November 2009  English (pdf )   French (pdf) 

All data as of  03 December 2009   
The December-January report will be produced at the end of January

Afghanistan to be first country to use bivalent oral polio vaccine (bOPV) in Supplementary Immunization Activities for polio eradication: The 13-15 December vaccination campaigns in the country will be conducted using this new formulation of polio vaccine, which protects children from both surviving strains of wild poliovirus concurrently and greatly simplifies logistics.
 

The ACPE recommendations for the endemic countries included:

• Maintain Head of State engagement and oversight to ensure accountability of local authorities in ensuring that all children are reached by immunization activities;

• Optimize use of  available vaccine tools, by rapidly introducing bOPV;

• Conduct independent management reviews of key areas where management, operational constraints and lack of accountability continue to affect Supplementary Immunization Activity (SIA) quality, in order to identify root causes of programme problems and identify solutions;

• Develop district-specific plans for security-compromised areas to ensure tailored strategies to access children, including through negotiated access with parties to the conflict;

• Adopt sero-surveillance as an additional monitoring tool, particularly in areas of discordant programmatic and epidemiological data, to verify programme performance and vaccine efficacy and to guide strategy;

• Expand environmental surveillance appropriately to provide information that will be supplemental to AFP surveillance in assessing the persistence of wild poliovirus;

• Continue to systematically re-assess community knowledge, attitudes and practices (KAP) every six months to evaluate interventions and to further tailor social mobilization and communications strategies.

India

• The number of cases for 2009 is 650: 77 cases are type 1, 572 are type 3 and one is a type 1/type 3 co-infection. Last year at the same time, India had 524 cases: 65 type 1 and 459 type 3.

• The India Expert Advisory Group (IEAG) reviewed the programme in November and concluded that the country is firmly on the right path to finish polio eradication. Wild poliovirus is now restricted to a very small geographical area with only one surviving genetic lineage of type 1 polio. Research on the recently developed bivalent OPV was reviewed and the IEAG recommended its use in 2010, allowing continued prioritization of type 1 polio elimination and simultaneous type 3 polio control. The Government of India plans to use bOPV for the first time in Bihar in the January NID.

• Subnational Immunization Days (SNIDs) were conducted on 8 November in the high-risk areas of Bihar and Uttar Pradesh (UP), re-infected areas and areas known to be destination points of large-scale population movements from these two endemic states. Reports indicate that operations were improved in the traditionally hard-to-reach Kosi River area of Bihar.   

• Efforts continue to close immunization gaps in young children and migrants - the groups which are currently sustaining wild poliovirus transmission - particularly in 107 high-risk blocks of western UP and central Bihar. Since 2003, over 80% of all type 1 polio cases have been reported from these 107 blocks (which represent approximately 2% of the country's geographic blocks). Ensuring high OPV coverage during every SIA in these blocks is the key to success. 

• Eight VDPV cases have been confirmed in 2009, two type 1 and six type 2. The date of onset of paralysis of the most recent case was 14 October in UP. There are plans to use trivalent OPV (tOPV) during the December SNID in selected areas of West UP where type 2 VDPVs have been detected.

• The next SNIDs will be conducted on 6 December, in key high-risk areas of Bihar, Uttar Pradesh, re-infected areas, and areas known to be destination points of large-scale population movements.

• Nationwide polio campaigns (NIDs) are scheduled for 10 January and 7 February 2010. In January, tOPV will be used all over the country except parts of Bihar.

• Four cricketers from the Delhi and Uttar Pradesh local cricket teams came together to "Bowl out Polio" on 26 November. Cricketers spoke in particular about the need to wipe out polio in UP, home state to three of the players. Given the significance of migrants in sustaining transmission, and the high migration between Delhi and UP, players also spoke about the need for parents to vaccinate their children, particularly when travelling.

Nigeria 

• The number of cases for 2009 is 384: 74 type 1 cases, 310 type 3. Last year at the same time, Nigeria had 768 cases in total, 703 of which were type 1.

• No type 1 has been recorded anywhere in the country for more than three months. The operational improvements achieved this year during Supplementary Immunization Plus Days (SIPDs) has resulted in a 50% decline in the overall number of polio cases and a 90% decline in type 1 cases compared with 2008. The intensity of transmission of all three serotypes (wild type 1, wild type 3 and circulating vaccine-derived poliovirus type 2 - cVDPV2) continues to decline. 

• During November IPDs, sustained improvements in operations were again evident. In particular in Kano, a traditional high-risk virus reservoir, religious, traditional and local government area (LGA) leadership was visibly engaged, resulting in strong community demand. The Emir of Kano officially launched these latest activities by immunizing his grandson at a public Flag-Off ceremony.

