July / August  2010

All data as of 18 August 2010

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HEADLINES

• Pakistan - polio infrastructure supports flood relief effort: Polio eradication staff and resources are being used to help in the response to the devastating floods affecting Pakistan. Polio epidemiologists and surveillance officers in the worst-affected areas of the country are equipped with vehicles, radio equipment, satellite phones, vital medicines and potable water tanks. The immediate focus has been on conducting a thorough and rapid assessment of the extent of the devastation, and communicating these findings back to Provincial and Federal Authorities to enable more effective relief planning. Staff have also been engaged in helping establish early warning systems for diseases, are part of mobile medical teams and are helping with broad immunization services in internally-displaced persons camps. The UN has launched a flash appeal for the flood relief effort, and as part of this, funds would go to support an emergency measles/polio campaign.
  
  
  
• Horn of Africa outbreak stopped: The outbreak which had affected the Horn of Africa appears to have been successfully stopped, as no new cases due to wild poliovirus (WPV) have been reported in more than 12 months. The outbreak began in 2008, following the re-appearance of wild poliovirus type 1 (WPV1) in the border area of southern Sudan and Ethiopia. In early 2009, the outbreak then spread to northern Sudan and to nearby Kenya and Uganda. A combination of a series of multi-country immunization campaigns, scale-up of technical support, and strong political engagement by the affected countries proved to be the backbone behind the successful outbreak response. Efforts are continuing to strengthen AFP surveillance to achieve certification-standard, including at the level of individual states.
  
  
  
• Angola - only expanding polio outbreak in Africa this year: Angola's ongoing polio outbreak is currently expanding, the only one in Africa currently to do so. Angola has the highest number of cases this year of any African country. Originally restricted to the Luanda-Benguela corridor along the Atlantic coast, the outbreak has this year spread to previously polio-free provinces in the country, as well as into the Democratic Republic of the Congo (DR Congo). Additionally in DR Congo, a case was detected in Katanga province, in the east of the country, genetically-linked to virus last detected in eastern DR Congo in 2008. In 2009, a case was detected in Burundi, which was linked to the same transmission chain. The situation in central Africa is now considered to be the greatest risk to Africa's polio eradication effort, particularly given the progress achieved in Nigeria, in west Africa and in the Horn of Africa. Central Africa is putting at risk the achievement of a key global milestone of the new GPEI Strategic Plan 2010-2012, to stop all 're-established' transmission by end-2010. Key to rapidly improving outbreak operations is head of state engagement and engagement by provincial governors.
  
  
  
• Cases in endemic countries continue to plummet: Although this year there have been 612 cases reported worldwide (compared to 839 cases for the same period in 2009), 75% of these cases are associated with the outbreak in Tajikistan (452 cases). The situation in the endemic countries is looking significantly more positive, with 85 cases reported this year, compared to 601 cases for the same period last year. The bulk of this reduction can be attributed to a 99% decline in cases in Nigeria, and a more than 80% decline in India.
  
  
  
• Tajikistan remains a risk for international spread of polio: While the outbreak in Tajikistan appears to have peaked, as the number of newly-reported cases continues to decline, it is important to note that the outbreak is not over and continued outbreak response is urgently necessary. Additionally, the risk of further international spread from the country remains high. Results are being awaited from Russia, from investigations to determine the most likely source of infection of seven WPV cases in the country and their connections to Tajikistan. Outbreak response in Tajikistan is continuing, and to minimise the risk and consequences of further international spread, National Immunization Days (NIDs) are being held in neighbouring countries, including Uzbekistan, Turkmenistan, Kazakhstan and Kyrgyzstan. See 'Tajikistan' section below for more.
  
  
  
• President of Chad receives prestigious Rotary award: President of Chad Idriss Deby Itno received the prestigious Rotary 'Polio Eradication Champion' award. The award was given in recognition of the President's personal engagement in Chad's polio eradication efforts, which led to significant operational improvements in 2010. Officially presenting the award at a ceremony at the presidential palace in N'Djamena, Bob Scott, Chairman of Rotary's International PolioPlus Committee, said: "Your personal engagement in the fight against this disease has translated into concrete action which has led to the reduction in polio cases in your country." More.
  
  
  
• African Ministers of Health to discuss polio eradication:  Ministers of Health from 46 African countries are expected to review recent progress towards polio eradication, at the upcoming Regional Committee for Africa on 30 August in Malabo, Equatorial Guinea. Ministers are expected to examine remaining challenges and put forward recommendations to ensure a polio-free Africa can be rapidly attained. A draft Resolution on polio eradication will be submitted to the Ministers for their consideration, and can be viewed here.

