April 2010

All data as of 04 May 2010                                                             English (pdf ) French (pdf)

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Polio outbreak in Tajikistan: Wild poliovirus type 1 (WPV1) has been detected in Tajikistan, representing the first importation of poliovirus in the WHO European Region since it was certified polio-free in 2002.  The virus is most closely related to viruses originating in Uttar Pradesh, India. 199 cases of acute flaccid paralysis (AFP) have been reported, the majority of these having had onset of paralysis in April.  To date, WPV1 had been isolated in 32 of these cases.  This outbreak underscores the danger that spread from WPV transmission anywhere in the world continues to pose to polio-free regions everywhere.  A comprehensive outbreak response is currently being planned.  See 'importation countries' section below for details.

Afghanistan and Indian cricketers join forces to 'bowl out polio': At the 1 May ICC World Twenty20 cricket tournament, Indian and Afghanistan cricketers came together ahead of the match to 'bowl out polio'.  Indian batsman Suresh Raina and Afghan Captain Nowroz Mangal exchanged 'bowl out polio' cricket bats, autographed by members of each team, to show regional solidarity to eradicate polio from both India and Afghanistan.  

West Africa outbreak: Multi-country synchronized outbreak response campaigns in west Africa are continuing.  Such efforts have significantly slowed the outbreak: however, complacency is the major risk to stopping the outbreak once and for all , as residual transmission is continuing in five countries of the region:  Senegal, Mali, Mauritania, Sierra Leone and Liberia.  While the outbreak had by early 2010 been restricted to the westernmost part of the region, confirmation in April of new cases in Liberia and Mali underscores the dangers of the outbreak 'circling back' eastwards. 

World Health Assembly to be presented with new Strategic Plan: Health ministers from the 193 Member States of WHO will review the new GPEI Strategic Plan 2010-2012 at the 17-21 May World Health Assembly (WHA).  In 2008, recognizing delays in achieving eradication, the WHA had requested the development of a new strategic plan.  Since then, a major independent evaluation of barriers to polio eradication, trials on new vaccines, and new approaches for reaching previously missed children helped inform the development of the new plan, which was produced in broad consultation with stakeholders and governments of the remaining polio-affected countries.  The text version of the Plan which will be presented to the WHA is available at www.polioeradication.org. 

India - no cases for seven weeks: India's most recent case had onset of paralysis on 7 February, and the country has not reported a case of either WPV1 or wild poliovirus type 3 (WPV3) in seven weeks.  This is the longest period ever without any cases of WPV1 simultaneously in the remaining endemic states of Uttar Pradesh (UP) and Bihar.  The highest strategic priority is to rapidly interrupt remaining low level transmission (the importance of which is underscored by recent cases in Nepal and Tajikistan genetically linked to previous WPV1 viruses from Bihar and UP, respectively).  See 'India' section below, for more details on specific strategies to eradicate polio from India once and for all in the country.

New cases in Niger underscore ongoing risk from Nigeria:  Despite strong improvements in implementation and political commitment achieved over the past 12-18 months in Nigeria which has also indirectly benefitted  neighbouring Niger (see 'March 2010' situation report), this month's confirmation of WPV3 importations in Niger, originating from Nigeria, is a stark reminder that even low levels of endemic transmission are a danger to neighbouring countries.  An appropriate outbreak response is currently being finalized in Niger.

India

• India is experiencing its longest stretch yet without WPV1 in UP and Bihar – simultaneously.  However, residual transmission of WPV1 and 3 is likely continuing in areas of central Bihar, western UP and among mobile populations. 

• The recently-approved '107 high-risk block plan' aims to fill any remaining operational gaps in central Bihar (notably Kosi river) and western Uttar Pradesh, to ensure that any remaining un- or under-vaccinated, susceptible children are regularly reached.

• Recognizing the unique virus transmission dynamics in the setting of northern India, new approaches to reduce the risk factors contributing to this highly efficient transmission are being evaluated and implemented.  These include instigating simple sanitation measures, sensitizing communities to hygiene, and offering zinc supplementation to reduce the incidence of diarrhoeal disease.

• Targeted outreach is now regularly conducted to ensure children among mobile populations are reached.  At any given moment, upwards of five million people are mobile across northern India.  Migrant population sites are regularly identified, also in destination states, and special vaccination teams reach out to increase outreach to mobile groups.   

• In addition to pursuing efforts to interrupt the remaining chains of WPV1 and WPV3 transmission in the country, vigilance against a circulating vaccine-derived poliovirus type 2 (cVDPV2) is continuing.  Although no new cVPDV2 cases have occurred since 18 January, district-specific mop-ups will be instigated with trivalent in response to any further detected cVDPVs.  Additionally, two nationwide rounds were conducted in January and February, with mostly trivalent OPV

Nigeria 

• Nigeria continues to see strong progress against polio.  The most recent Immunization Plus Days (IPDs) were conducted on 24-27 April, using bivalent OPV.  Seven states in the north of the country delayed the activity by four days, due to delays in receiving bivalent OPV as a result of the recent closure of European airspace. 

