March 2010

All data as of 6 April 2010

HEADLINES

Polio in decline: Polio has declined this year compared to 2009, both in terms of the number of cases and geographic restriction. Fifty-six cases have been reported year-to-date, compared to 231 cases for the same period in 2009, and progress has been particularly strong at curbing type 1 in traditional reservoir areas such as northern Nigeria (no type 1 cases this year nationwide) and northern India (three type 1 cases this year nationwide). Geographically too, polio is on the decline. Last year at this time, 69 districts were affected by polio, compared with 39 districts this year.

Outbreak response in west Africa restricts virus to westernmost part: Multi-country synchronized outbreak response campaigns in west Africa are continuing, as the outbreak which had in 2009 affected the entire region appears to have been cornered to the westernmost part (Senegal and Mauritania). See 'west Africa' section below for more.

Niger also benefits from progress in Nigeria: The progress achieved in Nigeria and resulting decline in polio is also having benefits to populations in neighbouring Niger. Niger has in previous years been affected by repeated virus importations from Nigeria. However, as a result of ongoing high-quality SIAs in Niger, and decline in virus transmission in Nigeria, no new cases have been reported in Niger since May 2009.

Melinda Gates visits India - discussed polio and family health: Melinda Gates, co-chair of the Bill and Melinda Gates Foundation, visited India in late March. On her visit, she participated in polio supplementary immunization activities (SIAs) and met with senior federal and state political leaders, including Uttar Pradesh Chief Minister Mayawati, to discuss family health and polio eradication.

ENDEMIC COUNTRIES

India

• India is experiencing very low levels of type 1 transmission at the same time in both of the traditional reservoir areas of western Uttar Pradesh and central Bihar.
• The recently-approved 107 high-risk block plan, to maximise operations in the 107 high-risk blocks of western Uttar Pradesh and Bihar, is now being actively implemented to close any remaining operational gaps in these areas.
• At the same time, operational gaps to reach mobile populations area also being addressed. Virologic and epidemiologic evidence suggests polio transmission is now largely being sustained by population movements, and represents a significant risk to India's polio eradication effort. New approaches are being implemented to reach mobile groups both in high-risk areas of Uttar Pradesh and Bihar, as well as in destination states.

Nigeria

• The Expert Review Committee on Polio Eradication (ERC) convened on 22-24 March. Given the opportunity the current low-level transmission presents, the group put forward key new approaches to further build on the progress achieved over the past 12 months.

• 85 high-risk and very high-risk Local Government Areas (LGAs) have now been clearly identified (ie areas where the proportion of 0-dose children remains >10%). LGA-specific plans will now be developed for these areas, and technical support will be prioritized to support the planning and implementing of the plans.
• At the same time, the possibility of conducting specific interim SIAs in these LGAs during the summer, ahead of the rainy season, is currently being explored by the government. In particular, technical assistance could be significantly scaled-up to urban areas of Kano, where 19 of the 85 LGAs in question are located.
• Elsewhere, the possibility of conducting a special Short Interval Additional Dose (SIAD) activity in Plateau state is currently being explored. Plateau, and in particular the city of Jos, has this year been affected by insecurity and SIAs have been repeatedly postponed in key areas. A SIAD round would rapidly help boost population immunity in this area.
• In the margins of the ERC, a special research group meeting was also convened, to discuss the possible implementation of key studies to further sensitize and evaluate strategic approaches, including seroprevalence studies, operational research, programme evaluation and social/communications studies. Following the ERC, a social data training session was conducted for all communication officers on 26-27 and 29-30 March 2010 in Kaduna and Kano, respectively.

Pakistan

• Efforts are continuing in Pakistan to improve population immunity levels to both type 1 and type 3 polio in the three reservoir zones of Sindh (Karachi), Balochistan (the Quetta area), and security-compromised districts of North West Frontier Province (NWFP) and agencies in Federally Administered Tribal Areas. District/agency-specific plans have been developed and are now being implemented.
• Following its initial use in February, the March SIAs also used bivalent OPV in large areas of the country. While overall high-quality was achieved, significant operational gaps continued to mar the quality of the activity in key transmission zone areas, notably in Quetta and Karachi.
• While increased political and civil engagement was noted in key districts and towns, this commitment was not consistent across all persistent transmission areas. Ownership at this critical programme implementation level is key to overcoming SIA operational gaps.

