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Post00276 TECHNET STRATEGIC FRAMEWORK - PART 3 21 August 2000 CONTENTS 1. RECOMMENDATIONS AND PROPOSED PRIORITY ACTIVITIES: TECHNET'96 1. RECOMMENDATIONS AND PROPOSED PRIORITY ACTIVITIES: TECHNET'96 The agreement of a Technet Strategic Framework is an essential task that we must complete to enable the institutionalization of the Technet within the WHO. As an aid to this development process the Technet Forum is posting the recommendations and priority activities resulting from the Technet Consultation Meetings. This posting is the third in a series that should help us to formulate and agree on a Technet strategic framework. [The recommendations and agreed action points of Technet'99 were posted in Technet Forum Post00271, on 8 August 2000 and in Post00274 on 15 August 2000.] Thre were 21 recommendations and 17 Priority Activities. These are the recommendations that were agreed upon in a plenary session of the Technet members meeting, 12-16 February 1996 in Manila. * The posting of these recommendations is to inform our discussions and to enable the development of the Technet Strategic Framework. * Technet'94 Recommendations will be posted soon, with the earlier recommendations to follow as we convert them to plain text. It should be noted that many recommendations have been implemented, others overtaken by events, and some ...? Technet Consultation, Manila, 12-16 February 1996 9. Recommendations and proposed priority activities The Recommendations pertaining to the main subject areas of the Consultation, given previously in the respective Chapters, are presented below under the Session headings (see Agenda, Annex 2) in conjunction with the proposed priority activities deriving from them. SESSION 1 - VACCINE VIAL MONITORS Recommendation 1: VVMs on vials of OPV are a valuable addition to immunization services, enabling health workers to decide whether or not the vaccine should be used. Technet recommends that VVMs be introduced for all vaccines as soon as possible. Recommendation 2: The utilization of VVMs with OPV should be enhanced to assure vaccine quality at point of use and to improve the management of vaccine delivery. Recommendation 3: Because VVMs accurately indicate only the heat exposure of the vials they are on, VVMs on OPV vials should not be used as a means of evaluating the heat exposure of any other vaccines. Other monitors (CCM, Stop!Watch) should be used until VVMs are available for other vaccines. Priority activity 1: Enhancing utilization of VVMs on OPV TRAINING * Every regional EPI managers? meeting should receive country reports on the status of the VVM training effort. * A resource packet of good examples of training materials and how they have been used should be compiled and distributed to each country using VVMs (PATH to compile packet; WHO/EPI to distribute it). * A minimum package of activities should be completed by every country receiving VVMs, including: - a national orientation session (as part of a scheduled meeting if possible) at which central and provincial staff learn key messages, decide local policy guidelines, and determine the training approach for local staff (UNICEF to be asked to coordinate through its country offices); - distribution by national ministries of health of at least one printed item with basic messages to each immunization delivery point; - incorporation of at least a basic training component on VVMs and their use in all training sessions for polio NIDs; WHO should revise the relevant sections of the Polio Eradication Field Guide to cover the introduction, use and management of VVMs with OPV. * WHO/GPV/VSQ will explore the possibility of getting all OPV manufacturers to add brief, non-verbal instructions for using VVMs to the package insert, as has already been done by Smith Kline Biologicals. * Wherever feasible (and particularly in conjunction with other studies), sub-studies of health worker and supervisor knowledge, attitudes and practice relating to VVMs should be carried out to monitor the progress of training. Model study protocols will be prepared by PATH and EPI and made available to WHO and UNICEF offices. * With assistance from WHO and UNICEF staff and Technet members, countries should consider opportunities to incorporate basic VVM training into pre-service curricula for health workers. SUPERVISION * Model items for supervisory checklists (measuring health worker knowledge and action with regard to VVMs) should be developed, pretested, shared with country programmes and incorporated into manuals and forms. * Supervisory visits should be considered as opportunities for training on the use of VVMs. USE OF VVMS FOR MANAGEMENT OF VACCINE DELIVERY * While the current training materials provided by WHO offer good support for point-of-use interpretation of individual vials, they give no guidance on use for the management of vaccine storage, handling and delivery. WHO/EPI should revise current materials, with the assistance of PATH and selected national EPI staff, to incorporate a set of guidelines on acceptable and unacceptable uses of OPV VVMs for enhancing management of vaccine delivery. These guidelines should point out the opportunities to use VVMs for the following purposes and give examples and discussion of the rationale and limitations of each use: - stock management at district and lower levels; - allocation of resources (equipment, supervision, training) to priority areas; - investigation of specific incidents or of patterns of problems; - stretching the cold chain for OPV beyond