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August 2008

All data as of 26 August 2008

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Headlines

Nigeria outbreak increases global eradication budget: The Global Polio Eradication Initiative has published, revised increased budget figures for 2008-2009. The budgetary increases relate primarily to emergency outbreak response activities in Nigeria and across west and central Africa, due to the new type 1 polio outbreak spreading from northern Nigeria (see 'Nigeria' section below, for more). As at August 2008, the two-year global funding gap now stands at US$ 355 million, of which US$ 90 million is needed this year. In addition to taking into account the increase in budgetary requirements, these latest funding gap figures also reflect US$ 190 million in new contributions by development partners, including US$ 150 million by the Bill and Melinda Gates Foundation. More.
Pakistan responds to increase in polio cases: the Government of Pakistan is strengthening its capacity to respond to the recent increase and geographic spread of polio cases. Federal Minister for Health Sherry Rehman called for closer involvement of provincial and district leadership, as well as cross-ministerial engagement, including between the health, education and family welfare departments, to ensure all sections of the administration are channelled appropriately to increase operational quality of polio campaigns. At the same time, the provincial Sindh government is now placing the responsibility for polio eradication directly onto district-level governments. Pakistan has recently experienced spread of poliovirus to polio-free areas, including Islamabad and Punjab. See 'Pakistan' section below for more.

Country Focus

India

In 2008, 372 cases have been reported (16 type 1, 355 type 3, and one type 1/type 3 co-infection).
Five additional type 1 polio cases have been reported from western Uttar Pradesh, including one from Moradabad district (historically the highest-risk district for type 1 transmission in the country). These latest cases represent local transmission of the type 1 polio originally imported into Badaun from Bihar. The core highest-risk districts of western Uttar Pradesh had previously been free of type 1 polio for more than 12 months.
All efforts are now being made to stop the importation and prevent the further spread of type 1 polio into other areas, particularly within western Uttar Pradesh. The Government of India has launched an aggressive and appropriate mop-up outbreak response strategy, to respond to recently-detected polio cases.
Large-scale mop-ups with type-specific monovalent OPVs are being conducted throughout August and September across Uttar Pradesh and Bihar, as well as recently re-infected areas (Andhra Pradesh, Assam, Haryana and West Bengal).
Technical support is being scaled-up from low-risk areas of the country to support these activities, in efforts to ensure the highest-possible quality.
To urgently interrupt the only remaining indigenous type 1 polio transmission in the country – in access-compromised areas of Bihar state (such as the Kosi river basin) – specific strategies to reach all populations continue to be implemented.
Interrupting type 1 transmission in India this year remains a primary strategic objective of the Global Polio Eradication Initiative.

Nigeria

In 2008, 597 cases have been reported (547 type 1 and 49 type 3).
The highest number of type 1 polio cases in any state in the country this year are from Kano (204 of 547 type 1 cases).
With recent confirmation of a polio case in Burkina Faso caused by wild poliovirus with origin in northern Nigeria, the current type 1 outbreak affecting northern Nigeria threatens to spread further. Transmission of the virus remains intense, and large-scale population movements are expected for the upcoming Hajj season (pilgrimage to Mecca, Saudi Arabia).
To minimise the risk of international spread and as part of urgent efforts to stop the current type 1 outbreak, the Government of Nigeria has recently established high-level Task Forces, to rapidly overcome the operational challenges which continue to mar polio campaigns, and to ensure that state and local government leaders are held accountable to polio eradication efforts.
While this restructuring is encouraging, it must now translate urgently into improvements in campaign quality.
Further efforts must be made to achieve operational improvements, including better vaccinator selection and supervision, enhanced and coordinated social mobilization efforts, and increased use of independent out-of-house monitoring of activities.

