Report of the 2012 Global IB-VPD New Vaccines Surveillance Meeting 1

Report of the

Global New Vaccines Surveillance Meeting

for

Invasive Bacterial Vaccine Preventable Diseases (IB-VPD)

Washington DC, 9-11 October 2012

Report of the 2012 Global IB-VPD New Vaccines Surveillance Meeting 2

Table of Contents

Section

Pages

I

Executive Summary

3 - 4

II

Complete List of Meeting Recommendations Made to Advance the Network during 2013

5 – 9

III

Meeting Report

IB-VPD recommendation related to the Global Accountability Framework of the Global Vaccine Action Plan

10

Status of the IB-VPD Sentinel Hospital Surveillance Network 10 Measuring Impact of PCV Introduction: Use of Sentinel Surveillance vs.

Population-based Surveillance 11

Ministry of Health (MoH) and Sentinel Hospital Site Perspectives: Targeting Global and Regional Support

12

Improving the quality of the IB-VPD network by use of Hospital Sentinel Site Assessments and Standardized Assessment Tools

13

Improving the Quality of the IB-VPD Network by Estimating the Catchment Population (Denominator) for a Tier 1 Meningitis Sentinel Site

14

Presenting IB-VPD Data 14

Pneumonia 15 IB-VPD Laboratory Network 15 Global Laboratory EQA Programme 16 Laboratory Rapid Diagnostic Testing 17 Laboratory Serotyping/serogrouping by PCR techniques 18 Informal Technical Advisory Group Meeting 19 WHO Closed Session 19 IV

Agenda

20 – 21

V

List of Participants

22 - 26

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I. Executive Summary for the Global New Vaccines Surveillance Meeting for Invasive Bacterial Vaccine

Preventable Diseases (IB-VPD), Washington DC, 9-11 October 2012

Background:

In the past, many individual organizations conducted invasive bacterial vaccine preventable diseases (IB-

VPD) surveillance, and consequently it was agreed that during 2008 and 2009, that these networks and

sites be transitioned to WHO coordination with the goal to ensure a standardized global sentinel hospital

surveillance network that would provide data useful to national decision makers as well as the global

public health community. To support the newly established network and in particular the sentinel

hospitals, WHO developed a network of global, regional and national laboratories, and standard

operating procedures. Member States have regularly provided data that WHO disseminates via twice

annual IB-VPD surveillance bulletins. During the September 2011 global IB-VPD surveillance meeting,

partners made recommendations to further improve IB-VPD data quality including: focus on improving

meningitis (Tier 1) surveillance, fully use the global laboratory external quality assurance (EQA)

programme to target support, provide rapid diagnostic test kits to sentinel hospitals, ensure genotyping

at Regional Reference Laboratories (RRLs), further standardize clinical and laboratory processes,

facilitate standardized sentinel site assessments, improve data management, develop a methodology to

estimate a denominator for a sentinel hospital, and secure funding.

2012 Global IB-VPD Meeting Objectives:

1. Evaluate the impact of the 2011 IB-VPD surveillance meeting recommendations to improve data quality to help assess disease changes associated with vaccine introduction and use;

2. Develop consensus on the status of the IB-VPD surveillance network; and 3. Agree on prioritized steps to advance the network during the next 12 months.

Meeting Structure:

Representatives from Ministries of Health, sentinel hospital sites, WHO (HQ, Regional and Country

Offices), Global and RRLs as well as invited immunization experts met in Washington DC during 9-11

October 2012. Plenary discussions included the role of surveillance in the Decade of Vaccines

Monitoring and Accountability Framework, a review of the status of the IB-VPD network, perspectives of

Ministry of Health and sentinel sites, review of the standardized site assessment process and update on

pilots to develop a methodology to establish a denominator for a Tier 1 meningitis site, and discussion of

how to best present IB-VPD data. For the laboratory network, the global EQA was reviewed as well as

implementation of rapid diagnositic and polymerase chain reaction testing. Closed sessions were held

with the WHO informal Technical Advisory Group and WHO colleagues. During the final meeting plenary

session, participants received feedback on all findings and recommendations and agreed on prioirity

activities for the next 12 months.

Findings:

Meeting participants agreed substantial progress was made to further improve the quality of the IB-VPD

surveillance network. Of the 31 recommendations made at the 2011 global meeting, 11 (35%) were

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completed, 19 (61%) were in progress and 1 (3%) was deferred. The number of countries reporting >20

pneumococcal meningitis cases increased from 8 in 2011 to 16 in 2012; Ministries of Health and sentinel

sites shared experiences, and noted commitment varied by country but had generally improved within

the past 1-2 years. Standardized sentinel site assessments were conducted in 16 countries with

recommendations provided. A methodology was developed to estimate a denominator for a Tier 1 site

which melded with the newly established methodology from influenza surveillance and which was

piloted in 4 countries. A laboratory manual and clinical/laboratory posters were successfully developed.

The laboratory EQA expanded with 68% of the 69 participating laboratories receiving a pass score in

2012 versus 54% of 56 laboratories in 2011. The number of countries contributing serotype data

increased from 28 in 2011 to 35 in 2012. More sentinel hospitals began using rapid tests particularly The

BinaxNow for detection of Streptococcus pneumoniae (Spn), and the RRLs network was strengthened to

provide technical support and PCR capacities for detection and molecular characterization of Spn,

Haemophilus Influenza (Hi) and Neisseria meningitidis (Nm). Data management was enhanced.

Prioritized Recommendations to Advance the IB-VPD Network during 2013:

Of 43 recommendations made and included in the full report, the following were seen a priority:

1. Global Accountability Framework of the Global Vaccine Action Plan: Include an indicator for new vaccines surveillance to promote global attention for VPD surveillance;

2. WHO management: Include non-GAVI lower middle income countries in the network; continue to provide training, conduct standardized sentinel site assessments and hold regional and global surveillance meetings; ensure NITAGS review IB-VPD surveillance data and that all data from South East Asian countries is incorporated; ensure Member States understand implications of not meeting established IB-VPD funding criteria;

3. Advocacy: Better communicate the work of the network with the global community by publishing and potentially partnering with a communications group;

4. Epi/Clinical: consider the implications of a US study finding that sentinel sites identifying >30 invasive pneumococcal cases per year mirror vaccine impact findings of population based sites; explore use of administrative data to assess pneumonia in selected countries with good quality data; develop a user friendly guide for the denominator methodology;

5. Laboratory: maintain Gram Stain and culture in all sentinel site laboratories but add rapid diagnostic test kits (BinaxNow for Spn in most countries; latex agglutination for Hi and Nm in meningitis belt countries and countries not using Hib vaccine); standardize referral of specimens to RRLs; strengthen the EQA by expanding to all sentinel sites, creating a more sophisticated panel for RRLs/GRLs, and developing a clear objectives and plan document; consider use of filter paper for CSF transport from countries to RRLs; standardize laboratory procedures to reduce the number of untypable serotypes and start implementing the new real-time multiplex PCR developed by the CDC Global Reference Laboratory; improve the reporting system of PCR results at RRLs; finalize the priority testing algorithm for cerebrospinal fluid at sentinel sites;

6. Data Management: better characterize sentinel site practices to understand data variability, plan for sentinel site specific data reporting and consider web-based data collection; develop a companion to the data management pamphlet for optimal data presentation.

