GPEI

• Summary of new cases this week:
• An advance notification has been received of one new wild poliovirus type 1 (WPV1) case in Afghanistan.
• Three new WPV1 positive environmental samples have been reported from Pakistan.
• One circulating vaccine-derived poliovirus type 2 (cVDPV2) positive environmental sample has been reported from Nigeria.
• An advance notification has been received of one new cVDPV2 positive contact in Somalia.

WHO

Papua New Guinea confirms poliovirus outbreak, launches response

A child is protected from lifelong polio paralysis through OPV vaccination.

WHO

PORT MORESBY, 25 June 2018 – The National Department of Health of Papua New Guinea and the World Health Organization (WHO) today confirmed that the strain of poliovirus first detected in a child from Morobe Province in April is now circulating in the same community.

The one confirmed case is a 6-year-old boy with lower limb weakness, first detected on 28 April 2018. A vaccine-derived poliovirus type 1 (VDPV1) had been isolated as the cause of the paralysis on 21 May 2018.

On 22 June 2018, the United States Centers for Disease Control and Prevention confirmed that the same virus was also isolated from stool specimens of two healthy children from the same community. This means that the virus is circulating in the community—representing an outbreak of the virus.

“We are deeply concerned about this polio case in Papua New Guinea, and the fact that the virus is circulating,” said Pascoe Kase, Secretary of the National Department of Health (NDOH). “Our immediate priority is to respond and prevent more children from being infected.”

The NDOH has formally informed WHO and has been working with WHO and other partners in launching a response. Some of the immediate steps include conducting large-scale immunization campaigns and strengthening surveillance systems that help detect the virus early. These activities are also being strengthened in neighbouring provinces.

“Since the detection of poliovirus in April, WHO has been working with the Government on the investigation, laboratory confirmation, enhanced surveillance and response activities,” said Dr Luo Dapeng, WHO Representative in Papua New Guinea. “We will continue to support the Government to ensure children are protected.”

Papua New Guinea has not had a case of wild poliovirus since 1996, and the country was certified as polio-free in 2000 along with the rest of the WHO Western Pacific Region.

In Morobe Province, polio vaccine coverage is low, with only 61% of children having received the recommended 3 doses. Water, sanitation and hygiene are also challenges in the area.

Public health response

Outbreak response activities are ongoing in Morobe Province. Experts from the NDOH, Papua New Guinea’s Central Public Health Laboratory, Provincial Health Authorities, UNICEF and WHO have conducted field missions to undertake clinical investigation, house-to-house surveys, sample collection and contact tracing.

The team also collected stool specimens from family members of the patient and from the community. A “mop up” immunization campaign was done in the community targeting children under 15 years old. To date, 845 children from the Lufa Mountain Settlement have been vaccinated.

Circulating vaccine-derived poliovirus

Oral polio vaccine (OPV) contains an attenuated (weakened) vaccine-virus, which activates an immune response in the body. When a child is immunized with OPV, the weakened vaccine-virus replicates in the intestine for a limited period, thereby developing immunity by building up antibodies. During this time, the vaccine-virus is also excreted. In areas of inadequate sanitation, this excreted vaccine-virus can spread in the immediate community (and this can offer protection to other children through ‘passive’ immunization), before eventually dying out.

On rare occasions, if a population is seriously under-immunized, an excreted vaccine-virus can continue to circulate for an extended period of time. The longer it is allowed to survive, the more genetic changes it undergoes. In very rare instances, the vaccine-virus can genetically change into a form that can paralyze—this is what is known as a circulating vaccine-derived poliovirus (cVDPV).

Because of relatively limited travel to and from this area and the planned immunization activities, WHO assesses the risk of international spread of the cVDPV from Papua New Guinea to other countries to be low.

However, it is important that all countries—in particular those with frequent travel and contacts with polio-affected countries and areas—strengthen surveillance for cases of AFP to rapidly detect any virus importation and facilitate a rapid response. Countries, territories and areas should maintain high immunization coverage to minimize the consequences of any new virus introduction.

WHO recommends that all travellers to polio-affected areas be fully vaccinated against polio. Residents (and visitors for more than 4 weeks) from infected areas should receive an additional dose of OPV or inactivated polio vaccine (IPV) within 4 weeks to 12 months of travel.

For further information, please contact:

National Department of Health, AOPI Centre, Waigani, Port Moresby
Email: Jacob_Marcos@health.gov.pg / jcbmarcos@gmail.com
Phone: +675 301-3745 / +675 7206-8115

World Health Organization, 4th Floor AOPI Centre, Waigani, Port Moresby
Email: rezam@who.int / taukarair@who.int
Phone: +675 325-7827 / +675 7197-1499 / +675 7543-7337

ABC News

Reuters

“….Sakina Bibi, 50, and her 20-year-old daughter, Alizah, were giving immunization drops to children when two gunmen riding on a motorcycle shot them….Efforts to eradicate the disease have been undermined by opposition from militants, who say immunization is a foreign ploy to sterilize Muslim children or a cover for Western spies…….”

