cvdpv2 outbreak response myanmar 2016
SEA-Immun-98
Distribution: General
External 3-Month Assessment:
cVDPV2 Outbreak Response
Myanmar, March 2016
© World Health Organization 2016
All rights reserved.
Requests for publications, or for permission to reproduce or translate WHO
publications – whether for sale or for noncommercial distribution – can be obtained
from SEARO Library, World Health Organization, Regional Office for South-East
Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India
(fax: +91 11 23370197; e-mail: searolibrary@who.int).
The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of the World
Health Organization concerning the legal status of any country, territory, city or area
or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not
yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not
imply that they are endorsed or recommended by the World Health Organization in
preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital
letters.
All reasonable precautions have been taken by the World Health Organization to
verify the information contained in this publication. However, the published material
is being distributed without warranty of any kind, either expressed or implied. The
responsibility for the interpretation and use of the material lies with the reader. In no
event shall the World Health Organization be liable for damages arising from its use.
This publication does not necessarily represent the decisions or policies of the World
Health Organization.
Printed in India
Contents
Page
Acronyms .............................................................................................................. v
Executive summary ...............................................................................................vii
1.
Objectives of the outbreak response assessment ............................................ 1
2.
Background ................................................................................................... 1
3.
Methodology of the outbreak response assessment ........................................ 3
4.
Observations and conclusions of the assessment teams .................................. 6
5.
Conclusions ................................................................................................. 16
6.
Recommendations....................................................................................... 16
7.
Acknowledgement....................................................................................... 18
Annex
List of participants ................................................................................................ 19
iii
Acronyms
AFP
acute flaccid paralysis
cVDPV
circulating vaccine-derived poliovirus
EAPRO
Regional Office for East Asia and the Pacific UNICEF
GPEI
Global Polio Eradication Initiative
IEC
information, education and communication
IDP
internally displaced population
IHR (2005)
International Health Regulations (2005)
INGO
international nongovernmental organization
MoH
Ministry of Health
NP-AFP
non-polio acute flaccid paralysis
OBRA
outbreak response assessment
OPV
oral polio vaccine
ORI
outbreak response immunization
PCM
post-campaign monitoring
POL3
polio immunization, third dose
RCA
rapid coverage assessment
RI
routine immunization
RSO
Regional surveillance officer
SEARO
Regional Office for South-East Asia
SIA
supplementary immunization activity
tOPV
trivalent oral polio vaccine
UNICEF
United Nations Children’s Fund
WHO
World Health Organization
WHA
World Health Assembly
v
Executive summary
An outbreak of circulating vaccine-derived poliovirus (cVDPV) type 2 in Rakhine
state, Myanmar, was confirmed in December 2015. A national public health
emergency was declared in the country and considerable resources from the
Ministry of Health, development partners, international nongovernmental
organizations (INGOs) and nongovernmental organizations (NGOs) were mobilized
to implement an outbreak response plan. Four rounds of supplementary
immunization activities (SIAs) with trivalent oral polio vaccine (tOPV) were
conducted between December 2015 and February 2016. These included three
subnational vaccination campaigns and one nationwide campaign. Efforts to
strengthen surveillance activities for poliovirus detection as well as to improve
routine immunization (RI) coverage were also initiated in the outbreak-affected
areas.
An inter-agency team comprising experts from the World Health Organization
(WHO) and United Nations Children’s Fund (UNICEF) headquarters, regional and
country offices conducted an outbreak response assessment (OBRA) in Myanmar
from 28 March to 5 April 2016. The objectives of the assessment were to evaluate
the adequacy and quality of the outbreak response and to determine whether
poliovirus transmission had been interrupted following the activities undertaken.
The assessment involved extensive field visits, covering multiple townships in five
provinces, desk analysis of the acute flaccid paralysis (AFP) data and laboratory
reports, review of programme documents and face-to-face interviews with health
officials, community leaders, administrators and representatives from NGOs and
INGOs.
The assessment team concluded that commendable efforts had been put in
place by the Ministry of Health and partners in Myanmar to interrupt the
transmission of cVDPV type 2. However, the team could not determine
conclusively whether transmission had been interrupted, due to surveillance gaps.
The assessment team was concerned with the global implications of the outbreak,
especially since the global switch dates were approaching. The team strongly
recommended that Myanmar should conduct another SIA with tOPV in selected
high-risk townships, prior to switch, since this will be the last opportunity for the
country to use a type 2 containing oral polio vaccine (OPV) before the switch. The
assessment team also recommended actions to strengthen RI coverage and AFP
surveillance, as well as efforts to assess the feasibility of conducting environmental
surveillance in the country.
vii
1.
2.
Objectives of the outbreak response assessment
Assess the quality and adequacy of polio outbreak response
activities to evaluate whether the response is on track to
interrupt polio transmission, as per World Health Assembly
established standards.
Provide additional technical recommendations to assist the
country to meet this goal.
Background
Type 2 vaccine-derived polio virus (VDPV2) was detected in two cases of
AFP that developed paralysis in the months of April and October 2015.
Both cases were reported from Maungdaw township in Rakhine state
(Figure 1). The laboratory reports received on 5 December 2015 confirmed
that the vaccine-derived polioviruses isolated from the two cases were
genetically linked. The nucleotide changes of these isolates suggested that
the vaccine-derived polioviruses had been in circulation for more than one
year. Prior to the confirmation of the outbreak, an outbreak response
immunization (ORI) was conducted in three wards and two villages
covering around 500 households on 4 November and 15 November 2015.
