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June 2009

All data as of 30 June 2009

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Headlines

Polio on agenda of global leaders: On 4 June 2009, US President Barack Obama, during his historic address in Cairo, Egypt, highlighted the need for cooperation to eradicate polio and announced "a new global effort with the Organization of the Islamic Conference (OIC) to eradicate polio." At the Rotary International Convention in Birmingham, UK on 23 June, UN Secretary General Ban Ki-moon urged the global development community to complete the job of polio eradication, saying: "I call on governments around the world to help us. Together, we can fulfil Rotary's vision and give future generations a polio-free world." At the Convention, Ban Ki-moon was presented the prestigious Polio Eradication Champion Award by Rotary International President DK Lee and Rotary Foundation Trustee Chairman Jonathan Majiyagbe. The Secretary General stated that he would continue to call for Days of Tranquillity this year for conflict-affected areas (see 'Afghanistan' section below, for more). At the G8 Summit in l'Aquila, Italy on 8 July, G8 leaders committed to work towards completing the task of polio eradication.
Global advisory body recommends use of a new bivalent oral polio vaccine (bOPV): On 11 June, the Advisory Committee on Poliomyelitis Eradication (ACPE), the advisory body to the Global Polio Eradication Initiative (GPEI), recommended that a new bOPV (containing type 1 and type 3 poliovirus) be added to the mix of monovalent and trivalent OPVs. A clinical field trial of the new bOPV in India demonstrated that for both serotypes, bOPV is superior to trivalent OPV and almost as effective as the respective monovalent OPVs in achieving protection.
Special session on polio held at UNICEF Executive Board meeting: During its bi-annual Executive Board meeting in June, UNICEF held a special session on polio eradication, which highlighted the urgent need to finish the job and brought renewed interest within the organization's leadership to continue their critical role as one of the spearheading partners of the GPEI. Speakers included Dr Muhammad Ali Pate, Executive Director/CEO of Nigeria’s National Primary Health Care Development Agency, and Dr Robert Scott, Chairman, International PolioPlus Committee, Rotary International.
Polio eradication veteran Dr Wahdan retires: Special Advisor for Polio Eradication to the Regional Director at WHO's Eastern Mediterranean Regional Office in Egypt since 1998, Dr Mohamed Helmy Wahdan has been instrumental in the fight against polio and communicable diseases at WHO since 1979. Under Dr Wahdan's leadership, indigenous transmission of polio was successfully interrupted in all but two countries in the region; he has trained and mentored numerous polio eradication staff worldwide, and will be missed personally as much as professionally. The GPEI wishes him all the best in retirement and pays tribute to his professionalism, his expertise and his dedication to the health and well-being of children across the world. The GPEI hopes to continue in the future to benefit from his expertise and advice.
India technical body concludes country is 'on the right track' for eradication: The India Expert Advisory Group on Polio Eradication (IEAG), convening in Delhi on 24-25 June, reviewed the epidemiologic, virologic, genetic, operational and technical evidence, and concluded that India is firmly on the right track to complete the job of polio eradication. Additionally, the group put forward a range of new eradication strategies to hasten success. For more, see 'India' section below, and at www.polioeradication.org.
Research takes centre stage in Geneva: On 2-3 June, the Polio Research Committee (PRC), the body providing strategic guidance to research and product development of the GPEI, convened in Geneva and reviewed new and ongoing research relating to both pre- and post-eradication issues. Highlighted issues were addressing compromised OPV efficacy in northern India and activities to develop new and 'affordable' inactivated polio vaccine (IPV) options for the post-eradication era. Convening on 23-25 June, the Global Polio Laboratory Network reviewed global trends in the detection of polioviruses and progress towards the development of new laboratory diagnostic procedures. In particular, the group reviewed a new state-of-the-art diagnostic method–real time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR)–to accelerate the identification of wild polioviruses and improve detection of vaccine-derived polioviruses. This new method was piloted in 2008, and will now be introduced into all endemic regions by end-2009. Click here for more on both meetings.

