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December 2009 & January 2010

All data as of 2 February 2010

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Headlines

WHO Executive Board points way forward on new three-year Programme of Work: Delegates expressed strong support for finishing the job of polio eradication and finalizing a new three-year Programme of Work to do so, despite a particularly challenging year epidemiologically in 2009. After hearing a report from the Chair of the Independent Evaluation of Major Barriers to Interrupting Poliovirus Transmission and frankly acknowledging the remaining hurdles, delegates noted other, positive outcomes of 2009, in particular the impact of tactical and scientific innovations in each endemic area and the development and introduction of a new, bivalent, oral polio vaccine.
Funding a major barrier as Programme of Work consultation advances: Of note, the discussion at the Executive Board did not extend to the resources required to finish the job: conservative January budget estimates for 2010-2012 top US$ 2.1 billion, against which there is a funding gap of at least US$ 875 million. To secure ownership at all levels and across all sectors for polio eradication, the Global Polio Eradication Initiative is consulting widely with both polio-affected countries and members of the international development community in the development of the Programme of Work 2010-2012, which is to be presented to the World Health Assembly in May 2010.
Type 1 declines dramatically in Nigeria: Cases of type 1 in 2009 have dropped by 90% over 2008. In Kano State, no type 1 cases have been detected in the past 12 months, despite strong disease surveillance.
Bivalent oral polio vaccine (bOPV) reaches India and Nigeria: India used bOPV for the first time in Bihar during National Immunization Days starting 10 January. Nigeria became the first African country to use bOPV in the national 30 January Immunization Plus Days. Both countries follow Afghanistan, which first used the vaccine on 16 December 2009.
Preparations start for multi-country campaigns in Africa: On 6 March, Nigeria and 15 other west African countries will be joined by Cameroon, Central African Republic (CAR) and Chad, to vaccinate 85.5 million children and boost immunity across the "importation belt."
WHO African Regional Office leadership highlights Chad risk: The Regional Director of the WHO Regional Office for Africa in December convened an extraordinary consultation with the Ministries of Health of Nigeria, Chad, Angola and DRC to review the findings of the Independent Evaluation on the Major Barriers to Interrupting Poliovirus Transmission. Chaired by the RD for its entire 10-hour length, the consultation recognized the particular risk posed by Chad, now the country with the highest number of cases in Africa in the past six months (53), with an expanding type 3 outbreak.
Grants available for polio research: Driven by the need to evaluate innovative mechanisms to close remaining immunity gaps in remaining polio-affected areas, the Polio Research Committee is soliciting research proposals (by 30 March) with particular focus on understanding mucosal immunity in India and addressing low vaccine coverage in Nigeria. Please visit the research page.

Endemic Countries

India

Only one genetic lineage of type 1 wild poliovirus survives in India (as compared to seven lineages in 2007), and the priority remains the rapid interruption of this serotype.
While both Bihar and Uttar Pradesh have – at different times – successfully interrupted type 1 transmission in the past, this success has never been simultaneous, and each state has subsequently re-infected the other. The current low levels of this serotype in both states are encouraging.
Special outreach strategies to vaccinate children in migratory/ mobile populations are being strengthened to achieve high coverage in these high risk populations.
107 high-risk blocks have been identified across western Uttar Pradesh and Bihar, and a special "107 block plan" plan is being finalized for these blocks that will overcome the remaining challenges to eliminate polio. The plan envisages not only ensuring the highest quality polio immunization activity and strengthening routine immunization services in these blocks but also launching new initiatives to address factors contributing to poliovirus transmission such as interventions to improve water and sanitation conditions and reducing prevalence of diarrhea through promotion of ORS and zinc..
Rotary International bestowed its prestigious 'Polio Eradication Champion Award' to Bihar Chief Minister Nitish Kumar, for his personal engagement and commitment to polio eradication in the state. Under his leadership, strengthened focus is being given to activities in the high-risk blocks of Bihar, and on reaching populations in hard-to-reach areas such as the Kosi river basin.
The Government of India used bOPV for the first time in Bihar in the 10 January National Immunization Days (NIDs). The majority of the country used trivalent OPV while a few areas used monovalent type 1 or type 3 as a part of the mop up responses.
The NIDs in January were inaugurated in the capital by the President of India, Pratibha Patil. Other notable events included the administration of OPV by the Dalai Lama at Bodh Gaya in Bihar and the NID launches in the state of Maharashtra by the Union Minister of Health, Mr Ghulam Nabi Azad and in Delhi by the Chief Minister of Delhi at her residence. Indian billionaire Lakshmi Mittal and his wife along with Rajashree Birla and senior Rotarians from India inaugurated a Rotary Health Camp in Delhi.
A second round of NIDs is scheduled for 7 February.