A national health emergency was declared by the Director-General of
Public Health, Myanmar, on 21 December 2015.
1
External 3-Month Assessment: cVDPV2 Outbreak Response
Figure 1: Map of Myanmar showing the cVDPV2 outbreak, 2015
Source: WHO South-East Asia Region data as of March 2016
Following the confirmation of the outbreak, the Director-General of
Public Health, along with senior technical staff of the Ministry of Health,
Myanmar, visited the affected township (Maungdaw) and adjoining
township (Buthidaung), demonstrating a strong political will and
commitment to respond to the polio outbreak. The Chief Minister of
Rakhine launched the polio vaccination campaign in affected townships.
Large-scale SIAs began on 5 December 2015 and four rounds of SIAs
were conducted as a part of the outbreak response (refer to Table 1 &
Figure 2). The first SIA was conducted in 15 townships and targeted
360 000 children (0–5 years of age). A total of 580 000 children were
targeted in 22 townships during the second SIA conducted on
26 December 2015. The targeted age group was expanded to 0–10 years
in Maungdaw and Buthidaung townships (the outbreak-affected townships)
2
External 3-Month Assessment: cVDPV2 Outbreak Response
during the second SIA. A total of 171 townships targeting 2.4 million
children (0-5 years) were included for coverage during the third SIA on 23
January 2016. The fourth SIA was a nationwide campaign conducted on 20
February 2016 targeting 4.6 million children (0-5 years) in 330 townships of
the country.
Table 1: Timeline of events after outbreak confirmation, Myanmar 2015
cVDPV2 outbreak
confirmation
Date
(interval)
6 Dec. 2015
# of
children
First SIA
Second
SIA
Third SIA
Fourth SIA
5 Dec.
2015
(0 days)
26 Dec.
2015
(21 days)
23 Jan.
2016
(28 days)
20 Feb.
2016
(28 days)
2.4 million
4.6 million
360 000
580 000
Source: WHO South-East Asia Region data as of March 2016
3.
Methodology of the outbreak response
assessment
WHO and UNICEF, in close coordination with the Ministry of Health,
conducted an external assessment from 28 March to 5 April 2016 in
Myanmar, to evaluate the effect of outbreak response in interrupting the
polio virus transmission activities according to World Health Assembly
resolution WHA59.1 in 2006. Five teams comprising experts from WHO
and UNICEF headquarters, regional offices, country office and officials from
the Ministry of Health, Myanmar, visited the following states/townships:
(1)
Rakhine state, Maungdaw township
(a)
Dr Abu Obeida Babiker (UNICEF-EAPRO)
(b)
Dr Ye ZinZin (WHO-Myanmar)
(c)
Dr Htet Arkar Win (UNICEF-Myanmar)
(d)
Dr Aye Mya Chan Thar (MoH-Myanmar)
3
External 3-Month Assessment: cVDPV2 Outbreak Response
(2)
(3)
(4)
(5)
Yangon and Nay Pyi Taw states
(a)
Dr Graham Tallis (WHO-HQ)
(b)
Dr Tin Tin Aye (WHO-Myanmar)
(c)
Dr Tin ThitsarLwin (MoH-Myanmar)
(d)
Dr Ag Myat Htay (RSO, WHO-Myanmar)
Shan East state, Kyentong, Tarchileik township
(a)
Dr Suleman Rahim Malik (UNICEF-HQ)
(b)
Dr Aung NaingOo (WHO-Myanmar)
Mandalay Region (Urban) PyinOoLwin, Yamethin township
(a)
Dr Hasan ASM Mainul (UNICEF-HQ)
(b)
Dr Tin Htut (UNICEF-Myanmar)
(c)
Dr HninNweni Aye (MoH-Myanmar)
(d)
Dr Myo Thant Khine (RSO, WHO-Myanmar)
(e)
Dr Su Mon Kyaw (UNICEF-Mandalay Office)
Rakhine State, Sittwe and Pauktaw townships
(a)
Dr Sudhir Khanal (WHO-SEARO)
(b)
Dr Allison Gocotano (WHO-Myanmar)
(c)
Dr ThihaHtun (UNICEF-Myanmar)
(d)
Dr Aung Kyaw Moe (MoH-Myanmar)
A desk review of the AFP surveillance indicators and parameters of RI,
SIA and analysis of programme data on human resources and
communication, as well as a document review were conducted by these
teams to assess the quality and adequacy of outbreak response activities.
4
External 3-Month Assessment: cVDPV2 Outbreak Response
A detailed review of the field assessments by the inter-agency teams of
external experts was done on 4 April 2016. The findings and
recommendations of the outbreak report assessment (OBRA) were shared
with the Ministry of Health, Government of Myanmar on 5 April 2016.
The three-month OBRA was designed to determine if adequate and
appropriate measures had been undertaken, following the confirmation of
the type 2 cVDPV outbreak in Myanmar.
Seven key areas were assessed to evaluate whether the outbreak
response complied with the World Health Assembly-established standards.
The seven areas included the following:
(1)
Did the outbreak response activities meet the outbreak response
standards, particularly in terms of speed and appropriateness?
(2)
Have national authorities and partners played their expected
role as laid down in World Health Assembly and Regional
Committee resolutions?
(3)
Has SIA quality been sufficient to ensure that poliovirus
transmission is interrupted within the shortest time possible?
