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Post00280 MONITORING THE IMPACT OF POLIO ERADICATION 26 SEPTEMBER 2000 CONTENTS 1. CHECKLIST AND INDICATORS FOR MONITORING THE IMPACT OF POLIO ERADICATION 2. PROGRESS TOWARD POLIOMYELITIS ERADICATION: EUROPEAN REGION 1998-JUNE 2K 1. CHECKLIST AND INDICATORS FOR MONITORING THE IMPACT OF POLIO ERADICATION Tracey Goodman, WHO/V&B, has kindly posted the draft checklist: USING POLIO ERADICATION ACTIVITIES TO STRENGTHEN ROUTINE IMMUNIZATION: The Ten-Step Programme, and the draft "9 Key Indicators". This is a tool to be used! Check out you own program! You will find the checklist and indicators reproduced in plain ASCII text format. You can also download the file in Adobe Acrobat portable document format. Get the free viewer at http://www.adobe.com * The file is available for download in adobe Acrobat format. * Go to the website: ftp://ftp.acithn.uq.edu.au/Technet/1-ClickHereForTECHNETfiles/PolioErad/ and click on the file: polioImpactCheckistDraft4September2000.pdf * Or get the file by email! Send an email to: [[email protected]][email protected][/email] with the message: get technet polioImpactCheckistDraft4September2000.pdf ___________________________________________________________________________ From: [[email protected]][email protected][/email] Date: Mon, 04 Sep 2000 11:56:17 +0200 To: Subject: Polio Impact Checklist and Indicators Allan, I am attaching the latest DRAFT version of the Polio Impact Checklist which now includes 9 key indicators to go with it. We thought it important to have the Checklist and Indicators distributed together. Many thanks. Tracey ___________________________________________________________________________ Introduction to Checklist and Indicators for Monitoring the Impact of Polio Eradication Global eradication of poliomyelitis should strengthen national immunization programmes (1988 WHA Resolution 41.28). We have learned: * Positive impacts of PE do not occur automatically, rather they have to be deliberately pursued; and * Most negative impacts of PE can be avoided through better planning. The attached draft checklist and indicators has been developed as an "Aide Memoire" -- to help national decision-makers and programme managers, maximize the positive impact of PE on routine immunization services. ___________________________________________________________________________ Footnote: The development of this simple to use tool has been a collaborative effort based on the wisdom and experience of many who work with PE and routine immunization services. WHO is particularly grateful to USAID/BASICS for their assistance. ___________________________________________________________________________ * PE is the Acronym for Polio Eradication ___________________________________________________________________________ USING POLIO ERADICATION ACTIVITIES TO STRENGTHEN ROUTINE IMMUNIZATION: The Ten-Step Programme PE Activity 1. ADVOCACY:To achieve PE, sustained political and financial commitment is necessary at all levels. Actions to Strengthen Routine Immunization * Combine Efforts: Explain to decision-makers that PE depends on strong routine immunization services; State the importance and needs of routine immunization in all PE advocacy opportunities. * Highlight the Context: When reporting NIDs coverage, compare with routine coverage for DPT3 and measles (e.g. publish tables comparing district coverage ) * Troubleshoot: Use high-visibility of NIDs to solve administrative and technical bottlenecks that affect routine immunization and impede PE (i.e. slow release of funds, staffing). Are you doing this (yes/no)? How to improve? PE Activity 2. PARTNER COORDINATION:PE relies on coordinated partners to ensure that all resource requirements are addressed. Actions to Strengthen Routine Immunization * Think Bigger: Ensure that Inter-Agency Coordinating Committee (ICC) meets throughout the year; Expand mandate of ICC to include routine immunization. Are you doing this (yes/no)? How to improve? PE Activity 3. INFORMATION, EDUCATION, COMMUNICATION (IEC):Nation-wide multi-sectoral awareness is critical for PE. Actions to Strengthen Routine Immunization * Generate Demand: Include messages in NIDs training, materials, or media events about other EPI vaccines and the need for children to be fully- immunized (e.g., where and when to receive other immunizations). Are you doing this (yes/no)? How to improve? PE Activity 4. SOCIAL MOBILIZATION:Active participation of community leaders, volunteers, parents, and private sector is needed to achieve PE. Actions to Strengthen Routine Immunization * Maintain Involvement: Use the organizations, media, and people mobilized for PE to support the delivery of routine immunization services in all areas (e.g. develop social mobilization plan for routine immunization ). Are you doing this (yes/no)? How to improve? PE Activity 5. PLANNINGComprehensive strategic and annual micro-planning is necessary for PE to reach every child with OPV. Actions to Strengthen Routine Immunization * Share Plans Early: To avoid disruptions to other health services, share planned NIDs dates widely with all health programs. * Double Up: Use