

08:30–10:30

Closed working session

09:40–10:10 GROUP PHOTO AND COFFEE BREAK 10:00–10:30 COFFEE BREAK 10:00-10:30 COFFEE BREAK 10:10–10:20 10:20–10:40 10:40–11:00 11:00–11:20 11:20–12:00

1. Recommendations of the 2019 Technical Advisory Group on Immunization and Vaccine-preventable Diseases

2. Regional update 3. Implementation of polio laboratory containment GAPIII: Global and

Regional update Discussion 4. Country presentations Papua New Guinea

10:30–12:00

Country presentations (continuation) Cambodia Hong Kong SAR (China) Japan

10:30–11:30 11:30–12:30 12:30–12:45

Closed working session Regional Certification Commission conclusions and recommendations Closing Session

12:00–13:00 LUNCH BREAK 12:00–13:00 LUNCH BREAK 12:45–14:00 LUNCH BREAK 13:00–15:00

Country presentations (continuation) China Philippines Malaysia

13:00–14:30

Country presentations (continuation) The Lao People's Democratic Republic Macao SAR (China) Mongolia

15:00-15:30 COFFEE BREAK 14:30–15:00 COFFEE BREAK 15:30–15:45 15:45–16:00 16:00–16:20

16:20–17:30

5. Global overview and analysis of circulating vaccine-derived poliovirus (cVDPV) outbreaks

6. Overview and analysis of cVDPV outbreaks in WHO South-East Asia Region

7. Overview and analysis of cVDPV outbreaks in WHO Western Pacific Region

Discussion The key points include: 1. Risk of: a. Importation of wild poliovirus; b. Emergence of VDPV, including iVDPV; c. Exportation/importation of VDPV; d. Spread of poliovirus. 2. Targets and strategies for: a. Interruption of ongoing outbreaks in the Region; b. Prevention of emergence of VDPV; c. Prevention and early detection of circulation of

VDPV. 3. Verification of elimination of VDPV in the Region.

15:00-16:30

Country presentations (continuation) Pacific island countries and areas Singapore Viet Nam

18:00–19:30 Regional Director's reception

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