traditional limits; - taking OPV beyond the cold chain (i.e. without active cooling); - broadening cold chain equipment purchasing options or relaxing equipment replacement schedules at the periphery, based on VVM indications. These materials will be pretested and made available to UNICEF and WHO field offices and national EPI managers at various meetings. FURTHER STUDIES * Additional studies to decide whether or not to go forward with VVMs for other vaccines are no longer needed. However, utilization studies, to provide feedback on how VVMs are being used and to improve their use, should be carried out in accordance with a protocol approved by WHO/EPI. Such studies should include cost-effectiveness measures and should be designed in collaboration with experts in economic analysis. At least one study in each region where VVMs are used should be completed by mid-1999. Technet assistance should be provided to interested countries. EXPANDING VVM USE TO COUNTRIES PROCURING OPV DIRECTLY * An advocacy package (including a summary paper on the potential impact of OPV VVM use on vaccine quality and cold chain management) and practical information on specification of VVMs in direct procurements of vaccine should be prepared by EPI and VSQ and distributed to those countries not using UNICEF/WHO procurement or expecting to begin independent vaccine procurement within the next five years. * Work to encourage and assist qualified national vaccine manufacturers in adopting VVMs should continue (WHO/VSQ and PATH). Priority activity 2: VVMs for all EPI vaccines As stated in Recommendation 1, the development and deployment of VVMs for all EPI vaccines should proceed as rapidly as possible. A small product development team comprising representatives from WHO/GPV, UNICEF Technical Centres and PATH will coordinate efforts to develop and implement three VVMs with different specifications but with presentations consistent with the OPV VVMs, to cover all existing priority vaccines, for instance DTP, DT, TT, HBV, measles and BCG. * On the basis of Artur Galazka?s estimates of stability the group will elaborate specifications, in close collaboration with VVM and vaccine manufacturers, for three time/temperature indicators: - Category A - highly stable vaccines: toxoids and hepatitis B vaccine; - Category B - vaccines of moderate stability 5 : BCG, yellow fever and measles vaccines; - Category C - stable vaccines: pertussis (whole cell), including DTP vaccines. * It was decided that development efforts for all three VVMs should proceed in parallel and as quickly as possible. As soon as any one of them has been validated for use in the field it should be deployed. VVMs should be deployed as soon as they are available, even if any other additional indicators, such as threshold or freeze indicators, are appropriate for use on a given vaccine but are not available concurrently with the VVMs. Additional indicators should be added as they are developed. Specification will include a requirement that the time/temperature indicators be removed or destroyed as the vial is opened for reconstitution. This may result in different manufacturers placing the VVM on different places on the vial/cap. It must be determined if this will present significant problem for training and use. STEPS FOR INTRODUCING VVMS ON ALL EPI VACCINES (not all the steps are needed for all vaccines; not necessarily in order of implementation): * Inform countries and other partners of the decision and likely time scale. * Development of specifications for VVM manufacturers. * Establishment of WHO minimum requirements (including matters relating to consistency of presentation). * Vaccine manufacturers? agreement on specifications. * Development and production of VVMs. * Development of technology for label application. * Vaccine manufacturers? validation of VVMs. * WHO validation of VVMs. * Field studies to validate usability of VVMs with lyophilized vaccines. * Validation of correspondence between VVM performance and vaccine potency. * Development of training materials for new VVMs. * Development of a comprehensive introduction plan. SESSION 2 - THE COLD CHAIN Recommendation 4: Having reviewed the experience with CFC-free refrigeration equipment, the relative advantages and weaknesses of various refrigerants as well as their respective global warming potential, Technet recommends that R134a remains the refrigerant of choice for cold chain appliances. Recommendation 5: Countries producing or importing refrigerators/freezers with R600a or other hydrocarbon refrigerants for their domestic markets may accept such systems for the storage of vaccines provided that: * the equipment meets WHO/UNICEF standards; * maintenance skills are raised to a standard guaranteeing that repairs are conducted in strict compliance with safe practices for hydrocarbon refrigerants (HCRs) ; * policy-makers, managers, supervisors and health workers are made fully aware of the risks and requirements for the correct use of equipment with HCR; * all HCR refrigeration equipment is clearly and permanently marked with non-verbal instructions indicating the refrigerant type. Recommendation 6: To improve the future cost effectiveness and performance of national cold chain systems, it was agreed that: * the performance required of refrigerators used for vaccine storage should be more closely related to the climatic and energy environment where they will be used; * the equipment, temperature monitoring, management and staffing of national central stores should be evaluated in accordance with a standard protocol and