POLIO [to 28 November 2015]

POLIO [to 28 November 2015]
Public Health Emergency of International Concern (PHEIC)

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Statement on the Seventh IHR Emergency Committee meeting regarding the international spread of poliovirus
WHO statement
26 November 2015 [Editor’s text bolding]
The seventh meeting of the Emergency Committee under the International Health Regulations (2005) (IHR) regarding the international spread of poliovirus was convened via teleconference by the Director-General on 10 November 2015. The Director General of WHO had noted the concerns expressed by the Emergency Committee in its August 2015 report with respect to circulating vaccine-derived polioviruses (cVDPV). In response, she convened this meeting of the Emergency Committee with broader terms than was previously the case to also look at outbreaks of cVDPV. During the current polio endgame cVDPVs reflect serious gaps in immunity to poliovirus due to weaknesses in routine immunization coverage in otherwise polio-free countries. Moreover, there is a particular urgency to stopping type 2 cVDPV in advance of the globally synchronized withdrawal of type 2 OPV in April 2016.

The following IHR States Parties submitted an update on the implementation of the Temporary Recommendations since the Committee last met on 4 August 2015: Afghanistan and Pakistan. The following IHR State Parties were invited to present their views to the committee and all except South Sudan submitted reports on measures and plans to stop circulating vaccine derived poliovirus: Nigeria, Guinea, Madagascar, Ukraine and Lao People’s Democratic Republic.

Wild polio
The Committee noted that since the declaration that the international spread of polio constituted a Public Health Emergency of International Concern (PHEIC), strong progress has been made by countries toward interruption of wild poliovirus transmission, implementation of Temporary Recommendations issued by the Director-General, and overall decline in occurrence of international spread of wild poliovirus. The Committee appreciated these commendable achievements. The Committee acknowledged the strong efforts of countries in Africa to eradicate polio noting that no cases of wild poliovirus have been reported in Africa for more than twelve months, and that Nigeria has interrupted endemic transmission of wild poliovirus. The Committee was particularly encouraged by the intensified efforts and the strong progress toward interruption of poliovirus in Pakistan and Afghanistan.

The Committee noted however that the international spread of wild poliovirus has continued, with two new documented exportations from Pakistan into Afghanistan which occurred in July and August 2015. The poliovirus isolates found in the two cases in Afghanistan were more closely related to strains recently circulating in Pakistan than to those currently found in Afghanistan. Both of these cases occurred in Achin district of Nangarhar Province, adjacent to the border with Pakistan. While there has been no new exportation from Afghanistan to Pakistan, ongoing transmission particularly in inaccessible parts of the Eastern Region of Afghanistan close to the international border presents an ongoing risk.

The Committee noted that while Pakistan and Afghanistan have historically shared a vast common zone of poliovirus transmission, the recent spread between the two countries is occurring from discrete zones of persistent transmission in each country. Strong programmatic action in such zones should interrupt such cross-border transmission, as illustrated by the experience in regions that were previously endemic for polio. The committee re-emphasized that under the IHR, spread of poliovirus between two Member States can constitute international spread. While the Committee appreciated that efforts are being made for cross border collaboration, the committee noted and concurred with the recent recommendation of the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI). The IMB has recommended that the GPEI partners should help the governments of Pakistan and Afghanistan to establish a joint executive and planning body to instigate cross-border polio prevention and control. The committee was pleased that the Temporary Recommendations for international travellers of all ages are now being implemented in Afghanistan at the international airport in Kabul.

The committee noted that globally there are still significant vulnerable areas and populations that are inadequately immunized due to conflict, insecurity and poor coverage associated with weak immunization programmes. Such vulnerable areas include countries in the Middle East, the Horn of Africa, central Africa and parts of Europe. The hard-earned gains can be quickly lost if there is re-introduction of poliovirus in settings of disrupted health systems and complex humanitarian emergencies. The large population movements across the Middle East and from Afghanistan and Pakistan create a heightened risk of international spread of polio. There is a risk of missing polio vaccination among refugee and mobile populations, adding to missed and under vaccinated populations in Europe, the Middle East and Africa. An estimated three to four million people have been displaced to Turkey, Lebanon, and Jordan and are at the centre of a mass migration across Europe.

