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January 2009

All data as of 27 January 2009

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Headlines

Donors commit more than US$630 million in new funding for polio eradication: On 21 January, the Bill & Melinda Gates Foundation and Rotary International announced a joint financing commitment of US$355 million towards the global effort to eradicate polio. Bill Gates, co-chair of the Bill & Melinda Gates Foundation, said, "Rotarians, government leaders and health professionals have made a phenomenal commitment so polio afflicts only a small number of the world's children. Rotary in particular has inspired my own personal commitment in achieving eradication." In addition, the governments of the United Kingdom and Germany are giving US$150 million and US$130 million, respectively, to the Global Polio Eradication Initiative.
WHO Executive Board calls for intensified action for polio eradication: On 26 January, WHO's governing body called for Afghanistan, India, Nigeria, and Pakistan to make polio eradication their top operational priority in 2009 and to report to the World Health Assembly (WHA) in May on their progress. Member states supported the Director-General's proposal to conduct an independent review of program implementation in the endemic countries to determine the remaining barriers to stopping transmission. The Board called for the Director-General to report on the findings of the independent review and how they will guide next steps for the polio eradication initiative at the WHA in May. The Board also highlighted concerns about re-infection of polio-free countries and called for additional measures to prevent the importation of case.

Endemic Countries

Nigeria

In 2008, 791 cases have been reported (721 type 1, 69 type 3, and one type 1-type 3 co-infection).
The ongoing type 1 polio outbreak in the north of the country continues to spread, as new associated cases are reported from neighbouring countries in west Africa (see 're-infected countries' section below). The risk of additional importations into these countries depends fully on the quality of supplementary immunization activities (SIAs) in northern Nigeria.
In late November/early December, nationwide staggered integrated measles campaigns with monovalent oral polio vaccine type 1 (mOPV1) were conducted.
While monitoring data indicate overall good quality was achieved in the southern states, the activity in highest-risk northern states was again affected by suboptimal quality (eg inadequate vaccinator and supervisor performance, poor microplanning, etc), in particular in the highest-risk Local Government Areas (LGAs) of Bauchi, Kano, Kaduna, Katsina and Zamfara. Upwards of 60% of children in these states remain under-immunized (ie, ≤3 doses of OPV), and these areas account for more than 70% of the country's type 1 cases.
Kano State remains the global epicentre of type 1 polio, accounting for nearly 30% of the worldwide type 1 burden.
While Nigeria benefits from a re-invigorated high-level political commitment at the national level, it is urgent that this renewed commitment be rapidly and fully translated into operational improvements to the quality of activities in all high-risk states in the north. Key to achieving this is increased political engagement at state- and LGA-level. In Jigawa state, where this type of engagement occurred in 2008, marked improvements in the quality of operations have been seen.
The next nationwide Immunization Plus Days (IPDs), originally scheduled for 24-27 January, have been postponed by one week. The activities will be launched on 31 January, using mOPV3, except in Lagos, where mOVP1 will be used due to recent type 1 transmission there.

India

In 2008, 556 cases were reported (73 type 1 and 483 type 3). In addition, the first case of 2009 in India has been reported: a type 1 from Uttar Pradesh.
Aggressive outbreak response is continuing in western Uttar Pradesh, to stop an ongoing type 1 polio outbreak. Virtually all type 1 polio reported from India over the past six months is related to this ongoing outbreak. Western Uttar Pradesh had been free of endemic type 1 polio for nearly 18 months before being re-infected in mid-2008 from neighbouring Bihar state.
The next NID round will be launched on 1 February, following NIDs held on 21 December. Monvalent OPV1 will again be used in Bihar, Uttar Pradesh and key re-infected areas, and trivalent OPV in the rest of the country. For this round, key activities are focusing on identifying and immunizing children among migrant labour groups, particularly in migrant destinations (eg, Delhi, Mumbai, Punjab, and Gujarat).
Key new appointments have been confirmed within the state governments of both Uttar Pradesh and Bihar. In Uttar Pradesh, Mr Pradeep Shukla has been appointed new Principal Secretary of Health, Mr Lalit Verma in the new Secretary of Health and Chanchal Kumar Tiwari is new Secretary of Family Welfare. In Bihar, Bhanu Pratap Sharma has been appointed as new Secretary of Health.

