June 2010

All data as of 29 June 2010

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HEADLINES

• Strategic Plan 2010-2012 plan launched: On 18 June, the new Global Polio Eradication Initiative Strategic Plan 2010-2012 to eradicate wild poliovirus was launched at a key stakeholder meeting. The Ministers of Health of Nigeria, Angola and Senegal, among a number of other senior health ministry officials, existing and potential funders, vaccine manufacturers and key partner organizations attended the event – co-hosted by WHO Director-General Margaret Chan and UNICEF Executive Director Tony Lake–to discuss the implementation, monitoring, economics and financing of the new Plan. Mr Lake called on the gathering to "act with an eye to results: we must all dedicate ourselves to writing this final chapter and closing the book on polio forever. For every child." More
• Funding gap threatens: While stakeholders fully endorsed the range of approaches and new tools in the new strategic plan – which are already showing positive results – a $1.3 billion funding gap is forcing a reprioritization of further planned activities to respond to the outbreaks in west Africa. Demand for oral polio vaccine (OPV) has recently gone up, due to the outbreak in Tajikistan, resultant activity in that country and its neighbours and the continued needs for supplementary immunization activities in west Africa. This demand has absorbed much of the flexible funding held for emergencies. While additional funds are expected later in the third quarter, activities planned for July and August in particular may require some adjustments. Decisions to delay or curtail some activities are being made based on epidemiology, protecting activities in highest-risk areas (endemic countries and those with re-established transmission). Details
• Tajikistan conducts multiple immunization rounds to rapidly raise immunity: Tajikistan has held four short-interval rounds of polio vaccination activities to rapidly raise childhood immunity in response to an outbreak now totalling 334 polio cases (data in WHO headquarters as of 29 June). The size of the outbreak means that Tajikistan accounts for more than 70% of all polio cases in the world this year. The Tajikistan experience reaffirms the imperative of completing polio eradication: until polio is eradicated, any country is at risk of an importation, and high population immunity is the only protection against a large outbreak.
• Africa aims to kick polio out forever: Africa accounts for 13% of all cases this year - largely due to the impressive 99% reduction in cases in Nigeria. In Chad, President Idriss Deby Itno delayed his departure for an official international visit in order to personally express his firm commitment to eradicating polio by signing Rotary's Kick Polio Out of Africa football, which has captured the imagination of Africa's political leaders in the lead-up to the World Cup.
• Studies give new insight into polio eradication: The New England Journal of Medicine published in June two studies on polio eradication which look at long-term OPV use and at fractional inactivated polio vaccine (IPV) dosage, offering useful new insights both for the pre- and post-eradication era. The first study reaffirms that circulating vaccine-derived poliovirus (cVDPV) is as transmissible and paralytic as wild poliovirus, supporting the strategy of responding to cVDPV outbreaks in the same way as wild poliovirus outbreaks. The second study, part of evaluating a variety of approaches to achieve affordable IPV options for the post-OPV era, shows that fractional doses of IPV are as effective in immunizing children as full doses of IPV. The need to effectively manage cVDPVs both in the pre- and post-eradication eras, and the importance of pursuing strategies to reduce the cost of IPV for the post-eradication era, were underscored in an accompanying editorial. Details.

ENDEMIC COUNTRIES

Afghanistan

• In response to a wild poliovirus type 1 case in Kandahar (onset of paralysis on 23 May), a mop-up vaccination campaign was held in five districts of Kandahar Province with bivalent oral polio vaccine (bOPV) from 29 June to 1 July, targeting more than 330,000 children under five. Various discussions are ongoing with relevant parties who can play a part in reaching children the inaccessible areas.
• A mop-up was also held in the northern areas bordering Tajikistan from 1-3 June, in synchronization with Tajikistan. These immunization activities book- ended sub-national Immunization Days (SNIDs) from 7-9 June, with bOPV administered in the Southern, South-Eastern and Eastern Regions. While access improved across Southern Region, Taliban obstruction was reported in the east, in Nuristan and Kunar, where it remains difficult to reach many areas across dangerous terrain due to heavy mining on roads among other things. Four permanent vaccination posts have been established in the districts bordering Tajikistan and Uzbekistan, Due to the deteriorating security situation in Kandahar, both WHO Southern Region team leaders and UNICEF Chief of Zonal office have been relocated and neighbouring countries to Kabul.
• In keeping with the recommendations of the Technical Advisory Group, a communication planning workshop was held and clear timelines established for finalizing and implementing district-specific communication plans for the 13 persistent-transmission districts before the start of the next SNID planned for 25 July. A separate meeting was held in Kabul to finalize district-specific operational plans for three of these 13 districts with the aim of improving quality and increasing access to all children.
• The next SNIDs are planned for 25 July, again using bOPV.