• UNICEF strengthened its technical presence in local level communication planning and implementation at State and LGA levels through deployment of LGA Consultants, STOP and Communication Consultants before the November IPDs. The focus was also to build the capacity of partners to implement communication activities in high-risk States.

• Journalists against Polio (JAP) and the Forum of Muslim Women of Nigeria (FOMWON), both with networks in the high-risk states in the north, are helping to ensure an integrated approach to the implementation of communication activities, including deployment of media monitors, capacity building, partnership with the media and community meetings. Members of JAP and FOMWON have undergone training and were deployed to the field for the November IPDs.

• In Sokoto and Kebbi states, the November IPDs were postponed to early December. Insecticide treated bed-nets are being distributed in select areas, as part of the IPD strategy to offer additional health interventions to communities during polio activities.

• Key messages have been developed – based on social data from a KAP study – focusing on immunization benefits, missed children and non-compliance. These have been shared with state and local communication networks for their use in mass and traditional media, and through interpersonal networks, such as key traditional leaders, including the Sultan of Sokoto.

• The next IPDs are nationwide and scheduled to start on 30 January and 27 February, 2010.

Pakistan

• Pakistan has reported 81 cases in 2009 – 56 type 1 cases, 24 type 3 cases, and one type 1/type 3 co-infection – compared with 104 cases at the same time last year (75 type 1 cases and 29 type 3).

• During the most recent NIDs from 16-18 November, access was increased in key areas of North West Frontier Province / Federally Administered Tribal Areas (NWFP/FATA). The proportion of inaccessible populations dropped to its lowest level in nearly two years (to 5% of the target population, compared to 18% in July). However, greater Karachi (in Sindh) – a fully accessible area – demonstrated operational gaps again. Full political ownership and accountability at the implementation level (district and union council level) is urgently needed to address the persistence of these operational gaps. 

• Communications reviews were held in NWFP/FATA and Sindh in November 2009. Review panel members noted progress in the collection and use of data to identify the local issues and to guide programme planning. Focus continues to be on the development of local level plans based on data to address the local challenges including access, awareness, mobilization of appropriate teams and local level accountability.

• The partnership between the polio eradication effort and Samaa TV was recognized at the 7th Annual Asian Forum for Corporate Social Responsibility in the area of health initiatives. The polio 'control cell' consistently supports the promotion of polio campaigns by identifying underperforming teams and resulting in the immunization of more than 25,000 missed children during vaccination campaigns. President Asif Ali Zardari personally wrote to appreciate this initiative and the award, reiterating the importance of media partnerships in eradicating polio.

• The next SNIDs will take place from 14-16 December.

Afghanistan

• Afghanistan has reported 29 cases in 2009, 15 type 1 and 14 type 3, compared with 31 cases at the same time last year - 24 type 1 cases and seven type 3.

• Since mid-year, Afghanistan is affected primarily by type 3 transmission, restricted to eight high-risk districts in security-compromised areas of the Southern Region (Hilmand and Kandahar). Efforts during the most recent NIDs on 15-17 November again focused on increasing access in these districts. 

• Concerted efforts this year to engage traditional and community leaders, as well as NGOs contracted by the Government to deliver the basic packages of health, have led to increased access, particularly in the second half of the year, during some SIAs. However, access continues to fluctuate from round to round - in July, the proportion of inaccessible children was reduced for the first time to less than 5% in the Southern Region (down from 20% at the start of the year), while during this most recent November activity, this figure rose slightly to 8%. This fact underscores the extreme and dangerous challenges polio staff continue to face in efforts to implement the polio eradication strategies. 

• Bivalent OPV will be used in SIAs – for the first time ever –during the next SNIDs from 13-15 December in Afghanistan, if supply is sufficient. In November 2007, the ACPE had recommended the GPEI explore the potential benefits of a bivalent OPV. A clinical trial conducted this year in India confirmed that it would be a useful new tool in the arsenal of polio eradication, and the vaccine is positioned for large-scale use in the GPEI by mid-2010. 

ACPE recommendations for re-infected countries included the following:

• The independent monitoring process for the African Region presented to the ACPE should be implemented as rapidly as possible in all re-infected countries, with monitoring results made available internationally within 15 days of each immunization round.

• SIAs should be carried out in 2010 and 2011 in the areas at persistent high risk of importation in West Africa, Central Africa, and the Horn of Africa (i.e. the 'importation belt'), prioritizing currently infected areas and those with the weakest routine immunization coverage.

