Polio and prevention
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Monthly situation reports
Newsletter - Polio News
All data as of 28 October 2008
NEJM publishes studies confirming feasibility of polio eradication
: On 16 October, two important studies affirming the technical feasibility of polio eradication were published in the New England Journal of Medicine. The studies evaluated the efficacy of monovalent oral polio vaccine type 1 (mOPV1) compared with trivalent OPV in northern Nigeria, as well as among newborn children in Egypt. Both studies found mOPV1 to be significantly more effective than trivalent OPV. The programmatic implications of these studies are significant. The seroconversion results indicate that mOPV1 has the capacity to rapidly stop this year's type 1 polio outbreak in northern Nigeria, if the quality of vaccination campaign operations is improved. At the same time, the results indicate that in key endemic areas – such as northern India – the immunity gap against type 1 in the youngest children (who are most vulnerable to polio) can be bridged more rapidly by mOPV1.More.
WHO DG and EMRO RD express concern over recent rise in polio cases in Pakistan
: WHO Director-General Dr Margaret Chan and Regional Director for WHO's Eastern Mediterranean Office Dr Hussein A Gezairy have expressed concern over the recent rise in polio cases affecting Pakistan. Addressing the health ministers from EMRO's 22 countries at the annual Regional Committee on 11 October in Cairo, Egypt, Dr Chan stated: "In Pakistan, we are now experiencing an outbreak in previously polio-free regions and outside the key endemic areas. This resurgence clearly demonstrates that polio eradication must be completed. Control is not an option." Dr Chan and Dr Gezairy also paid tribute to three polio staff members killed while on duty when a suicide bomb hit their convoy on 14 September as they were on their way to prepare for a polio immunization campaign. (See September monthly situation report for more.)
In 2008, 496 cases have been reported (59 type 1 and 437 type 3).
In western Uttar Pradesh, an aggressive response continues to the type 1 outbreak, with further campaigns to be held in November and December, following an October round. In total, six large-scale campaigns will have been conducted with mOPV1 in this area in the second half of 2008. Free of endemic type 1 polio for nearly 18 months, the core highest-risk districts of western Uttar Pradesh have recently experienced local spread of type 1 originally imported from Bihar.
In Bihar, catch-up campaigns were held in several districts which had not been covered during the recent activities in September, due to extensive flooding. As in western Uttar Pradesh, additional campaigns will be held in November and December.
With upcoming large-scale population movements expected in November between Bihar and Uttar Pradesh during the festival season, special transit vaccination teams are being deployed to major transit points and gathering sites.
Interrupting type 1 transmission in India this year remains a primary strategic objective of the Global Polio Eradication Initiative. Key to success is sustaining the political momentum which has brought India so close to eradicating type 1 polio. In 2008, 18 districts are infected with type 1 polio, compared to 40 districts for the same period in 2007 (a 55% reduction in type 1-infected districts).
In 2008, 736 cases have been reported (677 type 1 and 58 type 3).
In Nigeria, state-level analyses of operations are being conducted, based on performance during the most recent Immunization Plus Days, in August. The outcomes will drive operational planning for upcoming activities.
Convening in Abuja on 27-28 October, the Expert Review Committee on Polio Eradication and Routine Immunization (ERC) reviewed the current epidemiology and put forward key recommendations.
Despite the ongoing, large-scale type 1 outbreak affecting the north of the country, the ERC noted that 80% of this year's type 1 cases have been reported from six of the country's 37 states: Bauchi, Jigawa, Kaduna, Kano, Katsina and Zamfara.
While progress is evident in some of these states (notably Jigawa, which has reduced the proportion of 'zero-dose' children from 24% in 2007 to 4% in 2008), the ERC expressed concern at the ongoing significant operational challenges which continue to mar the quality of polio campaigns in other states. In Kano, 33% of children have never been vaccinated, a proportion unchanged since 2007.
Among other major recommendations, the ERC called for enhancing the engagement of state governors and – through them – the local government area chairpersons, particularly in Kano and Zamfara (which together account for 50% of cases this year). The group noted that in areas where strong state and local engagement is evident, the operational quality of polio campaigns improved significantly.
Pakistan and Afghanistan
In 2008, 87 cases have been reported in Pakistan (63 type 1 and 24 type 3); and 22 cases have been reported in Afghanistan (17 type 1 and five type 3).
In Afghanistan, National Immunization Days (NIDs) held on 19-21 October focused on increasing access to all populations, particularly in security-compromised areas of the Southern Region. Polio is largely restricted to the Southern Region (where 20 of this year's 22 cases occurred).
To address the recent increase in new polio cases in Pakistan, an urgent consultation of experts convened in Cairo, Egypt, on 10 October. Since July, type 1 polio has spread into previously polio-free areas of the country, notably Punjab and Islamabad, causing an outbreak of 25 type 1 cases in Punjab and three type 1 cases in Islamabad. The group also noted a similar increase in type 3 cases in North West Frontier Province (NWFP), particularly in Peshawar.
