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October 2009

All data as of 11 November 2009

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Headlines

Independent Evaluation Report released: The Report of the Independent Evaluation of the Major Barriers to Interrupting Poliovirus Transmission has been released, stating that if the managerial, security and technical issues it has identified can be addressed, "polio eradication can be achieved". Composed of 28 experts in public health, immunization, vaccinology, programme communications and security, the evaluation teams have identified cross-cutting and country-specific barriers and recommended strategies to address each of these in order to reach eradication as quickly as possible. WHO country offices, Ministries of Health and GPEI partners are now discussing the implications and draft a plan to adapt the polio eradication response accordingly. More.
Nigeria case count: Nigeria reported just one case of wild poliovirus (WPV) in all of October. By comparison, in October 2008 it reported 57 cases, 50 of which were type 1. The last recorded case of WPV1 in Nigeria had onset of paralysis on 21 August in the southern state of Abia. In what have traditionally been the nine highest-risk far northern states, Borno and Kebbi have not recorded a WPV1 case since July, Sokoto and Zamfara since May, Bauchi since March, while Kano, Katsina, Yobe and Jigawa's last WPV1 cases were in January.
UN targeted in Afghanistan and Pakistan: The UN has faced targeted attacks in Afghanistan and Pakistan in the past month as the security situation continues to deteriorate. On 6 October, the United Nations World Food Programme offices in Islamabad were attacked by a suicide bomber, while on 27 October, attacks on a UN Guest House in Kabul, Afghanistan, occurred while the polio program's national staff meeting was taking place in the main UN compound. Movement of UN staff has been severely restricted by these attacks, with all international staff in Afghanistan temporarily relocated from Kabul and international staff in North West Frontier Province (NWFP) relocated to Islamabad. Despite this, immunization activities continue to take place, with access to children actually improving in some areas such as Swat, NWFP, and key districts of Afghanistan's Southern Region. These immunization activities are a great credit to the courage and commitment of the immunization teams and polio staff.
Polio spreads to Mauritania: Mauritania has reported two cases of WPV - its first cases since 2001 - as the outbreak that initially spread out of Nigeria last year continues to move westwards. International outbreak response guidelines are currently being implemented in Mauritania. See 'West Africa' overleaf for details.
World Polio Day celebrates being "this close": On 24 October, Rotary clubs around the world celebrated World Polio Day, with fundraising and awareness-building activities, including national outreach campaigns in Germany and Austria. To see an update on Rotary's efforts to eradicate polio, and see how far Rotarians have come in meeting Rotary's US$200 Million Challenge, click here.
Pakistan president challenges provincial leadership: Pakistan President Asif Ali Zardari has called on the country's provincial and district-level leadership to ensure that no child under five in Pakistan is missed in polio immunization campaigns. More
Polio vaccine delivered safely without icepacks in study: Oral polio vaccine (OPV) may be able to be delivered safely and effectively without the recommended cold chain temperatures in geographically challenging settings or where cold chain materials are not available, an Optimize study has found. During National Immunization Days in Mali, 39 vaccination teams immunized a total of 14,913 children, with some teams using icepacks and others not, and found that all vials were still usable as indicated by the vaccine vial monitors, despite ambient temperatures ranging from 25 to 40C. More.

Endemic Countries

Nigeria

The number of cases for 2009 is 383: 73 type 1 cases, 308 type 3 and two type 1/3 co-infections. Last year at the same time, Nigeria had 753 cases in total, 683 of which were type 1.
Sub-national Immunization Days (SNIDs) were completed on 13 October, using mOPV3 across the northern and middle-belt states and mOPV1 in selected southern states. International field monitors highlighted an unprecedented synergy between the administrative and traditional leaders and health staff, with Local Government Authority Chairmen and local traditional leaders monitoring the immunization campaign and vastly improved cross-border coordination with Niger and Benin.
To ensure that recent operational improvements are sustained and improved upon, systematic supervisor training and engagement of key traditional leaders is taking place ahead of the next immunization activity, to be held from 21-24 November (using mOPV3 in the north and mOPV1 in selected districts in the south).
Nigeria's type-2 circulating vaccine-derived poliovirus (cVDPV) outbreak has slowed, with one case reported in October (onset of paralysis on 3 October). The number of cVDPV cases is 146 countrywide in 2009. This continued drop in cases indicates that the outbreak has been quelled, undoubtedly because the May and August immunization campaigns, conducted with trivalent OPV, were of significantly improved quality.