What was the quality of SIA planning, delivery, monitoring and
communication?
(4)
Is the AFP surveillance system sensitive enough to detect
transmission?
(5)
Have the polio outbreak response activities been undertaken in
a manner that would strengthen RI performance, particularly in
the highest risk areas?
(6)
Have sufficient financial, material and human resources been
made available to support full implementation of all
recommended polio outbreak response activities?
(7)
What are the remaining risks to stopping the outbreak?
5
External 3-Month Assessment: cVDPV2 Outbreak Response
4.
Observations and conclusions of the assessment
teams
4.1
Did the outbreak response activities meet the outbreak
response standards, particularly in terms of speed and
appropriateness?
The outbreak response in Myanmar met nearly all the established
standards, particularly in terms of speed and appropriateness, as the
response plan was prepared and adhered to during the implementation of
the outbreak response activity. The steering committee meeting organized
and chaired by the Union Minister, during the last quarter of 2015,
confirms that sufficient importance was given to the outbreak response to
contain the spread of polio in the community. The outbreak activities were
initiated on the ground despite some delay in finalization of the formal
outbreak plan, which took longer than the defined time period of two
weeks. Effective steps to curb the spread of cVDPV could begin because the
national authorities were well-sensitized to the existing ground realities
particularly to the gaps in RI and AFP surveillance in the hard-to-reach
townships.
Four SIAs with more than 95% coverage were conducted in the
country (refer to Figure 2). The post-campaign monitoring (PCM) was
initiated only after the second SIA and reports were highly encouraging. A
rapid analysis of the laboratory data and AFP data was conducted.
6
External 3-Month Assessment: cVDPV2 Outbreak Response
Figure 2: SIA response to cVDPV2 outbreak
Source: WHO South-East Asia Region data as of March 2016
The availability of tOPV was adequate for implementing four largescale immunization rounds targeting all children below 5 years of age. The
scope of coverage was enhanced during the second SIA both in terms of
geographical coverage extending to 22 townships of Rakhine state and also
expansion with regards to coverage of all individuals up to 10 years of age.
The availability of resources was ensured by close coordination between
the Ministry and development partners.
7
External 3-Month Assessment: cVDPV2 Outbreak Response
4.2
Have national authorities and partners played their expected
role as laid down in WHA and RC resolutions?
Outbreak focal point for Ministry of Health, WHO, UNICEF designated in first
week of outbreak
YES
Weekly calls with WHO HQ and Regional Office on outbreak
YES
Weekly calls with UNICEF HQ and Regional Office on outbreak took place
YES
Weekly technical coordination meetings chaired by government and attended
by all partners at national and subnational level
YES
Funds for outbreak response disbursed on time
NO*
*Funds were delayed during the third and fourth SIA; however, activities were not compromised
despite the delay.
The involvement of administrative, political and religious heads at
central, state and township levels was evident. A health sector coordination
committee meeting had been organized in Rakhine state. Visits to the
affected township (Maungdaw) and adjoining township (Buthidaung) were
made by the Director-General, Deputy Director-General and senior
technical staff from the Ministry of Health as well as by technical experts
from the regional and country offices of WHO and UNICEF.
Country focal points for the outbreak response from WHO and
UNICEF were designated, and they participated in weekly technical
coordination meetings that were chaired by government officials. Adequate
budgetary provisions were in place for outbreak management and although
funds disbursement was delayed during the third and fourth SIAs, activities
on the ground were not compromised.
INGOs and NGO supported social mobilization and resource
mobilization and also provided additional volunteers and vaccinators for
the campaigns. Resources (human resource, logistics and funds) were
available to implement the ORI and supplementary immunization
campaigns.
8
External 3-Month Assessment: cVDPV2 Outbreak Response
4.3
Has SIA quality been sufficient to ensure that poliovirus
transmission is interrupted within shortest time possible?
What was the quality of SIA planning, delivery, monitoring
and communication?
National guidelines for SIA preparation and implementation
available
YES
SIA priority activities as per national plan implemented
YES
Overall quality of SIAs
V. GOOD
Quality of SIAs in highest risk areas
GOOD (SOME GAPS)
Strategies to reach insecure areas, mobile populations
YES (NEED TO
IMPROVE)
Cross-border activities implemented
PARTIAL*
* IHR Temporary Recommendations not being fully implemented.
National guidelines for SIA preparation and implementation were
available and formed the basis for conducting all activities. Strategies to
reach insecure areas and mobile populations had been implemented.
Social mobilization activities helped to achieve high coverage in hard-toreach populations and the internally displaced populations (IDP) during the
SIAs.
Cross-border activities had been implemented by setting up
vaccination posts along the Myanmar-Bangladesh border. More than 7000
children were reported vaccinated in Sittwe township of Rakhine state
through cross-border activities conducted between 5 December 2015 and
29 February 2016. In addition, OPV birth dose was introduced in
Maungdaw and Buthidaung townships and an immunization post was set
up at the border point that had population movement with Bangladesh.
However, some gaps were identified in the immunization coverage at the
bordering areas in Chin province, along the Myanmar-Thailand border.
The implementation of temporary recommendations made under the
International Health Regulation (IHR) following the addition of Myanmar to
the list of countries where the recommendations are applicable, required
attention and improvement.