Endemic Countries

Nigeria

The number of cases for 2009 is 321: 72 type 1 cases (compared to 321 type 1 cases at this time last year), 247 type 3, and two type 1/type 3 co-infection. Nigeria also has a significant outbreak of an ongoing type 2 circulating vaccine-derived poliovirus (cVDPV), with 103 cases confirmed for 2009.
The most recent Immunization Plus Days (IPDs) were held from 30 May to 2 June; reports suggest overall better quality was achieved than previously, particularly in key high-risk areas. The round was conducted with trivalent OPV, in response to the increase in type 2 cVDPV cases (a further trivalent campaign is planned for August).
An important indicator of quality of operations will be the impact of this latest trivalent OPV round on the type 2 circulating vaccine-derived poliovirus (cVDPV) affecting the country. This will be closely monitored over the coming weeks. No new cVDPV cases have been reported since this latest campaign, though it is too early to assess the significance of this.
On 15 June, at a meeting of traditional and religious leaders chaired by the Sultan of Sokoto, the Sultan urged all leaders to personally become involved in upcoming immunization campaigns. The Traditional and Religious Leaders Task Team was formed to design a plan of action and monitor activities. The Traditional and Religious Leaders Task Team was formed in Kaduna and met in Abuja the following week to design a plan of action to monitor activities. A follow-up meeting was scheduled for 8 July in Kaduna.
The next IPDs are scheduled for 4-7 July, using monovalent OPV type 1 (mOPV1).

India

The number of cases for 2009 is 89, compared to 287 at this time last year. Of these, 24 cases are type 1 (compared to five type 1 cases at this time last year), 64 are type 3 and one is a type 1/type 3 co-infection. In 2009, type 1 and type 3 cases are more geographically restricted in both Bihar and Uttar Pradesh, than at any time before.
The IEAG concluded that India's eradication effort was 'on track' to achieve success. In particular, the group noted that genetic biodiversity is at an all-time low, with only one lineage of type 1 polio surviving in 2009. Community resistance to OPV is also at unprecedented low levels. Key to success is ensuring all tools are optimized, and operations are fully implemented particularly in the Kosi River, Bihar.
To hasten progress, the IEAG put forward a number of key new recommendations, in particular by incorporating the new bOPV into the country's accelerated supplementary immunization activities (SIA) schedule as of November (the earliest this product will be available on a large-scale).
Other new strategies include prioritization of activities through a new geographic 'risk classification' in both Bihar and Uttar Pradesh; evaluating ways to address underlying risk factors to compromised vaccine efficacy through administration of zinc supplements (associated with a reduction in diarrhoeal disease); further targeting strategies to reach 'hard to reach' groups (such as in the Kosi River) and migrant groups; introducing environmental surveillance in Delhi to help monitor virus circulation in western Uttar Pradesh and Bihar (as successfully applied in Mumbai); and evaluating the potential role of additional vaccine solutions (including IPV).
The IEAG also endorsed an enhanced Underserved Communication Strategy that will target ‘hard to reach’ and high-risk groups such as migrants, mobile and nomadic populations in Bihar and Uttar Pradesh.
The IEAG was attended by the new Joint Secretary of Health (with responsibility for polio eradication), Amit Mohan Prasad, who expressed his commitment to polio eradication and announced he would personally travel to Uttar Pradesh and Bihar and discuss the new eradication strategies with the state health sectors.
The IEAG finalized an aggressive SIA schedule for the rest of the year, with large-scale activities planned for early July, early August, early September, and again in November and December (with mop-ups as necessary in October).
Two VDPVs have been confirmed, in Assam and Bihar, with onset of paralysis on 7 April and 30 April, respectively. Mop-ups in the infected areas have been conducted. There is no evidence of secondary spread with either of these VDPVs.

Pakistan

Pakistan has reported 20 cases in 2009 – 13 type 1 cases and seven type 3.
A joint Technical Advisory Group (TAG) meeting was held for Afghanistan and Pakistan in Cairo, Egypt on 1-2 June. The TAG focused on assessment and recommendations for key infected areas.
Following National Immunization Days (NIDs) on 28-30 May with trivalent OPV, Subnational Immunization Days (SNIDs) were conducted in high-risk districts from 22-24 June, with mOPV1. Following this, a Short Interval Additional Dose (SIAD) round is currently ongoing with mOPV1 in camps and communities with large internally displaced populations. Approximately 700,000 children under the age of five years are targeted. Such SIAD activities aim to deliver an additional dose to children from previously inaccessible areas, in between large-scale SNIDs/NIDs.
Following concerted efforts to reach children associated with large-scale population movements due to insecurity in North West Frontier Province (NWFP), no polio cases have followed these large-scale movements (although it is too early to fully assess the full impact of these efforts). Special vaccination teams continue to operate in camps for internally displaced populations (IDPs); overwhelming demand for vaccination in camps has been noted. Nearly 2.5 million people have been internally displaced due to the ongoing conflict in NWFP.
An inter-provincial ministers meeting will be convened on 11 July in Karachi, chaired by the Federal Minister of Health ahead of the next NIDs, which will be held on 20-22 July. Discussions will focus on strategies for improving campaign quality in the key problem areas as well as the recommendations of the recent TAG meeting.