Vaccine derived poliovirus
The current cVDPV outbreaks across three WHO regions illustrate serious gaps in routine immunization programs of affected countries leading to large pockets of vulnerability to polio outbreaks. In 2015, five outbreaks of circulating vaccine derived poliovirus have occurred, three cVDPV1 outbreaks (Ukraine, Madagascar and Lao People’s Democratic Republic) and two cVDPV2 outbreaks (Nigeria and Guinea); furthermore an additional case of VDPV2 in a conflict-affected state of South Sudan is of concern.

There has been no international exportation of cVDPV during 2014 and 2015. Nonetheless, at least five past episodes of international spread of cVDPV have been recorded, all due to cVDPV type 2. While historically the overall risk of international spread of cVDPV appears to be lower than WPV, lack of adequate measures to control cVDPV can increase that risk.

The committee was concerned by the slow initial response in Ukraine and Madagascar, but encouraged that the response is improving in both countries. Additional efforts are needed to improve SIA quality in both countries. The committee also noted that targeted communication and strong engagement of communities were needed in Ukraine and Lao People’s Democratic Republic to overcome vaccine hesitancy, and that GPEI should assist with development of appropriate communications strategies and materials. The significant decline in immunization rates and AFP surveillance in Guinea and neighbouring Liberia and Sierra Leone due to the health system disruption caused by Ebola outbreak poses a risk for further spread of cVDPV, and the committee urged international partners to increase support to Guinea in its cVDPV outbreak response. Moreover, the testing of samples from AFP cases should be restored immediately and the overall systems for surveillance and immunization should be strengthened as soon as possible in the three Ebola-affected countries. The committee emphasized the importance of maintaining the quality of the programme along with strong political and civic engagement until global certification of polio eradication.

Conclusion – PHEIC
The Committee unanimously agreed that the international spread of polio remains a PHEIC and recommended the extension of the Temporary Recommendations, as revised, for a further three months. The Committee considered the following factors in reaching this conclusion:

:: The continued international spread of wild poliovirus during 2015 involving Pakistan and Afghanistan.

:: The risk and consequent costs of failure to eradicate globally one of the world’s most serious vaccine preventable diseases.

:: The continued necessity of a coordinated international response to improve immunization and surveillance for wild poliovirus, stop its international spread and reduce the risk of new spread.

:: The serious consequences of further international spread for the increasing number of countries in which immunization systems have been weakened or disrupted by conflict and complex emergencies. Populations in these fragile states are vulnerable to outbreaks of polio. Outbreaks in fragile states are exceedingly difficult to control and threaten the completion of global polio eradication during its end stage.

:: The importance of a regional approach and strong cross-border cooperation, as much international spread of polio occurs over land borders, while recognizing that the risk of distant international spread remains from zones with active poliovirus transmission.

:: Additionally with respect to cVDPV:
…cVDPVs also pose a risk for international spread, and if there is no urgent response with appropriate measures, particularly threaten vulnerable populations as noted above;
…The emergence and circulation of VDPV in three WHO regions, underline significant gaps in population immunity at a critical time in the polio endgame, potentially threatening successful completion of global polio eradication;
…There is a particular urgency of stopping type 2 cVDPV in advance of the globally synchronized withdrawal of type 2 component of the oral poliovirus vaccine in April 2016….

…Additional considerations for all infected countries
The Committee strongly urged global partners in polio eradication to provide optimal support to all infected countries at this critical time in the program for implementation of the Temporary Recommendations under the IHR. The Committee advised that in view of the evolving situation, periodic review and assessment of the risk of international spread and measures to mitigate these risks are warranted.