ENDEMIC COUNTRIES

Afghanistan

• In Afghanistan, WPV transmission continues to be primarily restricted to 13 high-risk districts in the country's Southern Region. These districts together account for a target population of >670,000 children under the age of five years.
  
  
• The focus in these districts is to prepare more detailed microplans, and ensure efficient training of vaccination teams and supervisors, and other supplementary immunization activity (SIA) staff working on the ground. Trainings were conducted throughout July, and district-level operational plans, including for social mobilization/communication, were finalized and are being actively operationalized in 11 of the 13 districts. 600 community mobilizers are now active in these high-risk districts, and activities continue to focus on access negotiations with community elders in conflict-affected areas.   
  
  
• 13 cases have this year been reported, compared to 17 for the same period last year. However, while last year it was primarily due to WPV1 transmission, this year there have been five WPV1s and eight WPV3 cases reported.
   
• The Acting Minister of Health on 10 July chaired a meeting with key officials from the 13 high-risk districts, and requested monthly updates on progress. At the same time, capacity continues to be built-up in these areas.
  
  
• Collaboration with NGOs on the ground is ongoing, including NGOs contracted by the Government of Afghanistan to deliver the basic package of health services (BPHS NGOs. Discussions on possible cooperation in two districts of Southern Region are also ongoing with the Afghanistan Red Crescent Society (ARCS), supported by the International Committee of the Red Cross. ARCS has a network of more than 1,000 community-based first-aid workers in eleven districts of Kandahar province, and potential access in a number of difficult areas.
  
  
• An international surveillance review is planned to take place on 22-28 August 2010.
  
  
• Social mapping and survey exercises to enable data-driven communication were conducted in five social mobilization clusters in Spin Boldak district and nine clusters in Kandahar city. In addition, social mobilization plans have been drawn up for Balabalook and Khaksafed districts of Farah province where the structure of the National Solidarity Programme (NSP) will be used for social mobilization and communication for polio eradication.
  
  
• The next NIDs are scheduled for 26-28 September, using bivalent oral polio vaccine (OPV), in synchronization with Pakistan. These activities may be postponed to October, due to upcoming parliamentary elections.

India

• In the two endemic states of Uttar Pradesh and Bihar, no WPV1 cases have been reported since November and October 2009, respectively. However, WPV1 cases have been recently reported from the states of West Bengal, Jharkhand and Maharashtra. WPV1 has also been detected from the environmental sampling in Delhi. This is evidence of ongoing low-level WPV1 transmission in the country.  The cases from West Bengal are particularly concerning, due to ongoing operational gaps.

• The focus in India continues to be on improving SIA and routine immunization coverage in the 107 high-risk blocks of western Uttar Pradesh and central Bihar, by increasing coverage among mobile populations, which now appear to be sustaining WPV transmission in the country. Special strategies to cover migrant and mobile populations are being put in place in the endemic states, as well as in states that are known destinations for these populations.   

• A new communications data analysis tool is being introduced by UNICEF, to enable staff to quickly identify areas at block- and district-level where social mobilization must be improved.  Additionally, the 2010 Knowledge, Attitudes and Practices (KAP) study has been initiated in August, to cover over 10,000 households in high-risk areas. Preliminary data is expected by September. And in West Bengal, in response to recent detection of WPV1 cases, social mobilization activities have been strengthened.

• In West Bengal, in response to recent detection of WPV1 cases, social mobilization activities have been strengthened. through an increase in NGO mobilization, particularly in Murshidabad. Activities in West Bengal, Maharashtra states, have as well been supported by the SMnet by sending experienced SMnet staff form Uttar Pradesh and Bihar to assist in preparations and monitoring of the various mop up activities.

• The annual Shravani Mela festival in Bihar, which celebrates the coming of the rains and takes place over 26 days in July and August, is an opportunity to vaccinate approximately 300,000 high-risk children. UNICEF has supported a mobile van which is traveling through key districts and transit points providing information on polio. The mobile van travels along the route of the Mela where vaccination booths are placed, running polio videos on LCD screens, and making announcements to direct people to the transit polio booths.

• Technical support continues to be deployed from polio-free areas to high-risk and endemic areas, to help in planning, monitoring and implementing both SIA and surveillance activities.

• Mop-up vaccination campaigns are being conducted in August in all areas with recent WPV cases. The next SNID is planned to cover endemic, re-infected and high-risk areas with bivalent OPV, starting 19 September. 