Afghanistan

Afghanistan has reported ten cases in 2009, all type 1.
SNIDs were conducted on 21-23 June, in highest-risk districts of the Southern Region, using mOPV1. Initial reports indicate access was improved in key areas, though in several districts it remained hampered due to insecurity. Increasingly, health NGOs based in the Southern Region are being engaged in polio eradication activities, and this appears to have a positive effect on increased access.
Increasing access in the 11 highest-risk districts of the three provinces of the Southern Region - Hilmand, Kandahar and Uruzgan - remains the overriding strategic priority for Afghanistan's polio eradication effort.
Accepting the Rotary Polio Eradication Champion Award,UN Secretary General Ban Ki-moon dedicated the award to three polio workers killed in Afghanistan in September last year. The Secretary General said: "To honour their heroic efforts, I will continue to call for Days of Tranquillity this year in all areas where conflict is preventing access to children during polio eradication drives."
The next NIDs will be held on 26-28 July, with trivalent OPV.

Re-infected countries

West Africa

West Africa has reported 72 cases in 2009 (Benin: 20; Burkina Faso: 10; Côte d'Ivoire: 17; Guinea: 3; Liberia: 1; Mali: 1; Niger: 14; and, Togo: 6).
The third in a series of large-scale, multi country outbreak response campaigns was held from 29 May to 2 June, following activities in February and March. In total, eleven countries across the region participated, aiming to reach more than 74 million children. Such aggressive, multi-country outbreak response campaigns successfully stopped a similar regional outbreak in west Africa in 2004-2005.
Despite these efforts, confirmation that the outbreak is ongoing is evidenced by new cases since the March campaigns in Benin, Burkina Faso, Côte d'Ivoire and Niger, as well as onward spread of virus to Guinea and Liberia.
Outbreak response is continuing in these areas - campaigns were held on 26 June, and further activities are planned for 24 July. Key to success is to ensure high quality outbreak response activities.

Horn of Africa

The Horn of Africa has reported 64 cases in 2009 (Kenya: 16; Sudan: 40; and, Uganda: 8).
The Horn of Africa Coordination Meeting was held on 15 June in Nairobi, Kenya. Attended by senior representatives from the ministries of health of Chad, Ethiopia, Eritrea, Kenya, Somalia and Uganda, and representatives from WHO, CDC, UNICEF and the Bill and Melinda Gates Foundation, the meeting reviewed outbreak response plans for the remainder of 2009. In particular, discussions focused on improving the quality of immunization activities, and cross-border coordination to ensure access to all populations.
While outbreak response continues across the infected areas, urgent improvements are needed in campaign quality in southern Sudan, northern Kenya and Uganda to stop the outbreak.
An analysis of outbreak response to date indicates significant operational gaps in all three countries, which must be urgently addressed ahead of upcoming SIAs. In particular, focus must be on rapidly improving microplans, to ensure efficient 'house-to-house' campaigns are implemented.

Central Africa (Angola, DR Congo and CAR)

Central Africa has reported 21 cases (Angola: 10; Central African Republic-CAR: 9; and, Democratic Republic of Congo - DR Congo: 2).
Outbreak response across all three countries is continuing. Stopping the outbreak in Angola is the overriding priority in the region, given persistent gaps in outbreak response, persistent transmission of both type 1 and type 3 and periodic spread to neighbouring countries.
In Angola, NIDs were conducted on 14-28 June, in conjunction with a measles campaign. Additional activities are planned for July and August. Due to ongoing subnational surveillance gaps in the country, and a marked reduction in reporting of AFP cases in 2009 over the previous year, undetected circulation of both type 1 and type 3 cannot be ruled out.
In CAR, activities in the infected province of RS3 will be launched on 10 July with mOPV3, with the rest of the country conducting SNIDs on 24 July (possibly with an additional dose to be delivered in RS3 at that time, as well).
In DR Congo, SNIDs were conducted in early May and early June in infected and high-risk areas, with next activities planned for 9 July. DR Congo continues to use a mix of monovalent OPV and trivalent OPV, depending on geographic area and epidemiological risk assessment.

Chad

Chad has reported three cases in 2009 (type 3), all in the greater N'Djamena area.
Given the chronic low coverage in N'Djamena and recent confirmation of new cases there, it is critical that operations improve in the greater N'Djamena area.
A SNID will take place in selected southern districts from 10 July in the west and south, using mOPV3.
Due to ongoing, subnational surveillance gaps, undetected circulation (of both type 1 and type 3 serotypes) cannot be ruled out.

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.