External 3-Month Assessment: cVDPV2 Outbreak...

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: [email protected]).

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

iii

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

v

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

vii

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.

1

1. 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.

2. 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.

External 3-Month Assessment: cVDPV2 Outbreak Response

2

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)


3

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 First SIA

Second

SIA Third SIA Fourth SIA

Date

(interval)

6 Dec. 2015 5 Dec.

2015

(0 days)

26 Dec.

2015

(21 days)

23 Jan.

2016

(28 days)

20 Feb.

2016

(28 days)

# of

children

360 000 580 000 2.4 million 4.6 million


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)


4

(2) 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)

(3) Shan East state, Kyentong, Tarchileik township

(a) Dr Suleman Rahim Malik (UNICEF-HQ)

(b) Dr Aung NaingOo (WHO-Myanmar)

(4) 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)

(5) 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.


5

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?


6

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.


7

Figure 2: SIA response to cVDPV2 outbreak


The availability of tOPV was adequate for implementing four large-

scale 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.


8

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.


9

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-to-

reach 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.


10

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).


11

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.


12

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


13

Table 4: Number of AFP cases by township, Rakhine state

Township 2012 2013 2014 2015

Ann 1 1

Buthidaung 1 2 3 3

Wa 1 1 1

Kyaukpyu 1 1

Kyauktaw 2 1 2 3

Man aung 1 1

Maungdaw 3 1 2 4

Minbya 1 1

Myauk oo 2 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

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.


14

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 (<1 year old)

Year 2011 2012 2013 2014 2015

Myanmar 90 87 76 88 89

Rakhine 91 70 44 70 72

Mungdaw 97 50 21 55 68

Sittwe 86 46 24 27 31

The assessment team concluded that the outbreak activities have not

yet contributed to strengthening RI, particularly in the high-risk outbreak

areas, although an opportunity does exist.


15

Figure 3: National RI coverage, 2015


4.6 Have sufficient financial, material and human resources

been made available to support full implementation of all

recommended polio outbreak response activities?

Adequate human resource surge support through local NGOs and UN

partners was available and had been utilized to coordinate the outbreak

response and support other activities of outbreak response, including

developing the appropriate communication for development strategies for

the outbreak and RI. The funding provisions by Global Polio Eradication

Initiative were sufficient and timely. Appropriate logistic support was

maintained by the development partners during the outbreak response. The

adequate availability of tOPV was ensured for conducting the outbreak

response immunization activities.

<70%

70% - 79%

80% - 89%

>90%


16

4.7 What are the remaining risks to stopping the outbreak?

The undetected transmission of poliovirus due to AFP surveillance gaps

poses a major risk to stopping the outbreak. The other challenge in the

outbreak and neighbouring areas is the very low RI coverage. Suboptimal

immunization of migrant and mobile populations during SIA and RI is

another risk as it will facilitate continued transmission of VDPV2 and could

also support its spread.

5. Conclusions

The overall response by the national authorities, with support from WHO

and UNICEF regional and country offices, has been strong and appropriate

following the confirmation of the outbreak of cVDPV2 in Myanmar. The

overall SIA planning and quality has been good and in accordance with

WHA guidelines. Adequate funds and other logistics had been ensured to

implement the planned outbreak response activities. RI coverage is

suboptimal, especially in the outbreak area. The transmission of VDPV2

may have been interrupted; however, uncertainty in concluding this

remains due to gaps in AFP surveillance quality in Myanmar. The risk of

further cVDPV2 transmission after the switch has global implications; so,

there exists an urgent need to address the gaps identified in outbreak

response.

6. Recommendations

A number of recommendations have been made by the assessment team.

These have been categorized under the following four areas of work:

A. Supplementary immunization activity

Consider conducting an additional SIA in selected high-risk

townships in Rakhine, prior to the switch.

The additional SIA should be closely supervised and

independently monitored.


17

Robust arrangements need to be made to withdraw all tOPV

immediately after the SIA and before the switch.

A fully budgeted outbreak response plan should be developed to

handle any Type 2 detection post-switch.

B. Surveillance

Urgent efforts should be made to improve AFP surveillance at

the national and subnational levels to ensure sensitive

surveillance in all subnational areas.

The feasibility of initiating environmental surveillance in

Myanmar should be explored.

The two vacant positions of regional surveillance officers (RSOs)

need to be filled on priority.

Ensure independent mobility for all RSOs to support active

surveillance.

Ensure systematic sampling of (up to five) contacts of all AFP

cases found in high-risk districts for a minimum of the next six

months, based on standardized protocols to be developed and

shared with targeted states by the end of May 2016.

C. Routine immunization

Develop plans to improve RI coverage, pursuing the principles of

reaching every child, with a focus on high-risk outbreak

townships, migrants, slums, pre-urban areas and hard-to-reach

areas.

Develop and implement special plans for RI coverage

improvement in areas with low reported coverage.

Ensure adequate human resources, financial provisions and

adequate logistics to maintain and improve RI coverage.

The professional networks, community-based partners along

with community and religious leaders should leverage reach,

foster better linkages and focus on person-to-person

communication.


18

Efforts undertaken during the current outbreak immunization

response should be taken as a great opportunity to build trust

between the community and health system for RI, especially in

the outbreak areas.

D. Improve data quality

Improvement of data quality, particularly a proper denominator,

should be a priority for SIAs, surveillance and RI.

Utilization of digital technology/Internet could be explored for

reporting and data-quality assessment.

7. Acknowledgement

The assessment team would like to express sincere gratitude to the Ministry

of Health, Myanmar, WHO-Myanmar and UNICEF-Myanmar for their

support, coordination, guidance and overall facilitation of the assessment

mission. The team appreciates the efforts put in by everyone, especially

those who contributed to the field visits.


19

Annex 1

List of participants

MoH Myanmar

Dr Aung Kyaw Moe

Dr Aye Mya Chan Thar

Dr Hnin Nwe Ni Aye

Dr Tin ThitsarLwin

UNICEF-Myanmar

Dr Daniel Ngemera

Dr Htet Arkar Win

Dr Tin Htut

Dr Thiha Htun

Dr Nay Myo Thu

UNICEF-EAPRO

Dr Abu Obeida Babiker

UNICEF headquarters

Dr Suleman Rahim Malik

Dr Hasan ASM Mainul

WHO-Myanmar

Dr Rajendra Bohara

Dr Ye Zin Zin

Dr Tin Tin Aye

Dr Ag Myat Htay

Dr Aung Naing Oo

Dr Myo Thant Khine

Dr Allison Gocotano

WHO-SEARO

Dr Sunil Bahl

Dr Sudhir Khanal

Dr Aarti Garg

WHO headquarters

Dr Graham Tallis

External 3-Month Assessment: cVDPV2 Outbreak...

Documents

Transcript of External 3-Month Assessment: cVDPV2 Outbreak...