Nigeria

• The significant reduction in cases in Nigeria is continuing, with a 98% decline in 2010 compared with the same period in 2009. 

• Despite this impressive reduction, however, Nigeria remains affected by low-level transmission of all three serotypes:  WPV1, WPV3 and a circulating vaccine-derived poliovirus type 2 (cVDPV2 - most recent case had onset of paralysis on 2 July).  An increased proportion of long-chain viruses is being observed in 2010, indicating missed detection of circulating polioviruses by the surveillance system.  Targeted efforts are ongoing to strengthen surveillance.  The most recent WPV1 is from Borno state, on the border with Chad, and had onset of paralysis on 18 June.

• A special mop-up was conducted in early August, in highest-risk Local Government Areas (LGAs) in northern states.  Preparations had focused on updating all microplans for each participating LGA, and conducting refresher trainings for vaccinators and supervisors, and on securing full local religious and traditional leader engagement. To this effect, state representatives of the National Task Team of Northern Traditional Leaders, which had been called into existence by His Eminence the Sultan of Sokoto in mid-2009, convened meetings with LGA Chairpersons to review key areas and plan out participation. Senior-level supervisors from the National Primary Healthcare Development Agency (NPHCDA) and partner agencies monitored in the mop-up in the highest-risk areas.    

• In parts of Borno, the activity was hampered by heavy rains, which limited access to some populations. Discussions are underway to determine if an additional catch-up campaign in Borno could be implemented ahead of the next subnational Immunization Plus Days (IPDs), scheduled for 18-21 September. Borno is of particular concern, as it is from here that virus has in the past moved internationally towards the east. 

• To help more rapidly detect any potential residual transmission, surveillance activities are being strengthened, including through conducting of active case searches, in several high-risk LGAs. 

Pakistan

• Pakistan is the only one of the four endemic countries which is this year reporting more cases than for the same period last year (37 compared with 35). Pakistan has a higher number of cases this year than any other endemic country or country with re-established transmission. 

• Due to the severe flooding affecting the country, SIAs initially scheduled for 3-5 August were postponed in some areas of NWFP and Punjab. In total, approximately two-thirds of the originally-planned activities took place, however in some areas, notably Peshawar (NWFP), the quality was severely undermined as a result of the floods. 

• With the large-scale population movements and expected intensified transmission of poliovirus due to the floods, concerns are growing over widespread polio transmission and a possible outbreak. To this effect, discussions are underway to change the planned SNID of September to full nationwide NIDs, to start as soon as environmental conditions permit.    

• With the widespread flooding, the immediate emphasis of the programme is to monitor population movements, including to internally-displaced persons camps, and implement special strategies to reach these groups with polio vaccine. 

• Environmental surveillance in Karachi continues to detect poliovirus, underscoring the risk that ongoing transmission poses to this key urban reservoir.

• Prior to the floods, efforts in July had been strengthened to improve SIA quality, particularly in the three transmission zones in the country (the districts of Quetta in Balochistan; Karachi, Sindh; and, areas of NWPF and Federally Administered Tribal Areas - FATA).  District-specific plans continued to be developed and implemented, and technical support re-deployed from polio-free areas of the country. 

• Special strategies are being elucidated for security-compromised areas, and to reach mobile populations and internally-displaced groups. The Governor of NWFP has now constituted a Crisis Task Force for Polio Eradication in FATA, to be headed by the Additional Chief Secretary of FATA, to develop a strategy to address access issues, with a first meeting held on 16 August.

RE-ESTABLISHED TRANSMISSION COUNTRIES

Angola

• In Angola, with an expanding outbreak ongoing (see 'headlines' section above), efforts are ongoing to significantly fill vaccination coverage gaps. During SIAs, upwards of 25% of children continue to be missed, particularly in Luanda, and the newly-infected provinces of Lunda Sul and Lunda Norte, near the border with DR Congo. 

• Efforts are focusing on ensuring a more appropriate vaccinator selection, on strengthening microplans, and assuring vaccination teams and supervisors are appropriately trained. 

• Key to success is to secure head of state engagement, and engagement of provincial governors, to translate into sub-national accountability at district-levels. 

• Following mop-ups in response to recently-detected cases in June, including with neighbouring DR Congo, NIDs were conducted in the first half of August, with further NIDs planned for September. In a public statement, WHO and UNICEF in Angola had called for full engagement of all sectors of government for these NIDs.

