Global & Disaster Medicine

Archive for the ‘Polio’ Category

Moving targets: A Pakistani vaccination strategy as agile and stubborn as the polio virus itself.

The Guardian

“….makeshift vaccination clinics set up at bus stops, border crossings, army posts, and police checkpoints across the country in an effort to reach children who are on the move…..

At hundreds of sites, teams of health workers verify that every child passing through receives the vaccine.

Another child, another family, another generation is protected, and Pakistan moves one step closer to having zero polio cases…..”


Yemen: UNICEF vaccination campaign reaches five million children


“….In the first campaign of its kind this year, 40,000 vaccinators spread across Yemen to provide children with polio vaccine and vitamin A supplements. Mobile health teams have reached children wherever they are, including in places where access to health services has been cut off by the fighting. Health workers have shown heroic resolve in crossing frontlines, mountains and valleys to vaccinate children…..”

A little boy is vaccinated against polio in Sa’ada, Yemen. (file) Photo: UNICEF/UN026952/Madhok


Response to a Large Polio Outbreak in a Setting of Conflict — Middle East, 2013–2015

Chukwuma Mbaeyi, DDS1; Michael J. Ryan, MD2; Philip Smith, MD2; Abdirahman Mahamud, MD2; Noha Farag, MD, PhD1; Salah Haithami, MD2; Magdi Sharaf, MD2; Jaume C. Jorba, PhD3; Derek Ehrhardt, MPH, MSN1

Weekly / March 3, 2017 / 66(8);227–231


What is already known about this topic?Afghanistan, Nigeria, and Pakistan are the only three countries that have never interrupted endemic transmission of wild poliovirus (WPV). Continued WPV circulation in these countries poses a risk for polio outbreaks in polio-free regions of the world, especially in countries experiencing conflict and insecurity, with attendant disruption of health care and immunization services.

What is added by this report?A WPV outbreak occurred in Syria and Iraq during 2013–2014 after importation of a poliovirus strain circulating in Pakistan. The outbreak represented the first occurrence of polio cases in both countries in approximately a decade, and resulted in 38 polio cases, including 36 in Syria and two in Iraq. Development and implementation of an integrated response plan for strengthening acute flaccid paralysis surveillance and synchronized mass vaccination campaigns by eight national governments in the Middle East facilitated interruption of the outbreak within 6 months of its identification.

What are the implications for public health practice?Countries experiencing active conflict and chronic insecurity are at increased risk for polio outbreaks because of political instability and population displacement hindering delivery of immunization services. Adoption of a concerted approach to planning and implementing response activities, with involvement of more stable neighboring countries, could serve as a useful model for polio outbreak response in areas affected by conflict, as exemplified by the Middle East polio outbreak response.

As the world advances toward the eradication of polio, outbreaks of wild poliovirus (WPV) in polio-free regions pose a substantial risk to the timeline for global eradication. Countries and regions experiencing active conflict, chronic insecurity, and large-scale displacement of persons are particularly vulnerable to outbreaks because of the disruption of health care and immunization services (1). A polio outbreak occurred in the Middle East, beginning in Syria in 2013 with subsequent spread to Iraq (2). The outbreak occurred 2 years after the onset of the Syrian civil war, resulted in 38 cases, and was the first time WPV was detected in Syria in approximately a decade (3,4). The national governments of eight countries designated the outbreak a public health emergency and collaborated with partners in the Global Polio Eradication Initiative (GPEI) to develop a multiphase outbreak response plan focused on improving the quality of acute flaccid paralysis (AFP) surveillance* and administering polio vaccines to >27 million children during multiple rounds of supplementary immunization activities (SIAs). Successful implementation of the response plan led to containment and interruption of the outbreak within 6 months of its identification. The concerted approach adopted in response to this outbreak could serve as a model for responding to polio outbreaks in settings of conflict and political instability.

Outbreak Detection and Epidemiology

Detection of the Middle East outbreak depended upon systems for AFP surveillance in the affected countries, including the World Health Organization’s (WHO’s) Early Warning, Alert and Response Network (EWARN)§, through which the outbreak was identified in October 2013. The nonpolio AFP (NPAFP) and stool adequacy rates served as indicators for assessing the ability of the affected countries to detect polio cases and also to determine when the outbreak had been interrupted.

