Public Health Emergency of International Concern (PHEIC)
Polio this week as of 22 November 2017 [GPEI]
:: On the 14 November, the 15th IHR Emergency Committee convened to review the risk of international spread of poliovirus. The committee agreed that the risk of international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC), and recommended the extension of revised Temporary Recommendations for a further three months.
:: To mark World Children’s Day, we reported on how the polio eradication programme helps deliver a bright future to children in Nigeria.

:: Summary of newly-reported viruses this week:
Afghanistan: Four new wild poliovirus type 1 (WPV1) positive environmental samples, three collected from Kandahar province, and one from Kabul province.
Pakistan: One new WPV1 positive environmental sample, collected from Sindh province.
Syria: Seven new circulating vaccine derived poliovirus type 2 (cVDPV2) cases reported, all from Deir Ez-Zor governorate.

Statement of the 15th IHR Emergency Committee regarding the international spread of poliovirus
WHO statement
14 November 2017
[Excerpts; Editor’s text bolding]
The fifteenth meeting of the Emergency Committee under the International Health Regulations (2005) (IHR) regarding the international spread of poliovirus was convened by the Director-General on 14 November 2017 at WHO headquarters with members, advisers and invited member states attending via teleconference.

The Emergency Committee reviewed the data on wild poliovirus (WPV1) and circulating vaccine derived polioviruses (cVDPV). The Secretariat presented a report of progress for affected IHR States Parties subject to Temporary Recommendations. The following IHR States Parties presented an update on the current situation and the implementation of the WHO Temporary Recommendations since the Committee last met on 3 August 2017: Afghanistan, the Democratic Republic of Congo (DR Congo), Nigeria, Pakistan and the Syrian Arab Republic.
Wild polio

Overall the Committee was encouraged by continued steady progress in all three WPV1 infected countries, Afghanistan, Nigeria and Pakistan and the fall in the number of cases globally, and that international spread remained limited to between Afghanistan and Pakistan only. While falling transmission in these three countries decreased the risk of international spread, the consequences of any failure to prevent spread would increasingly be a set-back to eradication and a risk to public health, as funding winds down in the coming years.

The Committee commended the high-level commitment seen in both Afghanistan and Pakistan, and the high degree of cooperation and coordination, particularly targeting the high risk mobile populations that cross the international border, such as nomadic groups, local populations straddling the border, seasonal migrant workers and their families, repatriating refugees (official and informal), and guest children (children staying with relatives across the border). Stopping transmission in these populations remains a major challenge that cannot be under-estimated, underlining the critical continuing need for cross border activities in surveillance and vaccination.

The Committee commended the achievements in Pakistan that have resulted in the number of cases falling to just five so far in 2017; achievements included the improved accessibility, improved communication to reduce missed children and better quality supplementary immunization activities (SIA). However, WPV1 transmission continues to be widespread geographically as detected by environmental surveillance and this remains a source of major concern, notwithstanding that the intensity of environmental surveillance is now higher than previously, meaning the probability of environmental detection is now higher.
The Committee was concerned by the ongoing risks to eradication posed by the number of inaccessible and missed children in Afghanistan, particularly in the southern region resulting in ten cases to date in 2017.

The Committee was impressed by the innovations that continue to be made in Nigeria to reach children in Borno, but was very concerned that although the number of inaccessible settlements has fallen, there remains a substantial population in Borno state that is totally inaccessible, including around 160,000 – 200,000 children aged under five. The Committee concluded that there is a substantial risk that polioviruses are still circulating in these inaccessible areas. Nigeria also reported on ongoing efforts to ensure vaccination at international borders (including at airports), other transit points, IDP camps and in other areas where nomadic populations existed, but the Committee felt that efforts to date were inadequate. The Committee also noted that routine immunization, particularly in high risk areas of northern Nigeria, is performing poorly and along with polio eradication has been made a national priority. Although it is over 13 months since the last detection of WPV1 in Nigeria, the recent outbreak response assessment by global polio experts concluded ongoing transmission could not be ruled out.

There was ongoing concern about the Lake Chad basin region, and for all the countries that are affected by the insurgency, with the consequent lack of services and presence of IDPs and refugees. The risk of international spread from Nigeria to the Lake Chad basin countries or further afield in sub-Saharan Africa remains high. The Committee was encouraged that the Lake Chad basin countries including, Cameroon, Chad, the Central African Republic (CAR), Niger and Nigeria continued to be committed to sub-regional coordination of immunization and surveillance activities. However, there is concern about the Lake Chad islands which are currently inaccessible and also about significant gaps in population immunity exist in some areas of these countries in border areas with Borno, and the ongoing population movement in the sub-region was a major challenge.