India

• India's extraordinary reduction in case numbers has continued, with no cases of type 1 reported in Uttar Pradesh and Bihar since November 2009. India is completing SNIDs in June and early July, using bOPV in western Uttar Pradesh, central Bihar and high-risk destination states for mobile populations (in Bihar, the SNIDs were officially inaugurated by the Honourable Chief Minister Shri Nitish Kumar); a mop-up round with mOPV1 is being conducted in districts of Bihar that border Nepal. With the monsoon season upon us, the SNIDs are the last large-scale campaigns before September, though staggered mop-ups are planned throughout July, using a mix of bOPV, monovalent OPV type 1 (mOPV1) and monovalent OPV type 3 (mOPV3).
• India is responding swiftly to two recent type 1 cases in West Bengal, with central government representatives dispatched to the district, together with nine Surveillance Medical Officers from the East Region, in order to rapidly close the gaps in SIA quality in that district. A large-scale mop-up in West Bengal using mOPV1 was held on 13 June (with another to follow on 11 July).
• The Government of Delhi is moving forward with a plan to expand the list of construction sites in the state covered during SIAs and surveillance in attempts to ensure India's migrant populations are adequately covered during immunization activities.

Nigeria

• Like India, Nigeria is enjoying a dramatic reduction in wild poliovirus cases, with no new cases reported in June.
• Mr Bill Gates, co-chair of the Bill and Melinda Gates Foundation, travelled to Nigeria in June to meet with political and traditional leaders, including President Goodluck Jonathan and state governors. Mr. Gates applauded the tremendous efforts being undertaken in Nigeria to eradicate polio, and highlighted those efforts needed to continue to finish polio eradication once and for all. During his visit, a group representing business, political, religious, women's, medical, non-governmental and media communities came together to sign the 'Polio Eradication Pledge', recognizing the remaining challenges to securing a polio-free Nigeria and promising to work to leverage support for the programme. Mr Gates' visit also coincided with a meeting of the northern traditional leaders committee in Jigawa State, where the leaders reaffirmed their full commitment to ensure the highest possible coverage in all the northern states.
• The June IPDs saw a significant scale-up of the Majigi - a community mobilization strategy using locally adapted films to emphasize to parents the importance of ensuring every child is vaccinated.
• Staggered sub-national Immunization Plus Days (IPDs) were held in June, allowing the re-allocation of technical resources to support highest-risk areas.
• IPDs in July will for the first time focus on 106 of the highest-risk Local Government Areas (LGAs), with these targeted district-specific approaches a key pillar of the newly-launched strategic plan.

Pakistan

• Pakistan continues to regularly report cases, although the 27 cases reported to date are from just 12 towns, districts or agencies (from Tribal Agencies/ Federally Administered Tribal Areas, Peshawar and adjoining districts in North West Frontier Province, Quetta block in Balochistan and Karachi in Sindh).
• Mop-up vaccination campaigns were held with mOPV 1 from 14-16 June in response to recent cases, and special SIAs have been held in Karachi, targeting underserved population groups, and in persistently-infected 'union-councils' (sub-districts) of Killa Abdullah district in Balochistan, with additional technical support deployed to support the planning, implementing and monitoring of the activities.
• Environmental surveillance in Karachi continues to detect poliovirus. The most recent positive sample is the fourth since May, and while no type 1 polio cases have yet been detected in Karachi, this underscores the risk that ongoing transmission poses to this key urban reservoir.
• The next National Immunization Days (NIDs) are to be held 12-14 July.

RE-ESTABLISHED TRANSMISSION COUNTRIES

Angola

• Angola has type 1 transmission in the northern states of Lunda Norte and Lunda Sul, mining areas bordering Democratic Republic of Congo (DRC). With frequent population movements across the border, the risk of international spread remains high.
• Mop-up activities in these states using mOPV1 have been held, synchronized with southern DRC, following National Immunization Days (NIDs) using trivalent OPV (tOPV). Independent monitoring suggests a high proportion of children were missed during the mop-up, with upwards of 20% of children not reached. Strengthened technical support is focusing on addressing operational issues for future campaigns, such as better microplanning and more effective vaccinator selection and training, and supervision.
• With Angola rapidly becoming the greatest risk to polio eradication in Africa, it is essential that all tiers of government commit to urgently address vaccination coverage gaps. Angola's Minister of Health, Dr José Vieira Dias Van-Dúnem, attended the launch of the Strategic Plan in Geneva and promised that the Ministry was working to improve the quality of vaccination campaigns.
• The next NIDs are tentatively planned for 30 July to 1 August, using bOP.