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II. Complete List of Meeting Recommendations Made to Advance the Network during 2013; from the 2012 Global IB-VPD Surveillance Meeting, Washington DC 9-11 October

Session: IB-VPD recommendation related to the Global Accountability Framework of the Global Vaccine

Action Plan

1. An indicator should be included for new vaccines surveillance to promote global attention for VPD surveillance;

Session: Status of the IB-VPD Sentinel Hospital Surveillance Network

2. Consider fully characterizing sentinel sites to better understand the existing data variability, specifically to know which diagnostic tests are in use and which specimens are referred to a RRL;

3. Ensure IB-VPD data that has been collected in SEAR countries during the past years is fully incorporated into the existing SEAR and HQ databases to allow full utilization of this valuable information;

4. Further evaluate the availability of serotype data by seeking to expand the information available from countries, seeking to reduce untypeables and looking at ‘emerging’ serotypes not just the vaccine types;

5. Seek to include non-GAVI-eligible countries in the network who may benefit from the technical support available as well as access to RRL expertise with a particular focus on low to middle income countries;

Session: Measuring Impact of PCV Introduction: Use of Sentinel Surveillance vs. Population-based

Surveillance

6. Ensure consistency in surveillance methods by distributing standard operating procedures (laboratory manual, laboratory/clinical posters, data management pamphlet) and providing technical support;

7. Better characterize sentinel sites to understand their catchment areas, and healthcare seeking behavior. (This recommendation links with recommendations number 17-21 on determining the denominator for an Tier 1 site);

8. Continue to improve quality with a goal of increasing the number of detected pneumococcal pathogens; detection of 20 to 30 pneumococcal meningitis cases annually appears to be required at a sentinel site in order to reliably measure the magnitude of PCV impact; however, far fewer numbers of Spn may be needed to accurately measure a decline in the number of cases detected following PCV introduction;1

9. Sentinel hospital surveillance should be continued for multiple years following vaccine introduction to increase the ability to detect vaccine impact. The SAGE recommended IB-VPD surveillance be continued for five years following PCV introduction;

1 Hampton et. Al. Sentinel versus population-based surveillance of pneumococcal conjugate vaccine effectiveness. Bull World Health Organ 2012;90:568–577

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Session: Ministry of Health (MoH) and Sentinel Hospital Site Perspectives: Targeting Global and

Regional Support

10. WHO should continue traditional activities in support of MoH and sentinel hospitals such as: a. Trainings, regional workshops, technical review of data, follow-up visits, and regular

monitoring and evaluation of data quality; b. Particular attention should be paid to increase engagement of clinicians through training and

feedback; 11. WHO should consider enhancing activities through:

c. Ensuring National Immunization Technical Advisory Groups (NITAGs) are fully involved. NITAGs and Inter-Agency Coordinating Committees should help to generate advocacy for surveillance in country. Clinician and pediatric groups should in particular be included in this work;

d. Encourage ‘in-country’ advocacy for IB-VPD surveillance. Sentinel sites should proactively approach the MoH to share and discuss their data. Data should be shared with the MoH frequently and MoH should be requested to provide advocacy for IB VPD surveillance;

Session: Improving the quality of the IB-VPD network by use of Hospital Sentinel Site Assessments and

Standardized Assessment Tools

12. The standardized IB-VPD sentinel site assessment methodology and tools that have been developed are extremely important and useful. Sentinel site assessments using these tools should be continued, and an annual assessment is recommended for each sentinel site, as feasible;

13. The standardized assessment tools could be improved with the addition of an advocacy component, specifically development of a template of power-point slides that can be used during briefing and de-briefing of senior level officials, including MoH and sentinel site;

14. The current tool should be revised to further strengthen the IB-VPD laboratory component. 15. During the in-country briefings, the website links (provided in the tools and relevant other links)

should be shared particularly to provide country-specific data and other resources; 16. Standardized operating procedures are generally needed and felt to be useful throughout the

network;

Session: Improving the Quality of the IB-VPD Network by Estimating the Catchment Population

(Denominator) for a Tier 1 Meningitis Sentinel Site

17. The methodology presented appears sound and there is great desire throughout the network to estimate the denominator for a Tier 1 meningitis sentinel site. Thus, WHO should finalize the assessment of the four country pilots and refine the methodology, as needed, with regards to the issue of referrals and the percent of cases used to identify the geographical catchment area;

18. WHO should develop a user-friendly guide to estimate the denominator for a Tier 1 site by end-2012. This guide may need to be field tested before it is widely distributed;

19. WHO should consider the development of a computer program/software to aid the field work. However, there are both pros and cons in the use of software, which need to be considered;

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20. The denominator methodology should be implemented through the network in 2013. As feasible, combining the determination of the denominator with a sentinel site assessment is good practice;

21. Further consideration is required to determine how often to perform the estimation of the denominator for a Tier 1 sentinel site;

Session: Presenting IB-VPD Data

22. WHO should develop a comprehensive set of instructions as a companion aid for the data management pamphlet on the optimal presentation of IB-VPD data which includes:

a. Common problems in data presentation; b. Helpful tools for optimal display of data; c. Encouragement for laboratories to generate basic graphs and bars as an aspect of data

analysis and cleaning; d. Inclusion of confidence intervals for measurement to indicate precision; e. Utilization of endpoints that get the attention of MoH and stakeholders, e.g. number of cases

of hospitalized pneumonias;

Session: Pneumonia

23. Careful consideration should be given to the possibility of using the existing wealth of administrative data in some countries to supplement data from the IB-VPD surveillance network to monitor PCV impact;

24. PAHO-AMRO has already begun this work and further discussions should be held to explore options in detail in a few countries;

Session: IB-VPD Laboratory Network

25. The IB-VPD laboratory network serves a valuable role and should be maintained as well as further strengthened;

26. Guidelines are required for sending specimens to RRLs including: a. Appropriate storage of specimen; b. Specimen selection for shipment (e.g. all probable bacterial meningitis cases with adequate

CSF volume); c. Specimen shipment: import permits, proper packaging, appropriate tubes d. Data reporting from RRL to laboratories in countries and to WHO ROs and linkage of clinical

and laboratory data;

Session: Global Laboratory EQA Programme

27. Continue the global EQA program which is extremely useful and very well conducted by the NICD GRL. Recommendations to improve the EQA programme are: Ensure WHO is fully informed at all stages of programme implementation

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28. WHO follow-up with participant laboratories is critical including preparation of the survey and implementation of corrective actions to poor performing sites. Regional office focal persons should follow-up with the non-responders laboratories (20 out of 73 laboratories in 2012) to understand reasons of non-participation and to encourage participation in the following survey. RRLs should receive a more sophisticated and challenging panel to assess capacities and methods used. WHO should explore options with the United Kingdom’s Health Protection Agency (HPA), who has generously offered the use of an existing EUR IBD LABNET EQA programme.

