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February/March 2009

All data as of 10 March 2009

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Headlines

Sudan outbreak raises polio alarm: An outbreak of wild poliovirus type 1, previously restricted to southern Sudan and western Ethiopia, has spread to northern Kenya, northern Uganda and northern Sudan (Khartoum and Port Sudan). The report of a case in Port Sudan is particularly concerning, given it was from this port city that an outbreak spread to Saudi Arabia, Indonesia, Somalia and Yemen in 2004-06, resulting in 1,200 cases and requiring more than US$150 million in international emergency outbreak response costs. WHO has informed its Member States of the high risk of international spread of the disease. Locally, detection of the case has sparked urgent and immediate outbreak response activities in the affected areas and heightened surveillance in countries at risk. More
Nigerian governors commit to end polio: A landmark public commitment signed on behalf of Nigeria's 36 state governors by the Ministry of Health and the Chairman of the Executive Governors' Council has pledged to hold Local Government Authorities (LGAs) accountable for the performance of their eradication programs. In 2008, the New England Journal of Medicine reported that if 90% of children under five in Nigeria each received three polio vaccine doses, polio transmission would be stopped. On 2 February in Abuja, with Bill Gates Jr. in attendance, the governors recognized the urgent need to tackle the ongoing coverage gaps, signing the historic "Abuja Commitments to Polio Eradication in Nigeria" in a public pledge to mobilize the state and LGA civil administrations to reach the necessary 90% coverage target.
Pakistan Prime Minister takes lead on polio: On 26 February, Prime Minister Syed Yousaf Raza Gillani launched a Polio Action Plan, with the immediate aim of assuring inter-sectoral support for polio eradication. Key representatives from ministries including the Ministry of Interior, Ministry of Information, Ministry of Religious Affairs, Ministry of Education and Ministry of Railways attended the meeting to ensure a co-ordinated approach to polio eradication. The PM also directed the Ministry of Health (MoH) to gear up its efforts to keep all stakeholders on board and asked MoH representatives to launch an effective media campaign to raise awareness about the repercussions of failing to be immunized.

Endemic Countries

Nigeria

In 2009, 51 cases have been reported in 32 infected districts - 25 of these are wild polio virus type 1 cases, 25 are type 3, and one is type 1/3.
The ongoing type 1 outbreak in the north of the country continues to spread, while new outbreaks have been recorded in central Nigeria and in the Ogun and Lagos districts of the south-west.
The total number of cases for 2008 is 801 (727 type 1, 73 type 3 and one type 1/3 mixture).
Nigeria joined six neighbours in a cross-border synchronised immunization campaign from 27 February - 2 March in re-infected countries in west Africa (Ghana's immunization day took place on 12 February). Nigeria immunized 25 million children with monovalent oral polio vaccine type 1 (mOPV1) in 15 states and selected high-risk areas. The next Immunization Plus Days (IPDs) are scheduled for 27-30 March, using mOPV1. Further IPDs using trivalent OPV (tOPV) are scheduled for May.
New associated cases continue to be reported from neighbouring countries.
The GPEI is also assisting medical authorities in their response to a meningococcal meningitis epidemic in Nigeria. Polio surveillance units have already proven essential in identifying and recording meningococcal cases, while epidemiological and technical staff have been provided to assist in the epidemic response.

