POLIO [to 1 November 2014]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 22 October 2014
Global Polio Eradication Initiative
Editor’s Excerpt and text bolding
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: World Polio Week, which ran 23 to 29 October, provided an opportunity to recognize the progress made towards the global eradication of polio in 2014. This year is the first year with South East Asia certified as polio-free.
:: Jonas Salk, who developed the first polio vaccine in the 1950s, celebrated his 100th birthday on 28 October. Read more about the legacy of the polio vaccine here.
:: The Federation of Islamic Medical Associations launched a call to action [see below] this week to Muslim physicians across the world to join the urgent effort to protect all children from vaccine preventable diseases.
:: The Independent Monitoring Board has published its 10th report, following its meeting in early October. The report is available here. [see below]
:: At last week’s meeting of the Strategic Advisory Group of Experts on Immunization (SAGE), the group reviewed the readiness criteria for type 2 OPV withdrawal globally, and concluded that preparations for such a withdrawal in early 2016 are on track. They recommended that Member States accelerate preparations and facilitate international coordination. More. [see below]
Pakistan
:: Ten new wild poliovirus type 1 (WPV1) cases were reported in the past week in Pakistan. Of these, 4 are from the Federally Administered Tribal Areas (FATA) (1 from North Waziristan, 1 from Frontier Region Bannu and 2 from Khyber Agency); 1 from Zhob district in Balochistan province, previously uninfected in 2014; 1 from Peshawar district of Khyber Pakhtunkhwa (KP) province; and 4 from Sindh province (1 from Khigadap, 2 from Khikorangi and 1 from Dadu, the latter 2 districts were previously uninfected in 2014). The most recent case had onset of paralysis on 1 October. This brings the total number of WPV1 cases in 2014 to 220 compared to 53 in 2013 by this date.
:: One new type 2 circulating vaccine-derived poliovirus (cVDPV2) case was reported in the past week. This case had onset of paralysis in Khyber Agency, FATA, on 16th September. The case brings the 2014 cVDPV2 country total to 20 .
:: Immunization activities are continuing with particular focus on known high-risk areas, in particular the newly opened areas of FATA. At exit and entry points of areas that are inaccessible during polio campaigns, 163 permanent vaccination points are being used to reach internally displaced families as they move in and out of the inaccessible area.

Independent Monitoring Board of the Global Polio Eradication Initiative – 10th Report – October 2014
36 pages :: pdf – http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/11IMBMeeting/11IMB_Report_EN.pdf
The Independent Monitoring Board provides an independent assessment of the progress being made by the Global Polio Eradication Initiative in the detection and interruption of polio transmission globally. This tenth report follows our eleventh meeting, held in London from 30 September to 2 October 2014

Conclusions and Recommendations, pp 35-36
[Full text; Editor’s text bolding]
The programme will certainly not achieve its end-2014 target of stopping global polio transmission. This is not the first time that a major target has been missed, and this failure will not be welcome news.

The IMB is adamant that the programme should not be stung by this failure into looking to the comfort zone of a single short-term priority – reaching for a polio-free Africa. Global polio incidence cannot be allowed to move further out of control because Pakistan and the many countries with low levels of immunity are put on the programme’s back burner. Three priorities must be pursued with equal tenacity. The great prize of clearing polio out of Africa in the next six months is achievable but still is enormously challenging. The work to achieve this must go hand in hand with securing a sharp downturn in cases of polio in Pakistan over the same time period, as well as a surge in levels of immunity everywhere that the polio virus could seek a fresh mandate to kill and to paralyse.

Pakistan’s polio programme is a disaster. It continues to flounder hopelessly, as its virus flourishes. Home to 80% of the world’s polio cases in 2014, and with a programme that is incomparably weak, Pakistan is the major stumbling block to global polio eradication. To claim that this low-transmission season will be its last has no basis in reality. The country, supported by its neighbours, needs to change its polio eradication programme drastically, urgently, and transformatively.

The government of Pakistan has a decision to make. A determined effort now – led by the National Disaster Management Authority – could stop polio in Pakistan, and so in the region. If the programme simply continues as it is, Pakistan is very likely to be the polio virus’ last home on earth, with the entire global community spending huge sums of money simply to keep Pakistan polio virus out of their countries.

Strong progress in Nigeria creates, for the first time, the possibility of a polio-free Africa. There is a mood of excitement within the programme that this is already a ‘done deal’. This concerns the IMB. Nothing could be further from the truth. The achievement of this goal, both in Nigeria and in wider Africa, is beset with complexity and risk. Nigeria must not celebrate victory before it is earned. It cannot claim that polio transmission is interrupted until vaccine-derived polio and wild polio virus are both gone from the whole country. The road to polio-free certification will be a rocky one. As India has found, keeping polio out requires a programme hitting sustained levels of excellence. This is what the Nigeria programme must strive for if the gains of the last year are not to be lost.

