Public Health Emergency of International Concern (PHEIC)

Polio this week as of 19 July 2017 [GPEI]
:: The Polio Research Committee (PRC) issued a call for research proposals, to support the implementation of the Polio Eradication & Endgame Strategic Plan, with particular focus on:  vaccine schedule immunogenicity; surveillance; product development on innovative IPV formulations or administration techniques; epidemiology/virology; monitoring and evaluation; and, basic immunology.  The deadline for submission of proposals is 6 October 2017.  Submission guidelines and procedures are available here.

:: Animations from WHO on the Polio Surveillance System, Reaching Every last Child and Responding to a Polio Outbreak have won the Innovation (Screen) category of the EVCOM Clarion Awards, for offering a fresh and unique way of engaging audiences in projects concerning the environment, health, education, social welfare and sustainability.

:: Summary of newly-reported viruses this week:  Afghanistan – one new wild poliovirus type 1 (WPV1) isolated from an acute flaccid paralysis (AFP) case and one new WPV1-positive environmental sample; Syria – four new circulating vaccine-derived poliovirus type 2 (cVDPV2) isolated from AFP cases.

Ambassador Yousef Al Otaiba Joins Global Leaders in Pledging Additional Support for Fight to Eradicate Polio
— Embassy of the United Arab Emirates says since 2013, UAE Committed $150 Million to Deliver Vaccines in Afghanistan, Pakistan and Syria —
WASHINGTON, July 18, 2017 /PRNewswire-USNewswire/ — United Arab Emirates (UAE) Ambassador to the US Yousef Al Otaiba joined Gates Foundation Co-Chairman Bill Gates and other members of the Global Polio Eradication Initiative in Atlanta, Georgia to announce a $30 million gift from the Government of the UAE that will help drop the level of global polio infections down to zero. The gift was announced at the Rotary International Convention, along with representatives from other donor nations, such as Canada, Germany, Japan, and the European Commission…


WHO Grade 3 Emergencies  [to 22 July 2017]
:: Yemen cholera situation report no. 4   19 JULY 2017
:: National Emergency Operations Centres (EOCs) in Aden and Sana’a have now been redesigned and strengthened to harness the full capacity of United Nations agencies and partners to support the cholera response.
:: The national Case Fatality Ratio (CFR) has been reduced to 0.5%, with 99.5% of people with suspected cholera surviving.
:: Surveillance confirms a decline in suspected cases over the past two weeks in some of the most affected governorates (e.g. Amanat al-Asimah, Amran and Sana’a). This data should be interpreted with caution, however, given a backlog in the analysis of suspected cases. Even if the outbreak is beginning to slow in some areas, thousands are falling sick every day. Sustained efforts are required to stop the spread of this disease.
:: The World Health Organization (WHO) has successfully established 47 diarrhoea treatment centres of the 50 centres in the original plan.
  :: A cholera vaccination campaign originally planned for July 2017 has been postponed at the request of the health authorities, in favour of a much larger preventive campaign next year targeting millions of Yemenis at risk of the disease.
:: WHO and UNICEF are supporting a door to door awareness campaign at the end of July to help people understand how they can keep their families safe from cholera.

South Sudan
:: WHO scales up cholera response with 500 000 doses of oral cholera vaccine for vaccination campaign in South Sudan
Juba, South Sudan, 19 July 2017: The World Health Organization (WHO) received 500 000 doses of oral cholera vaccine (OCV) on 17 July 2017. WHO is working with the Republic of South Sudan’s Ministry of Health and partners to scale up cholera vaccination campaign from 28 July to 3 August 2017.

Cumulatively, a total of 17 785 cholera cases including 320 (CFR 1.8%) deaths have been reported from 24 counties in South Sudan since the outbreak in June 2106.

“Cholera is endemic in South Sudan and historically, outbreaks have occurred along major commercial routes and rivers in the dry season as well as during the rainy season,” said Dr Joseph Wamala, WHO Epidemiologist. “South Sudan has suffered from several major cholera outbreaks in the last four years. Following other successful oral cholera vaccine campaigns, WHO and partners can make a real difference in controlling the outbreak in Tonj and Kapoeta states and in other parts of the country.”