India

The total number of cases for 2009 is 17 (eight type 1, nine type 3), compared to 82 at this time last year. The most recent case had onset of paralysis on 16 February (type 1 from Barabanki, Uttar Pradesh (UP)). The total number of cases for 2008 is 559 (75 type 1, 484 type 3).
No new type 1 polio cases have been reported in western UP in the past four weeks, signalling the significant decline of the outbreak that occurred following an importation from Bihar in 2008.
India held a National Immunization Day (NID) on 1 February, using mOPV1 in Bihar, Uttar Pradesh and key re-infected areas, and tOPV in the rest of the country.
A sub-national vaccination campaign, targeting 73.9 million children, took place on 1 March in Uttar Pradesh, Bihar, and high-risk areas of other states using mOPV1. Monovalent oral polio vaccine type 3 (mOPV3) was also administered in some selected areas.
Twenty-six senior surveillance medical officers (SMOs) from polio-free regions of India have volunteered to spend two months in Uttar Pradesh and Bihar assisting the 180 SMOs already on the ground in ensuring optimum delivery of upcoming immunization rounds.
Two type 1 cases reported in the Araria district of Bihar - precariously close to the border with polio-free Nepal - have caused concern, as it was from this area that a multi-case type 1 outbreak occurred two years ago. However, it is hoped a rapidly implemented block-level response, with 70,000 children immunized within 10 days of the first case being reported, will help to interrupt this local transmission.
Key new appointments have been confirmed within the Ministry of Health & Family Welfare in the Union Government. Mr Amit Mohan Prasad, Joint Secretary, has been assigned the portfolio that includes polio eradication, whereas Ms S.D. Gamlin will look after the Universal Immunization Program.

Pakistan

In Pakistan, the total number of cases for 2009 is eight (four type 1, four type 3). The total number of cases for 2008 remains 118 (81 type 1, 37 type 3). The most recent case had onset of paralysis on 11 February (WPV3 in Karachi).
An SIA took place from 9-11 February using mOPV3 in north Punjab (six districts with three million children targeted) and central NWFP (more than three million children targeted). A mop-up took place from 23-25 February, using mOPV1, in targeted areas of Karachi (2.3 million children) and parts of four districts of central Punjab (1.2 million children).
It is hoped that two targeted mOPV1 rounds can be quickly completed in the conflict-affected Swat Valley, using the window of the current ceasefire.
The next NID is scheduled for 16-18 March, using tOPV.
The security situation in North-West Frontier Province remains unstable, with 96,851 children classified as "inaccessible" in the eight districts targeted this month. On 9 February, a strategic mop-up campaign immunized 1,964,958 children in four "accessible" and four "inaccessible" districts. Overall, it was determined that 45,661 (47%) of the "inaccessible" children were immunized, with immunizers reaching 86% of the "inaccessible" target population in Peshawar and 50% in Charsadda. However, FR-Kohat and Kyber were unable to undertake immunizations due to ongoing fighting in the area.
On 15 February, Swat Valley militants declared a ceasefire, although this has yet to translate into safe passage for immunizers.
Pakistan's weekly Polio Journal reports that 42 religious leaders from throughout the country met in the last week of February to address the challenge of strengthening routine polio immunization. The religious leaders reinforced their commitment to help ensure community demand for polio immunization.

Afghanistan

The total number of cases for 2009 is four (all type 1), while the total number of cases for 2008 remains 31 (25 type 1, six type 3). The last reported case had onset of paralysis on 6 February (type 1 from Hilmand Province)
The next NIDs are planned for 15-17 March using tOPV, with a supplementary national immunization day (SNID) to follow on 12-14 April, using mOPV1 and mOPV3.
A national polio staff meeting, with the Ministry of Health, WHO, UNICEF and many leading NGOs participating, was held on 16-17 February in Kabul. Described as very helpful, the meeting focused on fine-tuning activities to overcome access problems in the south.
A cross-border meeting held on 10-11 February between Federal and Provincial government representatives from both Pakistan and Afghanistan, together with representatives of WHO, Rotary International and UNICEF addressed the remaining operational issues in delivering optimum immunization along the border and transit routes.

Re-infected countries

West Africa

The total number of cases for West Africa in 2009 is 13 (type 1: two in Benin, four in Burkina Faso, three in Togo, one in Mali, type 3|: three in Niger).
In 2008, 41 cases have been reported from seven countries (type 1: four in Benin, six in Burkina Faso, one in Cote d'Ivoire, eight in Ghana, one in Mali, 13 in Niger and three in Togo; type 3: one in Benin and four in Niger). The new case in Cote d'Ivoire is the first case in the country since 2004.
A seven-country synchronized cross-border immunization campaign was held across west Africa from 27 February-2 March (Ghana conducted its first-round immunization day on 12 February), with a second round from 27-30 March. More than 28 million children from Benin, Burkina Faso, Cote d'Ivoire, Mali, Niger and Togo joined the 25 million children being immunized with mOPV1 in 15 states in Nigeria.