standard criteria. Recommendation 7: Because adsorbed vaccines are exposed to freezing damage in winter in temperate and cold climates it is recommended that Technet proceed with the development of low-temperature-protected vaccine storage and transport equipment specifications, test procedures and guidelines. PRIORITY ACTIVITY 3: COLD CHAIN INVENTORIES Reports were made of national cold chain equipment inventory surveys in ten countries of Africa and six countries of South-East Asia. These inventories have been used to plan equipment needs in the African countries and similar plans will be made in the South-East Asian countries for management and training needs. * Before conducting such surveys a clear strategy for government, bilateral or multilateral funding for the needed equipment must exist. * When conducting inventory surveys, a five-year plan for equipment replacement, training, maintenance and spare parts should be prepared and a system for regular updating through a national reporting process should be installed. If these measures are not taken, expectations are raised and then frustrated and survey data quickly become obsolete. * Having recognized the role of good quality equipment and its management in ensuring potent vaccine at the point of use, Technet recommends that: - governments plan and budget for preventive maintenance, parts, repairs,training, supervision, placement and cyclical replacement of equipment using inventory systems which are updated regularly; - inventory systems be used which enable managers to monitor whether storage and service delivery points have functioning cold chain equipment appropriate to their level and operational needs; - occasional surveys be conducted to strengthen existing inventory management systems; - a subgroup be set up to develop specifications for equipment management systems and to review existing software. PRIORITY ACTIVITY 4: CHOICE OF REFRIGERANTS Experience with CFC-free refrigeration equipment was reviewed as well as the relative advantages and weaknesses of various refrigerants together with their respective global warming potential. Technet recommends that R134a remain the refrigerant of choice for cold chain appliances. The use of hydrocarbons, however, is considered possible provided a number of conditions are met, as outlined in Recommendation 6. * Technet will work with the refrigeration industry to monitor the development and introduction of HCRs and will continue to evaluate them. * the equipment, temperature monitoring, management and staffing of national central stores should be evaluated in accordance with a standard protocol and standard criteria. Recommendation 7: Because adsorbed vaccines are exposed to freezing damage in winter in temperate and cold climates it is recommended that Technet proceed with the development of low-temperature-protected vaccine storage and transport equipment specifications, test procedures and guidelines. Priority activity 3: Cold chain inventories Reports were made of national cold chain equipment inventory surveys in ten countries of Africa and six countries of South-East Asia. These inventories have been used to plan equipment needs in the African countries and similar plans will be made in the South-East Asian countries for management and training needs. * Before conducting such surveys a clear strategy for government, bilateral or multilateral funding for the needed equipment must exist. * When conducting inventory surveys, a five-year plan for equipment replacement, training, maintenance and spare parts should be prepared and a system for regular updating through a national reporting process should be installed. If these measures are not taken, expectations are raised and then frustrated and survey data quickly become obsolete. * Having recognized the role of good quality equipment and its management in ensuring potent vaccine at the point of use, Technet recommends that: - governments plan and budget for preventive maintenance, parts, repairs, training, supervision, placement and cyclical replacement of equipment using inventory systems which are updated regularly; - inventory systems be used which enable managers to monitor whether storage and service delivery points have functioning cold chain equipment appropriate to their level and operational needs; - occasional surveys be conducted to strengthen existing inventory management systems; - a subgroup be set up to develop specifications for equipment management systems and to review existing software. Priority activity 4: Choice of refrigerants Experience with CFC-free refrigeration equipment was reviewed as well as the relative advantages and weaknesses of various refrigerants together with their respective global warming potential. Technet recommends that R134a remain the refrigerant of choice for cold chain appliances. The use of hydrocarbons, however, is considered possible provided a number of conditions are met, as outlined in Recommendation 6. * Technet will work with the refrigeration industry to monitor the development and introduction of HCRs and will continue to evaluate them. * WHO/GPV will develop, draft and circulate final specifications to the Technet working group on low-temperature protection by the end of 1998. * Guidelines will be drafted and circulated for comments to this working group by the end of 1998. * Low-temperature-protected vaccine storage equipment will be incorporated in the equipment performance specifications and test procedures manual. All recommended vaccine storage and transport equipment for the temperate