PE microplanning and training opportunities to improve planning of routine immunization services (e.g. frequency , sites, etc). * Use Data: Encourage use of NIDs target population data for routine immunization, if these are more accurate than official data. Are you doing this (yes/no)? How to improve? PE Activity 6. COLD CHAIN/LOGISTICSPE requires effective logistics and cold chain to ensure safe and potent administration of OPV with minimum wastage. Actions to Strengthen Routine Immunization * Protect the Investment: Ask NIDs partners to invest in cold chain that meets EPI standards, and to support the preventive maintenance, spare parts and training to keep it functioning for routine immunization. * Waste Not, Want Not: Apply good vaccine management practice in NIDs to reinforce/teach stock management for routine vaccines (e.g., to adjust OPV requirements and re-distribute stock after NIDs). * Exploit Technology: Provide training on the use of VVMs as a management tool for routine immunization services. Are you doing this (yes/no)? How to improve? PE Activity 7. SERVICE DELIVERY & SUPERVISIONPE needs to provide high quality services (OPV) at point of delivery in NIDs and during routine immunization. Actions to Strengthen Routine Immunization * Build Capacity: Use PE training opportunities to refresh routine immunization skills and knowledge. * Work Together: Combine Surveillance and Routine supervisory visits; Ask PE Surveillance Officers to check fridge temperatures, stock levels, knowledge of VVMs, etc. Are you doing this (yes/no)? How to improve? PE Activity 8. SURVEILLANCEHigh-performing, timely AFP surveillance system is essential to achieve PE. Actions to Strengthen Routine Immunization * Get Integrated: Gradually include other priority diseases with AFP surveillance and reporting. Train AFP Surveillance Officers; develop/adapt case investigation & reporting forms. Are you doing this (yes/no)? How to improve? PE Activity 9. INJECTION SAFETYPE offers opportunities to promote safe injection practices. Actions to Strengthen Routine Immunization * Play It Safe: Ensure that any NIDs activity that includes injectable vaccines has a detailed plan of action to ensure safe injection and waste disposal at all levels. Establish safe practices/systems for routine immunization. Are you doing this (yes/no)? How to improve? PE Activity 10. MONITORINGAchievement of the PE goal requires careful monitoring. Actions to Strengthen Routine Immunization * Play It Safe: Ensure that any NIDs activity that includes injectable vaccines has a detailed plan of action to ensure safe injection and waste disposal at all levels. Establish safe practices/systems for routine immunization. Are you doing this (yes/no)? How to improve? ___________________________________________________________________________ 9 Key Indicators (Draft): Monitoring the Impact of Polio Eradication (PE) on Routine Immunization Programmes 1. Trends in Routine Immunization Coverage: * Monitor and analyze annual DTP3 and measles coverage by district over time. 2. Trends in Financial Resources: * Trend analysis of annual financing (external and national) of PE compared to financing (external and national) of routine immunization services (if possible also compare to overall health sector budget/expenditures) 3. Surveillance: * Number of other diseases integrated with "active" AFP surveillance activities 4. Cold Chain Improvement: * % of district cold stores with full complement of functioning equipment and system for maintenance 5. Integration of Other Services: * In countries with vitamin A deficiency problems, delivery of vitamin A is integrated with routine immunization services 6. Information, Education, and Communication: * Existence of PE communication and social mobilization plan that includes routine immunization (and if appropriate, surveillance) 7. Vaccine Logistics: * Inclusion of vaccine vial monitor (VVM) training for PE campaign activities 8. Partner Coordination: * Inter-Agency Coordinating Committee (ICC) is used for broader health sector coordination (mandate and membership are not PE-specific) 9. Human Resource Development: * Systematic use of PE microplanning to improve the delivery of routine health services ____________________________________*______________________________________ 2. Progress Toward Poliomyelitis Eradication: European Region 1998-June 2K From Morbidity & Mortality Weekly Report (MMWR) Progress Toward Poliomyelitis Eradication --- European Region, 1998--June 2000 [MMWR 49(29):656-660, 2000. Centers for Disease Control] Report In 1988, the World Health Assembly resolved to eradicate poliomyelitis globally by 2000 [1]. Substantial progress has been made since 1995, when the World Health Organization (WHO) European Region (EUR), comprising 51 member states (including Israel and the Central Asian Republics), accelerated efforts toward polio eradication [2--4]. This report summarizes progress toward polio eradication during 1998--June 2000, and suggests that indigenous transmission of wild poliovirus has been interrupted in EUR. Routine Vaccination Coverage In 1999, 38 EUR countries routinely used oral poliovirus vaccine (OPV) for infant vaccination, seven used inactivated poliovirus vaccine (IPV), and six used sequential IPV--OPV schedules. In 1998, the regional average for coverage with a primary series of polio vaccination by age 1 year was 94% (range: 77%--100%, with 26 countries reporting), compared with 83% in 1993 (range: 45%--100%, with 46 countries reporting); coverage levels in many of the Newly Independent States of the Former Soviet Union improved to pre- independence levels after reaching their lowest points during the economic transitions of the early 1990s. Supplemental Vaccination Activities From 1995 to 1997, National Immunization Days (NIDs)* were conducted in 18 contiguous countries of the WHO Eastern Mediterranean (Afghanistan, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Pakistan, Palestinian Authority, and Syrian Arab Republic) and European regions (Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Russian Federation, Tajikistan, Turkey, Turkmenistan, and Uzbekistan) as part of "Operation MECACAR" (Eastern Mediterranean, Caucasus, and Central Asian Republics). Reported coverage with two doses of OPV was >95% in each year [2]. Beginning in the fall of 1997 with "mopping-up" vaccination(1), coordinated activities in countries of the two regions continued as "Operation MECACAR Plus". In 1998, all MECACAR countries participated in NIDs. Since 1999, activities have been more limited; sub-NIDs or supplemental vaccination programs were not conducted in some MECACAR countries of EUR. NIDs were conducted during April--May 2000 in Tajikistan, Turkey, Turkmenistan, and Uzbekistan, and sub-NIDs in Armenia, Azerbaijan, and Russian Federation, with reported coverage >/=93% for each round, and sub-NIDs in Bosnia and Herzegovina, with coverage >/= 90%. Since fall 1998, the quality of supplemental vaccination in high-risk eastern and southeastern provinces of Turkey has improved dramatically because of improved provincial planning, house-to- house vaccination, supervision, and social mobilization. Surveillance By 1997, all 17 countries where polio was recently endemic (i.e., polio cases reported since 1992) had established AFP surveillance (Table 1). In addition, 22 countries where polio is not endemic also routinely reported AFP surveillance data. From January 1999 through June 2000, all but three of the 17 countries where polio was recently endemic (Albania, Azerbaijan, and Bosnia and Herzegovina) have achieved the minimum AFP reporting rate indicative of sensitive surveillance (>/=1 nonpolio AFP case per 100,000 children aged /=1 since 1998. The overall collection rate for two adequate stool samples? from AFP case-patients in countries where polio was recently endemic increased from 78% in 1998 to 88% by June 2000 (Table 1). During 1999--2000, most countries consistently achieved the WHO- recommended target of two adequate stool specimens collected from at least 80% of persons with AFP. Training and assessment programs have been conducted since 1997, with resources focused on improved monitoring, supervision, and active surveillance. Since 1999, emphasis has been placed on monitoring AFP surveillance performance of lower administrative levels within countries where polio was recently endemic, enabling more appropriate tailoring of corrective interventions. Since 1999, all 39 countries conducting AFP surveillance are reporting case-based AFP surveillance data weekly to the WHO regional office. By June 2000, completeness of reports received for weekly reporting was 86% and timeliness of reporting was 82%. EUR Laboratory Network The EUR polio laboratory network consists of 39 laboratories: 32 national, one subregional, and six regional reference laboratories (four serve also as national laboratories). Annual WHO accreditation of national laboratories is ongoing [4]; 36 (92%) network laboratories have received full accreditation. All AFP cases reported in 2000 have been processed in fully accredited laboratories. The timeliness of specimen transport to national laboratories has been inadequate in nine countries where 8 years was initially reviewed during 1998--1999; countries where polio was recently endemic will be reviewed during 2000--2001. In addition, a process was initiated in 1999 for registering, containing, and/or destroying any wild poliovirus isolates or potentially infectious material [5]. Reported by: Communicable Diseases Unit, World Health Organization Regional Office for Europe, Copenhagen, Denmark. Dept of Vaccines and Biologicals, World Health Organization, Geneva, Switzerland. Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Vaccine Preventable Disease Eradication Div, National Immunization Program, CDC. Editorial Note Indigenous poliovirus transmission probably was interrupted in EUR countries in 1998; this status is attributed to improvements in routine vaccination coverage and the successful implementation of coordinated supplemental vaccination through Operation MECACAR and MECACAR Plus. In addition, AFP surveillance in nearly all EUR countries where polio was recently endemic has improved substantially. Along with continued observation, the quality of surveillance and timely transport of specimens in some areas of the region need further improvement to document that indigenous transmission has been interrupted and that any transmission secondary to imported poliovirus is detected promptly. Strengthening of surveillance and specimen transport is particularly important in some areas of Turkey. Eastern and southeastern areas of Turkey adjacent to Syria, Iran, and Iraq remain at high risk for wild poliovirus transmission; wild polioviruses have been isolated from AFP cases in Iraq during 1999 and in early 2000 [4, 6]. Although cross-border travel is generally prohibited and tightly monitored, Tajikistan, Turkmenistan, and Uzbekistan remain at risk for polio because of ongoing poliovirus transmission in neighboring Afghanistan [7]. Interregional and intercountry efforts are ongoing to coordinate surveillance and supplementary vaccination activities in key high-risk border areas. Supplemental vaccination activities will be needed at least through 2002 in Tajikistan, Turkey, Turkmenistan, and Uzbekistan under Operation MECACAR Plus. This activity will be coordinated with bordering Eastern Mediterranean Region (EMR) countries and include mopping-up campaigns in October and November 2000 to ensure interruption of any remaining chains of poliovirus transmission and to impede circulation in the case of reintroduction of virus. EUR priorities include 1) maintaining and strengthening AFP surveillance systems, particularly in the Caucasus, Turkey, and the Central Asian Republics; 2) conducting high-quality NIDs or sub-NIDs through Operation MECACAR Plus in selected countries with persistent high risk for wild poliovirus circulation, in coordination with bordering EMR countries; 3) implementing coordinated house-to-house supplemental vaccination activities among key border area populations; 4) maintaining and strengthening the political commitment of governments for polio eradication and certification; 5) consolidating the support of donor governments and partner agencies to ensure sufficient financial and human resources**; and 6) implementing laboratory containment of wild poliovirus and potentially infectious materials. These activities will ensure that the interruption of poliovirus transmission is maintained and that the region can be certified as polio-free by 2003. --- References World Health Assembly. Global eradication of poliomyelitis by the year 2000. Geneva, Switzerland: World Health Organization, 1988; resolution no. 41.28. CDC. Progress toward poliomyelitis eradication---Europe and Central Asian Republics, 1997--May 1998. MMWR 1998;47:504--8. CDC. Wild poliovirus transmission in bordering areas of Iran, Iraq, Syria, and Turkey, 1997--June 1998. MMWR 1998;47:588--92. CDC. Progress toward global eradication of poliomyelitis, 1999. MMWR 2000; 49:349--54. World Health Organization. WHO global action plan for laboratory containment of wild polioviruses. Geneva, Switzerland: World Health Organization, 1999; WHO/V&B/99.32. CDC. Progress toward poliomyelitis eradication---Eastern Mediterranean Region, 1998--October 1999. MMWR 1999;48:1057--71. CDC. Progress toward poliomyelitis eradication---Afghanistan, 1994--1999. MMWR 1999;48:825--8. --- 1 Mass campaigns over a short period (days to weeks) in which two doses of OPV are administered to all children in the target age group, regardless of previous vaccination history, with an interval of 4--6 weeks between doses. 2 Focal mass campaign in high-risk areas over a short period (days to weeks) in which two doses of OPV are administered during house-to-house visits to all children in the target age group, regardless of previous vaccination history, with an interval of 4--6 weeks between doses. 3 Two stool specimens collected within 14 days of onset of paralysis at an interval of at least 24 hours. WHO recommends that >/=80% of patients with AFP have two adequate specimens collected. * A confirmed case of polio is defined under the virologic scheme of classification as AFP with laboratory-confirmed wild poliovirus infection; in countries where virologic surveillance is inadequate, clinical cases have either residual paralysis at 60 days, death, or no follow-up investigation at 60 days. Since 1997, all countries in EUR but Tajikistan have used the virologic scheme of classification of AFP cases, for which some AFP cases with residual paralysis at 60 days, death, or no follow-up investigation may be considered as polio-compatible cases. Since 1999, the virologic classification scheme has been applied throughout EUR. ** Polio eradication efforts in EUR have been supported by the governments of countries where polio was recently endemic, WHO, United Nations Children's Fund (UNICEF), Rotary International, U.S. Agency for International Development, the Japanese International Cooperation Agency, the United Nations Foundation, CDC, and other countries. ____________________________________*________________________ Selected news item reprinted under the fair use doctrine of international copyright law: http://www4.law.cornell.edu/uscode/17/107.html ____________________________________*________________________
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