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Post00274 TECHNET STRATEGIC FRAMEWORK - PART 2 15 August 2000 CONTENTS 1. RECOMMENDATIONS AND PROPOSED PRIORITY ACTIVITIES: TECHNET'98 The agreement of a Technet Strategic Framework is an essential task that we must complete to enable the institutionalization of the Technet within the WHO. As an aid to this development process the Technet Forum is posting the recommendations and priority activities resulting from the Technet Consultation Meetings. This posting is the second in a series that should help us to formulate and agree on a Technet strategic framework. [The recommendations and agreed action points of Technet'99 were posted in Technet Forum Post00271, on 8 August 2000.] These are the recommendations that were agreed upon in a plenary session of the Technet members meeting, March 1998 in Copenhagen. * The posting of these recommendations is to inform our discussions and to enable the development of the Technet Strategic Framework. * Technet'96 Recommendations will be posted soon, with the earlier recommendations to follow as we convert them to plain text. It should be noted that many recommendations have been implemented, others overtaken by events, and some ...? 1998 Technet consultation, Recommendations and Proposed Priority Activities [Prepared 16 April 1998 & 12 December 1998, Technet '98 CDRom, WHO V&B, Geneva, Switzerland] Recommendations Technet Consultation 16-20 March 1998 Copenhagen, Denmark EXPANDED PROGRAMME ON IMMUNIZATION GLOBAL PROGRAMME FOR VACCINES AND IMMUNIZATION World Health Organization, Geneva, 1998 TECHNET CONSULATION Copenhagen, 16-20 March 1998 RECOMMENDATIONS AND PROPOSED PRIORITY ACTIVITIES SESSION 1 - VACCINE VIAL MONITORS RECOMMENDATIONS R1. Vaccine Vial Monitors on vials of OPV are a valuable addition to immunization services, enabling health workers to decide whether or not the vaccine should be used. Technet recommends that appropriate VVMs for all vaccines be introduced as soon as possible. R2. The utilization of OPV/VVM must be enhanced to assure vaccine quality at point of use and to improve management of vaccine delivery. R3. Because VVMs accurately depict only the heat exposure of the vials they are on, OPV VVMs should not be used as proxy for evaluating the heat exposure of any other vaccines. Other monitors (CCM, Stopwatch) should be used until such time as VVMs are available for other vaccines. PRIORITY ACTIVITIES 1. ENHANCING UTILIZATION OF VVMs ON OPV Training : 1.1 WHO/EPI should include a time on the agenda of every regional EPI managers meeting for country reporting on the status of the VVM training effort. 1.2 A resource packet of good examples of training materials and how they have been used should be compiled and distributed to each country using VVMs (PATH to compile packet; WHO/EPI to distribute it). 1.3 A minimum package of activities should be completed by every country receiving VVMs, including * a national orientation session to be held (wherever possible, as part of other scheduled meetings), at which central and provincial staff learn key messages, decide local policy guidelines, and determine the training approach for local staff (UNICEF to be asked to coordinate through its country offices) * distribution by national MOHs of at least one printed item with basic messages on it to each service delivery point for immunization * incorporation of at least a basic training component on VVMs and their use in all training sessions for polio NIDs; WHO should revise the relevant sections of the "Polio Eradication Field Guide" to cover the introduction, use and management of OPV VVMs 1.4 WHO/GPV/VSQ will explore the possibility of getting all OPV manufacturers to add brief, non-verbal instructions for using VVMs, to the package insert, as has already been done by SmithKline Biologicals. 1.5 Wherever feasible (and particularly in conjunction with other studies), sub-studies of health worker and supervisor KAP regarding VVMs should be carried out to monitor the progress of training. Model study protocols will be prepared by PATH and EPI and made available to WHO and UNICEF offices. 1.6 With assistance from WHO and UNICEF staff and Technet members, countries should consider opportunities to incorporate basic VVM training into pre-service curricula for health workers. Supervision 1.7 Model items for supervisory checklists (measuring health worker knowledge and action with regard to VVMs) should be developed, pre-tested and shared with country programs and incorporated into manuals and forms. 