and cold climate zone will be expected to comply with this specification. * Manufacturers will be invited to produce equipment to low-temperature- protection specifications. Equipment meeting the specifications will be included in the PIS. Guidelines for vaccine shipping and transport * The WHO/UNICEF guidelines for international vaccine shipments should be revised and updated to incorporate low temperature protection for shipments to and in temperate and cold climates. [Guidelines on the international packaging and shipping of vaccines, WHO/EPI/CCIS/81.04/Rev.5, (revised July 1992)] * Vaccine transport equipment for use in temperate and colder climates should maintain safe vaccine storage temperatures in an external ambient temperature range of +43?C to -30?C for 48 hours. * Vaccine transport equipment should be tested for performance in this temperature range. * Operational guidelines should be prepared. Session 3 - Vaccine demand, supply and financing Recommendations Recommendation 8: Countries should have reliable forecasts of vaccine requirements so that adequate supplies can be provided, vaccine wastage can be minimized, vaccine shortfalls eliminated, and forward budgeting performed. Priority activity 6: Vaccine forecasting * All countries should have forecasts of vaccine requirements based on an appropriate method of estimation, with projections for three to five years. These forecasts should be the official national estimates of requirements used for budgeting and procurement by all involved agencies. The forecasts must be reviewed prior to ordering national requirements, particularly for orders made through UNICEF or WHO. * WHO and UNICEF country staff and Technet members should provide countries with whatever support they need in the preparation of estimates. Vaccine requirement forecasting should be on the agenda of all Regional EPI meetings. * Baseline data on the situation of vaccine forecasting by Region should be jointly prepared by WHO and UNICEF and made available to Regional Offices by the end of 1998. * Existing methods of forecasting requirements will be reviewed by WHO and UNICEF and recommendations will be made by the end of 1998. Session 4 - Injection safety and injection technologies Recommendations Recommendation 9: Technet highly recommends the implementation of the strategy for safe injections. By the end of 1998 WHO/GPV/EPI should have identified partners for implementation, a structure for coordination, management and administration, and a detailed plan of action. Recommendation 10: Technet reaffirms that auto-destruct syringes are the preferred type of disposable syringes and that by 2001 all disposables used in immunization programmes should be of this kind. Recommendation 11: Multidose, needle-free injectors with a reusable fluid path should only be used for immunization if they pass standard WHO safety tests. On this basis the latest evidence suggests that none of the models that have been tested in the laboratory can be used for immunization. Recommendation 12: Considering the safety, operational advantages and potential cost savings demonstrated by field trials of single-dose, prefilled injection devices over recent years, Technet encourages the wider introduction of new, injectable vaccines in this format, equipped with VVMs. Recommendation 13: The recommended method of destruction of used syringes and needles is incineration under controlled conditions. WHO/EPI policy on the disposal of used syringes and needles should be revised to incorporate changes suggested during the Consultation. Recommendation 14: As part of the strategy for safe injections, a task force will be set up to develop and promote safe disposal and destruction systems which reduce human and environmental risk. Priority activity 7: Injection safety Technet noted that, following the recommendations of the Manila consultation, a number of injection practice surveys had been conducted and that several countries had developed plans for injection safety. * Measures taken to ensure safe immunization should include not only safe injection but also proper vaccine handling and reconstitution as well as safe collection, disposal and destruction of used syringes. Adherence to safe immunization policies should be improved by better supervision. * Immunization programmes should take advantage of renewed interest in measles control and elimination in order to invest in safe injection. * By the end of 1998, following the WPRO framework and national examples, every country should devise or update a national plan of action for injection safety aimed at achieving 100% safe injections by 2000. WHO will continue to monitor the status of these plans and will report to Regional EPI Managers? meetings and the next Technet consultation. Priority activity 8: Injection technologies * Sterilizable syringes and needles supplied by the UNICEF supply division should be bundled with TST spots and safety boxes. * All injection equipment should be accompanied by an appropriate number of safety boxes. Multidose, reusable needle-free injection devices * WHO should continue laboratory and field tests to identify, in the shortest possible time, one or more models of safe needle-free injection devices for use in immunization. Non-reusable single-dose prefilled injection devices Pouch and needle devices The Group proposed the following measures to start the process of implementing Recommendation 12, using needle-based injection devices by the end of 2000: * Introduction and post-introduction evaluation of non-reusable single-dose injection