The Committee recommended that international partners assist countries affected by cVDPV with development of appropriate communications strategies and materials to ensure clear public understanding of cVDPV, their distinction from wild poliovirus and maintenance of confidence in the effectiveness, safety and necessity of polio vaccines during the polio endgame. Recognizing that cVDPV illustrate serious gaps in routine immunization programs in otherwise polio free countries, the Committee recommended that the international partners in routine immunization, for example the Gavi Alliance, should urgently assist affected countries to improve the national immunization program.
The Committee requested the Secretariat to conduct an analysis of the public health benefits and costs of implementing the temporary recommendation requiring exporting countries to vaccinate all international travellers before departure.

Based on the advice concerning wild poliovirus and circulating VDPV, the reports made by Afghanistan, Pakistan, Nigeria, Madagascar, Guinea, Ukraine and Lao People’s Democratic Republic and the currently available information, the Director-General accepted the Committee’s assessment and on 25 November 2015 determined that the events relating to poliovirus continue to constitute a PHEIC, including with respect to cVDPV. The Director-General endorsed the Committee’s recommendations for ‘States currently exporting wild polioviruses or cVDPV’, for ‘States infected with wild poliovirus or cVDPV but not currently exporting’ and for ‘States no longer infected by wild poliovirus, but which remain vulnerable to international spread, and states that are vulnerable to the emergence and circulation of VDPV’ and extended the Temporary Recommendations as revised by the Committee under the IHR to reduce the international spread of poliovirus, effective 25 November 2015.

The Director-General thanked the Committee Members and Advisors for their advice and requested their reassessment of this situation within the next three months.

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GPEI Update: Polio this week as of 25 November 2015
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: The emergency committee of the International Health Regulations (IHR) has met for the seventh time and assessed that the international spread of polio continues to constitute a Public Health Emergency of International Concern (PHEIC). They also expanded the temporary recommendations to outbreaks of circulating vaccine derived poliovirus, due to the importance of stopping all types of poliovirus as we near the finish line of polio eradication. Learn more about cVDPVs. The statement from the emergency committee can be found here.

:: In 2015, wild poliovirus transmission is at the lowest levels ever, with fewer cases reported from fewer areas of fewer countries than ever before. In 2015, 57 wild poliovirus cases have been reported from two countries (Pakistan and Afghanistan), compared to 305 cases from nine countries during the same period in 2014.

:: On November 27 – 29, heads of governments, staff and experts from 53 commonwealth nations will gather in Malta to discuss shared global priorities at the biennial Commonwealth Heads of Government Meeting (CHOGM). Commonwealth leadership on polio has brought the disease within touching distance of eradication. Now is the time to reaffirm support and wipe the disease off the face of the earth. Sustained political and financial commitment from all countries remain critical to finishing the job to eradicate polio for good.

[Selected elements from Country-level reports]
Afghanistan
:: Three new wild poliovirus type 1 (WPV1) cases were reported in the past week, from Faryab and Nangahar provinces. The most recent case had onset of paralysis on 27 October, from Nangahar. The total number of WPV1 cases for 2015 is 16.
:: One new WPV1 environmental positive sample was reported in the past week, collected on 25 October from Lashkargah district of Hilmand province.
:: Urgent efforts are underway to strengthen the implementation of the national emergency action plan in the country. Focus is on:
– Improving governance and coordination of partners through the National and Provincial Emergency Operations Centres
– Improving SIA quality by focusing resources on low-performing districts, and clearly identifying and targeting persistently missed children
– Maximising the impact of front-line health workers through more systematic vaccinator selection, training and supervision
– Ensuring closer cross-border coordination in border areas with Pakistan
– Further strengthening surveillance, including by expanding environmental surveillance activities
:: Mop up campaigns have taken place in areas of Farah using trivalent and bivalent OPV from 15 to 24 November, and Subnational Immunisation Days (SNIDs) are planned from 29 November to 1 December in the south and east of the country using bivalent OPV

Pakistan
:: One new wild poliovirus type 1 (WPV1) case was reported in the past week, with onset of paralysis on 1 November. It is the most recent WPV1 case in the country, from Kamari town, Karachi, Sindh. The total number of WPV1 cases for 2015 is now 41.