Nigeria

A year has passed since the onset of paralysis of the most recent case of type 1 polio in Kano state (23 January 2009) in northern Nigeria, once the epicentre of polio in the country and the source of multi-country outbreaks. A type 3 outbreak in the country, however, has led to 101 cases in Kano alone in 2009.
The sharp decline in cases nationwide (50% overall and 90% in type 1) compared with 2008 is likely a result of the operational improvements achieved this year during Immunization Plus Days (IPDs) thanks to strengthened engagement by local-level political, traditional and religious leadership.
Transmission also appears to have slowed considerably in the past six months. Since August 2009, Nigeria has reported 13 cases of wild poliovirus.
In December, an integrated campaign with OPV and insecticide treated bed-nets took place in Kebbi and Sokoto, where it was officially launched by the Sultan of Sokoto.
While analysis from the most recent IPDs in November again suggests operational improvements were achieved, high quality was not consistent everywhere. In some high-risk local government areas, key operational challenges continue to mar the quality of activities.
The Northern Traditional and Religious Leaders Forum for Primary Healthcare and Polio Eradication held its first meeting of the year on 14 January, attended by the Federal Minister of Health and the Executive Director of the National Primary Healthcare Development Agency. Citing the pivotal role of the traditional leadership in garnering local support and reaching children, the Minister of Health said, "What I'm setting for 2010 is collaboration with you, looking to your leadership. We shall drag polio from Nigeria this year."
National IPDs were held starting 30 January, using bOPV. This is the first use of bOPV on the African continent. Northern states will hold a vaccination campaign on 6 March to coordinate with the 15-country west Africa SIAs.

Pakistan

Sub-national Immunization Days (SNIDs) took place on 14 and 21 December using mOPV1. The activity was staggered in Punjab – to allow the movement of experienced staff to assure high quality – and postponed in Balochistan due to a strike by paramedics. Some areas of NWFP/Federally Administered Tribal Areas (FATA) were again inaccessible. A Short Interval Additional Dose (SIAD) round is planned in some of these areas, as and when a window of opportunity for access is identified.
The most recent SNIDs were launched on 18 January with high-level participation including the President and the Minister of Health as well as senior political leadership in Lahore.
120 journalists from FATA have taken part in 2009 in 'Re-thinking Journalism' training as part of UNICEF support to Ministry of Health efforts to engage the media. The training focuses on getting health issues in the headlines, with particular focus on polio.
Two new initiatives being explored are: the scale up of community-based polio eradication activities for surveillance and social mobilization being piloted in two agencies of FATA where access is compromised; and the increased involvement of the Pathan community in Karachi, whose movements to and from NWFP are important in the spread of virus.
On 25 January, key religious leaders from across the country convened in Islamabad as part of the Inter-religious Council for Health project, to promote the importance of polio eradication, immunization and overall maternal and child health. In the coming months, key influential people at the federal, provincial and district/agency level will be working to harness the support of religious leaders at the community level.
Sindh Governor Dr Ishrat Ul Ebad Khan expressed concern at the number of polio cases in the province. "Problems should not be made an excuse for polio," he said while chairing a high-level meeting on 23 January, "but should be solved with wisdom and all capabilities." He announced the formation of Community Service Coordination Committees, aimed at promoting a cross-sectoral approach to polio eradication at every level.
The next NIDs are planned for 15-17 February, possibly using bOPV and coordinated with SNIDs in southern Afghanistan.

Afghanistan

Afghanistan became the first country in the world to use bOPV during SIAs for polio on 15-17 December 2009.
Focus is again on increasing access in the 13 districts with persistent transmission, in the Southern Region. Due to insecurity, access to all children in these districts continues to be the main challenge (upwards of 20% of children have never been vaccinated in these districts).
A planning meeting was held in January to create district-specific plans for these 13 districts, based on the local culture, local partners and nature of the conflict.
A December 2009 case is the first from Nangarhar Province in the Eastern Region of Afghanistan since November 2008 and is related to both to virus circulating in the Kandahar area and in Punjab in Pakistan . A mop-up took place in the province, targeting all 400,000 children under five years of age with bOPV on 24-26 January.
The next SIAs are Sub-national Immunization Days (SNIDs) planned for 14-16 February, in coordination with Pakistan.