The use of the OCV is one of the strategies available to prevent and combat outbreaks. At the same time, South Sudan is implementing the integrated approach for cholera control. The strategy harnesses strategies for improving access to patient care, surveillance, social mobilisation, water, sanitation and hygiene, and use of oral cholera vaccines.

South Sudan recently requested OCV to complement the current response in areas with active cholera transmission. The country has developed extensive experience in deploying OCV to prevent cholera in endemic areas and to interrupt transmission for ongoing outbreaks. As a result of these integrated and comprehensive strategies, especially with deployment of OCV, cholera transmission in Bor, Mingkaman, Duk, Ayod, Bentiu, Leer, Aburoc, Malakal Town, and several other areas has been controlled.

A planned OCV campaign is scheduled to take place 28 July to 3 August, 2017 in four selected counties with high active transmission. These include Tonj East, Kapoeta South, Kapoeta North and Kapoeta East counties. In Tonj East, the surrounding payams will be targeted to limit further spread of the outbreak. WHO jointly with the Health Cluster, UNICEF and MSF-CH facilitated a training of over 26 supervisors drawn from the Ministry of Health and partners to oversee the OCV campaign in the above mentioned counties. County level cascade trainings are slated for 25-26 July 2017.

With some 6 million people in South Sudan facing starvation, WHO and partners have been responding across the country, particularly in places facing famine, food insecurity and disease outbreaks.

Furthermore, food insecurity is putting people at increased risk of starvation and malnutrition, which will further contribute to the risk of spread of the cholera outbreak in South Sudan. Drought has also led to the drying of water points in some regions leading to the population using contaminated water from the remaining few unprotected points leading to repeated outbreaks of water-borne diseases including cholera.

Many countries and partners have introduced OCVs as part of their cholera control programs in endemic and epidemic settings. Currently, the International Coordinating Group manages the global stockpile for emergency use of OCV.

Iraq  – No new announcements identified.
NigeriaNo new announcements identified.
The Syrian Arab Republic – No new announcements identified.
WHO Grade 2 Emergencies  [to 22 July 2017]
:: WHO and Health Cluster partners support rapid health assessments and response in flood-affected areas, Rakhine State
Since the beginning of July 2016 heavy monsoonal rains have hit several areas of Myanmar, resulting in floods in five townships of Rakhine State and putting other States and Regions of the country (Sagaing and Magway regions, Chin state) on high alert for flooding risk. Around 27,000 people have been affected by flooding according to Government and UN estimates, and many remain displaced due to high water levels in their townships…

Cameroon  No new announcements identified
Central African Republic  – No new announcements identified.
Democratic Republic of the CongoNo new announcements identified
EthiopiaNo new announcements identified.
LibyaNo new announcements identified.
Niger  – No new announcements identified.
Ukraine  – No new announcements identified
UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
Syrian Arab Republic
:: 21 Jul 2017 Syria: EWARS Weekly Bulletin, Week No. 23 (4 Jun– 10 Jun 2017)
(4) AFP cases were reported during this week, (3) cases from Al-Mayadin in Deir-ez-Zor, (1) case from Rural Damascus. v A notable decrease in SM cases reported for three consecutive weeks.
(58) Suspected Measles cases were reported during this week: from Ar-Raqqa (17), Damascus (17), Deirez-Zor (14), and Dar’a (6)
:: 15 Jul 2017 Millions of Syrians benefit from cross-border operations
Three years after the adoption of a Security Council resolution on relief delivery across border lines in Syria, cross-border operations continue to play a pivotal role in the delivery of life-saving assistance to millions of Syrians.