• A WPV3 from Zamfara state, the first case since January, is evidence of ongoing circulation of polio in the country. While progress has been achieved, a number of high-risk areas continue to be affected by operational gaps.

• 85 high-risk and very high-risk Local Government Areas (LGAs) have now been identified (ie those areas where the proportion of 0-dose children remains >10%).  LGA-specific plans will now be developed for these areas, and technical support prioritized. 

• As part of intensified social mobilization efforts, UNICEF conducted an orientation on the outcomes of the most recent April IPDs to the Journalists Against Polio network. 

• Despite positive developments, Nigeria continues to have confirmed circulation of all three serotypes:  WPV1, WPV3 and a cVDPV2.  The most recent cVPDV2 case had onset of paralysis on 17 February in Kano.  Any detection of further cVDPV2 cases will immediately trigger an LGA-wide mop-up with trivalent OPV.

Pakistan

• Efforts are continuing in Pakistan to improve population immunity levels to both type 1 and type 3 polio in the three transmission zones of Sindh (Karachi), Balochistan (the Quetta area), and conflict-affected areas in the Federally Administrated Tribal Agencies (FATA) and North West Frontier Province (NWFP).  District/agency-specific plans have been developed and are now being implemented.

• National Immunization Days (NIDs) were held on 26-28 April, using trivalent OPV, following subnational activities in March with bivalent OPV.  Political commitment at the critical programme implementation level, notably in key areas of Quetta (Balochistan) and Karachi (Sindh) remained inconsistent and suboptimal, contributing to ongoing significant operational gaps. 

• A special cross-border meeting with Afghanistan was held in April, attended by senior-level public health staff from both governments and GPEI partner agencies.  With more than two million children under the age of five years having crossed the border between the two countries in 2009, the meeting centred on how to coordinate activities between the two countries, including ensuring optimal microplanning activities. 

• Trainings of the Inter-religious Council for Health (IRCH) in all provinces were completed in 27 districts, to support mobilization for polio, immunization and child health.

• Pakistan launched its first-ever Vaccination Week (26-30 April) during which a polio NID was also conducted.  The focus was on advocacy and social mobilization, building on the polio infrastructure.  All polio communications partners, including the media, motorway police, Pakistan Post have been mobilized to celebrate Vaccination Week.

Afghanistan

• NIDs took place in the country for 2-4 May, using trivalent OPV, following NIDs in March with bivalent OPV. 

• The overriding priority in Afghanistan is to rapidly improve population immunity in 13 highest-risk districts of Southern Region, where upwards of 20% of children remain un-immunized. 

• A key to reaching these unvaccinated children is to scale up capacity in these districts.  To help address this, a capacity-building workshop for these districts was held from 14-24 April, with 350 district and field-level supervisors. 

• In preparation for the May NIDs, collaboration with local NGOs was also expanded. 

• Specific district-level plans for these 13 districts have now been finalized and are actively being implemented. 

• A contingency plan has been developed to further boost population immunity in the north of the country, with recent confirmation of the polio outbreak in Tajikistan.  Disease surveillance is being further strengthened in the areas bordering Tajikistan, to rapidly detect any potential importation and activate the emergency contingency plan.  For the 2-4 May NIDs, particular focus was on provinces bordering Tajikistan, and an additional mop-up in those border areas is being discussed, in synchronization with Tajikistan's outbreak response.    

Angola, Democratic Republic of Congo

• In Angola, in response to the reporting of its first case in 2010 (onset of paralysis on 8 April), a large-scale mop-up immunization campaign was held on 23-25 April, with monovalent OPV type 1.  More than 300,000 children under the age of five years were targeted in the immediate area around the case. 

• This activity will be followed by Subnational Immunization Days (SNIDs) in May (again with monovalent OPV type 1), followed by NIDs in June using trivalent OPV. 

• In DR Congo, the most recent case had onset of paraysis on 24 June 2009.  SNIDs are planned for June and July, with bivalent OPV and trivalent OPV, respectively.  The activities will see technical support prioritized to areas considered at highest-risk, including North and South Kivu, Orientale, Bas-Congo and Kasai Occidental, though full geographic extent of the campaigns are still being finalized. DR Congo has not conducted campaigns since November 2009.

• In both Angola and DR Congo, population immunity gaps remain in key areas, and undetected circulation due to subnational surveillance gaps cannot be ruled out.  In Angola, the 'problem' area is the Luanda-Benguela corridor, while in DR Congo, immunity levels must urgently be improved in the east of the country, particularly in the provinces of North and South Kivu. 

• For both countries, recent Technical Advisory Group (TAG) meetings put forth key recommendations to help address these issues, and these are now being implemented.  Operational guidelines are being revised and updated, focusing on retraining of supervisors, vaccination teams and mobilizers.  Additionally, in conflict-affected areas of DR Congo, plans are being developed to run operations under such conditions. 