1.8 Supervisory visits should be considered as opportunities for training in VVM use. Use of VVMs for Management of Vaccine Delivery 1.9 While the current training materials provided by WHO offer good support for point-of-use interpretation of individual vials, they give no guidance on use for the management of vaccine storage, handling and delivery. WHO/EPI should revise current materials, with the assistance of PATH and selected national EPI staff, to incorporate a set of guidelines on acceptable and unacceptable uses of OPV VVMs for enhancing management of vaccine delivery . These guidelines should point out the opportunities to use VVMs for the following purposes and give examples and discussion of the rationale and limitations of each use: * stock management at district and lower levels * allocation of resources (equipment, supervision, training) to priority areas * investigation of specific incidents or of patterns of problems * stretching the cold chain for OPV beyond traditional limits * taking OPV beyond the cold chain (i.e., without active cooling) * broadening cold chain equipment purchasing options or relaxing equipment replacement schedules at the periphery, based on VVM indications These materials will be pre-tested disseminated to UNICEF and WHO field offices and to national EPI managers at various meetings Further studies 1.10 Additional studies to decide whether or not to go forward with VVMs for other vaccines are no longer needed. However, utilization studies, to provide feedback on how VVMs are being used and to improve their use, are still needed and should be carried out, following a WHO/EPI approved protocol. Such studies should include cost-effectiveness measures and should be designed in collaboration with experts in economic analysis. At least one study in each region where VVMs are used should be completed by mid-1999. Technet assistance should be provided to interested countries. Expanding VVM use to countries procuring OPV directly 1.11 An advocacy packet (including a summary paper on the potential impact of OPV VVM use on vaccine quality and cold chain management) and practical information on specification of VVMs in direct procurements of vaccine should be prepared by EPI and VSQ and distributed to those countries not using UNICEF/WHO procurement or expecting to begin independent vaccine procurement within the next 5 years. 1.12 Work to encourage and assist qualified national vaccine manufacturers in adopting VVMs should continue (WHO/VSQ and PATH). 2. VVMs FOR ALL EPI VACCINES As stated in Recommendation R1, development and deployment of VVMs for all EPI vaccines should proceed as rapidly as possible. A small product development team comprised of representatives from WHO/GPV , UNICEF Technical Centers and PATH will coordinate efforts to develop and implement three VVMs with different specifications but with presentations consistent with the OPV/VVMs, to cover all existing priority vaccines. 2.1 From the estimates of the stability provided by Artur Galazka the group will elaborate specifications, in close collaboration with VVM and Vaccine manufacturers for three time/temperature indicators: * Category A-Highly stable vaccines: Toxoids and Hepatitis B vaccine * Category B - Vaccines with medium stability : BCG, Yellow Fever and measles vaccines * Category C - Vaccines with moderate stability: Pertussis (whole cell) including DPT vaccines 2.2 It was determined that development efforts for all three VVMs should proceed in parallel and as fast as possible. As soon as any one of them has been validated for use in the field it should be deployed. VVMs should be deployed as soon as they are available, even if any other additional indicators, such as threshold or freeze indicators, are appropriate for use on a given vaccine but are not available concurrently with the VVMs. Additional indicators should be added as they are developed. Steps for introducing Vaccine Vial Monitors on all EPI vaccines: (not all steps needed for all vaccines/ not necessarily in order of implementation) * Inform countries and other partners of the decision and likely timeline * Development of specifications for VVM manufacturers * Establishment of WHO minimum requirements (including aspects regarding consistency of presentation) * Vaccine manufacturers' agreement on specifications * Development and production of Vaccine Vial Monitors * Development of technology for label application * Vaccine manufacturers' validation of Vaccine Vial Monitors * WHO validation of VVMs * Field studies to validate usability of VVMs with lyophilized vaccines * Validation of correspondence between VVMs performance and vaccine potency * Development of training materials for new VVMs * Development of a comprehensive introduction plan SESSION 2 - THE COLD CHAIN RECOMMENDATIONS : R4. Having reviewed the experience to date with CFC free refrigeration equipment, the relative advantages and weaknesses of various refrigerants as well as their respective Global Warming Potential, TECHNET recommends that R134a remains the refrigerant of choice for cold chain appliances. R5. Any country producing or importing refrigerators/freezers with R600a or other hydrocarbon refrigerants, for their domestic market, may accept such systems for the storage of vaccines, provided that : * the equipment meets WHO/UNICEF standards * maintenance skills are raised to a standard guaranteeing that repairs are conducted in strict compliance with safe practices for HCR * policy makers, managers, supervisors and health workers are made fully aware of the risks and requirements for the correct use of equipment with HCR. * all HCR refrigeration equipment is clearly and permanently marked with non verbal instructions indicating the refrigerant type. R6. To improve the future cost effectiveness and performance of national cold chain systems, it was agreed that: * the performance required of refrigerators used for vaccine storage should be more closely related to the climatic and energy environment where they will be used and * the equipment, temperature monitoring, management