9
External 3-Month Assessment: cVDPV2 Outbreak Response
Pre-campaign activities conducted in Myanmar included advocacy
meetings with local leaders and training of vaccinators – which included
training on SIA implementation, AFP surveillance, RI and planning for social
mobilization. Efforts to cover the hard-to-reach populations in the villages
and camps during the house-to-house visits had been conducted. House
markings were observed by the team in all places visited in townships of the
outbreak. The vaccination sites were found to have been monitored by
supervisors, and checklists had been duly filled.
Post-campaign rapid coverage assessment (RCA) had been conducted
by partner agencies and INGOs working in the area and the RCA findings
were matching with the administrative reported coverages. In all places the
denominators used were the household head count and not the projected
population provided by the government. In Sittwe, the RCA conducted by
external monitors confirmed coverage to be around 97%.
The use of invitation and information cards during the campaign was
implemented as an innovative method for community participation.
Materials for information, education and communication (IEC) had been
developed and distributed. The material was developed in the national
language; however, timely availability was a concern in some states. There
was no issue of acceptance of vaccine in any of the areas.
The field visits confirmed that the four SIAs were of high quality with
high coverage.
4.4
Is the AFP surveillance system sensitive enough to detect
transmission?
The review of AFP surveillance indicators for the past three consecutive
years indicates an improvement in the overall national non-polio acute
flaccid paralysis (NP-AFP) rate from 1.91 in 2013 to 2.24 in 2015 (refer to
Table 2).
10
External 3-Month Assessment: cVDPV2 Outbreak Response
Table 2: AFP surveillance indicators, Myanmar
Indicators
2013
2014
2015
NP-AFP rate (annualized) *
1.91
1.82
2.24
Percent adequate stool specimens
95
96
95
Percent weekly reports received on time
96
92
96
Percent AFP cases investigated within 48 hours of
notification
89
100
96
Stool specimens arriving at lab within 72 hours of
shipment
78
93
62
Stool specimens arriving at lab in good condition
100
100
100
Percent lab results within 14 days after specimen
receipt
92
94
94
Percent stool specimens with NPEV isolation
11
14
13
*Per 100 000 population under 15 years of age.
While there was an overall improvement in the surveillance indicators
at the national level, suboptimal surveillance quality continued in a number
of states. Nine of the 17 states did not achieve the NP-AFP rate of
≥ 2/100 000 population up to 15 years of age in 2014. There was a
marginal improvement in the NP-AFP at the subnational level in 2015 but
8/17 states still did not achieve the NP-AFP rate of ≥ 2/100 000
population. It is pertinent to mention that Rakhine state was consistently
not achieving the desired targets, post the civil conflict in 2012. Twelve
states, including Chin, Rakhine and Yangon, did not achieve the
recommended NP-AFP rate during the first half of 2015. Some
improvement was visible during the second half of 2015, with only four out
of 17 states not achieving the NP-AFP rate of ≥ 2/100 000 population
(refer to Tables 3 & 4). However, Sittwe township in Rakhine had not
reported any AFP cases in 2016.
11
External 3-Month Assessment: cVDPV2 Outbreak Response
Table 3: NP-AFP rate by state, Myanmar
Province
2013
2014
2015
Ayeyarwady
1.62
2.29
2.57
Bago(east)
2.4
2.21
2.9
Bago(west)
2.95
2.72
3.85
Chin
2.01
2.98
1.03
Kachin
1.34
1.91
5.15
Kayah
2.72
3.59
2.19
Kayin
2.2
2.18
1.97
Magway
2.07
1.84
2.89
Mandalay
1.48
1.53
2.32
Mon
2.62
2.31
5.82
Naypyitaw
0.21
0.43
0.84
Rakhine
1.88
1.18
1.41
Sagaing
1.55
1.04
1.49
Shan(east)
2.27
2.53
2.12
Shan(north)
1.53
1.08
1.37
Shan(south)
2.05
2.67
2.51
Tanintharyi
1.91
1.72
1.21
Yangon
2.08
1.72
1.81
12
External 3-Month Assessment: cVDPV2 Outbreak Response
Table 4: Number of AFP cases by township, Rakhine state
Township
2012
2013
2014
2015
Ann
1
1
Buthidaung
1
2
3
Wa
1
1
1
Kyaukpyu
1
1
Kyauktaw
2
1
Man aung
1
Maungdaw
3
1
Minbya
1
1
Myauk oo
2
2
Myebon
1
3
Pauktaw
2
1
3
3
Ponnagyun
1
Ramree
1
1
1
3
Rathedaung
1
Sittwe
2
6
Taungup
1
1
Thandwe
1
1
2
3
3
1
2
4
2
The assessment team concluded that the AFP surveillance system in
Myanmar is not sensitive enough to detect polioviruses. In view of this, the
team could not conclude whether transmission of cVDP2 had been
interrupted or not in Myanmar.
Recent efforts had been made to improve AFP surveillance in the
outbreak area, including a sensitization of the clinicians and health staff on
AFP surveillance prior to the SIAs.
13
External 3-Month Assessment: cVDPV2 Outbreak Response
4.5
Have the polio outbreak response activities been undertaken
in a manner that would strengthen RI performance,
particularly in the highest-risk areas?
The last five-year data analysis regarding POL 3 coverage in less than
one-year-old population demonstrates a deterioration of RI coverage in
selected areas of the country, following the civil conflict in 2012. (Refer to
Table 5 & Figure 3). The low RI in the outbreak area is the probable cause
for the emergence of cVDPV Type 2 in Myanmar.