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. 

• Following this event, on 12 March a meeting of provincial governors was convened, where the governors publicly signed a commitment to provide the necessary leadership to stop polio in the country at the latest by end-2010. 

• NIDs were subsequently conducted on 24 April.  Preparations had focused on revising outbreak response microplans, including revising and updating training materials for vaccinators and other SIA staff.  In N'Djamena, a key polio reservoir in the country, district-heads were charged by the Office of the Governor to improve SIA performance.  The new Minister of Health was personally also engaged during the campaign, visiting and participating in the activity in Hajer Lamis province.

• New approaches are being implemented in key, high-risk areas.  In particular, a new approach of staggering the NIDs at district-level by deploying technical support and vaccination teams to individual districts for one day, before moving on to the next district.  Tally-sheets were also simplified, encouraging vaccination teams to focus solely on the number of children immunized and fingermarking.  Although coverage data from this latest campaign are not yet available, evidence suggests that these and other approaches, including strengthened political engagement by key provincial leaders and at the federal level, have led to operational improvements and more children being reached. 

• The next SIAs are planned for May and June.

Southern Sudan

• Although no new cases have been reported in southern Sudan since June 2009, undetected circulation of poliovirus cannot be ruled out, due to the persistence of subnational surveillance gaps. 

• Recent improvements were noted in filling the subnational surveillance gaps, and these efforts must continue.  International technical support remains strong in southern Sudan, with 11 eSTOP professionals on the ground, supporting efforts to fill the gaps, and also to help plan SIAs for later in the year. 

• Southern Sudan implemented the second round of NIDs from 29-31 March 2010, using bivalent OPV for the first time.

West Africa

• The multi-country synchronized outbreak response campaigns across west Africa are continuing.

• Following synchronized activities in February and March, a further round was held in late April using a combination of bivalent OPV and monovalent OPV type 1 in Benin, Burkina Faso, Côte d'Ivoire, Guinea, Guinea Bissau, Ghana, Liberia, Mali, Mauritania, Niger, Senegal, Sierra Leone and Togo.  In some areas, the activity was delayed by a few days, due to late arrival of vaccine which had been grounded in European airports due to the closure of European airspace. 

• The ongoing outbreak response appears to have pushed back the outbreak to its westernmost part, to Senegal and Mauritania.  However, confirmation of recent cases in Mali and Liberia underscores the fragility of this progress, as the outbreak could circle back eastwards.  Complacency is now the biggest danger in the region.

• Independent monitoring highlighted operational gaps in outbreak response in some areas of Senegal, Guinea, Mali (particularly in Bamako) and Liberia (particularly Monrovia).  In Bamako, Mali, for example upwards of 40% of children were missed during the March SIA.       

• The high-level engagement visible from previous activities continued.  The President of Mauritania personally launched the NIDs in that country, calling on all civic and political leaders to do the utmost to ensure all children are immunized.  Significant operational improvements were noted in Mauritania during this most recent activity. 

• The western-most affected area of the region will conduct further immunization campaigns in May. 

• In Niger, in response to this month's confirmation of a WPV3 importation from Nigeria, an outbreak response with monovalent OPV type 3 will be held on 28 May.

Tajikstan

• A series of three NIDs are currently being planned with monovalent OPV type 1 (mOPV1), in response to the confirmed polio outbreak.  An initial vaccination response took place in the capital Dushanbe and six surrounding districts starting 1 May, and nationwide rounds began on 4 May.  Technical support has been deployed to the country, to help in the planning and the outbreak response, and in monitoring and programme implementation. 

• Campaigns will also be held in neighbouring Uzbekistan and Kyrgyzstan in late May.  Preparations in both countries are ongoing.  Afghanistan is also putting in place contingency plans to boost population immunity in the north of the country.

• The viruses isolated in Tajikistan have been genetically linked to viruses previously circulating in Uttar Pradesh, India in 2009.

• The government has undertaken a massive communication campaign, including full media coverage and social mobilization with support from UNICEF, which organized a media workshop for local journalists in Dushanbe.

Nepal

• In Nepal, following recent confirmation of a WPV1 genetically-linked to WPV1 in Bihar, India, NIDs with bivalent OPV were held on 10 April.  A second round is currently being planned for 15 May (again with bivalent OPV), followed by SNIDs in June, with monovalent OPV type 1.

• A joint national/international VPD Surveillance review was conducted from 15-27 April.  Twelve teams covered 24 districts (one third of the country) focusing on the performance & sensitivity of the AFP surveillance system, location of mobile populations from India and OPV coverage in routine and SIA activities.  Special attention was given to the Terai area of Nepal (those districts boarding Uttar Pradesh and Bihar).

• The specific review recommendations for the AFP surveillance system and SIAs are being formatted into action plans for immediate implementation.

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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.