Among countries that reported polio cases, the NPAFP rate in Syria in 2012 was 1.4 cases per 100,000 persons aged <15 years, below the recommended benchmark of ≥2. The NPAFP rate for Syria improved, increasing to 1.7 cases per 100,000 persons in 2013, the year the outbreak was detected, and to 4.0 and 3.0 in 2014 and 2015, respectively (Table). In Iraq, the NPAFP rate ranged from 3.1 to 4.0 during 2012–2015; estimates of NPAFP rates in Syria and Iraq might, however, be inaccurate because of the large-scale conflict-related displacement of persons and the attendant impact on target population estimates. Among countries at risk, NPAFP rates were suboptimal in Jordan at the onset, but improved over the course of the outbreak, increasing from 1.4 in 2013 to 3.2 in 2015. Despite incremental improvements, NPAFP rates remained <2 in Turkey over the course of the outbreak, and rates declined in Palestine from 2.2 in 2013 to 1.2 in 2014 before improving to 2.2 in 2015. All other countries involved in the response achieved recommended benchmarks.

Rates of stool specimen adequacy (i.e., receipt of two stool specimens collected at least 24 hours apart within 14 days of paralysis onset and properly shipped to the laboratory) in Syria increased from 68% in 2013 to 90% in 2015; in Iraq, rates of stool specimen adequacy exceeded the benchmark of ≥80% in each year during 2012–2015. Lebanon showed substantial gaps in stool specimen adequacy before and during the outbreak with rates ranging from 45% to 70% during 2012–2014, but the rate improved to 84% in 2015.

A total of 38 WPV type 1 cases were reported during the outbreak, with dates of paralysis onset ranging from July 14, 2013 for the index case (Aleppo, Syria) to April 7, 2014 for the last confirmed case (Baghdad, Iraq). The outbreak was virologically confirmed in October 2013. Of the 38 cases reported, 36 occurred in Syria and two occurred in Iraq (Figure 1). Approximately two thirds (24 of 38) of reported cases occurred in male children and 74% of cases occurred in children aged <2 years. Fifty-eight percent of children with polio had never received oral poliovirus vaccine (OPV) either through routine or supplementary immunization (i.e., zero-dose children), and an additional 37% of children with polio had received ≤3 OPV doses. The remaining 5% of children with polio had received 3 OPV doses.

Thirty-five of the 36 polio cases in Syria were reported during 2013 and the last identified case had paralysis onset in January 2014. A breakdown of cases by governorate (Figure 2) indicates that 25 (69%) cases were reported from Deirez-Zour, five from Aleppo, three from Edleb, two from Hasakeh, and one from Hama. The two cases reported from Iraq occurred in February and April 2014; both were from Baghdad-Resafa Governorate. Both cases were related by genetic sequencing and were closely linked to WPV circulating in Syria. Genetic sequencing indicated virus circulation might have begun a year earlier somewhere in the Middle East, coincident with identification of WPV-positive environmental samples in Egypt in December 2012 (5). The implicated viral strain was genetically linked to strains circulating in Pakistan (6).


Outbreak Response Plan Development

Eight countries in the region (Egypt, Iran, Iraq, Jordan, Lebanon, Palestine, Syria, and Turkey) developed a concerted Middle East polio outbreak response plan, which was updated during the course of the outbreak. Countries were grouped into two areas: 1) countries with poliovirus transmission (Syria and Iraq), and 2) countries at significant risk for poliovirus importation based on geographic proximity and influx of displaced persons from the outbreak zone (Egypt, Iran, Jordan, Lebanon, Palestine, and Turkey). The strategic response in these areas occurred in three phases. Phase I (October 2013–April 2014) focused on interrupting WPV transmission and halting spread of the virus beyond the affected countries. Phase II (May 2014–January 2015) identified areas at high risk for poliovirus importation and circulation based on stipulated criteria, including presence of refugees and mobile populations, security-compromised areas, districts with low vaccination coverage, and geographically hard-to-reach communities. These areas were prioritized for SIAs and intensified surveillance activities. Phase III (February–October 2015) was aimed at further boosting population immunity against polio through strengthened routine immunization systems and SIAs.

Immunization Coverage. Conflict in Syria and Iraq in the years preceding and following the outbreak led to steep declines in routine vaccination coverage among children in both countries, in contrast to most other countries in the Middle East where coverage remained high. Estimated national routine vaccination coverage of infants in Syria with 3 doses of oral poliovirus vaccine (OPV3) declined from preconflict levels of 83% in 2010 to 47%–52% during 2012–2014. Estimates of coverage in Iraq were ≤70% and coverage in Lebanon was 75% during 2012–2014. All other countries involved in the response had coverage levels of >90% during 2012–2014.