and staffing of national central stores should be evaluated according to a standard protocol and criteria. R7. Recognizing that adsorbed vaccines are exposed to freezing damage in winter in temperate and cold climates, it is recommended that the TECHNET proceed with the development of Low Temperature Protected vaccine storage and transport equipment specifications, test procedures, and guidelines. PRIORITY ACTIVITIES 3. COLD CHAIN INVENTORIES Reports were made of national cold chain equipment inventory surveys in ten countries of Africa and six countries of south east Asia. These inventories have been used to plan equipment needs in the African countries and similar plans will be made in the south east Asian countries for management and training needs. Although these plans represent substantial progress it was noted that: 3.1 Before conducting such surveys, a clear strategy for government, bi-lateral or multi-lateral funding for the needed equipment must exist and 3.2 When conducting inventory surveys, a five year plan for equipment replacement should be prepared and a system for regular updating through a national reporting process should be installed. If these measures are not taken, expectations are raised and then frustrated and survey data quickly becomes obsolete. 3.3 Having recognized the role of good quality equipment and its management in ensuring potent vaccine at the point of use, TECHNET recommends that * governments plan and budget for preventive maintenance, parts, repair, training, supervision, placement and cyclical replacement of equipment using inventory systems which are updated regularly * inventory systems be used which enable managers to monitor whether or not storage and service delivery points have functioning cold chain equipment appropriate to their level and operational needs * occasional surveys be used to strengthen existing inventory management systems. * a subgroup be set up to develop specifications for equipment management systems and to review existing software. 4. CHOICE OF REFRIGERANTS Experience to date with CFC free refrigeration equipment was reviewed as well as the relative advantages and weaknesses of various refrigerants together with their respective Global Warming Potential. TECHNET recommends that R134a remains the refrigerant of choice for cold chain appliances. The use of Hydrocarbons is however is considered possible provided a number of conditions are met, as outlined in Recommendation R6. 4.1 Technet will work with the refrigeration industry to monitor the development and introduction of HCR and continue to evaluate them. 4.2 WHO/EPI and UNEP should commit to closer coordination of their activities on CFC free equipment (training materials, training courses, exchange of information?) 5. COLD CHAIN OF THE FUTURE Performance Specifications for Refrigerators 5.1 Current standards for vaccine storage will not be changed. However, WHO will modify the refrigerator Standard Performance Specifications and Test Procedures to present requirements for two to three climatic zones and for three zones of electrical power reliability. The modified requirements will be sent to all listed equipment suppliers and the next edition of the Product Information Sheets will be modified to indicate for which zone(s) each refrigerator is suitable. 5.2 Guidelines will be prepared on the selection and use of domestic refrigerators for vaccine storage. The guide will include instructions on the measures (modification kit) to be taken by the user to maximise the performance of such refrigerators and maintain 0?C to +8?C storage temperatures in ambient temperature ranges set after the review of environmental databases is completed. Certification of vaccine central stores 5.3 WHO will propose an accreditation scheme for central stores used for vaccines, involving one or more visits by WHO experts to inspect and certify stores according to a standard protocol. The protocol to be drafted will include standards of refrigeration and temperature monitoring equipment, management and staffing functions. The purpose of the scheme would be to raise performance to meet high standards in national central stores, to quantify necessary equipment upgrading and conduct staff training. Specification for low temperature protected refrigerators * Low Temperature Protected refrigerators for use in temperate and cold climates will meet WHO/EPI vaccine storage standards (0?C to +8?C) in an ambient temperature of +32?C to -10?C. * The refrigerators will maintain 0?C to +8?C in a diurnal operating range of +15?C and -10?C * Other performance characteristics will be consistent with existing equipment specifications. It is desirable that the specified operating ambient temperature range be consistent with the performance testing range set by the working group on the cold chain of the future for less hot climatic zones. Proposed Process: * Proposed operating temperature ranges for temperate and colder climates by reference to global environmental climate temperature databases will be confirmed (IT Power/WHO). This will also lead to a more explicit definition of the geographical extent of the colder populated temperate and colder zones * WHO/GPV will develop, draft and circulate final specifications to the TECHNET working group on low temperature protection