Session: Laboratory Rapid Diagnostic Testing

29. Gram Stain and culture on blood agar (BAP) and chocolate agar (CAP) should continue to be emphasized in all sentinel site laboratories;

30. The BinaxNow test kit is recommended for Spn detection as it increases case identification and has advantages over Pastorex in that BinaxNow can be stored at room temperature, has a long shelf-life, and requires only minimal training;

31. The Pastorex test kit has reasonable sensitivity combined with intrinsic limitations; however, this kit can play an important role in meningitis belt countries and countries that have not yet introduced Hib vaccine. Sites using Pastorex need training of laboratory staff as well as good quality control in the laboratory;

32. The Directigen test kit is not recommended as shown by the results of the comparative analysis study with Pastorex

Session: Importance of PCR for serotyping/serogrouping in the IBVPD network

33. The number of CSF specimens sent from countries to the RRLs for PCR testing should be carefully tracked so that the denominator of positive and negative results is known;

34. Standardization of PCR tests results is required and should include: a. The denominator of the number of specimens tested for each of the test b. PCR ct cut off values for real time PCR; c. Serotype and serogroup reporting; d. Method used at the RRL for serotyping;

35. Results should be reported carefully with use of footnotes to explain out of the ordinary situations; 36. Standardization is required for the process of storing specimens and for linking clinical with

laboratory data; 37. All serotypes/serogroups that are positive should be reported;

Session: Informal Technical Advisory Group Meeting

38. Efforts should be enhanced to demonstrate the utility of the network including to illustrate the many intangible benefits and to demonstrate what the network can do;

39. Experiences from the IB-VPD network should be shared with the global community, including: a. Description of the network; b. Highlight of good performers; c. Global EQA programme;

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d. Denominator methodology and work; e. Description of how countries have used the data; f. Lessons learned; g. The additional information generated such as identification of tuberculosis meningitis or

Salmonella typhi 40. Consider establishing linkages with a communications group who can assist with the above efforts.

Session: WHO Closed Session

41. The twice annual data reporting schedule will be modified to: a. By 15th July of year X for the data for January through December of year X-1, for rotavirus, IB-

VPD serotype and genotype data; b. By end November of year X for the whole data of year X-1 and for January through June of

year X, for rotavirus and IB-VPD data. 42. Sentinel site specific data will be collected and steps will be undertaken to initiate this process; 43. WHO will consider the allocation of 2013 resources based on WHO funding criteria.

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Session: IB-VPD Recommendation related to the Global Accountability Framework of the Global

Vaccine Action Plan

Prior to the beginning of the global Invasive Bacterial Vaccine Preventable Diseases (IB-VPD) surveillance meeting, a discussion was held of key stakeholders related to the Global Vaccine Action Plan and its Global Accountability Framework. During this session, Dr. Thomas Cherian reviewed the Global Vaccine Action Plan and the draft Global Accountability Framework. Meeting participants strongly urged that the Framework include an indicator on new vaccines surveillance. MINUTES: GLOBAL IB-VPD SURVEILLANCE MEETING — 9-11 OCTOBER 2012 Meeting rapporteurs: Dr. Chris Van Beneden, Dr. Brendan Flannery, Ms. Stephanie Schwartz, all from CDC DAY 1: TUESDAY 9 OCTOBER 2012 Welcome provided by Dr. Lucia Oliveira, New Vaccines Focal Point, PAHO/AMRO. Dr. Thomas Cherian presented meeting objectives as a “critical view of where surveillance stands.”

Session: Status of the IB-VPD Network Presentation A: What is the status of the IB-VPD surveillance network? Presenters: Dr. Mary Agócs, Dr. Fatima Serhan, WHO IB-VPD Surveillance Dr. Mary Agócs reviewed recommendations from 2011 IB-VPD surveillance meeting (see Matrix for Tier 1 [Meningitis] IB-VPD Surveillance handout): 30 of 31 are either completed or in progress (1 deferred.) Dr. Fatima Serhan reviewed laboratory aspects. Improvements: More countries reported ≥ 20 pneumococcal isolates annually; the number of serotyped organisms increased; SOPs have been completed (laboratory manual , clinical and lab posters); participation in global EQA expanded—with 73 participating laboratories and 68% with acceptable scores in 2013; Rapid Diagnostic Tests (BinaxNow for Spn) were distributed to sites; standard assessment forms were developed for sentinel sites and laboratories; an IB-VPD laboratory technical working group was formed to guide the laboratory network and discuss all laboratory issues. Changes: Laboratory testing at the RRLs included specimens from suspected meningitis cases, initial findings from few RRLs showed PCR at the RRL resulted in about 20% of culture-negative CSF found positive by PCR for one of the 3 VPD bacterial pathogens. Challenges: Case base data remains unavailable at WHO-HQ which makes it difficult to stratify positive cases by the laboratory test used; Linking laboratory and clinical data; ensuring funding is critical and will require advocacy —2012 funding was provided by GAVI with some funds from CDC targeted to support IB-VPD surveillance in middle-income countries. Discussion: 1. Need to standardize the clinical threshold for lumbar puncture—90% of suspected meningitis cases

should have an LP, but the percentage of probable bacterial meningitis varies markedly (5% to 90%), indicating either different clinical threshold for LP or poor diagnostic capacity to determine probable bacterial meningitis

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2. Data from Southeast Asia are needed to generate advocacy, and highlight the importance of obtaining data from regional office

3. Review of IB-VPD data revealed: a) A large proportion of cases with a confirmed bacterial VPD in AFRO which may be due to use of PCR or data quality issues; and b) A small proportion of confirmed bacterial VPD cases in EMRO with a lack of information about the laboratory tests performed. Overall, further standardization is required through the network and data quality needs to be enhanced/confirmed.

4. Unexpectedly high numbers of nontypeable Spn isolates was found via PCR and needs to be further assessed.

5. Additional efforts are warranted to include non-GAVI eligible countries in the network as has been achieved in some Regions (PAHO/AMRO)

6. Issues that will require further consideration include: What are alternatives to shipping samples to RRLs? Should filter paper be considered in this regards? Should the network build capacity for real-time PCR at country level?

Presentation B: Ministry of Health and Sentinel Site Perspective Presenters: Dr. Lourdes Moreno Castillo, Ministry of Health, Panama; Mr Migisha, Malago Hospital, Kampala, Uganda In Panama, surveillance data was obtained from x-ray confirmed cases with pneumonia and at four sentinel hospitals in Panama, and this information has been successfully used in making the decision to introduce pneumococcal conjugate vaccine. In Uganda, meningitis and rotavirus surveillance are conducted at 4 sites, and the data has been successfully used to demonstrate impact of Hib vaccine introduction. Challenges encountered in both countries include inadequate human resources, difficulties changing the perception that surveillance should be a routine activity rather than special project, and data sharing and transition to WHO. Discussion: 1. Pneumonia surveillance should be further considered including determination of how much detail

and data is enough to monitor vaccine impact. It may be possible to assess trends of radiographically-confirmed pneumonia at sentinel hospitals in PAHO/AMRO with initial efforts underway;

2. MoH ownership in Uganda can be leveraged to strengthen collaboration with hospital staff particularly to enhance data sharing.