In response to the Middle East polio outbreak, >70 SIAs were conducted during October 2013–December 2015. SIAs targeted approximately 27 million children aged <5 years in eight countries and were conducted using trivalent (types 1, 2, and 3) and bivalent (types 1 and 3) OPV. Strategies used during the campaigns included fixed-post (health facility), house-to-house visits, transit-point vaccination, and deployment of mobile teams to vulnerable populations and geographically hard-to-reach areas. Strategies were tailored to the unique sociocultural context of each country involved in the response.

Implementation of outbreak response plan. Following identification of the outbreak, Syria conducted two rounds of national immunization days (NIDs) in November and December 2013, eight NIDs and one round of subnational immunization days (SNIDs) in 2014, and four NIDs and two SNIDs in 2015 (Table). Postcampaign monitoring coverage estimates improved from 79% in December 2013 to 93% in March 2014, with coverage levels ≥88% during a majority of the campaigns. Iraq held 14 NIDs and four SNIDs as part of the response, with postcampaign monitoring coverage levels ranging from 86% to 94% during 2014. Egypt, Iran, Jordan, Lebanon, Palestine, and Turkey conducted two to 11 vaccination campaigns.

Active conflict in many parts of Syria and some parts of Iraq limited access for vaccination activities during the course of the response. Negotiations with local authorities and engagement of community leaders enabled implementation of a limited number of vaccination campaigns in some conflict-affected areas, but it was difficult to monitor these campaigns, or generate reliable data on the quality of response activities. Egypt, Iraq, Jordan, Lebanon, and Turkey received large numbers of Syrian refugees (7), which placed significant strain on their health care resources and increased costs of implementing outbreak response activities. Refugees aged <15 years living in camps in Jordan were vaccinated against polio upon registration and entry, and during special vaccination campaigns held in camps.

In assessing the effect of outbreak response activities, the vaccination status of nonpolio AFP cases in children aged 6–59 months in Syria and Iraq was reviewed. The proportion of NPAFP cases among children aged 6–59 months who were reported to have received ≥3 doses of OPV in Syria rose from 82% in 2013 to 94% in 2015, but remained at 93% among Iraqi children of the same age group during 2013–2015. The proportion of children aged 6–59 months with NPAFP who had never received OPV, or any other form of polio vaccination, decreased from 9% in 2013 to 2% in 2015 in Syria, but increased slightly from 1% to 3% in Iraq during the same period.



The Middle East polio outbreak occurred within an extremely challenging setting, given the ongoing civil war in Syria and conflict in several parts of Iraq. The near collapse of the health care system in conflict-affected parts of Syria resulted in plummeting levels of routine vaccination coverage that left many children born after the start of the civil war unimmunized or underimmunized against polio, and set the stage for the spread of poliovirus following importation within this age group and beyond.

Actions were taken to mitigate the risk for a polio outbreak in Syria when WPV-positive environmental isolates were identified in Egypt late in 2012. AFP surveillance activities in Syria, including in opposition-controlled areas, were intensified through WHO’s EWARN system, and polio vaccination campaigns were conducted in all of Syria’s governorates by January 2013 (6). However, the cohort of children born during the conflict remained vulnerable to a polio outbreak because of steep declines in routine polio vaccination coverage.

After a cluster of WPV cases was detected in Deirez-Zour Governorate, the government of Syria immediately declared the outbreak a public health emergency. A multicountry response plan was developed to contain and interrupt the outbreak, which was effectively contained within 6 months from the time of its identification. Improvements in AFP surveillance performance indicators in the outbreak-affected countries provided a basis for WHO to declare the outbreak over in 2015. In addition to intensified surveillance and immunization activities, the response owed its success in large part to the level of collaboration and concerted approach adopted by eight national governments in the region. Another factor contributing to the success of the response was that high routine immunization coverage in many countries in the region, coupled with high prewar vaccination coverage in Syria, limited the population of vulnerable persons to mostly children born after the onset of the civil war.

With the attention of GPEI focused on the final push to interrupt indigenous WPV transmission in the remaining three polio-endemic countries (810), vigilance must be maintained in the Middle East and other conflict-affected areas to forestall the risk for new WPV outbreaks. In the event of a new outbreak, the Middle East polio outbreak response provides a model for an effective response within challenging settings.