Pakistan and Afghanistan

In 2008, 118 cases have been reported in Pakistan (81 type 1 and 37 type 3); and 31 cases have been reported in Afghanistan (24 type 1 and seven type 3). The first case of 2009 in Pakistan has been reported (a type 3 case in Punjab).
Monitoring data from the most recent National Immunization Days (NIDs) in Afghanistan held on 11-13 January indicates good overall quality; however, key high-risk areas in the security-compromised Southern Region were again inaccessible (upwards of 200,000 children could not be reached).
The next NIDs in Afghanistan are planned for 15-17 March.
Dr. Hussein A. Gezairy, Regional Director for the WHO Regional Office for the Eastern Mediterranean (EMRO), travelled to Afghanistan and Pakistan for a high-level polio visit 9-11 January. In Kabul, Dr. Gezairy was received by HE President Hamid Karzai and the president's advisor on health and education and the Minister of Health. Dr. Gezairy also paid tribute to the heroic efforts of health workers in Afghanistan to eradicate polio under very challenging and dangerous circumstances.
In Islamabad, Dr. Gezairy attended the inaugural meeting of the Inter-provincial Committee on Polio Eradication, an oversight body to systematically foster district-level ownership and accountability. This oversight group was launched by the new Federal Minister of Health Mir Aijaz Hussain Jakhrani in December 2008.
Pakistan's high-level political support was in strong evidence during the country's NIDs on 19-21 January. The Federal Health Minister monitored the campaign implementation in rural areas of Islamabad and administered polio vaccine to children. The provincial Health Ministers of Balochistan and Sindh inaugurated the campaigns in Quetta and Sukkur, respectively. As a clear sign of increasing inter-sectoral engagement, the Education and Industry Ministers jointly inaugurated the activities in Peshawar. And the Chairman of the Task Force for Polio Eradication in Punjab, established by the provincial Chief Minister, launched the campaigns in Lahore.
As a result of such renewed political engagement, important operational improvements in key areas have been noted. However, ongoing coverage gaps must be filled in the transmission zones of NWFP and some parts of Sindh and Balochistan. In NWFP/FATA, initial data from these latest NIDs suggests upwards of one million children were again inaccessible due to a combination of insecurity and heavy snowfall. This represents 18% of the provincial target population. Negotiations among all parties is ongoing, and an initial catch-up campaign to reach 315,000 of these missed children in key districts took place 26-28 January.

Re-infected countries

West Africa

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.
The confirmation of new polio cases in Benin, Burkina Faso, Cote d'Ivoire, Ghana and Togo underscores the fact that west Africa continues to be at risk of international spread of polio from northern Nigeria. The risk of further circulation or additional importations into these western African countries depends fully on the quality of SIAs in northern Nigeria and of the outbreak response activities in the re-infected countries themselves.
Seven-country synchronized cross-border campaigns are planned for February and March in the re-infected countries, in coordination with Nigeria.
It is important that countries across west Africa strengthen disease surveillance for acute flaccid paralysis (AFP), in order to rapidly detect any poliovirus importations and facilitate a rapid response.

Chad

In 2008, 36 cases have been reported (two type 1 and 34 type 3).
The most recent cases are from the south of the country, close to the border with Central Africa Republic. Chad is affected by widespread geographic transmission of both type 1 and type 3, including in the east of the country (bordering Sudan), the south (bordering CAR) and the west (bordering Cameroon and Nigeria).
With suboptimal outbreak response activities implemented in 2008 (in quality, scope and timeliness), and subnational surveillance gaps, the risk of further spread of polio within Chad and bordering countries is high.
The key remains to urgently improve the quality of operations, as upwards of 40% of children were regularly missed during activities in 2008. Full political engagement and accountability, beginning with the President's office downward, is urgently needed.
Immunization campaigns planned for 26 January (measles campaign to which trivalent OPV will be added) have been postponed until early February.

Horn of Africa

In 2008, 29 cases have been reported from two countries (27 type 1 from the southern Sudan/western Ethiopia cross-border area; two type 3 in West Darfur, Sudan).
Immunization campaigns are currently underway in southern Sudan, using mOPV1. Increasing access to all populations in remote areas and in areas of insecurity remains the overriding challenge. Further activities are scheduled nationwide in both northern and southern Sudan in February and March.
In Ethiopia, OPV was added to a staggered measles campaign throughout December. The campaign continues to the end of January.

Central Africa (Angola, DR Congo and CAR)

In Angola, 28 cases have been reported in 2008, four type 1 and 24 type 3.
The most recent type 1 case is the first in the country since September, and the first type 1 in Luanda since January 2008. Genetic sequencing is ongoing to determine if it is a new importation, or ongoing circulation of the previously imported type 1.
An SIA schedule for the first half of 2009 is currently being finalized.
In the Democratic Republic of Congo (DR Congo), five cases have been reported in 2008 (four type 1 and one type 3).
A second-round mop-up with mOPV3 in the south (Kasai Occidental) was launched on 20 January, following an initial mop-up in December, in response to the recently confirmed type 3 case in the province. In the east of the country, outbreak response with mOPV1 is continuing, with the next campaign planned for early February.
A circulating vaccine-derived poliovirus type 2 (cVDPV) outbreak has been confirmed, with 11 cases. A response is currently planned, to conduct two large-scale rounds with trivalent OPV in the infected area in February and March.
Additionally, preventive campaigns are being carried out in the west of Uganda, Burundi and Rwanda, to prevent spread of type 1 polio from DR Congo. There is large-scale movement of refugees from DR Congo in particular into Uganda.
In Central African Republic (CAR), two cases have been reported in 2008 (both type 1). The risk of further importations from both Chad (to the north) and the Democratic Republic of Congo (to the south) remains high.

Asia (Nepal)

In 2008, six cases have been reported in 2008 (all type 3). Nepal remains at risk of importations from India, and continues to conduct preventive immunization activities as well as outbreak response mop-ups. Nationwide campaigns are planned for February and March.

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.