Session: Measuring Impact of PCV Introduction: Use of Sentinel Surveillance vs. Population-based Surveillance Presenter: Dr. Chris Van Beneden, Respiratory Diseases Branch, CDC, Atlanta Considerations were presented for using sentinel surveillance to measure impact of pneumococcal conjugate vaccines—see article in folder by Lee Hampton et al, Sentinel versus population-based surveillance of pneumococcal conjugate vaccine effectiveness. Bull WHO 2012. The study addressed the following questions:

Can sentinel surveillance be used to measure impact of pneumococcal conjugate vaccines?

Can this be done with any level of accuracy?

If so, what are the characteristics of sentinel hospitals where PCV impact can be measured?

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Main findings: 1) Sentinel hospitals with >30 IPD cases (or, >20 vaccine type serotypes) per year in the pre-vaccine baseline period and that accounted for more than 50% of IPD cases from the surveillance population can be used to measure the magnitude of PCV impact on IPD cases, and produced results that agreed with surveillance data from active, population-based surveillance. 2) Agreement with “gold standard” active, lab-based surveillance regarding the magnitude of decline increased as # of IPD cases at baseline increased (“more is better”); 3) Agreement improved with increasing time from introduction of PCV7 (from 2 years to 4 years to 6 years post introduction).

Discussion: 1. How many of the sentinel sites in the WHO network meet the criteria identified in the US study for

measuring PCV impact? 2. What is the most important measurement—direction of change (decline) or estimate of vaccine

effectiveness (precision)? Larger hospitals account for higher proportion of IBD cases in sentinel areas and influence trends in population—smaller hospitals in the same area may be grouped for the same effect

DAY 2: WEDNESDAY 10 OCTOBER 2012 Session: Ministry of Health and Sentinel Site Perspectives: Targeting Global and Regional Support Presentations (case studies) given by Dr. Ahsan Rathore, Pakistan; Dr. Gladys Turpo Mamani, Peru In Peru, surveillance was established in sentinel sites in 2000; PCV was introduced in 2009. Lessons learned: political commitment is critical to guarantee sustainability; keys to success include coordination, monitoring and evaluation, multilevel analysis and feedback. Training workshops and use of new technologies improve surveillance. In Pakistan: meningitis surveillance began in 2008; Tier 2 IB-VPD started in 2009. Two key problems encountered have been inadequate national ownership of surveillance and problems with timely and adequate specimen transport. Experiences from Philippines, Senegal: Philippines: A national surveillance system exists with mandated reporting; many partners are solicited to participate. MOH epidemiologists, laboratorians, data managers all helped make the program successful. The country is now introducing PVC. Senegal: Surveillance is integrated, and owned by MOH. Laboratories are integral to successful surveillance. Good internet capacity aids timely reporting; email and phone also are used. Data is integrated and managed centrally. At central level, a pediatric epidemiologist summarizes data every Friday and feeds back to all partners who contribute data including those at sentinel surveillance sites. MOH has sought to increase the capacity of the national laboratories; this has helped improve overall surveillance. Discussion: 1. The level of MOH ownership differs by country but has generally improved over the past 5 years. 2. NITAG/ICCss should be strengthened and encouraged to coordinate their efforts for advocacy.

Clinicians should be further engaged and their input integrated with the NITAG process. 3. Annual Regional meetings should be organized and should include countries with both good and bad

surveillance which was felt to provide a stimulus for poor-performing countries. 4. MOH ownership should be regenerated. Ownership is strongest when it starts with the initiation of

surveillance, so that surveillance is not perceived as a “study” or “project.” Aannual country plans of action should include the need for and use of surveillance data.

5. MoH information technology units should be included in order to enhance national data ownership.

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6. Regional workshops and technical support are still required to ensure quality activities are conducted in many countries/sites.

7. WHO should continue training, workshops, and regular monitoring of data quality. 8. Advocacy needs to continue. 9. To improve ownership, clinicians need increased training and feedback. Session: Improving the quality of the IB-VPD network by use of Hospital Sentinel Site Assessments and Standardized Assessment Tools Presentations: Experiences with new WHO standardized sentinel site assessment protocol Presentations: Dr. Fatima Serhan, Dr. Jason Mwenda, Dr. Rebecca Tagbo, Dr. Hinda Ahmed Dr. Serhan summarized the WHO standardized assessment methodology and tools. The assessment protocol includes:

prior communication with the WHO country office and request of data from country/hospitals,

an on-site assessment following a standardize questionnaire with observation of clinical assessment practices; collection, transport, and testing of specimens; availability of SOPs, data management;

review of feedback/data sharing during the surveillance process,

awareness of the purpose of surveillance and current data among MOH, and clinicians.

in-country debriefing and subsequent provision of a final written report using a standard template and scoring system.

During 2012, WHO standardized assessments using these tools were completed in 16 countries. AFRO and EMRO experiences and a country example from Nigeria were presented. In general, the use of assessment tools was successful and informative. AFRO expanded capacity to conduct assessments through a “train the trainers” workshop. Gaps in understanding surveillance and inadequate resources and supplies were identified. Assessments provided a realistic picture of sentinel site practices, needs, weaknesses and challenges. Other key findings included: clinicians are dissatisfied with limited laboratory results; engagement of high level MOH was limited; use and acceptance of lumbar punctures was less than ideal; and challenges with obtaining sentinel site catchment areas exist. Both poor and good performing sentinel sites were identified. The process of the assessment was felt to generally improve MOH support, strengthen teams and advocacy/motivation for surveillance, increase performance and improve data quality. The assessments were also used to problem solve on site and to identify opportunities for improvement. Prompt, on-site preliminary feedback prior to departing the country was very effective. The need for improved coordination and communication was a common finding. Discussion: 1. Add an advocacy component directly into the assessment tool in order to systematically promote

advocacy during the assessments. 2. During the pre-visit preparation stage, ensure a briefing appointment is secured. 3. Prepare slides for use during initial in-country debrief/feedback to help generate advocacy. 4. During the debriefing session, show links to country-specific bulletins/surveillance

reports/information/websites to help educate MOH/management. 5. WHO should incorporate recent experiences and feedback when revising current tools.

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6. Strengthen lab component of assessment tool. 7. Finalize the draft global standardized IB-VPD surveillance network SOPs. Session: Improving the Quality of the IB-VPD Network by Estimating the Catchment Population (Denominator) for a Tier 1 Meningitis Sentinel Site Presenters: Dr. Mary Agocs, Mr. James Sale, Dr. Brendan Flannery The session discussed the rationale and objectives for conducting the exercise to estimate a denominator, presented an overview of the methods and expected results; summarized experience from 4 pilots; and lessons learned. The strengths of this activity include: low cost; easily combined with a sentinel site assessment; can help validate IB-VPD data; and can enable estimation of hospitalization rates for suspected meningitis cases. Limitations include that non-sentinel hospitals evaluated may use different clinical judgment/criteria for enrolling suspected meningitis cases; district of residence information must be routinely collected; the denominator will change with time and should be reassessed; trained personnel are required to implement the methodology; and the rate should not be over interpreted. Other findings included that discharge diagnosis should be used when admission diagnosis information is unavailable A pending issues to be resolved includes how to handle referrals from non-sentinel site hospitals to sentinel site hospitals. Discussion:

8. The discussion raised the following questions: What about timing of this tool before and after vaccine introduction? Can this be adapted to be used in surveillance for X ray-confirmed pneumonia? What about review of blood culture books/logs? WHO must think carefully about when to do and how often to do these denominator estimations.