Lao People’s Democratic Republic
:: One new case of circulating vaccine-derived poliovirus type 1 (cVDPV1) was reported in the past week, from a new province. The case was reported from Hom district bordering Xaysomboune province, and had onset of paralysis on 3 October. The most recent date of onset is 7 October. The total number of cVDPV1 cases in 2015 is now four.
:: An emergency outbreak response is continuing in the country, with particular focus on three high-risk provinces. The first Subnational Immunization Days (SNIDs) using trivalent oral polio vaccine (OPV) targeted an expanded age group of children under the age of fifteen in the three most high risk districts, and childen under the age of ten elsewhere. According to independent monitoring conducted in the high-risk areas, coverage of 85-95% was achieved, with 5-15% of children missed (primarily due to children not being present at the time of the vaccination teams’ visit).
:: A second round of SNIDs is taking place from 16 – 30 November, and National Immunization Days (NIDs) will take place fom 21 to 31 December. Most of the campaigns are targeting an expanded age group range of children up to the age of 15 years.
:: All three cases are from the same village in the same province. Efforts are underway to further strengthen surveillance activities in other parts of the country, to determine if other sources of transmission are occurring elsewhere in the country.
:: Depending on the evolving epidemiology, the age group of the outbreak response may be expanded.
:: In neighbouring countries, notably Thailand and Vietnam, both surveillance and immunization activities have been stepped up, particularly in border areas.

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Circulating vaccine-derived poliovirus – Lao People’s Democratic Republic
Global Alert and Response (GAR) – Disease Outbreak News (DONs)
26 November 2015
Two additional cases of type 1 vaccine-derived poliovirus (VDPV1) have been reported from Lao People’s Democratic Republic (PDR), bringing the total number of cases in this outbreak to three.

Between 6 and 8 November 2015, the National IHR Focal Point of the Lao People’s Democratic Republic (PDR) notified WHO of 2 confirmed VDPV1 cases. Furthermore, circulating VDPV1 (cVDPV1) has also been isolated from the stools of 12 healthy contacts. All these contacts live in the same village, Bolikhan district (Bolikhamxay Province)…

…Public health response
Since the detection of the first confirmed cVDPV1 in Lao PDR, outbreak response activities have been conducted in three provinces, including the affected province (Bolikhamxay) and neighbouring provinces (Xaisounboun and Xiengkhuang). The national emergency operations centre has been activated to coordinate response efforts and a polio outbreak response plan was drafted. Enhanced surveillance is occurring throughout the country including daily zero-reporting of AFP cases. Active case finding is ongoing in the three provinces, including retrospective review of hospital and health centre records.

Six rounds with trivalent OPV vaccine have been planned from October 2015 to March 2016 (4 sub-national and 2 national) with ~ 8.6 million doses to be administered to children younger than 15 years. This age range was determined by the age distribution of the cases and their contacts. The first round of supplementary immunization activity (SIA) with OPV vaccine was completed in October in Bolikhamxay, Xaisounboun and Xiengkhuang provinces. Monitoring of October OPV SIA has occurred to identify areas with missed children and plan for mop-up activities. It is planned that this will continue during the next rounds to identify villages that require mop-up. Independent monitors were recruited to assess the quality of the campaigns.

To ensure the success of SIAs, emergency risk communications and social mobilization activities, including training of mobilizers and information sessions to build trust and address barriers to immunization, are being conducted. Key messages have been developed for radio and loudspeaker and are being translated to target identified communities…