Pakistan and Afghanistan

In 2008, 37 cases have been reported in Pakistan (30 type 1 and 7 type 3); and 15 cases have been reported in Afghanistan (10 type 1 and 5 type 3).
In Afghanistan, in preparation for the most recent National Immunization Days (NIDs) conducted on 3-5 August, efforts focused on involving all levels of civil society and increasing community engagement. In Nangarhar province for example, in the east of the country, more than 200 eminent religious leaders from all districts convened and agreed to disseminate messages in support of polio eradication to their communities.
As a result of such efforts in key high-risk provinces and areas, a higher proportion of children were accessible during these latest NIDs than in previous rounds, including in parts of the Southern Region.
In Pakistan, Federal Minister for Health Sherry Rehman expressed grave concern over the recent increase and geographic spread of polio cases. As a result, the Government is exploring ways to increase cross-ministerial collaboration, and increase ownership and accountability by the district-level political leadership. See 'Headlines' section above, for more.
The recent spread of polio into previously polio-free Islamabad and Punjab (importations from conflict-affected areas of North West Frontier Province – NWFP) is of great concern as these areas have been polio-free for over a year and they were only subjected to four NIDs in the last 12 months. It further underscores the risk the indigenous polio circulation in the known transmission zones continues to pose to Pakistan's children throughout the country.
The primary indigenous polio transmission zones are in NWFP, Balochistan and Sindh. While circulation in Balochistan and NWFP is primarily sustained by mobile populations and populations living in areas of insecurity, the resurgence of polio in Sindh this year is primarily as a result of significant operational challenges, which continue to hamper the quality of polio campaigns.
The programme is reviewing the planned SIA required to restore control over transmission outside the primary transmission zones and to achieve the target of cessation of transmission from Pakistan in early 2009.

Re-infected countries

Angola

In 2008, 25 cases have been reported, 2 type 1 and 23 type 3. Recent confirmation of a type 3 case in the previously polio-free province of Moxico in the east of the country indicates widespread geographic transmission of this serotype. Efforts must be strengthened to prevent the re-infection of neighbouring countries, including Zambia (which is polio-free) and the Democratic Republic of the Congo (which is currently affected by type 1 polio, but not type 3 polio).
In response, the Government of Angola – following suggestions by the recently-convened Technical Advisory Group (TAG) – is instigating a scaled-up outbreak response. In addition to house-to-house mop-up campaigns in re-infected and high-risk areas in September and October, the country is organizing nationwide 'accelerated routine immunization activities' in August, November and December. During such activities, a range of vaccines – including trivalent OPV – will be offered to communities using a 'fixed vaccination site' approach.

Central African Republic (CAR)

In 2008, one case has been reported (type 1). In response, the country held three nationwide campaigns, the latest of which was held on 22 August. The risk of further importations from both Chad (to the north) and the Democratic Republic of the Congo (to the south) remains high.

Chad

In 2008, 12 cases have been reported, all type 3. The most recent case had onset of paralysis on 1 June.
While immunization campaigns continue to be phased to allow for concentration of technical support to highest-risk areas (using windows of opportunity, as areas become accessible), the quality of operations remains suboptimal. In some areas – including accessible districts of N'Djamena, for example – upwards of 40% of children are missed during campaigns.
With active transmission of polio continuing both in the west and the east of the country, the risk of further spread of polio internationally either to Sudan or to CAR remains high.
Key to rapidly increasing the quality of operations is high-level, local government ownership and engagement.

Democratic Republic of the Congo

Three cases have been reported this year, all type 1.
Large-scale outbreak response activities continue. The Technical Advisory Group held in Luanda recommended intensified surveillance and operational improvements to stop the low-level transmission in the country. Campaigns will focus on areas along the Congo river, and also border areas in the east and north of the country, to prevent further spread of polio into neighbouring countries such as CAR and Uganda.

West Africa (including Benin and Niger)

In West Africa, 16 cases have been reported this year (two from Benin, one from Burkina Faso and 13 cases from Niger).
The confirmation of a polio case in Burkina Faso (with origin in northern Nigeria), the first in the country since 2004, underscores the risk of further international spread of polio from northern Nigeria. It is from these areas of west Africa that poliovirus originating from Nigeria spread further across west Africa in 2003-2004, re-infecting – among others – Côte d'Ivoire, Ghana, Guinea and Togo.
A further synchronized, cross-border outbreak response campaign in the region is currently being planned, following campaigns held in June and July.

Horn of Africa

Five cases have been reported in the Horn of Africa this year (four cases from the southern Sudan/western Ethiopia cross-border area, and one case in West Darfur, Sudan).
Convening in Ethiopia in July, the Horn of Africa TAG recommended an aggressive outbreak response strategy, for both the southern Sudan/western Ethiopia cross-border area, as well as in the Darfur provinces of Sudan. Efforts are focusing on preventing further spread of the virus, particularly ahead of the upcoming Hajj season.

Nepal

In 2008, five cases have been reported (all type 3). Genetic sequencing recently confirmed polio cases indicates new introductions of type 3 polio from India, rather than continuation of transmission within Nepal of previously-introduced viruses. Nepal remains at risk of importations from India.
Emergency mop-up campaigns were conducted in early August in/around the newly-infected area, with further activities to be held in September and October.

Polio eradication will only succeed if the necessary funds are made available, and with strong political commitment in polio-affected countries. More than 10 million children will be paralysed in the next 40 years if the world fails to capitalize on its >US$5 billion global investment in eradication.