* The quality of acute flaccid paralysis (AFP) surveillance is monitored by performance indicators that include 1) the detection rate of nonpolio AFP (NPAFP) cases, and 2) the proportion of AFP cases with adequate stool specimens. World Health Organization (WHO) operational targets for countries with endemic poliovirus transmission are an NPAFP detection rate of ≥2 cases per 100,000 population aged <15 years, and adequate stool specimen collection from ≥80% of AFP cases, in which two specimens are collected ≥24 hours apart, both within 14 days of paralysis onset, and shipped on ice or frozen packs to a WHO-accredited laboratory, arriving in good condition (without leakage or desiccation).

Mass campaigns conducted for a brief period (days to weeks) in which 1 dose of oral poliovirus vaccine is administered to all children aged <5 years, regardless of vaccination history. Campaigns are conducted nationally or subnationally (i.e., in portions of the country).




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  8. Morales M, Tangermann RH, Wassilak SG. Progress toward polio eradication—worldwide, 2015–2016. MMWR Morb Mortal Wkly Rep 2016;65:470–3. CrossRef PubMed
  9. Hampton LM, Farrell M, Ramirez-Gonzalez A, et al. ; Immunization Systems Management Group of the Global Polio Eradication Initiative. Cessation of trivalent oral poliovirus vaccine and introduction of inactivated poliovirus vaccine—worldwide 2016. MMWR Morb Mortal Wkly Rep 2016;65:934–8. CrossRef PubMed
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TABLE. Acute flaccid paralysis (AFP) surveillance indicators and outbreak response activities by country and year — eight countries in the Middle East, 2012–2015
Year/Activity Country
Egypt Iran Iraq Jordan Lebanon Palestine Syria Turkey
Nonpolio AFP rate* 3.9 3.5 3.8 1.5 2.2 1.3 1.4 0.9
AFP cases with adequate specimens (%) 92 92 90 84 50 95 84 80
Nonpolio AFP rate* 3 4 3.1 1.4 2.2 2.2 1.7 1.2
AFP cases with adequate specimens (%) 92 96 84 91 45 95 68 76
SIAs 2 NIDs 2 NIDs 2 NIDs 2 NIDs 1 NID 2 NIDs 2 SNIDs
Nonpolio AFP rate* 2.9 4.2 4 2.5 2.7 1.2 4 1.5
AFP cases with adequate specimens (%) 93 96 89 97 70 90 84 77
SIAs 2 NIDs 2 SNIDs 7 NIDs 3 NIDs 4 NIDs 1 NID 8 NIDs 5 SNIDs
Nonpolio AFP rate* 3 4.3 3.6 3.2 5.2 2.2 3 1.7
AFP cases with adequate specimens (%) 94 97 82 97 84 92 90 82

Abbreviations: NIDs = national immunization days; SIAs = supplemental immunization activities; SNIDs = subnational immunization days.
* Cases per 100,000 children aged <15 years (target: ≥2 per 100,000).
No NIDs or SNIDs conducted for the year.


Return to your place in the textFIGURE 1. Number of cases of wild poliovirus type 1 (WPV1), by month and year of paralysis onset — Syria and Iraq, 2013–2014

 The figure above is a bar chart showing the number of cases of wild poliovirus type 1, by month and year of paralysis onset in Syria and Iraq, during 2013–2014.


Return to your place in the textFIGURE 2. Cases of wild poliovirus type 1 (WPV1) — Syria and Iraq, 2013–2014*

 The figure above is a map showing cases of wild poliovirus type 1 in Syria and Iraq during 2013–2014.

* Each dot represents one case. Dots are randomly placed within second administrative units.

Suggested citation for this article: Mbaeyi C, Ryan MJ, Smith P, et al. Response to a Large Polio Outbreak in a Setting of Conflict — Middle East, 2013–2015. MMWR Morb Mortal Wkly Rep 2017;66:227–231. DOI:

Continued Endemic Wild Poliovirus Transmission in Nigeria, 2016


Nnadi C, Damisa E, Esapa L, et al. Continued Endemic Wild Poliovirus Transmission in Security-Compromised Areas — Nigeria, 2016. MMWR Morb Mortal Wkly Rep 2017;66:190–193. DOI:



3-Day Polio Immunzation Program: WHO, UNICEF and health authorities keeping Yemen polio-free.


National polio immunization campaign launched in Yemen

WHO is working closely with UNICEF and health authorities to keep Yemen polio-free

WHO is working closely with UNICEF and health authorities to keep Yemen polio-freeSANA’A, 20 February 2017—A nationwide polio immunization campaign was launched today in Yemen by national health authorities with support from WHO and UNICEF, aiming to immunize 5 019 648 children under the age of 5.