9. Data sources should be clarified before data extraction begins as the source of data usedto gather information may differ between different hospitals. Consider using the availability of information to assess possible denominators as a criteria for deciding which hospitals should be sentinel surveillance sites for meningitis

10. Use the experience from pilots to refine and finalize tool; resolve the issue of referral hospitals. 11. Develop user friendly guide by end of 2012 12. Continue discussions with Influenza group (who developed similar tool) 13. Consider development of a computer program/software 14. Expand use to other countries in 2013; prioritize countries; implement concurrently with sentinel site

assessments

Session: Presenting IB-VPD Data

Presentation: How Best to Present Data from the IB-VPD Network? Common Mistakes and Suggestions for Improvement Dr. Chris Van Beneden Accurate, complete and clear presentation of surveillance data is important to ensure appropriate interpretation of data, to communicate clearly the public health message, to generate advocacy for surveillance and use of vaccines, and to accurately monitor the impact of vaccine implementation. Dr. Van Beneden provided examples of how to optimally display IB-VPD findings to clearly convey and reflect the data and gave examples of common problems with reporting data, and ways to avoid sub-

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optimal means of displaying data. Suggestions were covered in terms of how to pick a title, including incorporation of what, where, when, and why. Some common problems covered included inconsistent use of case definitions (e.g. suspect vs. confirmed IBD); use of unnecessary and misleading embellishments (for example 3-D graphs and charts); insufficient information provided (use footnotes can resolve); and providing inaccurate details.

Discussion: A comprehensive set of instructions should be developed for optimal presentation of IB-VPD data, and would be useful as a companion piece to the data management pamphlet. These instructions on data presentation would include: a. Common problems in data presentation b. Helpful tools for displaying data c. Encouragement for laboratories to generate basic graphics and bars as a good source of data

cleaning d. Inclusion of confidence intervals for the measurements / to know how precise is a value. e. Utilization of endpoints that get the attention of MoHs and stakeholders, such as number of cases of

hospitalized pneumonias. Session: Pneumonia

Presentation: Considering options of using pneumonia administrative data to assess vaccine impact Dr. Claire Broome Dr. Broome presented an example of the use of administrative data collected for pneumonia-related hospitalizations from the United States that contributed to the demonstrate of PCV impact. Specifically, the US introduced PCV7 in February 2000, with a rapid uptake in vaccination coverage. The rate for all-cause pneumonia hospitalizations after vaccine introduction in 2006 was approximately 35% lower among children <2 years of age than during the pre-vaccine baseline years of 1997-1999, with most of the decrease occurring soon after vaccine introduction in 2000. The rate for all-cause pneumonia among children aged 2--4 years did not change after PCV7 introduction and remained stable. Discussion: Some countries with high-quality administrative data systems may be able to measure an impact of vaccine introduction by using such data. However, administrative data is known to have inherent limitations in terms of quality and availability; thus, WHO should carefully consider options on this approach. PAHO-AMRO has already initiated work in this area and it would be reasonable to consider further enhancement to this effort. Session: Reports from the Laboratory Network Each RRL provided a summary of their main activities, challenges and thoughts for improvement of the network. Please see the presentation handouts from participating RRLs in the meeting files.

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DAY 3: THURSDAY 11 OCTOBER 2012 Session: Global laboratory EQA program Presenters: Dr. Marshagne Smith, Dr. Fatima Serhan Dr. Smith summarized the 2012 EQA components that included providing proficiency testing (PT) panels, compiling and reporting results. The objectives of the EQA programme are to assess diagnostic capacity of participating laboratories and to identify areas of strengths and weaknesses that would require technical support and corrective actions to improve the laboratory capacities to identify the IB-VPD causing pathogens. The specific assessment areas included:

a) Microscopy b) Identification of the organism by any laboratory method including biochemical, PCR and antigen

detection by rapid diagnostic tests (e.g latex agglutination or immunochromatography test) c) Serotyping / serogrouping (when applicable) d) Antimicrobial susceptibility testing (AST) (when applicable and not included in overall scoring).

The EQA PT panels were developed in coordination with WHO and the laboratory technical working group. The PT panels consisted of simulated CSF smears for Gram stain and corresponding lyophilised bacterial cultures simulating growth from CSF. The current grading system scores a mark >75% as acceptable. The results of the 2011 and 2012 EQAs were compared. In 2012, 73% labs had a passing score, 22% did not answer the survey and 5% did not pass, compare to 61%, 33% and 7%, respectively, in 2011. Key EQA challenges are related to logistical issues and include incorrect delivery details, non-delivery due to customs restrictions, sample viability problems, non-responder laboratories, late results submissions, poorly completed results submitting forms, internal NICD staffing and database issues. Dr. Serhan next discussed the corrective actions process where NICD provides a corrective action form that summarizes the failed versus expected results of each laboratory. The laboratory staff completes the corrective action form with suggested cause of failure and the responsible laboratory staff propose remediation and share the form with the laboratory manager. WHO regional laboratory coordinators need to be involved in the corrective action implementation and should develop a system of continuous follow-up with the implicated laboratory to improve weaknesses found during the EQA exercise.

Discussion points: 1. Participants discussed whether the target for performance should be increased to 90% for the RRLs

or whether a more sophisticated EQA should be developed specifically for RRLs. A representative from the United Kingdom’s Health Protection Agency and member of the IBVPD laboratory technical working group (Dr. Mary Slack) shared the HPA experience in coordinating an EQA programme for the EUR IBD LabNet and proposed that WHO uses the same EQA unit at HPA to develop more sophisticated PT panels to be sent to the RRLs

2. Improvements in web-based submission of the NICD EQA might be possible if some fields were pre-loaded on the website so that scores can be generated instantly as results are submitted. Consideration should be given to increasing the target of performance to 80% for sentinel sites. The suggestion was made to focus not on the score per se but on corrective actions. It was agreed to maintain the passing score as 75%, and to review this as needed in 2013.

Recommendations 1. The global IV-VPD EQA programme is well-conducted and provides useful information. Thus, this

EQA programme should be continued.

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2. WHO should follow-up during both shipment and for corrective action. In particular, non-responders should be targeted by ROs for intervention. During 2012, 23% of laboratories were non-responders and it should be determined why the laboratories did not respond.

3. Corrective action plans should be utilized to feedback from the EQA to inform the best course for remediation. Focal points and involved personnel at all levels should be involved.

4. Scoring options require additional discussion including the usefulness of score trends over time. 5. WHO should explore a different layer of evaluation for RRLs, with the possibility to use the UK HPA’s

IBD-labnet panels for RRLs; if this option is adopted, the TWG should develop a standard document communicating the rationale.