Re-infected countries

West Africa

The countries in west Africa reporting cases of polio in the past 12 months are: Benin, Burkina Faso, Côte d'Ivoire, Guinea, Liberia, Mali, Mauritania, Niger, Senegal, Sierra Leone and Togo. All are type 1 except in Niger, which has one type 1 case and 14 type 3 cases.
Senegal's first cases of polio since 1998 represent an importation from neighbouring Mauritania. In response to the importation, large-scale outbreak response mop-ups are planned in Senegal and Mauritania on 12 and 15 February respectively, with mOPV1. Senegal benefits from high routine immunization levels.
This most recent country to join the west Africa outbreak underscores the ongoing risk in the region. In particular, intense transmission appears to be continuing in Guinea and Mauritania.
Cases have been reported within the past six months from Benin, Burkina Faso, Côte d'Ivoire, Guinea, Liberia, Mali, Mauritania, Senegal and Sierra Leone.
A synchronized immunization response was held on 4 December in Burkina Faso, Mali and Côte d'Ivoire, using mOPV1, followed by Mauritania on 8 and 22 December, Guinea on 12 December and Liberia on 14 December. Mauritania and Senegal are holding SIAs on 15 and 12 February respectively, with mOPV1.
Multi-country SIAs are taking place starting 6 March, targeting 85.5 million children across 15 west African countries (Benin, Burkina Faso, Cape Verde, Côte d'Ivoire, Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Mauritania, Niger, Senegal, Sierra Leone and Togo) as well as Cameroon, Central African Republic (CAR), Chad and Nigeria.

Horn of Africa

No cases have been reported across the Horn of Africa since July 2009. Uganda has not recorded a case since 10 May, Sudan's last case had onset of paralysis on 27 June and Kenya's on 30 July.
All cases across the Horn have been followed by at least two rounds of SIAs.
Although no new cases have been reported from the region since July, sub-national surveillance gaps persist and undetected circulation cannot be ruled out.
The most recent SIAs in the region were held in southern Sudan on 7 December and in northern Sudan from 14 December, with both areas using trivalent OPV. Community mobilization supported by UNICEF included mobile announcers, church and radio announcements. Inauguration ceremonies took place in four states of northern Sudan while West Darfur held a carnival. The Federal Minister of Health launched the campaign in South Kordofan while the Undersecretary of the Federal Ministry of Health launched the ceremony in South Kordofan. All the ceremonies were attended by the state ministers of health, state commissioners, Director Generals of state ministries of health, Directors of Primary Health care, senior paediatricians and members of the legislative council, women's unions and EPI management. The campaign received good media coverage by national and state TV and Radio as well as newsletters.
A coordination meeting for the Horn of Africa is planned to take place in Nairobi on 5-6 March, followed by a meeting of the Technical Advisory Group on 8-9 March.
Both southern and northern Sudan are holding campaigns – on 17 February and 22 February respectively, using mOPV1 in the south and bOPV in the north.

Angola, DR Congo, Burundi

In Angola, SNIDs were held on 11-13 December, using mOPV1, in Benguela, Bengo, Cuanza Sul, Cuanza Norte and Luanda. The next SIAs in Angola are planned to be nationwide in June, using mOPV1, followed by rounds in July and August.
While all cases have now been followed by three rounds of campaigns, serious operational flaws in the quality of SIAs in 2009 have led to the re-established transmission of wild poliovirus in Angola.
SIAs were held on 17 November in Burundi, Rwanda and the province of South Kivu in DRC, and on 26 November in North Kivu. SNIDs are planned in DRC for May and June.

Chad, CAR, Cameroon

Chad is now the country in Africa with the highest number of cases in the past six months (53). The type 3 outbreak is now spreading across the country. (Additionally, due to sub-national surveillance gaps, undetected circulation of type 1 cannot be ruled out.)
The outbreak has persisted as outbreak response has been inadequate in timeliness, scale and quality. SIAs continue to be marred by significant operational challenges, with as many as 50% of children missed, particularly in the greater N'Djamena area. Political engagement at every level is urgently needed.
At the consultation chaired by the Regional Director of the WHO African Regional Office (AFRO), there was consensus among the Member States and AFRO to enhance national financing, international resource mobilization, cross-border coordination (especially of SIAs), the translation of national political will into action at the local level, independent monitoring of SIA coverage, social mobilization and engagement of civil society.
Chad has not had an SIA since October 2009. SNIDs planned for 4 December were cancelled at the last minute. The next SIAs are nation-wide on 5 February. Chad will also take part in the multi-country SIAs starting 6 March and has rounds planned for April, October and November.
In Cameroon, NIDs using trivalent OPV were held 4 December. In CAR, a second round of Child Health Day immunizations were held from 26-30 December with trivalent OPV for under five-year olds nationwide. An accelerated routine immunization campaign is scheduled for end January. Both countries are taking part in the multi-country SIAs starting 6 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$8 billion global investment in eradication.