A polio-free Africa requires the programme to fire on all cylinders simultaneously. It requires every part of Africa – some with recent polio cases, some with low levels of immunity, some affected or threatened by Ebola – to be made and kept polio-free.

In Africa, our greatest concern lies with Cameroon, Equatorial Guinea, and the wider Central Africa sub-region. Neither government is giving polio the priority response that it deserves. Polio is just waiting to spill across the border into Central African Republic and Gabon, if it has not done so already. The WHO African Regional Office failed to mount a strong sub-regional outbreak response, and is now (understandably) impeded in doing so by its need to focus on Ebola.

Though it is about to miss another deadline, the global programme has made some progress. The job of eradicating polio must be seen through. The progress has particularly come from innovation. It is vital that the programme recognizes and embraces this fact. Too many times, the programme has achieved progress through innovation, only to then seemingly forget its importance and believe that it now has all of the answers. It does not. Open minds are needed to persuade those of a hardened vertical programme pedigree that routine immunisation must be allowed to sweep in and shape the polio programme in the time ahead.
Windows of opportunity often become apparent only in retrospect. One closed when Pakistani
vaccinators started to be attacked in December 2012, for example. The programme had got close to stopping polio transmission, but missed the chance to do so in time. Similarly, all are now wishing that Central Africa had properly dealt with polio before Ebola emerged and complicated matters substantially. Both examples illustrate that the programme must act when it has an opportunity to do so. The polio programme operates in a complex, ever-changing world. The virus’ distribution changes, as do the political and security situations where it lives. Nobody knows what is round the corner.
Both Africa and Pakistan now have a window of opportunity. In Pakistan, there is no longer a group of children in North Waziristan that the government cannot access. In Africa, there has never been less polio virus. In neither place is the situation easy, but it is probably as good as it is going to get, and may well get worse not better. It is absolutely vital that both opportunities are seized.
This is the moment for transformative action, not iterative year-by-year improvement. The World Health Assembly has declared polio eradication a programmatic emergency for global public health. WHO has declared polio’s spread a Public Health Emergency of International Concern. At the end of 2014, the programme will miss yet another target. It has to be the last time and the IMB’s recommendations reflect this vital moment in history.
The IMB recommends:
:: That the Prime Minister and Cabinet of Pakistan order the National Disaster Management
Authority to take on the task of stopping polio in Pakistan, with immediate effect.
:: That the plan for Pakistan’s Emergency Operations Center be strengthened, to provide
intelligence and coordination functions in support of the National Disaster Management Authority’s work. If there is delay in adopting the National Disaster Management Authority recommendation, the EOC should be strengthened to have the capacity and power that they need to run a programme truly set on eradication.

:: A special meeting of the Independent Monitoring Board in early 2015 with those who will lead the eradication of polio from Pakistan, at federal level, in each province and in FATA. It is to be hoped that the government of the United Arab Emirates might play an important part in such a meeting.

:: That the World Health Organization headquarters take over the management of the Central Africa outbreak from the World Health Organization African Regional Office, freeing the latter to focus on the Ebola crisis and simultaneously enabling a decisive Central Africa polio outbreak response.

:: That the International Health Regulations Expert Committee make a recommendation that all countries receiving travellers from polio-infected countries should ensure that they have a valid vaccination certificate, as a condition of entry. That this should be implemented urgently.

:: That the programme better integrate its work to strengthen routine immunisation with work to stop polio transmission. That Gavi is invited to become the sixth core partner, and its Chief Executive to join the Polio Oversight Board.

.

WHO: Summary of the SAGE October 2014 meeting
[Full text]
SAGE reviewed the readiness criteria for type 2 oral poliovirus vaccine (OPV) withdrawal globally which include:
1. at least one dose of inactivated poliovirus vaccine in OPV-using countries;
2. bivalent oral polio vaccine (bOPV) licensed for routine immunization;
3. type 2 poliovirus surveillance and response protocols and monovalent OPV stockpile;
4. appropriate containment and handling of residual type 2 materials; and
5. verification of global eradication of wild poliovirus type 2.

SAGE confirmed that preparations for OPV2 withdrawal in early 2016 are on track and recommended that WHO Member States be formally apprised of this through WHO’s governing bodies to accelerate preparations and facilitate international coordination.