6. WHO should develop a standard document on EQA to cement and communicate why the EQA is being performed.

Session: Global Laboratory Rapid Diagnostic Testing Presentations A: Update on status of rapid testing in the network Presenters: Dr. Mary Slack, Dr. Linda De Gouveia, Dr. Martin Antonio, Dr. Fem Paladin Comparisons of rapid diagnostic testing commercially available kits -- namely the latex agglutination (LA) Pastorex , Wellcogen and Directigen kits and immunochromatography test BinaxNow for Spn -- were completed by three groups, HPA’s Haemophilus Influenzae unit, UK, The National Institute for Communicable Diseases (NICD), South Africa, and the Medical Research Center (MRC), The Gambia. Dr. Slack summarized the HPA results: Artificial specimens were spiked with heat killed MenC, group B Streptococcus, or Hib in sucrose solutions in serial dilutions (103 to 108). Results on simulated specimens: Pastorex could detect SPdown to 104, failed Hib and MenC; many false positives with MenB/E. coli; Directigen slightly better, still some false positives; BinaxNow gave Spnpositive down to 106. BinaxNow was best for real CSFs specimens and no false positives were found. The CSFs spiked with Hib were Pastorex negative but strongly positive by Wellcogen kit. Both Pastorex and Directigen detected MenC at 103 3 cfu/ml. BinaxNow was better than LA for Spn detection ; Dr. De Gouveia summarized the NICD comparison: A combination of previously processed CSF specimens (PCR positive) were tested as well as some negative CSFs. Specimens were boiled, no centrifugation. Used optimal kits (stored and within expiry). Results: Variable (see slide 10 from her presentation); Pastorex most sensitive for SP and Nm; Gram disappointing. Limitations of the study included: no control over sample preparation (boiled, centrifuged); Gram specimens were not fresh, and there was limited volume. Conclusions included validation of parameters need to be defined. Additionally, more testing will be performed to assess the diagnosis capacities of the kits within and after their shelf-life. Dr Antonio summarized the MRC Experience: CSF specimens were collected from 2 hospitals. Gram stain Pastorex, BinaxNow and culture were performed in sentinel site laboratories and CSFs from same samples were sent to the RRL Gambia for quantitative PCR (qPCR). The BinaxNow, Pastorex and culture showed the same sensitivity/specificity at the site level. More analysis and data are needed to make conclusions . Dr. Paladin summarized the pilot testing of BinaxNow for Spn diagnosis at the national level in WPR, Papua New Guinea (PNG): Hib vaccine was introduced into PNG in 2008, and Spn is a major pathogen

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causing meningitis in the last 5 years. GAVI approved PCV13 and the vaccine is planned to be introduced in 2013. Challenges for diagnosis of the bacterial meningitis are many, and since Spn is the major agent causing meningitis, the use of BinaxNow for Spn diagnosis was pilot tested to assess whether there was an increase of diagnostic yield. The study used CSF specimens collected over 14 months at the PNG sentinel site. Culture, WBC count, Gram stain and protein/glucose tests were performed. BinaxNow and LA were performed on CSF specimens with a WBC>5. Overall, 113 CSFs were tested among which only 90 met the suspect meningitis criteria; BinaxNow detected 6 additional cases that were not detected by culture and LAT. Challenges identified included an insufficient sample volume to do PCR for comparison; suboptimal quality of routine tests; commitment to use BinaxNow as the test only detects Spn in a setting with a desire to detect Hib and Nm cases; as well as securing a robust supply chain. Future plans are to provide continued support to supply the BinaxNow and LAT, which will consider cost implications. Binax testing is being introduced into Mongolia and Vietnam. Discussion Conflicting results in different studies are due to variations in methods and weaknesses in study design or source of specimen as well as other reasons. Each approach has its own advantages and disadvantages. Suggestions included:

one of the best diagnostic approaches is to support well-controlled Gram stains that could be equivalent in quality to LAT;

WHO to address with the manufacturer whether it is possible to develop a BinaxNow combo for detection of the 3 organisms.

Recommendations

1. Gram and culture remain very important in meningitis diagnostics; training in these techniques should continue and be emphasized.

2. Quality assurance and quality control must be emphasized in all tests performed. 3. BinaxNow has important advantages. It increases sensitivity of Spn case detection, can be stored at

room temp, has long shelf life and has less room for user error as it does not need training if compared to LAT.

4. Pastorex has reasonable sensitivity with intrinsic limitations; important for meningitis belt countries and those that have not introduced Hib vaccine.

5. Directigen: not recommended as it showed an important number of false positives in one of the studies presented.

Session: Laboratory serotyipng / serogrouping by PCR techniques: Presenters: Dr. Carla Talarico, Dr. Jason Mwenda

Dr. Talarico gave an overview of PCR serotyping for Spn using conventional versus real-time assays. She emphasized that PCR has increased detection of bacterial pathogens. However, the IB-VPD network should examine PCR detection and serotyping data for indicators of contamination. The linkage between laboratories and clinical data must be reinforced. Dr. Mwenda discussed the value of PCR testing of culture negative CSFs at RRL as a component of IBD surveillance, describing AFRO as an example. Discussion:

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1. Molecular proficiency testing should be implemented to assess RRL PCR capacities and methods used.

2. During review and reporting of data, RRLs must remember to include the denominator of CSF positive and negative specimens to describe carefully trends over time.

3. Standardize reporting should be developed for PCR including Ct cutoffs captured, specification of both/either serogroup and serotype (as available) and method of serotyping used at RRL.

4. Careful reporting regarding serotype data should include adequate details, e.g. use of footnotes. 5. Standardization is also required for the storage of specimens and links of laboratory data from the

RRLs to epi/clinical data. 6. PCR still has some limitations, and thus it is important to remember to emphasize good culture

practices at the sentinel site laboratory. Session: Informal Technical Advisory Group Meeting The informal Technical Advisory Group (iTAG) reviewed the data and information presented during the

meeting. The iTAG noted that, overall, more efforts are needed to convey to the global public health

community the work of the IB-VPD network. The iTAG encouraged WHO to enhanced efforts to

demonstrate the utility of the network including to illustrate the many intangible benefits and to

demonstrate what the network can do. The iTAG noted that many experiences from the IB-VPD network

should be shared with the global community, including a description of the network, highlight of good

performers, global EQA programme, denominator methodology and work, description of how countries

have used the data, lessons learned and additional information generated such as identification of

tuberculosis meningitis or Salmonella typhi. Such information could be conveyed by scientific

presentations and other methods. In particular, the iTAG urged WHO to establish a linkage with a

communications group who can assist with such efforts.

Session: WHO Closed Session During this session, representatives from all WHO regional offices as well as some country offices

discussed WHO specific processes and issues. There was agreement to modify the twice annual data

reporting schedule as follows:

By 15th July of year X for the data for January through December of year X-1, for rotavirus, IB-VPD serotype and genotype data;

By end November of year X for the whole data of year X-1 and for January through June of year X, for rotavirus and IB-VPD data.

Additionally, the benefit and need for sentinel site specific data was discussed. This would be

particularly valuable, for example, to understand the variability in data due to laboratory diagnostic

practices. For the rotavirus network, sentinel site specific data is required to ensure seasonality of

reporting does not bias results. There was general agreement that sentinel site specific data will be

collected and steps will be undertaken to initiate this process. WHO also discussed the developed IB-

VPD funding criteria as established for GAVI-eligible countries. WHO will consider the allocation of 2013

resources based on WHO funding criteria.