by the end of June 1998. * Guidelines will be drafted and circulated for comments to the TECHNET LTP working group by the end of April 1998 (IT Power). * Low Temperature Protected vaccine storage equipment will be incorporated in the equipment performance specifications and test procedures manual. All recommended vaccine storage and transport equipment for the temperate and cold climate zone will be expected to comply with this specification. * Manufacturers will be invited to produce equipment to Low Temperature Protection specifications. Equipment meeting the LTP specifications will be included in the PIS. Guidelines for Vaccine Shipping and Transport Guidelines 5.4 The WHO/UNICEF guidelines for international vaccine shipments should be revised and updated to incorporate low temperature protection for shipments to and in temperate and cold climates. 5.5 Vaccine transport equipment for vaccine transport in temperate and colder climates should maintain safe vaccine storage temperatures in an external ambient temperature range of + 43?C to -30?C for a 48 hour period. 5.6 Vaccine transport equipment should be tested for performance in this temperature range. 5.7 Operational guidelines should be prepared. SESSION 3 - VACCINE DEMAND, SUPPLY AND FINANCING RECOMMENDATIONS R8. Countries must have reliable forecasts of vaccine requirements, to ensure adequate supplies are provided and vaccine wastage can be kept to a minimum, vaccine shortfalls can be eliminated, and forward budgeting can be carried out. PRIORITY ACTIVITIES 6. VACCINE FORECASTING 6.1 All countries must have forecasts of vaccine requirements based on an appropriate method of estimation, and projected for 3 to 5 years. These forecasts must constitute the official national estimates of requirements used for budgeting and procurement by all involved agencies. The forecasts must be reviewed prior to ordering national requirements, particularly for orders through UNICEF or WHO. 6.2 WHO and UNICEF country staff and Technet members must provide necessary support to countries in preparing estimates. Vaccine requirements forecasting should be an agenda item at all regional EPI meetings. 6.3 Baseline data on the situation of vaccine forecasting by region must be jointly prepared by WHO and UNICEF and made available to Regional offices by the end of 1998. 6.4 Existing methods of forecasting requirements will be reviewed by WHO and UNICEF and alternative methods recommended by July 1998. SESSION 4 - INJECTIONS SAFETY AND TECHNOLOGIES RECOMMENDATIONS R9. Technet highly recommends the implementation of the "strategy for safe injections". By the end of 1998 WHO/GPV/EPI should have identified partners for implementation, a structure for coordination, management and administration, and a detailed plan of action. R10. Technet reaffirms that autodestruct syringes are the preferred type of disposable syringes and that by the year 2001 all disposables used in immunization programs should be auto-destruct. R11. Multi-dose, needle-free injectors with a reusable fluid path may only be used for immunization if they pass standard WHO safety tests. The latest evidence from laboratory tests suggests that none of the models tested to date are able to be used for immunization on this basis. R12. Considering the safety, the operational advantages and the potential cost savings demonstrated by field trials of single-dose, pre- filled injection devices over the last several years, TECHNET encourages the wider introduction of new, injectable vaccines in this format, equipped with a Vaccine Vial Monitor (VVM). R13. The recommended method of destruction of used syringes and needles is incineration under controlled conditions. WHO/EPI policy on the disposal of used syringes and needles must be revised to incorporate changes suggested during the consultation. R14. As part of the "strategy for safe injections", a Task Force will be set up to develop and promote safe disposal and destruction systems which reduce human and environmental risk. PRIORITY ACTIVITIES 7. INJECTIONS SAFETY Technet noted that, following the recommendations of the Manila consultation, a number of injection practice surveys have been conducted and that several countries have developed plans for injection safety. 7.1 Measures taken to ensure safe immunization must include not only safe injection but also proper vaccine handling and reconstitution as well as safe collection, disposal and destruction of used syringes. Adherence to safe immunization policies must be improved by better supervision. 7.2 Immunization programs should take advantage of renewed interest in measles control & elimination to invest in safe injection. 7.3 By the end of 1998, following the WPRO framework and national examples, every country should make or update a National Plan of Action for Injection Safety towards the target of 100% safe injections by the year 2000.WHO will continue to monitor the status of these plans and will report to regional EPI Managers meetings and at the next Technet consultation. 8. INJECTIONS TECHNOLOGIES 8.1 Sterilizable syringes and needles supplied by the UNICEF supply division should be bundled with TST spots and safety boxes. 