Vaccine derived poliovirus
The Committee commended the efforts made in some very challenging circumstances in DR Congo and the Syrian Arab Republic. These outbreaks highlighted the presence of vulnerable under-immunized populations in areas with inaccessibility, either due to conflict or geographical remoteness. Furthermore, the delay in detection of these outbreaks illustrated that serious gaps in surveillance exist in many areas of the world, often related to weak health systems or to conflict resulting in disrupted health systems.

In DRC, there has been transmission after the initial SIA’s with geographical spread outside the health zones covered, into Tanganyika, necessitating further rounds with mOPV2. Risks are compounded by poor surveillance in many areas, and widespread gaps in population immunity.

The Committee was very concerned by the size of the outbreak in the Syrian Arab Republic, and the difficulty of reaching target populations because of the conflict. As type 2 population immunity rapidly wanes, the risk of spread within the Syrian Arab Republic and beyond its borders will increase substantially, meaning urgent action is needed to stop transmission. The Committee commended countries surrounding the outbreak zone that are responding to prevent importation, particularly among Syrian refugees in Lebanon, Jordan, and Turkey. The Committee urged any country receiving Syrian refugees, particularly from Deir Ez-Zor and Raqqa, to ensure polio vaccination with IPV.

The Committee noted with concern the recent detection of a single highly diverged VDPV2 in sewage in Mogadishu in Somalia, with genetic evidence of more than three years of replication without detection.

The Committee unanimously agreed that the risk of international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC), and recommended the extension of revised Temporary Recommendations for a further three months. The Committee considered the following factors in reaching this conclusion:

  • The potential risk of further spread through population movement, whether for family, social or cultural reasons, or in the context of populations displaced by insecurity, returning refugees, or nomadic populations, and the need for international coordination to address these risks, particularly between Afghanistan and Pakistan, Nigeria and its Lake Chad neighbors, and countries bordering the Syrian Arab Republic.
  • The current special and extraordinary context of being closer to polio eradication than ever before in history, with the incidence of WPV1 cases in 2017 the lowest ever recorded.
  • The risk and consequent costs of failure to eradicate globally one of the world’s most serious vaccine preventable diseases. Even though global transmission of WPV1 has fallen dramatically and with it the likelihood of international spread, the consequences and impact of international spread should it occur now would be grave and a major set-back to achieving eradication.
  • The risk of global complacency developing as the numbers of polio cases continues to fall and eradication becomes a tangible reality soon.
  • The outbreak of WPV1 (and cVDPV) in Nigeria highlighting that there are high-risk areas where surveillance is compromised by inaccessibility, resulting in ongoing circulation of WPV for several years without detection. The risk of transmission in the Lake Chad sub-region appears high.
  • 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 cross­border cooperation, as much international spread of polio occurs over land borders, while also 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, which without an urgent response with appropriate measures threatens vulnerable populations as noted above;
:: The large number of cases in the Syrian outbreak within a short space of time and close to the international border with Iraq in the context of ongoing population movement because of conflict, considerably heightens the risk of international spread;
:: The ongoing circulation of cVDPV2 in DR Congo, Nigeria, Pakistan and the Syrian Arab Republic demonstrates significant gaps in population immunity at a critical time in the polio endgame;
:: The ongoing urgency to prevent type 2 cVDPVs following the globally synchronized withdrawal of the type 2 component of the oral poliovirus vaccine in April 2016, noting that population immunity to type 2 polioviruses is rapidly waning;
:: The ongoing challenges of improving routine immunization in areas affected by insecurity and other emergencies
:: The global shortage of IPV which poses an additional risk.

Additional considerations
The Committee noted that in all the infected and vulnerable countries, routine immunization was generally quite poor, if not nationally, then in sub-national pockets. The Committee strongly encourages all these countries to make further efforts to improve routine immunization, and requested international partners to support these countries in rapidly improving routine immunization coverage to underpin eradication.

The Committee also strongly encouraged countries newly infected with WPV or cVDPV to act with a great degree of urgency in responding to outbreaks as national public health emergencies, and to ensure emergency operations are used to facilitate this accelerated response…

Based on the current situation regarding WPV1 and cVDPV, and the reports made by Afghanistan, DR Congo, Nigeria, Pakistan, and the Syrian Arab Republic, the Director-General accepted the Committee’s assessment and on 20 November 2017 determined that the situation relating to poliovirus continues to constitute a PHEIC, with respect to WPV1 and cVDPV…