More than 40 000 health workers are taking part in the 3-day campaign. In addition, religious and local council’s officials, as well as health educators are also mobilizing support for the campaign. High-risk groups, such as internally displaced persons (IDPs) and refugees, will also be reached.

“WHO is working closely with UNICEF and health authorities to keep Yemen polio-free. The threat of virus importation is serious and this campaign aims to curb any possible return of the virus to Yemen,” said Dr Nevio Zagaria, WHO Acting Representative in Yemen.

“WHO and its partners will continue to support the health authorities in increasing the vaccination coverage across Yemen.”

This is the first polio immunization campaign since April 2016. The security situation in Yemen has limited accessibility of many parts of the country, leaving many children at risk of vaccine preventable diseases.

As the nearly 2-year-old armed conflict in Yemen has been posing threats to the Expanded Programme on Immunization (EPI), WHO has supported the programme to keep polio vaccines safe through providing fuel, generators and solar-powered refrigerators to ensure the functionality of vaccine storage as well as cold chain transferring them from the war-torn areas into safer places.

“Despite huge security challenges, WHO is committed to supporting polio immunization campaigns and all activities of the EPI to maintain the polio-free status achieved by the country in 2006” said Dr Zagaria.

Afghanistan: Over 5.6 million children to be vaccinated against polio during large-scale vaccination campaign


Kabul 30 January 2017 – The Ministry of Public Health, WHO and UNICEF launched today the first polio subnational immunization days campaign of 2017. Over 5.6 million children will be vaccinated against polio in all provinces in the southern and south-eastern regions, most districts in the eastern region, as well as selected high-risk districts across the country, including Kabul city.

Photo essays

“The campaign will build on strong progress seen in 2016. Last year Afghanistan had only 13 cases of polio nationwide, down from 20 in 2015. This was made possible through hard work by thousands of frontline health workers and a renewed emphasis on monitoring and oversight,” said Dr Maiwand Ahmadzai, Director of the National Emergency Operations Centre for Polio Eradication at the Ministry of Public Health, speaking at a joint press conference held in Kabul.

This week’s campaign is carried out by over 31 000 trained polio workers and it runs until 3 February when vaccinators revisit children who were missed when the vaccinators first visited. These vaccinators and other polio workers are trusted members of the community and they have been chosen because they care about children.

“We have seen significant progress in our polio eradication efforts over the past year. Most of Afghanistan is now polio-free, the circulation of the poliovirus is restricted to small areas in the eastern, southern and southeastern parts of the country and we have seen huge improvements in vaccination campaign quality,” said Dr Hemant Shukla, director of the polio programme at WHO. “Our focus is now on reaching every single child during every vaccination campaign to stop the transmission of polio.”

“With our collective efforts, we will be able to eradicate polio from the world. Vaccines are the right of every child and no child should be missed during polio campaigns,” said Ms Melissa Corkum, UNICEF Polio director in Afghanistan. “Thousands of frontline workers visit every house in the country during campaigns. That’s not an easy task. Due to the hard work of these dedicated frontline workers, we are closer to polio eradication than ever.”

In 2016, new initiatives have been implemented to strengthen the polio eradication programme in Afghanistan. All polio eradication activities have been brought under one leadership as Emergency Operations Centres have been established at the national and subnational level. The surveillance system has been strengthened and the circulation of wild poliovirus is unlikely to be missed in Afghanistan. The quality of campaigns, routine immunization and rapid response to polio cases have improved tremendously over the past year.

In 2016, 13 polio cases were registered: 7 cases in Paktika, 4 cases in Kunar, one case in Kandahar and one in Helmand province. Afghanistan remains one of 3 polio-endemic countries together with Pakistan and Nigeria.


Over 5.6 million children to be vaccinated against polio across Afghanistan




The Strategic Advisory Group of Experts (SAGE) who advise the WHO on vaccine issues this week recommended that countries prepare to administer IPV intradermally instead of SQ as a dose-sparing tactic.


  • Administering the vaccine intradermally rather than subcutaneously could increase the available doses at least twofold.
  • In June the same panel approved a plan to stretch limited yellow fever vaccine supplies—drained by outbreaks in Angola and the Democratic Republic of Congo—by using one-fifth of the regular dose.


October 24 is World Polio Day

WHO: In a serious setback to eradicate polio from the world, 2 cases of paralysis caused by the virus have been detected in northeast Nigeria.

NY Times


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