• Countries at particular risk of polio importations should consider steps to ensure the immunization of travellers arriving to or from infected areas - prior to arrival and also at the point of entry - especially when large gatherings of travellers are expected (such as the African Cup of Nations and the World Cup).

• All identified countries at persistent high risk of importation should review or develop plans for strengthening routine immunization coverage.

• Angola and Chad have documented evidence of re-established polio transmission by virtue of the persistence of wild poliovirus for more than 12 months following importation, and Sudan and DR Congo are at risk of having re-established transmission. All four of these countries require the same levels of political ownership and commitment as endemic countries, and will require the same intensive level of partnership support.

West Africa

• West Africa has recorded a total of 144 cases in 2009 (Benin 21; Burkina Faso 14; Côte d'Ivoire 27; Guinea 36; Liberia 10; Mali 5; Mauritania 4; Niger 15; Sierra Leone 6; and, Togo 6). All are type 1 except in Niger, which has one type 1 case and 14 type 3 cases.

• Niger has not reported a case since May: a positive offshoot of the improvements in Nigeria.

• Confirmation of a type 1 case from Benin in October underscores the risk of ongoing circulation of polio in the region. Genetic sequencing of this case is currently ongoing, to determine if it is a new importation, or is sustained transmission of earlier cases in this region of west Africa (i.e. Benin and Burkina Faso).

• Farther west in the region, the second-wave of the outbreak continues. Recent cases in Mauritania are linked to earlier cases from Côte d'Ivoire.

• West Africa is part of a well-defined belt of high-risk countries which are subject to numerous and repeated importations (the others being in central Africa and the Horn of Africa). In addition to the high risk of importations, these areas are at high risk of subsequent secondary spread of imported virus (resulting in local outbreaks), due to a combination of factors including weak routine immunization. 

• Ghana conducted an immunization activity from 12 November (tOPV), as did Sierra Leone from 20 November (mOPV1), Niger from 21 November (tOPV), and Liberia from 23 November (mOPV1).

• A synchronised immunization response will be held from 4 December in Burkina Faso, Cote d'Ivoire, Mali and Mauritania, using mOPV1. Guinea will hold an activity on 11 December and Mauritania again on 18 December, while activities in Benin and Senegal are to be confirmed.

Horn of Africa

• No cases have been reported across the Horn of Africa since July. The region has reported 71 cases in 2009 (Kenya: 18; Sudan: 45; and, Uganda: 8). Uganda has not recorded a case since 10 May, Sudan's last case had onset of paralysis on 27 June and Kenya 30 July.

• All cases across the Horn have been followed by at least two rounds of SIAs.

• Although no new cases in the region have been reported since July, sub-national surveillance gaps persist, particularly in southern Sudan, and interruption of polio transmission needs to be verified. 

• Success depends on rapidly improving operational quality of SIAs in southern Sudan.  Political engagement at every level must be secured, in particular at the county and 'Payam' level. Additionally, community mobilization must be strengthened, to raise awareness of the dangers of polio and build demand for immunization. In southern Sudan, national and international focal points are being deployed to support each state effectively.

• Countries across the Horn of Africa continue to be considered at high risk until transmission of polio can be confirmed to have been interrupted, in the face of strong sub-national surveillance.   

Angola, DR Congo, Burundi

• Angola has recorded 28 type-1 cases in 2009, the most recent of which had onset of paralysis on 15 September.

• SNIDs were held in November in Benguela, Cuanza Sul, Cuanza Norte, Bengo (13-15 November) and Luanda (20-22 November); for the first time, independent monitoring data has been analysed within 15 days. This analysis (complete for the provinces that went first), showed that on average, 16% of children monitored were not vaccinated, as verified by finger-marking, with Benguela having as many as 34% not vaccinated in street surveys. Previously, significant operational gaps - particularly in Luanda and Benguela - have marred the quality of outbreak response.  As a result, the outbreak has persisted for more than 12 months.

• In DR Congo, no new cases have been recorded since 24 June. Though DR Congo has not reported type 1 polio since late 2008, it is suspected of having re-established transmission (with substantial periods of undetected virus) and has documented spread to its neighbour Burundi, which has recorded two cases this year.

• SIAs were held on 17 November in Burundi, Rwanda and the province of South Kivu in DR Congo, and on 26 November in North Kivu

Chad, CAR, Cameroon

• Chad has reported 48 cases in 2009 - all type 3. Central African Republic (CAR) has reported 14 type 3 cases, while the newly infected Cameroon has reported three type 3 cases, its first cases since 2006.

• In CAR, OPV was delivered during Child Health Days held 20-24 November, focusing on the polio-affected province of RS3. SIAs using tOPV are planned for 4 December in Cameroon, as are NIDs in Chad.

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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.