SAGE endorsed the protocols for the management and use of the global type 2 monovalent OPV (mOPV2) stockpile and for type 2 poliovirus response in the post-OPV2 era, the plan for expansion of environmental surveillance, and the revised strategy for containment of polioviruses ( i.e. the third edition of the WHO global action plan to minimize facility-associated risk in post-eradication/post-OPV era or GAP III). SAGE recognized and appreciated that countries with more than 95% of the global birth cohort, including almost all countries at highest risk for persistent type 2 circulating vaccine derived poliovirus (cVDPV2) emergence and circulation, either already use IPV or have formally expressed a commitment or intent to introduce IPV by end 2015. SAGE further urged:
a. accelerated licensure of bOPV for routine use and consideration of new regulatory approaches;
b. utilization of only global mOPV2 stockpiles to manage post-cessation type 2 poliovirus; and
c. completion of poliovirus containment phase 1 activities by end-2015.

SAGE re-iterated its concern about the persistent cVDPV2 circulation in Nigeria and Pakistan, and reinforced its previous recommendation (April 2014) that elimination of persistent cVDPV2 by mid-2015 at latest should have similar priority to elimination of wild polioviruses. SAGE concurred that Nigeria should schedule sufficient trivalent OPV (tOPV) campaigns across the northern states to interrupt the cVDPV2 by March 2015. Similarly, Pakistan should exploit the improved access in the northwest of the country to ensure sufficient tOPV is used in all areas, and especially for children from the conflict-affected areas, to interrupt the persistent cVDPV in that country as soon as possible.

SAGE endorsed the proposed risk-based approach for boosting immunity to type 2 poliovirus prior to OPV2 withdrawal by ensuring sufficient tOPV campaigns are planned and conducted to raise population immunity above the estimated threshold for transmission in areas at highest risk of cVDPV2 emergence. SAGE emphasized that planning for this risk-based approach should be done on a sub-national basis.
SAGE discussed the second annual report on the implementation of the Decade of Vaccine Global Vaccine Action Plan (GVAP). As in 2013, the GVAP secretariat prepared a detailed technical report on progress against each of the GVAP indicators. This year, the report was supplemented with additional inputs from the civil society organizations and also included progress on research and development indicators (which is reported every other year). SAGE noted the success in introducing new vaccines, and achievements in numerous countries in several areas such as the establishment and strengthening of National Immunization Technical Advisory Groups.
However, five out of the six GVAP goals still require substantial progress to bring them back on track. SAGE identified five areas for priority action:
:: Three years after its start date, implementation of the GVAP is sporadic and slow.

:: Poor data quality and use is impeding program management and improvement.

:: The affordability and supply of vaccines need to be urgently examined. Each may be causing a significant problems for a large number of countries, and the current lack of accurate information hinders understanding and corrective action.

:: Basic failures of integration mean that healthcare workers repeatedly miss easy opportunities to offer vaccinations when people are at the clinic with other health problems.
:: Vaccine delivery is impeded by disruptive situations, including war and major disease outbreaks (such as Ebola, currently). Such situations will always exist. Vaccination must continue to be delivered despite such situations.

SAGE issued various recommendations which are detailed in its GVAP assessment report 2014.1 One key recommendation is for the Regional Technical Advisory Groups and partners to support countries to rapidly finalize their national vaccine action plans based on both the Global and Regional Vaccine Action Plans and establish advisory bodies to guide and monitor implementation.

SAGE was requested to consider the preferred schedules for meningococcal A conjugate vaccine for infants and young children living in the African meningitis belt countries, to achieve sustainable disease control following the initial mass vaccination campaigns targeting those 1-29 years of age. SAGE reiterated the importance of efforts to complete mass vaccination campaigns in all African countries in the meningitis belt. SAGE recommended that countries completing vaccination campaigns introduce the vaccine into the routine childhood immunization programme within 1 to 5 years following campaign completion, along with a one-time catch-up campaign for young children born since the initial mass vaccination and who will be outside the target age for routine immunization. SAGE concluded that a one-dose schedule at 9 months of age or older is recommended. Although administration at 9 months of age is preferred for programmatic reasons to be co-administered alongside the routine vaccination schedule, the single dose could be scheduled at somewhat older ages (e.g. 12-18 months) based on local programmatic and epidemiologic considerations.

SAGE was provided with an update on the Ebola outbreak and response. A SAGE Working Group on Ebola Vaccines and Vaccination will be rapidly established.
SAGE also discussed the use of Japanese encephalitis vaccines, the use of the hepatitis E vaccine and the issue of vaccination hesitancy.

The full meeting report will be published in the WHO Weekly Epidemiological Record on 12 December 2014. The meeting documents — including presentations and background readings — can be found at the following link: http://www.who.int/immunization/sage/meetings/2014/october/en/index.html