8.2 All injection equipment must be accompanied by an appropriate number of safety boxes. Multi-dose, reusable needle-free injection devices 8.3 WHO should continue laboratory and field tests to identify, in the shortest possible time, one or more models of safe needle-free injectors for use in immunization Single-dose, pre-filled injection devices * Pouch-and-needle devices: The Group proposed the following measures to start the process of implementing Recommendation R12 using needle-based injection devices by the end of the year 2000: 8.4 Introduction and post-introduction evaluation of single-dose injection devices pre-filled with Tetanus Toxoid vaccine and Hepatitis B vaccine in several countries from at least three WHO regions. The evaluation should include the necessary training and a cost-benefit analysis of the whole delivery system. 8.5 Since several products, including injectable contraceptives, are expected to be presented in UNIJECT, standard identification coding and packing will be developed and tested in these countries to differentiate vaccines from each other and from other products. * Needle-free injection devices: 8.6 In view of the superior safety, to the community and to health workers, of needle-free injection devices, WHO/GPV/EPI & VRD and their collaborators should conduct research: * to assess the safety, efficacy and cost-benefit of needle-free injection devices, in relation to needle-based devices, if and when pre- filled, needle-free injection devices become available. * to develop and evaluate the safety and efficacy of alternative methods of drying and injecting dried or solid vaccine formats. 9. DISPOSAL AND DESTRUCTION Experience accumulated through field trials in the Western Pacific region indicates the following changes to the WHO/EPI policy on the incineration of used syringes and needles are necessary: Safe disposal: * Used syringes and needles should be discarded in safety boxes meeting WHO/EPI specifications. * Sufficient safety boxes should be provided for all injection activities. * Reusable plastic containers are not suitable for the collection of used syringes and needles. Transport to the point of incineration: * Safety boxes can be transported from the point of use to a designated destruction site. * From the point of use to the point of incineration, safety boxes should be tracked to ensure that all boxes are accounted for and destroyed. * During transport, used syringes should be in closed and sealed safety boxes. * Used syringes should be transported preferably when new syringes are distributed or collected. Destruction: * The preferred method of destruction is incineration at high temperature (greater than 850 C) in an appropriate incinerator. * Used syringes should be incinerated in closed safety boxes. * Auto-combustion incinerators without forced ventilation should not be used unless a correctly balanced load can be assured. Work will continue to identify both powered and auto-combustion incinerators which can be used for the destruction of used injection material. * If an appropriate incinerator for destruction at high temperature is not available, and intermediate storage is not feasible, open burning in a protected environment can be used as an interim destruction method for small quantities of used syringes in closed safety boxes. Environmental legislation: * National legislation and guidelines on incineration must be identified and complied with. This concerns both destruction in high temperature incinerators and open burning. 9.1 A Task Force on safe disposal and destruction will be set up to carry out the following functions: * develop performance specifications for incineration equipment with due regard to environmental concerns * develop guidelines on the destruction of used syringes and needles with due regard to existing guidelines on the disposal of medical waste * network with relevant agencies and organizations * develop a project proposal and actively raise funds for its implementation. 9.2 Technet will enhance advocacy for use of safety boxes and suitable incineration process 9.3 Technet members will conduct or facilitate research into alternative solutions for syringe disposal and destruction SESSION 5 - MASS IMMUNIZATION RECOMMENDATIONS R15. It is recommended that for all mass immunization activities conducted with injectable vaccines, staff knowledgeable of operations, logistics and safety issue be involved in the planning process. This planning should be initiated at least 6 months in advance of the campaign. PRIORITY ACTIVITIES 10. ACCELERATED MEASLES CONTROL IN HIGH RISK AREAS 10.1 As a priority, WHO should ensure that the following countries who are planning mass campaigns receive technical assistance from logisticians experienced in organizing campaigns with injectable antigens: Angola, Burkina Faso, Congo, Democratic Republic of Congo, Mali, Mozambique, Sierra Leone. These consultants should arrive in these countries as soon as possible.. 10.2 All Technet member are requested to forward to GPV/EPI any relevant training materials and guidelines regarding logistics for planning and implementing campaigns with injectable antigens. EPI will use these materials to prepare generic guidelines. 10.3 The cost analysis of campaigns conducted in Senegal and South Africa should be used as a basis for budgeting for measles campaigns in Africa. 