:: Yemen Humanitarian Bulletin Issue 25 | 16 July 2017
:: 332,658 suspected cholera cases and over 1,759 cholera deaths reported between 27 April and 13 July.
:: Two million people more need assistance, bringing the number of people in need to 20.7 million from 18.8 million in January.
:: From January to April 2017, 4.3 million people were assisted across Yemen out of the total target population of 11.9 million.
:: 22 civilians were killed or injured in an air attack on a market in Sa’ada near the border with Saudi Arabia.
Worst cholera outbreak in the world
More than 330,000 suspected cases with 1,759 associated deaths reported in less than three months
The cholera epidemic sweeping across Yemen is currently the worst such outbreak in the world. At the end of June, suspected cases exceeded 200,000 people, increasing at an average of 5,000 every day, with one person dying nearly every hour. Children and the elderly are the most affected; children under the age of 15 account for 40 per cent of suspected cases and a quarter of the deaths while those aged over 60 represent 30 per cent of fatalities. The governorates most affected by cholera are Amanat Al Asimah, Al Hudaydah, Hajjah and Amran. The situation is particularly worrying in ‘’hot spots’ like Ibb, Raymah, Dhamar, Hajjah and Al Mahwit, where case fatality ratios, a reference to the proportion of deaths within a designated population, have exceeded the one per cent emergency threshold established by the World Health Organisation (WHO).

Cholera is endemic to Yemen, but the current outbreak is the direct consequence of more than two years of heavy conflict that has moved an already weak and impoverished country towards social, economic and institutional collapse. The war has decimated Yemen’s health system, damaged key infrastructure and cut off 15.7 million people from access to adequate clean water and sanitation. In the last 10 months, about 30,000 health and sanitation workers have not received their salaries; only a third of critical medical supplies have entered the country compared to the period before March 2015; and garbage has piled up in the cities. Indeed, the current numbers of cholera cases are likely to be an underrepresentation of the magnitude of the epidemic since only 45 per cent of health facilities are effectively functioning and surveillance systems are weak.
Data collection and verification is a major challenge throughout the country. Between 27 April and 13 July 2017, a total of 332, 658 suspected cholera cases and 1,759 deaths were reported in all governorates except the island of Socotra.

Response ramped up but the magnitude of the outbreak is outstripping capacity to respond
Humanitarian partners have ramped up efforts to contain the outbreak. However, the magnitude of the outbreak is beyond the capacity, presence and reach of humanitarian organisations who have had to reprogramme meagre resources available to tackle widespread food insecurity for the cholera response. Displacement and high levels of food insecurity compound the cholera crisis.

The current cholera outbreak has overwhelmed what remains of Yemen’s conflictbattered health system. Hospitals and treatment centres are struggling to cope with large numbers of patients and medicines and intravenous fluids are quickly running out. Various partners are racing to stop the acceleration of the cholera outbreak, working around the clock to detect and track the spread of disease and to reach people with clean water, adequate sanitation and medical treatment. Rapid response teams are going house-to-house to reach families with information about how to protect themselves by cleaning and storing drinking water. Medical supplies such intravenous fluids, and Oral Rehydration Salts and water chlorination tablets have been shipped in and plans are underway for a nationwide anti-cholera campaign from 15 July in priority districts. Despite these efforts, the response continues to lag behind. Some 5,006 Cholera Treatment Centre beds are needed but only 2,351 are currently available, along with 2,003 Oral Rehydration Points, of which only 624 are currently available. On 4 July, WHO reported that out of 309 districts with reported cholera cases, cholera partners are only present in 121 districts.

Even then, the risk of the epidemic affecting thousands more people is real as the health, water, sanitation and hygiene systems are unable to cope and humanitarian funding remains low. As of 16 July, the 2017 Yemen Humanitarian Response Fund is 40 per cent funded. Additionally, humanitarian organizations continue to face restrictions on movements of supplies and people to and from Yemen. Al Hudaydah port, which is the main entry point for humanitarian supplies, is operating at limited capacity due to damage sustained from attacks. In Sana’a, the main airport is closed to commercial traffic, thus preventing people seeking medical assistance not available in Yemen to travel abroad for treatment.

UN OCHA – Corporate Emergencies
When the USG/ERC declares a Corporate Emergency Response, all OCHA offices, branches and sections provide their full support to response activities both at HQ and in the field.
:: Ethiopia Weekly Humanitarian Bulletin, 17 July 2017

:: Note d’informations humanitaires, 19 juillet 2017 : Mission du chef des affaires humanitaires des Nations Unies en République Démocratique du Congo
:: Horn of Africa: Humanitarian Impacts of Drought – Issue 8 (18 July 2017)