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GLOBAL MEETING ON IMMUNIZATION MONITORING AND SURVEILLANCE

AMR-PAHO building, Room A

9-11 October 2012, Washington DC

AGENDA

Tuesday 9 October 2012 8:15-9:00 Registration

9:00-9:30 Welcome and goals of meetings Regional Director Cuauhtemoc Ruiz

Review of the GVAP Monitoring and Accountability Framework

9:30-9:35 Opening remarks and objectives of the session T. Cherian

9:35-9:45 Summary of the Decade of Vaccines and GVAP M. Robert

9:45-10:00 Review of the draft GVAP indicators T. Cherian

10:00-10:30 Discussion and feedback on the GVAP monitoring indicators Moderator: T Cherian

10:30-11:00 COFFEE BREAK

11:00-11:30 Discussion on collection, review and reporting of data at regional and global levels (the reporting cycle)

T. Cherian & WHO RO reps

11:30-11:45 Documenting and tracking commitments for GVAP: building on the Accountability Framework for “Every Woman Every Child”

M.Robert

11:45-12:00 Tracking financial resources for GVAP DoVC consultant

12:00-12:45 Discussion and questions on accountability process Moderator: M Robert

12:45-13:00 Conclusions and wrap up

13:00-14:00 LUNCH

GLOBAL IB-VPD SURVEILLANCE MEETING

Chair: Dr. Rana Hajjeh, CDC IB VPD GRL Rapporteurs: B Flannery & C Van Beneden, CDC

OBJECTIVES and OUTCOMES 4. Review the status of the IB-VPD surveillance network including implementation 2011 recommendations, data availability & quality 5. Evaluate the impact of 2012 meeting recommendations to improve data quality & thus to help assess disease changes associated

with vaccine introduction, particularly: – The current status of Ministry of Health management & supervision – Standardized sentinel site evaluations & establishing a denominator/rate of admissions for Tier 1 meningitis – Global laboratory network activities, EQA, usefulness of rapid diagnostic testing at the sentinel site & more

characterization at the RRL (e.g. PCR) – Changes in the data management system

6. Review countries that do not meet the established funding criteria and discuss and agree on next steps Desired outcomes for meeting participants:

– Common understanding network status – Agreement on key gaps in the network – Consensus on next steps during 2013 to further improve the network

14:00- Background to genesis of the meeting & welcome L. Oliveira

Status of the IB-VPD Network and Measuring Impact of PCV Introduction

-15:00 What is the status of the IB-VPD surveillance network?

Implementation of action items from last year’s meeting & status of the network, including the laboratory

Discussion

M. Agócs F. Serhan

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15:00-15:30 Ministry of Health and sentinel site perspectives: What are the strengths of surveillance? What are the areas for improvement? How is the data used?

Panama experience

Uganda experience Discussion

TBC D. Mugisha

15:30-16:00 COFFEE BREAK

16:00-17:00 How can we use sentinel surveillance versus population-based surveillance to measure impact of PCV?

Discussion

C. Van Beneden

17:00 RECEPTION

Wednesday 10 October 2012

GLOBAL IB-VPD SURVEILLANCE MEETING: DAY 2

Chair: Dr. Nadia Teleb, WHO Rapporteurs: B Flannery & C Van Beneden, CDC

Ministry of Health & Sentinel Site Perspectives: Targeting Global and Regional Support

9:00-10:30 Ministry of Health and sentinel site perspectives: How can global & regional efforts be best targeted to support countries and sentinel sites? How can partners and WHO best support country efforts?

Peru: Case story

Pakistan: Case story Roundtable discussion: Philippines and Ethiopia (E. Manmud)

TBC A. Rathore

10:30-11:00 COFFEE BREAK

Improving the quality of the network

11:00-12:00 What are the experiences with the new WHO standardized IB-VPD sentinel site assessment protocol launched in 2012? How can we improve the process?

Standardized assessment methodology & tool

AFR Regional Office experience

Nigeria experience

EMR Regional Office experience

F. Serhan J. Mwenda B. Tagbo H. Ahmed

12:00-13:00 What is the best methodology to estimate a catchment population for a sentinel hospital conducing Tier 1 meningitis surveillance?

Summary of rationale & methodology to estimate a catchment population

Results: The Gambia, Nepal, Senegal, Sri Lanka

Implications for the network & next steps Discussion

M. Agócs B. Flannery

13:00-14:00 LUNCH

Chair: K. Fox Rapporteurs: S. Schwartz & L. De Gouveia

Presenting IB-VPD Data

14:00-14:30 How best to present data from the IB VPD network? Common mistakes & suggestions for improvement

C. Van Beneden

Reports from the Laboratory Network

14:30-15:30 Report from Regional Reference Laboratories RRLs

15:30-16:00 COFFEE BREAK

16:00-17:00 Continued RRLs

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Thursday 11 October 2012

GLOBAL IB-VPD SURVEILLANCE MEETING: DAY 3

Chair: H. Ahmed Rapporteurs: S. Schwartz & L. De Gouveia

Global EQA Programme

9:00-10:30 EQA

Summary of 2011 pilot test

2012 Survey

Corrective actions

M. Smith F. Serhan

10:30-11:00 COFFEE BREAK

Chair: A. Von Gottberg Rapporteurs: S. Schwartz & L. De Gouveia

Rapid Testing and PCR

11:00-13:00 Rapid diagnostic testing and polymerase chain reaction testing

Rapid testing: Update on status of rapid testing in the network o Preliminary results of comparison of LA with ICT kits o Pilot testing of Binax: example of WPR

PCR: o Value of Serotyping for surveillance o Implementation of PCR testing to improve quality of data and the role of

RRLs: AFR example Discussion

M. Slack L. De Gouveia M. Antonio F. Paladin C. Talarico J. Mwenda

13:00-14:00 LUNCH

Meeting Conclusions

14:00-14:30 Consensus and agreement on priority actions during 2013 Agócs & Serhan

IB-VPD Surveillance Meeting Ends

WHO Closed Session

14:30-15:30 WHO Closed session: Internal WHO discussion: Summary of key activities to improve IB-VPD data quality including clinician,

laboratory, data management, and epidemiological aspects. Discussion and next steps.

15:30-16:00 COFFEE BREAK

16:00-17:30 Continued

Report of the October 2012 Global IB-VPD New Vaccines Surveillance Meeting 23

World Health Organization

Department of Immunization, Vaccines and Biologicals Expanded Programme on Immunization

GLOBAL IMMUNIZATION, MONITORING AND SURVEILLANCE

FOR INVASIVE BACTERIAL DISEAESES (IBD) 9-11 October 2012

PAHO Building, Room A Washington, USA

List of Participants

MINISTRY OF HEALTH & HOSPITAL SENTINEL SITES

Ahsan Washeed Rathore Professor of Pediatrics & Medical Director The Children Hospital & The Institute of Child Health Lahore, Pakistan

Beckie N. Tagbo Chief Consultant Paediatrician Institute of Child Health, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria

David Mugisha Mulago Hospital Kampala, P.O BOX 705, Uganda

Endris Mohammed Mahmud Ethiopian Health and Nutrition Research Institute Addis Ababa, Ethiopia

El Hadji Mamadou Ndiaye Médecin Spécialiste en Santé Publique Chef de Division de l'Immunisation Ministère de la Santé et de l'Action Sociale B.P: 10 922, Dakar, Senegal