Table 5: National, Rakhine and township POL 3 (%) coverage during the
last five years
POL 3 coverage (%) in Myanmar (
Distribution: General
External 3-Month Assessment:
cVDPV2 Outbreak Response
Myanmar, March 2016
© World Health Organization 2016
All rights reserved.
Requests for publications, or for permission to reproduce or translate WHO
publications – whether for sale or for noncommercial distribution – can be obtained
from SEARO Library, World Health Organization, Regional Office for South-East
Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India
(fax: +91 11 23370197; e-mail: searolibrary@who.int).
The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of the World
Health Organization concerning the legal status of any country, territory, city or area
or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not
yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not
imply that they are endorsed or recommended by the World Health Organization in
preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital
letters.
All reasonable precautions have been taken by the World Health Organization to
verify the information contained in this publication. However, the published material
is being distributed without warranty of any kind, either expressed or implied. The
responsibility for the interpretation and use of the material lies with the reader. In no
event shall the World Health Organization be liable for damages arising from its use.
This publication does not necessarily represent the decisions or policies of the World
Health Organization.
Printed in India
Contents
Page
Acronyms .............................................................................................................. v
Executive summary ...............................................................................................vii
1.
Objectives of the outbreak response assessment ............................................ 1
2.
Background ................................................................................................... 1
3.
Methodology of the outbreak response assessment ........................................ 3
4.
Observations and conclusions of the assessment teams .................................. 6
5.
Conclusions ................................................................................................. 16
6.
Recommendations....................................................................................... 16
7.
Acknowledgement....................................................................................... 18
Annex
List of participants ................................................................................................ 19
iii
Acronyms
AFP
acute flaccid paralysis
cVDPV
circulating vaccine-derived poliovirus
EAPRO
Regional Office for East Asia and the Pacific UNICEF
GPEI
Global Polio Eradication Initiative
IEC
information, education and communication
IDP
internally displaced population
IHR (2005)
International Health Regulations (2005)
INGO
international nongovernmental organization
MoH
Ministry of Health
NP-AFP
non-polio acute flaccid paralysis
OBRA
outbreak response assessment
OPV
oral polio vaccine
ORI
outbreak response immunization
PCM
post-campaign monitoring
POL3
polio immunization, third dose
RCA
rapid coverage assessment
RI
routine immunization
RSO
Regional surveillance officer
SEARO
Regional Office for South-East Asia
SIA
supplementary immunization activity
tOPV
trivalent oral polio vaccine
UNICEF
United Nations Children’s Fund
WHO
World Health Organization
WHA
World Health Assembly
v
Executive summary
An outbreak of circulating vaccine-derived poliovirus (cVDPV) type 2 in Rakhine
state, Myanmar, was confirmed in December 2015. A national public health
emergency was declared in the country and considerable resources from the
Ministry of Health, development partners, international nongovernmental
organizations (INGOs) and nongovernmental organizations (NGOs) were mobilized
to implement an outbreak response plan. Four rounds of supplementary
immunization activities (SIAs) with trivalent oral polio vaccine (tOPV) were
conducted between December 2015 and February 2016. These included three
subnational vaccination campaigns and one nationwide campaign. Efforts to
strengthen surveillance activities for poliovirus detection as well as to improve
routine immunization (RI) coverage were also initiated in the outbreak-affected
areas.
An inter-agency team comprising experts from the World Health Organization
(WHO) and United Nations Children’s Fund (UNICEF) headquarters, regional and
country offices conducted an outbreak response assessment (OBRA) in Myanmar
from 28 March to 5 April 2016. The objectives of the assessment were to evaluate
the adequacy and quality of the outbreak response and to determine whether
poliovirus transmission had been interrupted following the activities undertaken.
The assessment involved extensive field visits, covering multiple townships in five
provinces, desk analysis of the acute flaccid paralysis (AFP) data and laboratory
reports, review of programme documents and face-to-face interviews with health
officials, community leaders, administrators and representatives from NGOs and
INGOs.
The assessment team concluded that commendable efforts had been put in
place by the Ministry of Health and partners in Myanmar to interrupt the
transmission of cVDPV type 2. However, the team could not determine
conclusively whether transmission had been interrupted, due to surveillance gaps.
The assessment team was concerned with the global implications of the outbreak,
especially since the global switch dates were approaching. The team strongly
recommended that Myanmar should conduct another SIA with tOPV in selected
high-risk townships, prior to switch, since this will be the last opportunity for the
country to use a type 2 containing oral polio vaccine (OPV) before the switch. The
assessment team also recommended actions to strengthen RI coverage and AFP
surveillance, as well as efforts to assess the feasibility of conducting environmental
surveillance in the country.
vii
1.
2.
Objectives of the outbreak response assessment
Assess the quality and adequacy of polio outbreak response
activities to evaluate whether the response is on track to
interrupt polio transmission, as per World Health Assembly
established standards.
Provide additional technical recommendations to assist the
country to meet this goal.
Background
Type 2 vaccine-derived polio virus (VDPV2) was detected in two cases of
AFP that developed paralysis in the months of April and October 2015.
Both cases were reported from Maungdaw township in Rakhine state
(Figure 1). The laboratory reports received on 5 December 2015 confirmed
that the vaccine-derived polioviruses isolated from the two cases were
genetically linked. The nucleotide changes of these isolates suggested that
the vaccine-derived polioviruses had been in circulation for more than one
year. Prior to the confirmation of the outbreak, an outbreak response
immunization (ORI) was conducted in three wards and two villages
covering around 500 households on 4 November and 15 November 2015.