India

The number of cases for 2009 is 568: 68 cases are type 1, 499 are type 3 and one is a type 1/type 3 co-infection. Last year at the same time, India had 503 cases: 62 type 1 and 441 type 3.
In India, Ms K Sujatha Rao was appointed the new Secretary of Health and Family Welfare. Ms Rao was formerly in charge of India's HIV/AIDS programme.
In October, the vast bulk of cases were children stricken with type-3 polio in western Uttar Pradesh (UP). To curb this outbreak, an immunization mop-up campaign using monovalent oral polio vaccine type 3 (mOPV3) was held from 4 October in the 24 key districts of west UP. Concurrently, a mop-up with monovalent OPV type 1 (mOPV1) was conducted in central Bihar.
At the Bihar Regional Review Meeting, it was confirmed that 14 Surveillance Medical Officers (SMOs) from polio-free states would be redeployed to the Kosi River area and other infected parts of Bihar for two months. Bihar's Principal Secretary of Health has also committed to visit high-priority districts with the state team.
In western UP, SMOs are currently in the process of being redeployed from 'quiet' districts to districts with the greatest number of cases or which pose the greatest threat.
The India Expert Advisory Group last week recommended the new supplementary immunization schedule for 2010, highlighted by the introduction of bivalent oral polio vaccine early next year, which will enable the programme to tackle both type 1 and 3 poliovirus concurrently. The IEAG agreed to sustain its intense effort to close immunization coverage gaps in young children and migrants, particularly in the 100 "high-risk" blocks of western Uttar Pradesh and Bihar that hold the key to eradication in India. In the short term, the IEAG recommended conducting mop-up immunization activities anywhere a type-1 wild poliovirus case occurred, and anywhere a type-3 case occurred outside western Uttar Pradesh or central Bihar.
The next immunization campaign, targeting 55.5 million children under five in UP, Bihar and selected key areas, will be held on 8 November, using mOPV1. A rapid response mop-up to the Punjab cases was held on 27 October, using mOPV1.
Vaccine-derived polio viruses (VDPVs) have been isolated from five Acute Flaccid Paralysis (AFP) cases in 2009, three type 2 & two type 1. The date of onset of the last case was 4 September 2009 in Ghaziabad, Uttar Pradesh. Clinical and virological data have confirmed the last case to be of iVDPV. The VDPV isolates are not genetically linked and there is no evidence of circulation.

Pakistan

Pakistan has reported 76 cases in 2009 – 52 type 1 cases, 23 type 3 cases, and one type 1/type 3 co-infection - compared with 96 cases at the same time last year, 71 type 1 cases and 25 type 3.
Despite the deteriorating security situation, the most recent immunization activities were able to reach a record number of children. Held from 12-14 October, using tOPV, immunization teams reported dramatically improved access in 'settled districts' of North West Frontier Province/Federally Administered Tribal Areas. An estimated 92% of children in Swat were accessible - the highest figure for more than two years. The Short Interval Additional Dose (SIAD) strategy was implemented in Swat from 28-30 October during which the number of inaccessible children further decreased to 1% thanks to the support of the Special Support Group and other key stakeholders. The next National Immunization Days (NIDs) take place from 16-18 November, in coordination with Afghanistan.
The Pakistan polio team has mobilized to immunize children fleeing the conflict in South Waziristan, with vaccination teams deployed at checkpoints on the main routes. Unlike the conflict in Swat in May, in which IDP children fleeing the conflict had been inaccessible to polio immunization teams for more than a year, children fleeing the Waziristan conflict have been accessible and are expected to have higher levels of immunity to polio.
In both Karachi and Lahore, environmental sampling has now been institutionalized, with positive isolates being collected. This has been identified as a key strategy in 2009, to validate a clearer epidemiological picture of both programme performance and vaccine efficacy in the country.

Afghanistan

Afghanistan has reported 24 cases in 2009, 15 type 1 and nine type 3, compared with 24 cases at the same time last year - 19 type 1 cases and five type 3.
NIDs were held from 11-13 October, using trivalent oral polio vaccine (tOPV). Preliminary reports suggest that while there were no major problems, access worsened in the southern region, particularly in the infected province of Hilmand, where five of this year's cases have been located. Initially, the "inaccessible" population was estimated at 160,000, however following some immediate consultation, several areas were opened to immunizers, with 103,000 children finally confirmed as "inaccessible" in the round.
The Afghanistan National staff meeting was held on 26-27 October in Kabul.