Chad

• Chad continues to focus on improving SIA operations in key areas, particularly in the greater N'Djamena area (the epicentre of transmission in the country) with renewed Government commitment, including by the Governors of N'Djamena and Chari-Baguirmi, being reflected by continued operational improvements. In particular, more effective microplanning and vaccinator performance is being observed.

• A mop-up was conducted at the end of July with monovalent OPV type 1 (mOPV1), in response to recent detection of a WPV1 in neighbouring Borno, Nigeria. 

• The Technical Advisory Group (TAG) convened in N'Djamena in July, to review current epidemiology and provide recommendations to further build on recent operational improvements.  SIAs are now planned for late August, September, October and November. 

• Four new cases have recently been reported in DR Congo, including in the southern province of Kasai Occidental (near the border with Angola), and in Katanga, in the east of the country.  While the cases in Kasai Occidental are linked to new importations from Angola, the Katanga case is linked to virus last detected in eastern DR Congo in 2008 (see 'headline' section for more.    

• SIAs in response to these latest cases will be held later in August, focusing on border areas and along the Congo river, with nationwide activities tentatively planned to follow in September and subnational activities in October.  The activities would use a mix of different oral polio vaccines (trivalent and monovalent type 1), depending on the area.

IMPORTATION COUNTRIES

Tajikistan and neighbouring countries

• The outbreak in Tajikistan has affected 452 people, and accounts for nearly 75% of all cases worldwide this year.

• While the number of newly-reported cases continues to decline week on week, and the most recent case had onset of paralysis on 4 July suggesting the outbreak has peaked, it is important to note that the outbreak is not over.  It is critical that outbreak response continue in the country. 

• All cases, except the most recent case, have now been covered by at least two SIAs.  A mop-up in the highest-risk areas is planned for early September, with additional nationwide activities planned for late September and late October.

• Additionally, with the risk of further international spread of polio from Tajikistan remaining high, neighbouring countries also continue to conduct SIAs, including Kazakhstan, Kyrgyzstan, Turkmenistan and Uzbekistan.  In Russia, results are being awaited further to investigations to determine the likely source of infection of seven WPV cases in the country, and their connections to Tajikistan.   

• A surveillance review in Tajikistan was conducted in early August.  The review found that overall, surveillance for AFP cases was strong, however it was suggested the country move to a more active system in searching for additional AFP cases.

Nepal

• A new WPV1 case was reported in early August with onset of paralysis on 9 June, from Rautahat district, Central Development Region (CDR).  Genetic sequencing confirmed ongoing transmission from an importation earlier this year. 

• In response, a mop-up was held on 14-15 August in 18 high-risk districts in the Terai, inter-Terai and Kathmandu valley using mOPV1.  This activity follows SNIDs held in  mid-June, mid-July and end-July.

• Although only two districts: Rautahat (four cases) and Mahottari (one case) have had confirmed WPV cases this year, over the past ten years, 80% of imported WPV cases have been confined to eight districts bordering Bihar, India.  The risk for re-infection in these areas is particularly high with sub-optimal routine immunization coverage and high seasonal migration from India.   

West Africa

• Although the most recent case in west Africa had onset of paralysis on 1 May (from Mali), it is too early to say that the outbreak has been successfully stopped.  Outbreak response must continue and countries should strengthen subnational surveillance sensitivity to rapidly detect any residual transmission or eventual new importations. 

• A mop-up in response to the Mali case was conducted on 30 July, synchronized across high-risk districts of Mali and Mauritania.  The activity had in particular focused on reaching nomadic populations.  SIAs were also held in early July in Burkina Faso and Guinea. 

• In Guinea, efforts are ongoing to strengthen subnational surveillance gaps.  Viruses found in the Spring in Mali and Liberia were found to originate in neighbouring Guinea, suggesting the area poses a particular risk to west Africa's outbreak response efforts.

• The next synchronized immunization campaigns across 12 countries of west Africa are scheduled for 10 October.

Horn of Africa

• No wild poliovirus cases have been reported across the Horn of Africa for 2010 (see 'headlines' section above).

• However, a circulating vaccine-derived poliovirus outbreak is ongoing in parts of Ethiopia, and appropriate outbreak response activities are ongoing.  A special SIA was held in the eastern part of the country on 6-9 August, following a June response. 

• While confirmation of no wild poliovirus cases for the past 12 months underscores the soundness of outbreak response strategies, it is critical that countries across the Horn of Africa maintain vigilance, by strengthening subnational surveillance sensitivity and continuing to boost population immunity levels.