Cameroon

• The first case of the year has been reported in Cameroon, from Extreme Nord province, bordering Borno state in Nigeria and Chad (greater N'Djamena area). There have been no cases reported in Nigeria's Borno state since July 2009.
• An outbreak response is currently being finalized, potentially in synchronization with Chad and Nigeria.

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 being reflected by continued operational improvements. In particular, more effective microplanning and vaccinator performance was observed.
• Staggered NIDs are ongoing through June with most of the country having conducted the activity from 7-9 June, Chari Baguirmi conducting activities last week and N'Djamena conducting activities from 20-27 June. Focus remains on addressing operational gaps. Further activities are planned for July, October and November.
• Democratic Republic of Congo (DRC)
• As of 24 June, DRC has been polio-free for 12 months. However, a recent cluster of cases in north-eastern Angola, close to DRC's border, underlines the need to raise childhood immunity to protect against wild poliovirus importations.
• Proposed SIAs are SNIDs in July and August (with bOPV and tOPV, respectively). The geographic extent of these activities is currently under review, following detection of cases in north-eastern Angola and detection of additional vaccine-derived poliovirus (VDPV).

IMPORTATION COUNTRIES

Tajikistan and neighbouring countries

• The outbreak in Tajikistan has affected 334 people, and now accounts for over 70% of all cases worldwide. While the number of newly-detected acute flaccid paralysis (AFP) cases continues to decline, suggesting the outbreak has peaked, 188 AFP cases remain pending for laboratory confirmation, and so the number of reported cases is still expected to rise.
• Four NIDs have now been conducted with mOPV1, using the Short-Interval Additional Dose strategy to rapidly raise immunity.
• Neighbouring countries continue to take precautionary measures: Uzbekistan has held two nationwide campaigns and is planning further SIAs from 5-9 July; children living in the bordering provinces of Afghanistan have been vaccinated twice since the outbreak was reported; while Kyrgyzstan will conduct SIAs 19-23 July,, Turkmenistan and Kazakhstan are also planning immunization activities in July and August, respectively..
• In Russia, type 1 wild poliovirus has been isolated in six individuals with AFP: the genetic sequencing of the viruses show they are related to the one circulating in Tajikistan. Case investigations are ongoing to determine where and when infection occurred. Control measures and heightened surveillance are in place.

Nepal

• In April and June, Nepal reported two type 1 polio cases from districts bordering India. The genetic sequencing suggests two separate importations of viruses originating in Bihar, India.
• NIDs were held on 10 April and 22-23 May, using bivalent OPV. SNIDs were conducted on 19-20 June, covering the districts boarding India and the Kathmandu valley, using mOPV1. Additional campaigns are planned for July.

West Africa

• The bulk of West African cases in 2010 (18 of 29 cases) are from Senegal, with other cases being reported from Liberia, Mauritania, Mali, Niger and Sierra Leone. However, the number of cases being reported is rapidly dwindling, thanks to repeated multi-country immunization activities. From 25 June, for instance, SIAs were synchronized across six countries: Senegal, Mauritania, Mali, Liberia, Burkina Faso and Gambia. Guinea briefly postponed its activities due to elections, and will hold its immunization activities on 2 July.
• Guinea poses a particular risk, due to sub-national AFP surveillance gaps (meaning undetected polio circulation can not be ruled out). Additionally, viruses recently found in neighbouring countries (Mali and Liberia) originated in Guinea. Additional technical support was provided to the country and a series of basic improvements are being put in place, such as systematic coverage in markets and transit areas, better recording of missed children and stronger first-line supervision.
• All countries have conducted at least three SIAs since detection of their latest respective cases and some have conducted five.
• Horn of Africa
• No wild poliovirus cases have been reported across the Horn of Africa for 2010. While on 27 June, Sudan was officially polio-free for more than 12 months, the risk remains of undetected circulation of poliovirus as a result of sub-national surveillance gaps in some areas, including parts of southern Sudan. Recent efforts have improved and helped fill these gaps, and this progress is being consolidated to rule out circulation with certainty or rapidly detect any cases.
• In southern Sudan, efforts at strengthening routine immunization continue, with training concluded in June for all 10 state and 79 county (district) cold chain officers/assistants on vaccine and cold chain management, including for polio SIAs as well as the reverse cold chain for AFP surveillance.
• On 21-23 June, 2010 northern Sudan carried out its first Child Health Days campaign for 2010. The interventions provided, house-to-house, were oral polio vaccine, vitamin A, de-worming tablets, awareness messages on child protection and peace promotion.