Re-infected countries

West Africa

West Africa reported six cases in October and as of 10 November, had recorded a total of 133 cases in 2009 (Benin 20; Burkina Faso 13; Côte d'Ivoire 27; Guinea 33; Liberia 10; Mali 5; Mauritania 2; Niger 15; Sierra Leone 2; and, Togo 6). All are type 1 except Niger, which has one type 1 case and 14 type 3 cases.
Only Guinea and Mali reported cases in October, although eight type 1 cases previously classified as from Mali were reclassified this week as Guinean children who crossed the border to seek alternative medical care in Mali.
Mauritania has reported two cases of wild poliovirus type 1. Genetic sequencing indicates the virus is of Nigerian origin which spread through west African countries infected in 2008-2009. International experts have travelled to Mauritania to prepare an emergency outbreak response and to determine the risks to neighbouring polio-free countries. An immunization plan is being drawn up, with a SIAD outbreak response using mOPV1 planned to cover 80% of the total population from 4-7 and 18-21 December.
Synchronised immunization activities (SIAs) will be held from 4 December in Burkina Faso, Cote d'Ivoire, Guinea and Mali, using mOPV1. Ghana is planning to conduct an immunization activity from 12 November (tOPV), as is Sierra Leone from 20 November (mOPV1), Niger from 21 November (tOPV), and Liberia from 23 November (mOPV1).

Horn of Africa

No cases have been reported across the Horn of Africa since July. The region has reported 71 cases in 2009 (Kenya: 18; Sudan: 45; and, Uganda: 8). Uganda has not recorded a case since 10 May, Sudan's last case had onset of paralysis on 27 June and Kenya 30 July.
In October, Kenya conducted two Short Interval Additional Dose (SIAD) campaigns, immunizing 380,000 children aged under 15 years in the three Turkana districts of the Rift Valley province with two doses of mOPV1 in two weeks, from 14-18 October and from 21-25 October. Four immunization activities have now taken place since Kenya's last recorded case.
Across Sudan, NIDs were held from 27 October, using mOPV1. SNIDs will follow in southern Sudan from 25 November, using tOPV. International and national polio focal points are currently being deployed to ensure that each state is effectively supported, especially to ensure strong surveillance.
Northern Sudan will conduct a surveillance review from 5-13 November.
Uganda held SIAs in 12 high-risk northern districts from 3-6 October and from 31 October-3 November, targeting 711,000 children with mOPV1. It will repeat the exercise from 31 October-3 November.
Ethiopia conducted SIAs from 22-26 October in the Gambela region, immunizing 75,000 children with mOPV1.

Angola, DR Congo, Burundi

Angola has recorded 28 cases in 2009, the most recent of which had onset of paralysis on 15 September.
SIAs in Angola, in particular in Luanda (from where the bulk of this year's cases have been reported), continue to be marred by significant operational problems and can only be solved through increased political ownership and engagement. In the coming months, advocacy efforts will be turned towards engaging the national and provincial governments in key provinces to ensure accountability during delivery of SIAs.
A SNID is planned for Luanda, Benguela, Cuanza Sul, Cuanza Norte and Bengo from 13-15 November, using mOPV1.
In DR Congo, no new cases have been recorded since 24 June. However, the infection of children in western Burundi - close to the DRC border - points to probable undetected transmission of wild poliovirus in Eastern DRC. An assessment is now being carried out in these areas to identify any areas of missed transmission.
Immunization campaigns were held in Bas Congo on 1 October, using mOPV3. OPV will also be given in conjunction with Child Health Days in Bas Congo, Kinshasa, and Bandundu from 10 November.
Burundi is responding to its first polio outbreak since 1999, with two cases in total, both five kilometres from the border with DR Congo and genetically linked to a DRC virus last found in Kivu in August, 2008 - an area compromised due to ongoing conflict.
Immunity in Burundi is reasonably high - 50 children in the immediate vicinity of the case were surveyed, with the median number of OPV doses being three.
Rwanda added tOPV to its measles immunization campaign on 6 October.
A synchronised emergency outbreak immunization campaign was held from 26 October in Burundi and Sud and Nord Kivu, using mOPV1. A second round is planned from 17-19 November in Burundi and Rwanda, with Nord and Sud Kivu yet to confirm these dates.

Chad, CAR, Cameroon

Chad has reported 33 cases in 2009 - all type 3. Central African Republic (CAR) has reported 14 cases, while the newly infected Cameroon has reported two type 3 cases, its first cases since 2006.
Chad held SIAs in the south and west, including the greater N'Djamena area where the bulk of cases have occurred, on 30 October, using mOPV3. NIDs are planned for 4 December, using tOPV.
In CAR, a group of technical experts were sent to two districts of RS3 - where all the cases of polio in CAR this year have been recorded - to ensure the SIAs held from 16 October were of the highest possible quality.
In Cameroon, SNIDs using mOPV3 were held in the highest-risk provinces bordering Chad, CAR and northern Nigeria on 9 October. OPV immunizations will now be included in Child Health Days from 16 November.

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$8 billion global investment in eradication.