The urgent consultation noted that the spread of polio was due to a combination of factors, including: deteriorating security in known endemic areas (resulting in increased population movements); an increased susceptibility of populations in areas free of the disease due to a lower number of SIAs during the last 12 months; suboptimal vaccination coverage in key areas; and, an immunity gap for type 3 virus in key districts of NWFP due to the suboptimal vaccination coverage noted above, and compounded by the emphasis given to the use of mOPV1 in these same districts.
The group recommended key strategic interventions, including: increasing the number of nationwide campaigns using tOPV to protect children across the country; optimizing outbreak response in recently re-infected areas using mOPVs as appropriate; and, increasing the quality of activities in the known transmission zones (in particular in those areas which are accessible but continue to be marred by operational challenges, such as Sindh).
In line with these recommendations, a campaign which had initially been planned as subnational was expanded to cover the entire country, and was conducted on 13-15 October.
Officially launching the activity, Federal Minister for Health Sherry Rehman emphasized the need for public commitment, stating: "All of us have to play our role to turn the dream of a polio-free Pakistan into reality."
Despite innovative new tactics to reach all children (including use of newly-created 'polio control centres' with key television channels, allowing families not visited by vaccination teams to call in for corrective action), indications are that large areas of the Federally Administered Tribal Areas/NWFP were again inaccessible due to insecurity.
In 2008, 25 cases have been reported, two type 1 and 23 type 3.
Outbreak response activities are continuing. Following activities with mOPV3 in September, NIDs were held on 24-26 October (using mOPV1), and nationwide 'accelerated routine immunization activities' are planned for November and December 2008. 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, two cases have been reported (both type 1). Three nationwide campaigns have been held, the latest on 19 September, and two further campaigns are being planned for 24-30 November (combined with measles) and 18-21 December 2008. The risk of further importations from both Chad (to the north) and the Democratic Republic of Congo (to the south) remains high.
In 2008, 26 cases have been reported (one type 1 and 25 type 3).
Chad is affected by both type 1 and type 3 circulation. With suboptimal outbreak response activities implemented in 2008 (in quality, scope and timeliness of activities), the risk of further spread of polio within Chad and internationally is high.
On 15-16 October, the Technical Advisory Group on Polio Eradication (TAG) convened in N'Djamena, to urgently review the situation. The group put forward key recommendations, including: improved microplans; aggressive interspersed utilisation of mOPV1, mOPV3 and trivalent OPV; outbreak response within 30 days of confirmation of any further polio cases; and systematically re-vaccinating any area where more than 5% of the population has been missed during previous campaigns.
The group also identified the need for stronger high-level political ownership and engagement, beginning with the President's office downward. It is strong political ownership at every level which will ensure that operations are improved (upwards of 40% of children were regularly missed during campaigns).
The TAG recommendations were presented to the Prime Minister, who expressed concern and provided assurance of increased government commitment towards polio eradication.
Democratic Republic of the Congo
In 2008, four cases have been reported (all type 1). With the most recent case in early August, outbreak response activities are ongoing, with focus on areas along the Congo River, and border areas of South and North Kivu to prevent further spread of polio into CAR or Uganda, Burundi and Rwanda.
Upcoming immunization activities may be affected by the increasing insecurity and associated large-scale population movements, particularly in the two Kivu provinces.
Horn of Africa
In 2008, ten cases have been reported (one type 3 in West Darfur, Sudan; and nine type 1s from the southern Sudan/western Ethiopia area).
Further outbreak response campaigns are planned for late October/late November across northern Sudan and the southern Sudan/western Ethiopia area, using a mix of mOPV1 and trivalent OPV.
The overriding priority is to stop the type 1 outbreak in southern Sudan/western Ethiopia. The outbreak here has continued to spread geographically, due to ongoing vaccination coverage gaps during campaigns. The key challenge remains accessing all populations (including those living in insecure areas and remote areas).
In 2008, five cases have been reported (all type 3). Nepal remains at risk of importations from India, and continues to conduct preventive immunization activities.Seven cases have been reported in the Horn of Africa this year (six cases from the southern Sudan/western Ethiopia cross-border area, and one case in West Darfur, Sudan).
In 2008, 18 cases have been reported (all type 1: two in Benin, one in Burkina Faso, two in Ghana and 13 in Niger).
West Africa continues to be at risk of international spread of polio from northern Nigeria. Confirmation this month of two polio cases in Ghana (previously polio-free since 2003) further underscores this risk. In 2003-2004, poliovirus originating from northern Nigeria spread to re-infect eight countries across west Africa (Benin, Burkina Faso, Côte d'Ivoire, Ghana, Guinea, Mali, Niger and Togo).
Cross-border outbreak response campaigns are continuing in late October and November in Benin, Burkina Faso, Mali and Niger. Outbreak response plans for Ghana have been finalized; the first round will be held on 13-15 November, and the second on 11-13 December 2008.
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.
The Global Polio Eradication Initiative
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