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SEA-Immun-98
Distribution: General
External 3-Month Assessment:
cVDPV2 Outbreak Response
Myanmar, March 2016
© World Health Organization 2016
All rights reserved.
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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)
External 3-Month Assessment: cVDPV2 Outbreak Response
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
Source: WHO South-East Asia Region data as of March 2016
3. Methodology of the outbreak response
assessment
WHO and UNICEF, in close coordination with the Ministry of Health,
conducted an external assessment from 28 March to 5 April 2016 in
Myanmar, to evaluate the effect of outbreak response in interrupting the
polio virus transmission activities according to World Health Assembly
resolution WHA59.1 in 2006. Five teams comprising experts from WHO
and UNICEF headquarters, regional offices, country office and officials from
the Ministry of Health, Myanmar, visited the following states/townships:
(1) Rakhine state, Maungdaw township
(a) Dr Abu Obeida Babiker (UNICEF-EAPRO)
(b) Dr Ye ZinZin (WHO-Myanmar)
(c) Dr Htet Arkar Win (UNICEF-Myanmar)
(d) Dr Aye Mya Chan Thar (MoH-Myanmar)
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
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?
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
7
Figure 2: SIA response to cVDPV2 outbreak
Source: WHO South-East Asia Region data as of March 2016
The availability of tOPV was adequate for implementing four 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.
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
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).
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
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
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
15
Figure 3: National RI coverage, 2015
Source: WHO South-East Asia Region data as of March 2016
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%
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
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.
External 3-Month Assessment: cVDPV2 Outbreak Response
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