Syria cVDPV2 outbreak situation report 23: 21 November 2017
Situation update 21 November 2017
…Seven (7) new cases of cVDPV2 were reported this week— 4 cases from Mayadeen and 3 from Boukamal district, Deir Ez-Zor governorate. The most recent case (by date of onset) is 9 September 2017 from Mayadeen district.
…The total number of confirmed cVDPV2 cases is 70.
…Outbreak response teams are planning a third mass immunization round to reach children under 5 with mOPV2 in areas where evidence of virus transmission continues.
…A request from the Syrian Ministry of Health for up to one (1) million doses of mOPV2 and 500 000 inactivated polio vaccine doses is being processed to ensure readiness for the second phase of the outbreak response
…Subnational immunization days aiming to reach children under 5 with bOPV started this week in areas of Rural Damascus, districts of Damascus, Homs, Aleppo and accessible areas of Deir Ez-Zor city. Children aged 2-23 months will also be reached with supplementary IPV during the subnational campaign, particularly in areas with large IDP populations.
…A joint supervisory team is monitoring the IPV campaign in all areas of Damascus, with a focus on areas where there are large IDP populations from Deir Ez-Zor to ensure campaign quality.


WHO Grade 3 Emergencies  [to 25 November 2017]
The Syrian Arab Republic
:: WHO gravely concerned by deteriorating situation in eastern Ghouta, Syrian Arab Republic
22 November 2017, Damascus, Syrian Arab Republic – Seven people have been killed and 42 people injured in Damascus city and surrounding areas in recent days.
In eastern Ghouta, Rural Damascus, local health authorities report that during a 4-day period alone from 14 to 17 November, 84 people were killed, including 17 children and 6 women; and 659 people were injured, including 127 children and 87 women.
During the same period, more than 200 surgical operations were conducted in eastern Ghouta’s overwhelmed and under-resourced hospitals.
Despite escalating violence and increasing humanitarian needs, life-saving medicines, medical equipment, and surgical supplies are prevented from entering the area…

:: Polio- Situation update 21 November 2017
[See Polio above for detail]

South Sudan
:: WHO in collaboration with the Ministry of Health established water quality control to prevent water-borne diseases in South Sudan
21 November 2017 Juba — The cost of delivering safe water, sanitation and hygiene services is a public health concern in South Sudan. To ensure high quality, sustainable water quality testing, monitoring and surveillance, WHO provided mobile water quality and safety testing kits to the National Public Health Laboratory. The mobile kits are to be used to test and monitor the quality and safety of water in the country.

:: Yemen – Cholera Response  W46 2017 [Nov 13-Npv 19]
Cumulative figures
-The cumulative total from 27 April 2017 to 19 Nov 2017 is 945,362 suspected cholera cases and 2,211 associated deaths, (CFR 0.23%), 1049 have been confirmed by culture.
-The median age of suspected cases is (20) and the median age of death is (38)
– 59.3 % of death were severe cases at admission
– The total proportion of severe cases among the suspected cases is 18%
– The national attack rate is 343.26 per 10,000. The five governorates with the highest cumulative attack rates per 10,000 remain Amran (801), Al Mahwit (760), Al Dhale’e (641), Abyan (491) and Sana’a (459).
– Children under 5 years old represent 27.8% of total suspected cases.
– In total, 20,884 rapid diagnostic tests (RDT) have been performed which represents 22.1% coverage.
– 2,375 cultures have been performed which represents 22.6% coverage.
– The last positive culture was on 7 Nov 2017 in Al Garahi district
– Among the 305 affected districts, 43 districts in 12 governorates (Abyen, Al Baydha, Al Hudei deh, Al mahrah, Hajjah, Lahj ,Marib, Mokal l a, Sa’dah, Seyoun, Shabwah, Taizz) did not report any suspected case the last three consecutive 3 weeks.
Governorate and District level
– At governorate level, the trend from W43-W45 decrease or was stable in all governorates.
– No district is reporting a CFR higher than 1%.
– The weekly number of cases is decreasing for the 10th consecutive week.
– The weekly proportion of severe cases has significantly decreased representing now 10% of the admitted cases.
-The use of RDTs has significantly increased since week 40.
Week 46
– 14,955 suspected cases and 6 associated deaths were reported.
– 10 % are severe cases
– 924 RDTs were performed, 176 were positive
– 0 Positive culture

WHO Grade 2 Emergencies  [to 25 November 2017]
:: Weekly Situation Report 4 – 22 November 2017
Key Highlights
…As of 21 November 2017, the cumulative number of new arrivals in all sites was 622,000. …This number includes over 341,000 arrivals in Kutupalong Balukhali expansion site, 235,000 in other camps and settlements, and 46,000 arrivals in host communities.
…153,765 adolescents and children received measles vaccination
…WHO Mental Health Gap Action Training commenced
Situation Overview
Approximately 170 health care facilities are known to be operating across all camps and settlements. However, many of these facilities provide a basic level of services and referrals for additional services within camps and outside of the camps remains a challenge. Government hospital facilities are overcrowded and do not have the resources to cope with the high volumes of referral patients. Moreover, the services provided are not standardized and the quality of health care services varies considerably.
The latest EWARS data show that fevers of unexplained origin are the most commonly reported disease (29%), followed acute respiratory infections (27%) and acute watery diarrhoea (21%). In view of the low immunization coverage among the Rohingya population, strengthening vaccination programmes is a priority.
Potential outbreaks of diarrhoeal diseases including