Horn of Africa

In 2009, 16 cases have been reported, all type 1. Of these cases, 11 are from Sudan, two from Kenya and three from Uganda.
In 2008, 29 cases were reported from two countries (27 type 1 from the southern Sudan/western Ethiopia cross-border area; two type 3 in West Darfur, Sudan).
In Turkana north, along Kenya's Rift Valley, close to the border with southern Sudan, a two-year-old girl was confirmed as Kenya's first poliovirus case since 2006. (The 2006 cases were localized in the Dadaab refugee camp in North Eastern province and were an importation from neighbouring Somalia.) Prior to that, Kenya had not had a wild polio virus case for 24 years.
Kenya's Ministry of Public Health immediately dispatched an expert team to conduct a detailed case and epidemiological investigation. The team observed trucks full of Sudanese families crossing the border to seek available medical care in Kenya, and found that the immunity profile of the Turkana North community was sub-optimal, thereby facilitating the outbreak.
Kenya held mop-up campaigns from 1-5 March throughout Turkana as an immediate response, using mOPV1.
Sudan held SIAs on 26 January and 23-25 February. A further immunization campaign is scheduled in northern and southern Sudan from 23-25 March, using tOPV.
On 1 February, Uganda recorded its first case of poliovirus since 1996 - in Amuru district, close to the southern Sudan border. Sequencing data has shown that this virus is genetically closely linked with a virus circulating in southern Sudan. Two outbreak response rounds, in late March and late April, are planned in the 25 high-risk districts, with a target of 1,719,714 children. A NID, probably combined with measles immunization, will be held in April.
On 26-27 February, the HOA Technical Advisory Group met to urgently address the polio outbreak in the region. The TAG noted that all countries in the HOA were at significant risk of outbreak, and called upon the Governments of HOA countries to make polio eradication a top priority until the current outbreaks were stopped and the risk of further spread gone. The TAG stressed that every effort must be made to improve the quality and reach of SIA rounds, and that co-ordination between countries was critical to an effective response.
This meeting followed the HOA co-ordination meeting, which focused on the need to improve the exchange of information at the local level - sharing maps, population movements, etc - to better control the flow of people across border areas.
In Chad, while no poliovirus cases have been reported in 2009, suboptimal outbreak response activities implemented in 2008 (in quality, scope and timeliness) and subnational surveillance gaps means the risk of further spread of polio within Chad and bordering countries is high. In Chad in 2008, 36 cases were reported (two type 1 and 34 type 3).
In Chad, a sub-national immunization campaign was held on 23 February, using tOPV.

Central Africa (Angola, DR Congo and CAR)

Thus far, only one case has been reported in 2009 (WPV1 from Benguela, Angola). In 2008 in Angola, 29 cases were reported: five type 1 and 24 type 3.
In Angola, small-scale mop-ups will be held in key areas of Benguela and Luanda in April and May, with nationwide rounds being held in June and July.
The 5th meeting of the Technical Advisory Group (TAG) on polio eradication in Angola, DRC, Namibia and Zambia was held in Luanda on 23-24 February, and noted that while last year's immunization response prevented major outbreaks, transmission of both type 1 and 3 polio continued. The TAG created a supplementary immunization activity schedule which, if fully implemented and vaccination coverage gaps can be filled, will stop transmission of the imported viruses.
To date, DRC has reported no polio cases in 2009. In 2008, DRC reported five cases (four type 1 and one type 3). SIA rounds are planned from April to July to cover Bas Congo, Kasai Oriental and Occidental, Maniema, South and North Kivu, Bandundu and parts of Oriental Province.
Preventive campaigns are being carried out in the west of Uganda, Burundi and Rwanda, to prevent spread of WPV1 from DRC. There is large-scale movement of refugees from DRC in particular into Uganda.
Central African Republic (CAR) has reported no cases in 2009. Three cases were reported in 2008 (all type 1), with the most recent having onset of paralysis on 30 December. The risk of further importations from Chad (to the north), DRC (to the south) and southern Sudan (to the east) remains high. Two additional rounds using tOPV have been planned for March and April 2009.

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.