A national health emergency was declared by the Director-General of
Public Health, Myanmar, on 21 December 2015.
1
External 3-Month Assessment: cVDPV2 Outbreak Response
Figure 1: Map of Myanmar showing the cVDPV2 outbreak, 2015
Source: WHO South-East Asia Region data as of March 2016
Following the confirmation of the outbreak, the Director-General of
Public Health, along with senior technical staff of the Ministry of Health,
Myanmar, visited the affected township (Maungdaw) and adjoining
township (Buthidaung), demonstrating a strong political will and
commitment to respond to the polio outbreak. The Chief Minister of
Rakhine launched the polio vaccination campaign in affected townships.
Large-scale SIAs began on 5 December 2015 and four rounds of SIAs
were conducted as a part of the outbreak response (refer to Table 1 &
Figure 2). The first SIA was conducted in 15 townships and targeted
360 000 children (0–5 years of age). A total of 580 000 children were
targeted in 22 townships during the second SIA conducted on
26 December 2015. The targeted age group was expanded to 0–10 years
in Maungdaw and Buthidaung townships (the outbreak-affected townships)
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External 3-Month Assessment: cVDPV2 Outbreak Response
during the second SIA. A total of 171 townships targeting 2.4 million
children (0-5 years) were included for coverage during the third SIA on 23
January 2016. The fourth SIA was a nationwide campaign conducted on 20
February 2016 targeting 4.6 million children (0-5 years) in 330 townships of
the country.
Table 1: Timeline of events after outbreak confirmation, Myanmar 2015
cVDPV2 outbreak
confirmation
Date
(interval)
6 Dec. 2015
# of
children
First SIA
Second
SIA
Third SIA
Fourth SIA
5 Dec.
2015
(0 days)
26 Dec.
2015
(21 days)
23 Jan.
2016
(28 days)
20 Feb.
2016
(28 days)
2.4 million
4.6 million
360 000
580 000
Source: WHO South-East Asia Region data as of March 2016
3.
Methodology of the outbreak response
assessment
WHO and UNICEF, in close coordination with the Ministry of Health,
conducted an external assessment from 28 March to 5 April 2016 in
Myanmar, to evaluate the effect of outbreak response in interrupting the
polio virus transmission activities according to World Health Assembly
resolution WHA59.1 in 2006. Five teams comprising experts from WHO
and UNICEF headquarters, regional offices, country office and officials from
the Ministry of Health, Myanmar, visited the following states/townships:
(1)
Rakhine state, Maungdaw township
(a)
Dr Abu Obeida Babiker (UNICEF-EAPRO)
(b)
Dr Ye ZinZin (WHO-Myanmar)
(c)
Dr Htet Arkar Win (UNICEF-Myanmar)
(d)
Dr Aye Mya Chan Thar (MoH-Myanmar)
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External 3-Month Assessment: cVDPV2 Outbreak Response
(2)
(3)
(4)
(5)
Yangon and Nay Pyi Taw states
(a)
Dr Graham Tallis (WHO-HQ)
(b)
Dr Tin Tin Aye (WHO-Myanmar)
(c)
Dr Tin ThitsarLwin (MoH-Myanmar)
(d)
Dr Ag Myat Htay (RSO, WHO-Myanmar)
Shan East state, Kyentong, Tarchileik township
(a)
Dr Suleman Rahim Malik (UNICEF-HQ)
(b)
Dr Aung NaingOo (WHO-Myanmar)
Mandalay Region (Urban) PyinOoLwin, Yamethin township
(a)
Dr Hasan ASM Mainul (UNICEF-HQ)
(b)
Dr Tin Htut (UNICEF-Myanmar)
(c)
Dr HninNweni Aye (MoH-Myanmar)
(d)
Dr Myo Thant Khine (RSO, WHO-Myanmar)
(e)
Dr Su Mon Kyaw (UNICEF-Mandalay Office)
Rakhine State, Sittwe and Pauktaw townships
(a)
Dr Sudhir Khanal (WHO-SEARO)
(b)
Dr Allison Gocotano (WHO-Myanmar)
(c)
Dr ThihaHtun (UNICEF-Myanmar)
(d)
Dr Aung Kyaw Moe (MoH-Myanmar)
A desk review of the AFP surveillance indicators and parameters of RI,
SIA and analysis of programme data on human resources and
communication, as well as a document review were conducted by these
teams to assess the quality and adequacy of outbreak response activities.
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External 3-Month Assessment: cVDPV2 Outbreak Response
A detailed review of the field assessments by the inter-agency teams of
external experts was done on 4 April 2016. The findings and
recommendations of the outbreak report assessment (OBRA) were shared
with the Ministry of Health, Government of Myanmar on 5 April 2016.
The three-month OBRA was designed to determine if adequate and
appropriate measures had been undertaken, following the confirmation of
the type 2 cVDPV outbreak in Myanmar.
Seven key areas were assessed to evaluate whether the outbreak
response complied with the World Health Assembly-established standards.
The seven areas included the following:
(1)
Did the outbreak response activities meet the outbreak response
standards, particularly in terms of speed and appropriateness?
(2)
Have national authorities and partners played their expected
role as laid down in World Health Assembly and Regional
Committee resolutions?
(3)
Has SIA quality been sufficient to ensure that poliovirus
transmission is interrupted within the shortest time possible?
What was the quality of SIA planning, delivery, monitoring and
communication?