devices prefilled with tetanus toxoid vaccine and hepatitis B vaccine in several countries from at least three WHO Regions. The evaluation should include the necessary training and a cost-benefit analysis of the whole delivery system. * Since several products, including injectable contraceptives, are expected to be presented in UniJect, standard identification coding and packaging will be developed and tested in these countries to differentiate vaccines from each other and from other products. * Research is needed to determine whether a single dose of dried vaccine may be stored in UniJect and automatically reconstituted during the process of delivering one dose of diluent or a compatible liquid vaccine to be combined with the lyophilized vaccine. Needle-free injection devices * In view of the superior safety to the community and to health workers of needle-free injection devices, WHO/GPV/EPI and VRD and their collaborators should conduct research: - to assess the safety, efficacy and cost-benefit of needle-free injection devices, in comparison with needle-based devices, if and when prefilled needle-free injection devices become available; - to develop and evaluate the safety and efficacy of alternative methods of drying and injecting dried or solid vaccine formats. Priority activity 9: Disposal and destruction Experience accumulated in field trials in the Western Pacific Region indicates that the following changes to the WHO/EPI policy on the incineration of used syringes and needles are necessary. Safe disposal * Used syringes and needles should be discarded in safety boxes meeting WHO/EPI specifications. * Sufficient safety boxes should be provided for all injection activities. * Reusable plastic containers are not suitable for the collection of used syringes and needles. Transport to the point of incineration * Safety boxes can be transported from the point of use to a designated destruction site. * Safety boxes should be tracked from the point of use to the point of incineration so that all are accounted for and destroyed. * During transport, used syringes should be in closed and sealed safety boxes. * Used syringes should preferably be removed at the same time as new ones are distributed. Destruction * The preferred method of destruction is incineration at high temperature (over 850?C) in an appropriate incinerator. * Used syringes should be incinerated in closed safety boxes. * Autocombustion incinerators without forced ventilation should not be used unless a correctly balanced load can be assured. Studies are continuing in order to identify both powered and autocombustion incinerators that can be used for the destruction of used injection material. * If an appropriate incinerator for destruction at high temperature is not available and intermediate storage is not feasible, open burning in a protected environment can be used as an interim destruction method for small quantities of used syringes in closed safety boxes. Environmental legislation * National legislation and guidelines on incineration should be examined and complied with. This concerns both destruction in high-temperature incinerators and open burning. * A task force on safe disposal and destruction will be set up to carry out the following functions: - development of performance specifications for incineration equipment with due regard to environmental concerns; - development of guidelines on the destruction of used syringes and needles with due regard to existing guidelines on the disposal of medical waste; - networking with relevant agencies and organizations; - development of a project proposal and active fundraising for its implementation. * Technet will enhance advocacy for use of safety boxes and suitable incineration process. * Technet members will conduct or facilitate research into alternative solutions for syringe disposal and destruction. Session 5 - Mass immunization Recommendations Recommendation 15: Staff knowledgeable about operations, logistics and safety issues should be involved in the planning of all mass immunization activities involving the use of injectable vaccines. Planning should begin at least six months in advance of any campaign. Priority activity 10: Accelerated measles control in high-risk areas * As a priority, WHO should assist all countries planning mass measles campaigns to ensure that: (1) the appropriate high-risk areas and groups are targeted; (2) the campaigns are effectively planned; (3) the safety of injections is guaranteed; (4) provision is made for impact evaluation. Whenever appropriate the countries should receive technical assistance from logisticians experienced in organizing campaigns with injectable antigens. Priority should be given to Burkina Faso, Congo, Democratic Republic of Congo, Mali, Mozambique, Niger, and Sierra Leone. Consultants should arrive in these countries at least four months before the implementation dates so that they can effectively assist in the planning process. * Generic guidelines on planning and logistical preparations for measles campaigns are required to assist managers at national and district level. All Technet members are requested to forward to GPV/EPI any relevant training materials and guidelines regarding logistics for planning and implementing campaigns with injectable antigens. EPI will use these materials to prepare generic guidelines. * Countries should document the cost of the measles supplemental activities. The cost analysis of campaigns conducted in Senegal and South Africa should be used as a basis for budgeting for measles campaigns in