Dashboard: International Coordinating Group (ICG) on Vaccine Provision on cholera  [accessed 22 July 2017]
Country: Yemen
ICG request receive date: 14 Jun 2017
Status: Partially-approved
Context: Outbreak response
Doses shipped: 500,000
Confirmed delivery dates: Vaccine scheduled to arrive in Saana on 6 July before the request was cancelled by requestor
Vaccination implementation: Vaccine redirected to another country

The Lancet Infectious Diseases
Published: 17 July 2017
Oral cholera vaccines: exploring the farrago of evidence
The development of a cheap and effective oral cholera vaccine (OCV) is a remarkable achievement in the field of cholera prevention. A meta-analysis on the efficacy and effectiveness of OCVs by Qifang Bi and colleagues1 updates the estimates of the 2011 Cochrane review.2 Their analysis includes additional studies published since 2011, yet provides estimates that are almost the same.

The debate about the low efficacy of OCVs in children aged younger than 5 years has continued to dominate the policy discourse in endemic countries such as India, where children are the main target of immunisation programmes. Older estimates identified children younger than 5 years to be at a disproportionately higher risk of cholera than other age groups;3 however, updated estimates have shown that making robust assertions in the absence of accurate age-specific morbidity and mortality data is difficult.4 This uncertainty has further contributed to a policy-level hesitancy in adopting OCVs for widespread use in endemic countries. Crucially, more accurate estimates of cholera burden should be established to enable programmatic implementation of OCVs, and the reasons for poor immune responses to OCVs in children need to be understood. Furthermore, we propose that the extent of herd protection offered by OCVs should be established, especially in children, if a targeted vaccination policy covering all age groups is endorsed for highly endemic hotspots.5

Water, sanitation, and hygiene (WaSH) interventions are considered to be the best method of cholera control, but gaps have been shown in the knowledge about which interventions work best.6 In our experience, in-house contamination of water remains a major problem, which sometimes persists despite efficient programmatic implementation of WaSH strategies.7 Trials in India have shown similar problems, and a rural sanitation programme failed to show evidence of prevention of diarrhoea and soil-transmitted helminth infections or reduction in faecal contamination of water sources.8, 9, 10

Modelling studies have suggested that in areas with poor sanitation, isolated efforts for water quality improvement are likely to be met with low success.11 Further, considering the high endemicity of cholera in low-income and middle-income countries (LMICs), single-pathway interventions are likely to be inadequate in the control of diarrhoeal diseases, and cholera in particular because of environmental persistence of vibrios, which might not be eradicated even with stringent implementation of such interventions.11 Besides, deploying adequate WaSH interventions takes time because it involves significant investment in infrastructural improvements and behavioural changes. Keeping these issues in mind, cheap and effective OCVs emerge as a viable option to keep cholera at bay, reducing morbidity and mortality, while the definitive WaSH interventions are identified and rolled out. The successful expansion of the Swachh Bharat (Clean India) mission in India provides a governance-driven model of sanitation and hygiene promotion that can be replicated in other LMICs; however, its effectiveness in reducing numbers of cases and deaths from cholera or diarrhoeal diseases needs to be systematically studied.

Although cholera outbreaks in areas of political and civil unrest are a major concern, strategies to mitigate the risks have been poorly studied. Mortality and morbidity from cholera in complex emergencies remains high. A systematic review showed that the evidence on the effectiveness of WaSH interventions in times of humanitarian crises is scarce and of poor quality.12 Only point-of-use interventions and safe water storage were effective measures in reducing diarrhoea incidence.12 By contrast, a single-dose regimen was an effective strategy to combat a cholera outbreak in South Sudan and an endemic focus in Bangladesh.13, 14

The creation of an OCV stockpile, and the commitment of Gavi, the Vaccine Alliance, to support vaccination of emergency and endemic areas of cholera activity, provides a cost-effective method by which countries can access vaccines as they work towards universal deployment of adequate WaSH facilities. In our opinion, a balanced public health policy needs to be in place, in which OCVs are used as a synergistic tool for cholera control, while the most efficient, cost-effective, and locally feasible, acceptable, and relevant WaSH interventions are identified and deployed. Given that even in endemic countries, cholera is a public health menace only in specific regions, with multiple local factors contributing to disease epidemiology, health policies need to be customised to fit the local contexts, eschewing one-size-fits all approaches