Afghanistan

• During the mid-March NIDs, with bivalent OPV, six of the 13 security-compromised high-risk districts of Southern Region were again inaccessible. The overriding strategic priority is to increase access in these persistent transmission areas.
• Of note, despite a deterioration of security across all Southern Region and other areas of Afghanistan, the quality of SIAs has actually improved in 2009 and early 2010 (outside of the 13 high-risk districts), as a result of new approaches implemented in 2009. Population immunity in these areas has either been maintained or increased. As a result, the virus has not managed to re-establish a foothold outside of the 13 high-risk districts. In the 13 high-risk districts, however, upwards of 20% of children remain un-immunized.
• District-level plans for these 13 districts have now been finalized and are being actively implemented. Focus is both on negotiating increased access through engagement of local access negotiators, local leaders and antigovernment elements; and on improving operations by addressing such factors as inappropriate vaccination team composition, training materials, inadequate supervision and training.
• Staff capacity is being actively expanded in the 13 districts, both in recruiting new staff and more adequately training staff already present, expanding the work and collaboration with local NGOs.

RE-ESTABLISHED TRANSMISSION COUNTRIES

Angola, Democratic Republic of Congo

• Angola reported its first case of the year, prompting a mop-up vaccination campaign scheduled 23-25 April.
• Earlier, the Technical Advisory Group (TAG) for both Angola and the Democratic Republic of Congo, convening in mid-March, noted some operational progress, but cautioned that there is a strong likelihood of undetected circulation of poliovirus in parts of both countries due to the persistence of sub-national surveillance gaps. In both countries, rapidly filling these gaps is a priority. At the same time, key immunity gaps remain in some areas of both countries due to operational SIA weaknesses.
• In Angola, the TAG recommended key interventions to urgently improve operations concentrating on the Luanda-Benguela corridor, and operational guidelines are now being revised and updated, focusing on retraining of supervisors, vaccination teams and mobilizers in these areas.
• In DR Congo, with no new cases reported in the country since August 2008, the highest priority is to enhance AFP surveillance sensitivity, particularly in the eastern provinces of North and South Kivu. To boost population immunity in these areas, microplans are being revised, refresher trainings of key staff implemented, and special plans developed to run operations in conflict-affected areas.

Chad

• In Chad, following the official launching of NIDs on 6 March by the President, when he called for direct oversight for polio eradication by provincial governors, efforts are now focusing on translating the national commitments into sub-national strengthened engagement.
• Upwards of 50% of children in key areas are regularly missed during SIAs, including in the greater N'Djamena area, due to a number of operational gaps in quality. These gaps can be rapidly addressed with sufficient political engagement from the provincial - and subsequently district - levels.
• At the same time, outbreak response microplans must now be urgently revised, including updated training materials for all staff (from planners to supervisors to vaccinators)

Southern Sudan

• Convening in March, the Horn of Africa TAG highlighted sub-national surveillance gaps in southern Sudan as an important risk to the entire region's polio eradication effort. The group concluded that although no new cases had been identified in southern Sudan since June 2009, undetected circulation could not be ruled out due to the persistence of sub-national surveillance gaps.
• While SIA operations have improved, in part thanks to scale-up of technical support in 2009, the TAG recommended key activities to rapidly fill the sub-national gaps and rapidly detect any residual virus circulation. Efforts to further build on the improvements from 2009 and further boost population immunity levels must also continue.
• Southern Sudan implemented the second round of NIDs from 29 - 31 March 2010, using bivalent OPV for the first time. A national review is planned for the last week of April.

IMPORTATION COUNTRIES

West Africa

• The multi-country synchronized outbreak response campaigns across west Africa are continuing.
• Following synchronized activities in February and March, a further round is planned on 26 April using a combination of bivalent OPV and mOPV1 in Benin, Burkina Faso, Côte d'Ivoire, Guinea, Guinea Bissau, Ghana, Liberia, Mali, Mauritania, Niger, Senegal, Sierra Leone and Togo.
• The ongoing outbreak response appears to have pushed back the outbreak to its westernmost part, to Senegal and Mauritania.
• However, ongoing gaps remain in outbreak response SIA quality, particularly in areas of Guinea, Mali, Mauritania and Senegal. Until the outbreak is fully stopped, the danger remains that the virus could circle backwards again, to re-infect countries of west Africa which now appear to have succeeded in stopping their respective outbreaks.
• The high level political engagement so visible during the March SIAs, when several heads of state launched the campaigns including the Presidents of Guinea, Mali and Liberia, the Prime Ministers of Senegal and Gambia, and the First Lady of Ghana, must be sustained.