(4)
Is the AFP surveillance system sensitive enough to detect
transmission?
(5)
Have the polio outbreak response activities been undertaken in
a manner that would strengthen RI performance, particularly in
the highest risk areas?
(6)
Have sufficient financial, material and human resources been
made available to support full implementation of all
recommended polio outbreak response activities?
(7)
What are the remaining risks to stopping the outbreak?
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External 3-Month Assessment: cVDPV2 Outbreak Response
4.
Observations and conclusions of the assessment
teams
4.1
Did the outbreak response activities meet the outbreak
response standards, particularly in terms of speed and
appropriateness?
The outbreak response in Myanmar met nearly all the established
standards, particularly in terms of speed and appropriateness, as the
response plan was prepared and adhered to during the implementation of
the outbreak response activity. The steering committee meeting organized
and chaired by the Union Minister, during the last quarter of 2015,
confirms that sufficient importance was given to the outbreak response to
contain the spread of polio in the community. The outbreak activities were
initiated on the ground despite some delay in finalization of the formal
outbreak plan, which took longer than the defined time period of two
weeks. Effective steps to curb the spread of cVDPV could begin because the
national authorities were well-sensitized to the existing ground realities
particularly to the gaps in RI and AFP surveillance in the hard-to-reach
townships.
Four SIAs with more than 95% coverage were conducted in the
country (refer to Figure 2). The post-campaign monitoring (PCM) was
initiated only after the second SIA and reports were highly encouraging. A
rapid analysis of the laboratory data and AFP data was conducted.
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External 3-Month Assessment: cVDPV2 Outbreak Response
Figure 2: SIA response to cVDPV2 outbreak
Source: WHO South-East Asia Region data as of March 2016
The availability of tOPV was adequate for implementing four largescale immunization rounds targeting all children below 5 years of age. The
scope of coverage was enhanced during the second SIA both in terms of
geographical coverage extending to 22 townships of Rakhine state and also
expansion with regards to coverage of all individuals up to 10 years of age.
The availability of resources was ensured by close coordination between
the Ministry and development partners.
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External 3-Month Assessment: cVDPV2 Outbreak Response
4.2
Have national authorities and partners played their expected
role as laid down in WHA and RC resolutions?
Outbreak focal point for Ministry of Health, WHO, UNICEF designated in first
week of outbreak
YES
Weekly calls with WHO HQ and Regional Office on outbreak
YES
Weekly calls with UNICEF HQ and Regional Office on outbreak took place
YES
Weekly technical coordination meetings chaired by government and attended
by all partners at national and subnational level
YES
Funds for outbreak response disbursed on time
NO*
*Funds were delayed during the third and fourth SIA; however, activities were not compromised
despite the delay.
The involvement of administrative, political and religious heads at
central, state and township levels was evident. A health sector coordination
committee meeting had been organized in Rakhine state. Visits to the
affected township (Maungdaw) and adjoining township (Buthidaung) were
made by the Director-General, Deputy Director-General and senior
technical staff from the Ministry of Health as well as by technical experts
from the regional and country offices of WHO and UNICEF.
Country focal points for the outbreak response from WHO and
UNICEF were designated, and they participated in weekly technical
coordination meetings that were chaired by government officials. Adequate
budgetary provisions were in place for outbreak management and although
funds disbursement was delayed during the third and fourth SIAs, activities
on the ground were not compromised.
INGOs and NGO supported social mobilization and resource
mobilization and also provided additional volunteers and vaccinators for
the campaigns. Resources (human resource, logistics and funds) were
available to implement the ORI and supplementary immunization
campaigns.
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External 3-Month Assessment: cVDPV2 Outbreak Response
4.3
Has SIA quality been sufficient to ensure that poliovirus
transmission is interrupted within shortest time possible?
What was the quality of SIA planning, delivery, monitoring
and communication?
National guidelines for SIA preparation and implementation
available
YES
SIA priority activities as per national plan implemented
YES
Overall quality of SIAs
V. GOOD
Quality of SIAs in highest risk areas
GOOD (SOME GAPS)
Strategies to reach insecure areas, mobile populations
YES (NEED TO
IMPROVE)
Cross-border activities implemented
PARTIAL*
* IHR Temporary Recommendations not being fully implemented.
National guidelines for SIA preparation and implementation were
available and formed the basis for conducting all activities. Strategies to
reach insecure areas and mobile populations had been implemented.
Social mobilization activities helped to achieve high coverage in hard-toreach populations and the internally displaced populations (IDP) during the
SIAs.
Cross-border activities had been implemented by setting up
vaccination posts along the Myanmar-Bangladesh border. More than 7000
children were reported vaccinated in Sittwe township of Rakhine state
through cross-border activities conducted between 5 December 2015 and
29 February 2016. In addition, OPV birth dose was introduced in
Maungdaw and Buthidaung townships and an immunization post was set
up at the border point that had population movement with Bangladesh.
However, some gaps were identified in the immunization coverage at the
bordering areas in Chin province, along the Myanmar-Thailand border.
The implementation of temporary recommendations made under the
International Health Regulation (IHR) following the addition of Myanmar to
the list of countries where the recommendations are applicable, required
attention and improvement.