Rohingya refugees in Bangladesh: Health Sector Bulletin No. 1
Period: 01 October – 15 November 2017
[1] Health Situation
Around 1.2 million people are estimated to be in need of health assistance. This number includes both newly arrived Rohingyas from Myanmar since 25 August, and their host communities. Based on the public health situation analysis published on 10 October 2017, WHO has graded this crisis as a level 3 emergency. the highest possible rating.

[5.4] Vaccines and Immunization
The baseline coverage for routine immunization is low. This, combined with crowded living conditions, lack of adequate water and sanitation and reported levels of high malnutrition, represents a public health risk to both the new arrivals and the host population.
Health Sector Response
The health sector has conducted several vaccination campaigns. In the first campaign, which ended on 3 October 2017, 135 519 children under 15 years of age were vaccinated against measles and rubella, 72 334 children under 5 years of age were vaccinated against polio and 72 064 children received Vitamin A.
To mitigate the outbreak of cholera, the International Coordinating Group (ICG) on Vaccine Provision mobilized 900,000 doses of oral cholera vaccine (OCV) for a large-scale cholera vaccination campaign among recently arrived Rohingyas and their host communities. The health sector worked with the MOHFW to plan, train volunteers, fund, implement and monitor this campaign. The campaign to administer the first dose (targeting 650 000 individuals over one year of age) was successfully implemented from 10 to 18 October 2017. It reached a total of 712 797 people, 179 848 of whom were children aged from one to five years old. To help improve personal hygiene, vaccinators handed out soap to each person vaccinated.
From 4 to 9 November 2017, the health sector supported the MOHFW in implementing the second phase of a cholera and polio vaccination campaign for children. A total of 199 472 children aged between one and five years received a second dose of oral cholera vaccine for added protection (estimated target population: 180 000), and 236 696 children under five years received oral polio vaccine (estimated target population: 210 000).
In addition, the health sector continues to support the MOHFW’s efforts to strengthen routine vaccination. Approximately 100 vaccinators have been trained on the current routine Expanded Programme on Immunization (EPI) schedule, key EPI messages, the importance of maintaining the cold chain, monitoring vaccine vials, injection safety, registration, reporting and waste management. Polio, measles and tetanus immunization began on 11 November from static sites within the camps. Through these static sites, to date 719 children have been vaccinated against polio, 589 children against measles and 476 pregnant women against tetanus.
Additionally, since 1 November, 970 children (6 months – 15 years) passing through the two transit sites have been vaccinated against measles and rubella (MR) and 1038 children under five years received oral polio vaccine (bOPV).
Establishing the routine Expanded Programme on Immunization (EPI) in camps and settlements and setting up vaccination posts at entry points into Bangladesh are both key to controlling measles and other diseases. However, in response to the significant increase in measles cases, MoHFW and health sector have agreed to rapidly initiate a measles campaign targeting 360 000 children under 15 for MR vaccination. In view of the urgency of the situation, the campaign is planned to start on 18 November and microplanning has begun…


WHO AFRO – Outbreaks and Emergencies Bulletin, Week 46: 11 – 17 November 2017
The WHO Health Emergencies Programme is currently monitoring 46 events in the region. This week’s edition covers key ongoing events, including:
:: Dengue fever in Burkina Faso,
:: Plague in Madagascar,
:: Lassa fever in Nigeria,
:: Marburg virus disease in Uganda,
:: Humanitarian Crisis in Central African Republic,
:: Humanitarian Crisis in the Democratic Republic of the Congo.

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
:: 25 Nov 2017  Urgent Call to Address Gender-based Violence in Syria [EN/AR]

:: 24 Nov 2017 – Yemen: Impact of the closure of seaports and airports on the humanitarian situation – Situation Update 3 | 23 November 2017
:: 24 Nov 2017 – Yemen Humanitarian Bulletin Issue 29 | 20 November 2017

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.
:: ISCG Situation Update: Rohingya Refugee Crisis, Cox’s Bazar – 23 November 2017
Editor’s Note:
We will cluster these recent emergencies as below and continue to monitor the WHO webpages for updates and key developments.
Yellow Fever  [to 25 November 2017]
Disease outbreak news
Yellow fever – Brazil – 24 November 2017