Maria Rosario Capeding Head, Microbiology Department Research Institute for Tropical Medicine Muntinlupia City, Philippines 1781

Amani Mustafa The Federal Ministry of Health P.O Box 303 Khartoum, Sudan

Valentyna Yanovska Central Sanitary Epidemiological Station of the Ministry of Health 41 Yaroslavskaya Street, 04071 Kiev, Ukraine

Danik De Los Angeles Valera Antequera National Institute of Health National Laboratory Network Bogotá, Colombia

Janice Woolford Maternal and Child Health Services Ministry of Health Brickdam, Stabroek, Guyana

Lourdes Moreno Epidemiology Department Ministry of Health Panama, Panama

Marcia Lopes de Carvalho Ministry of Health, Secretariat of Health Epidemiologic Surveillance Departament General Coordination of Infection Disease Brasília, Brazil

Report of the October 2012 Global IB-VPD New Vaccines Surveillance Meeting 24

Sanchez Edmundo Ministry of Health Managua, Nicaragua

GLOBAL, REGIONAL REFERENCE AND OTHER LABORATORIES

Amany Ghoneim Invasive Bacterial diseases Regional Reference Laboratory Central Puplic Health Laboratory - Egypt El Sheikh Rehan St. from Kasr El Eni St., Down Cairo, Egypt

Anne Von Gottberg National Institute of Communicable Disease Block NO 1 Modderfontein Road Private Bag X4, Sandringham 2132 Johannesburg, South-Africa

Balaji Veeraraghavan Christian Medical College Thorapadi P.O., Vellore – 632002, India

Elena Voropaeva Laboratory of Clinical Microbiology & Biotechnology Gabrichevsky Research Institute for Epidemiology and Microbiology Admiral Makarov Street 10, 125212 Moscow, Russia

Geoff Hogg Microbiological Diagnostic Unit University of Melbourne Melbourne, Australia

Gagandeep Kang Professor and Head The Wellcome Trust Research Laboratory

ndiaVellore TN 632004, I, hristian Medical CollegeC

Linda de Gouveia National Institute for Communicable Disease Modderfontein Road Private Bag X4, Sandringham 2132 Johannesburg, South Africa

Marshagne Smith National Institute of Communicable Disease Block no 1, Modderfontein Road Private Bag X4, Sandringham 2132 Johannesburg, South Africa

Martin Antonio Head of Regional pneumococcal Reference Laboratory Medical Research Council The Gambia

Mohammad Belal Hossain Department of Microbiology Bangladesh Institute of Child Health Dhaka Shishu Hospital Dhaka, Bangladesh

Maksuda Islam Department of Microbiology Bangladesh Institute of Child Health Dhaka Shishu Hospital Dhaka, Bangladesh

Samir K Saha Department of Microbiology Bangladesh Institute of Child Health Dhaka Shishu Hospital Dhaka – 1207, Bangladesh

Mary Slack Health Protection Agency Centre for Infections NW9 5HT London, United Kingdom

Stéphanie Schwartz Global Reference Laboratory Centers for Disease Control and Prevention Atlanta, GA 30333, USA

Leonard Mayer DBD Centers for Disease Control and Prevention Atlanta, GA 30333, USA

Carla Talarico Global Reference Laboratory Centers for Disease Control and Prevention Atlanta, GA 30333, USA

Report of the October 2012 Global IB-VPD New Vaccines Surveillance Meeting 25

Inacio Mandomando Manhiça Office Rua 12, Cambeve, Vila de Manhiça, CP 1929, Maputo Mozambique

Seong-Han Kim Deputy Scientific Director Division of Tuberculosis and Respiratory Infections Korea National Institute of Health Osong health Technology Administration Complex, Chungcheongbuk-do, Republic of Korea

Olga Marina Sanabria Cruz Grupo de Microbiología Instituto Nacional de Salud Ave calle 26 # 51-20 Lab B203 Bogotá, Colombia

María Cristina Brandileone Instituto Adolfo Lutz Setor de bacterias Piogenicas e Toxigenicas Secao de Bacteriologia Avenida Doutor Arnaldo, 355, Sao Paolo, Brazil

PARTNERS Anita Zaidi The Aga Khan University Karachi, Pakistan

Anthony Scott Kenya Medical Research Institute Mbagathi Rd. Nairobi, Kenya

Claire V. Broome Senior Adviser 26 Northgate Avenue Berkeley, CA 94708, USA

Ann-Marie Kimball The Bill & Melinda Gates Foundation 1551 Eastlake Avenue East Seattle, WA 98102, USA

Julia Bosch The Bill & Melinda Gates Foundation 1551 Eastlake Avenue East Suite 100 Seattle, WA 98102, USA

Chris Van Beneden Respiratory Diseases Branch Division of Bacterial Diseases Centers for Disease Control and Prevention Atlanta, GA 30333, USA

Hope Johnson GAVI Alliance 2 chemin des Mines 1211 Geneva 10, Switzerland

Mathuram Santosham Professor, Johns Hopkins University Department of International Health 615 N. Wolfe Street, MD 21205, Baltimore, USA

Rana Hajjeh Centers for Disease Control and Prevention Atlanta, GA 30333, USA

Brendan Flannery Centers for Disease Control and Prevention Atlanta, GA 30333, USA

James Sale Consultant 25, Oxford Street, Woodstock, Oxon, United Kingdom

REGIONAL STAFF

AFRO Cite du Djoue, Brazzaville, Congo

Jason Mwenda Keith Shaba

EMRO Abdul Razzak El Sanhouri Street

Nasr City, Cairo 11371, Egypt Nadia Teleb, VPI Regional Adviser Hinda Ahmed

Hossam Ashmony Eltayeb Elfakki

Report of the October 2012 Global IB-VPD New Vaccines Surveillance Meeting 26

AMRO – PAHO 525 23rd Street, N.W.

Washington, DC 20037-2895, USA Gina Tambini Cuauhtemoc Ruiz

Senior Advisor, World Health Organization

Lucia de Oliveira Gloria Rey

Jennifer Sanwogou

Jean-Marc Gabastou Port-of-Spain, Trinité et Tobago

Carolina Danovaro Carilu P. Tirso

Samia Samad Caixa Postal 08 70312-970 Brasília DF, Brazil

Cristina Pedreira Apartado Aéreo Santa Fé de Bogotá DC, Colombia

Nancy Vasconez APDO 1309, Managua, Nicaragua

Dilsa Lara Apartado 0843-0, Panamá, Panama

Fabiana Michel Casilla postal, Lima 12, Pérou

Rafael Baltrons 1172 Sucursal C, San Salvador, El Salvador

Miguel Elas 1172 Sucursal C, San Salvador, El Salvador

EURO 8, Scherfigsvej

Copenhagen, Denmark Annemarie Wasley

WPRO United Nations Avenue

P.O. Box 2932, 1000 Manila, Philippines Fem Julia Paladin Kimberley Fox

WHO HEADQUARTERS STAFF Avenue Appia, 20

1211 Geneva 27, Switzerland

Thomas Cherian Mary Agócs

Fatima Serhan Laure Dumolard

Elsa Dérobert