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External 3-Month Assessment: cVDPV2 Outbreak Response
Pre-campaign activities conducted in Myanmar included advocacy
meetings with local leaders and training of vaccinators – which included
training on SIA implementation, AFP surveillance, RI and planning for social
mobilization. Efforts to cover the hard-to-reach populations in the villages
and camps during the house-to-house visits had been conducted. House
markings were observed by the team in all places visited in townships of the
outbreak. The vaccination sites were found to have been monitored by
supervisors, and checklists had been duly filled.
Post-campaign rapid coverage assessment (RCA) had been conducted
by partner agencies and INGOs working in the area and the RCA findings
were matching with the administrative reported coverages. In all places the
denominators used were the household head count and not the projected
population provided by the government. In Sittwe, the RCA conducted by
external monitors confirmed coverage to be around 97%.
The use of invitation and information cards during the campaign was
implemented as an innovative method for community participation.
Materials for information, education and communication (IEC) had been
developed and distributed. The material was developed in the national
language; however, timely availability was a concern in some states. There
was no issue of acceptance of vaccine in any of the areas.
The field visits confirmed that the four SIAs were of high quality with
high coverage.
4.4
Is the AFP surveillance system sensitive enough to detect
transmission?
The review of AFP surveillance indicators for the past three consecutive
years indicates an improvement in the overall national non-polio acute
flaccid paralysis (NP-AFP) rate from 1.91 in 2013 to 2.24 in 2015 (refer to
Table 2).
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External 3-Month Assessment: cVDPV2 Outbreak Response
Table 2: AFP surveillance indicators, Myanmar
Indicators
2013
2014
2015
NP-AFP rate (annualized) *
1.91
1.82
2.24
Percent adequate stool specimens
95
96
95
Percent weekly reports received on time
96
92
96
Percent AFP cases investigated within 48 hours of
notification
89
100
96
Stool specimens arriving at lab within 72 hours of
shipment
78
93
62
Stool specimens arriving at lab in good condition
100
100
100
Percent lab results within 14 days after specimen
receipt
92
94
94
Percent stool specimens with NPEV isolation
11
14
13
*Per 100 000 population under 15 years of age.
While there was an overall improvement in the surveillance indicators
at the national level, suboptimal surveillance quality continued in a number
of states. Nine of the 17 states did not achieve the NP-AFP rate of
≥ 2/100 000 population up to 15 years of age in 2014. There was a
marginal improvement in the NP-AFP at the subnational level in 2015 but
8/17 states still did not achieve the NP-AFP rate of ≥ 2/100 000
population. It is pertinent to mention that Rakhine state was consistently
not achieving the desired targets, post the civil conflict in 2012. Twelve
states, including Chin, Rakhine and Yangon, did not achieve the
recommended NP-AFP rate during the first half of 2015. Some
improvement was visible during the second half of 2015, with only four out
of 17 states not achieving the NP-AFP rate of ≥ 2/100 000 population
(refer to Tables 3 & 4). However, Sittwe township in Rakhine had not
reported any AFP cases in 2016.
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External 3-Month Assessment: cVDPV2 Outbreak Response
Table 3: NP-AFP rate by state, Myanmar
Province
2013
2014
2015
Ayeyarwady
1.62
2.29
2.57
Bago(east)
2.4
2.21
2.9
Bago(west)
2.95
2.72
3.85
Chin
2.01
2.98
1.03
Kachin
1.34
1.91
5.15
Kayah
2.72
3.59
2.19
Kayin
2.2
2.18
1.97
Magway
2.07
1.84
2.89
Mandalay
1.48
1.53
2.32
Mon
2.62
2.31
5.82
Naypyitaw
0.21
0.43
0.84
Rakhine
1.88
1.18
1.41
Sagaing
1.55
1.04
1.49
Shan(east)
2.27
2.53
2.12
Shan(north)
1.53
1.08
1.37
Shan(south)
2.05
2.67
2.51
Tanintharyi
1.91
1.72
1.21
Yangon
2.08
1.72
1.81
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External 3-Month Assessment: cVDPV2 Outbreak Response
Table 4: Number of AFP cases by township, Rakhine state
Township
2012
2013
2014
2015
Ann
1
1
Buthidaung
1
2
3
Wa
1
1
1
Kyaukpyu
1
1
Kyauktaw
2
1
Man aung
1
Maungdaw
3
1
Minbya
1
1
Myauk oo
2
2
Myebon
1
3
Pauktaw
2
1
3
3
Ponnagyun
1
Ramree
1
1
1
3
Rathedaung
1
Sittwe
2
6
Taungup
1
1
Thandwe
1
1
2
3
3
1
2
4
2
The assessment team concluded that the AFP surveillance system in
Myanmar is not sensitive enough to detect polioviruses. In view of this, the
team could not conclude whether transmission of cVDP2 had been
interrupted or not in Myanmar.
Recent efforts had been made to improve AFP surveillance in the
outbreak area, including a sensitization of the clinicians and health staff on
AFP surveillance prior to the SIAs.
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External 3-Month Assessment: cVDPV2 Outbreak Response
4.5
Have the polio outbreak response activities been undertaken
in a manner that would strengthen RI performance,
particularly in the highest-risk areas?
The last five-year data analysis regarding POL 3 coverage in less than
one-year-old population demonstrates a deterioration of RI coverage in
selected areas of the country, following the civil conflict in 2012. (Refer to
Table 5 & Figure 3). The low RI in the outbreak area is the probable cause
for the emergence of cVDPV Type 2 in Myanmar.
Table 5: National, Rakhine and township POL 3 (%) coverage during the
last five years
POL 3 coverage (%) in Myanmar (