10.4 During 1998, an in-depth evaluation of all logistical aspects of measles campaigns, with special emphasis on safety, shall be conducted in two countries in Africa. SESSION 6 - IMMUNIZATION SERVICE DELIVERY RECOMMANDATIONS R16. Technet recommends that the appropriate authorities and partners monitor the quality of immunization in each setting using key indicators of activity, process performance and/or outcome and respond in order to sustain the benefits of immunization R17. A Technet sub-group consultation comprising experienced technical experts from within WHO, UNICEF, and other technical partners with experience in the NIS should be convened to focus on technical and operational problems facing the routine immunization systems of the NIS and design coordinated strategies for their resolution R18. TECHNET recognizes and endorses the importance of integrating training in EPI and child health with IMCI, and other child health and public health initiatives, within and outside WHO R19 Technet recommends the appointment of regional and national coordinators to support training activities, and create strong training networks. PRIORITY ACTIVITIES 11. HEALTH SECTOR REFORM (INCLUDING THE NIS) 11.1 Technet recognizes that the choice of health sector reform strategy and structure depends entirely on the local context and emphasizes the need to: * understand the effects of health sector reform and decentralization upon immunization * take every opportunity to ensure that the benefits of immunization are sustained 11.2 A NIS sub group of Technet should be convened. -- its terms of reference, mode of operation, precise focus (such as injection safety, cold chain and logistics, training, curriculum development, vaccine procurement, monitoring, IEC, etc.), composition, the periodicity of its technical consultations, and source of funding -- should be worked out at the earliest opportunity by the secretariat of TECHNET, in consultation with other interested technical and funding partners. (WHO to take the lead, by the end of May 1998) 12. TRAINING 12.1 To be optimally effective, training should be practice and competency based, and adopt a problem-solving approach to learning. Recognizing the demand for training of this type, it is recommended that WHO HQ adapts the Cold Chain Operations Management learning materials for wider use, and reproduces, translates and uses them for future workshops. 12.2 A flexible, modular approach to materials design is advocated, so that courses can be constructed at local levels to be specific to learning needs. 12.3 Distance learning materials and methodologies should be developed and evaluated for EPI. 12.4 Mechanisms should be established to ensure that: * a process exists to translate all materials in a timely manner; * learning resources can be shared between countries, regions and HQ; * there is wide dissemination of information regarding all EPI resources for teaching and learning; * there are easy methods available for finding EPI teaching and learning materials. 12.5 In order to promote the wide dissemination of materials, WHO and UNICEF country offices should ensure that provincial EPI offices are on the mailing lists for receipt of EPI materials. 12.6 Training can be adapted to become a powerful method of advocacy among decision makers, especially politicians, donors and policy-makers. The feasibility of using training in this way should be actively explored. SESSION 7 - LOGISTICS FOR SURVEILLANCE RECOMMENDATIONS R20. Considering the high priority given by the EPI to improving surveillance performance, TECHNET recommends that logisticians at all levels and epidemiologists work more closely to strengthen logistics for surveillance. R21. Considering the risk of contamination of vaccines when they are stored together with stool specimens from AFP cases, it is recommended that specimens and vaccines are not stored in the same refrigerator, freezer or cold box. Vaccine carriers which are used for specimen transfer should not again be used for vaccine storage unless they have been disinfected following WHO recommended procedures PRIORITY ACTIVITIES 13. LOGISTICS MANAGEMENT IN SURVEILLANCE Specimen collection and transfer 13.1 Packaging for international and national air shipment of polio specimens should meet IATA and UN regulations on the transfer of infectious materials. WHO should work with courier services and packaging companies to assure that all countries have access to the means for shipping specimens correctly and at the lowest cost. 13.2 WHO should explore such mechanisms as the Onchocerciasis Control Programme (OCP) inter-country agreement to facilitate cross border movement of specimens. Communications for the transmission of surveillance data Successful data communications are primarily dependent on management, rather than technology. However, to facilitate data transfer at sub- national levels: 13.3 suitable radio communications equipment should be identified for voice and data communications between the periphery and the district level and the information disseminated in the Product Information Sheets 13.4 Internet-based data communications should be established between the polio network laboratories, the WHO Regional offices and the EPI national managers in the countries. ____________________________________*_______________________

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