West, Central and East Africa. * During 1998 an in-depth evaluation of all logistical aspects of measles campaigns, with special emphasis on safety, will be conducted in two countries in Africa. Session 6 - Immunization service delivery Recommendations Recommendation 16: Technet recommends that the appropriate authorities and partners monitor the quality of immunization in each setting using key indicators of activity, process performance and/or outcome, and respond in order to sustain the benefits of immunization. Recommendation 17: A Technet subgroup consultation comprising experienced technical experts from WHO, UNICEF and other technical partners with experience in the newly independent states (NIS) should be convened to focus on technical and operational problems facing the routine immunization systems of the NIS and design coordinated strategies for their resolution. Recommendation 18: Technet recognizes and endorses the importance of integrating training in EPI and child health with Integrated Management of Childhood Diseases and other child health and public health initiatives, both within and outside WHO. Recommendation 19: Technet recommends the appointment of regional and national coordinators to support training activities and create strong training networks. Priority activity 11: Health sector reform (including the NIS) * Technet recognizes that the choice of health sector reform strategy and structure depends entirely on the local context and emphasizes the need to: - understand the effects of health sector reform and decentralization on immunization; - take every opportunity to ensure that the benefits of immunization are sustained. * An NIS subgroup of Technet should be convened. Its terms of reference, mode of operation, precise focus (such as injection safety; cold chain and logistics; training; curriculum development; vaccine procurement; monitoring; information, education and communication), composition, the periodicity of its technical consultations, and source of funding should be worked out at the earliest opportunity by the Technet secretariat in consultation with other interested technical and funding partners. (WHO to take the lead by the end of May 1998.) Priority activity 12: Training * To be optimally effective, training should be practice- and competency- based and should adopt a problem-solving approach to learning. Because of the demand for training of this type it is recommended that WHO headquarters adapt the Cold Chain Operations Management learning materials for wider use, and reproduce, translate and use them for future workshops. * A flexible, modular approach to materials design is advocated, so that courses can be constructed at local levels to meet specific learning needs. * Distance learning materials and methodologies should be developed and evaluated for EPI. * Mechanisms should be established to ensure that: - a process exists to translate all materials in a timely manner; - learning resources can be shared between countries, regions and headquarters; - there is wide dissemination of information regarding all EPI resources for teaching and learning; - there are easy methods available for finding EPI teaching and learning materials. * In order to promote the wide dissemination of materials, WHO and UNICEF country offices should ensure that provincial EPI offices are on the mailing lists for receipt of EPI materials. * Training can be adapted to become a powerful method of advocacy among decision-makers, especially politicians, donors and policy-makers. The feasibility of using training in this way should be actively explored. Session 7 - Logistics for surveillance Recommendations Recommendation 20: Considering the high priority given by EPI to improving surveillance performance, Technet recommends that logisticians at all levels and epidemiologists work more closely to strengthen logistics for surveillance. Recommendation 21: Considering the risk of contamination of vaccines when they are stored together with stool specimens from AFP cases, Technet recommends that specimens and vaccines should not be stored in the same refrigerator, freezer or cold box. Vaccine carriers used for specimen transfer should not be used subsequently for vaccine storage unless they have been disinfected in accordance with WHO recommended procedures. Priority activity 13: Logistics management in surveillance Specimen collection and transfer * Packaging for international and national air shipment of polio specimens should meet IATA and UN regulations on the transfer of infectious materials. WHO should work with courier services and packaging companies to assure that all countries have access to the means for shipping specimens correctly and at the lowest cost. * WHO should explore the possibility of using such mechanisms as the Onchocerciasis Control Programme (OCP) Inter-Country Agreement to facilitate the cross-border movement of specimens. TRANSMISSION OF SURVEILLANCE DATA Successful data communication depends primarily on management rather than technology. However, to facilitate data transfer at subnational levels the following steps should be taken. * Suitable radio communications equipment should be identified for voice and data communications between the periphery and the district level and the information should be disseminated in product information sheets. * Internet-based data communications should be established between the polio network laboratories, the WHO Regional Offices and the EPI national managers in the countries.


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