EID

Fernandez-Garcia MD, Majumdar M, Kebe O, Fall AD, Kone M, Kande M, et al. Emergence of vaccine-derived polioviruses during Ebola virus disease outbreak, Guinea, 2014–2015. Emerg Infect Dis. 2018 Jan [date cited]. http://dx.doi.org/10.3201/eid2401.171174

DOI: 10.3201/eid2401.171174

“…Although OPV has many advantages (easy administration by mouth, low cost, effective intestinal immunity, and durable humoral immunity), it has the disadvantage of genetic instability. Because of the plasticity and rapid evolution of poliovirus genomes and selective pressures during replication in the human intestine, vaccine poliovirus can lose key genetic determinants of attenuation through mutation or recombination with closely related polio and nonpolio enterovirus strains, acquiring the neurovirulence and infectivity characteristics of wild-type poliovirus (WPV) (3). Because of this genetic instability, in settings where a substantial proportion of the population is susceptible to poliovirus, OPV use can lead to poliovirus emergence and sustained person-to-person transmission and spread in the community of genetically divergent circulating vaccine-derived polioviruses (cVDPVs). ….”

CDC

Message from the Director of CDC’s Center for Global Health

October 24 is World Polio Day, and it is an opportunity for the global polio eradication community to renew its promise of a polio-free world for future generations. This year’s theme is “A Celebration of the Unsung Heroes of Polio Eradication.” There are many unsung heroes working to make polio eradication possible:  vaccinators, community volunteers, frontline health care workers, surveillance and laboratory staff, and civil society.

In 2016, the world saw the lowest ever number of wild polio cases with only 37. To date in 2017, there have been 12 polio cases reported from two of the three remaining polio endemic countries:  Afghanistan (7) and Pakistan (5). Since 1988, progress against polio has been strong and consistent, with cases reduced by over 99.99%. High-quality polio vaccine campaigns and innovative methods for reaching every child have restricted the virus and put polio eradication within our reach.

The progress made in polio control has been led by the Global Polio Eradication Initiative (GPEI), a public-private partnership led by national governments with five core partners – the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), the United Nations Children’s Fund (UNICEF) and the Bill & Melinda Gates Foundation. Its goal is to eradicate polio worldwide.

CDC in Action

CDC experts are diligently working with partners to eradicate polio around the world. During World Polio Day we highlight some examples of the work done by the “unsung heroes” of this effort:

Featured Story

Unsung Heroes of Polio Eradication Since the launch of the GPEI in 1988, the number of polio cases decreased by over 99% due to the heroic efforts of everyone involved in the polio program and the sustained commitment of partners and donors. Of the many unsung heroes of polio eradication efforts, CDC provides direct support to three major programs: the Stop Transmission of Polio (STOP), the National Stop Transmission of Polio (NSTOP) Program, and the CDC polio lab. Learn more about the contributions and impacts of these programs.

Other stories include:

• STOP Goes Beyond Polio to Support Overall Immunization System Strengthening Around the World
• A Model for Success: Multi-country Response Stops Middle East Polio Outbreak

Videos

“Vaccinating Millions of Children in 4 Days”: Vaccinating children to protect them against vaccine preventable diseases like polio is crucial. In endemic countries where routine immunization happens at a lower rate than other areas of the world, additional strategies are used in efforts to vaccinate children. This video highlights the importance of supplemental immunization activities and the incredible efforts made by vaccination teams to vaccinate children.

Blog

Overcoming obstacles to polio eradication in Pakistan: Get a glimpse behind the scenes of polio eradication efforts through the eyes of a Rotarian who works to prevent this disease in her home country of Pakistan. Experience what it was like to work in an area that not only has security challenges, but was also riddled with misconceptions about the polio vaccine. Learn how these unsung heroes overcame obstacles to help Pakistan go from more than 300 polio cases in 2014 to less only 5 cases in just three years.

Other blogs include:

• Polio Eradication and Beyond: What the Polio Endgame Means for Public Health by Manish Patel, MD (CAPT, USPHS)
• Rotary and CDC – Partners in Polio and Beyond by W. William Schluter, MD, MSPH, Director, Global Immunization Division
• CDC Maintains Vigilance to Eradicate Polio in Northern Nigeria by Chimeremma Denis Nnadi, MD, MPH, PhD

Photo Essays

Polio Campaigns in Africa: In 2016 there were only 4 cases of wild poliovirus in sub-Saharan Africa, all detected in Nigeria, the last polio-endemic country in Africa. In an effort to reach and protect children unreached by routine immunization services, oral polio immunization campaigns are being conducted in several African countries, with support from technical staff from CDC’s Global Immunization Division (GID)/Polio Eradication Branch/Africa team. Also available in French!

At Work For Immunization: When planning for routine immunizations, mass vaccination campaigns in response to outbreaks, or supplemental immunization activities, it is important to get as many people involved as possible to reach every child. Female health workers often join immunization activities because they know that vaccines work to save lives.

Reuters

‘……“We are very worried, because obviously if there is already one case of polio of a kid that is paralyzed it’s already an outbreak. We know for example that for one kid that is paralyzed there are almost 200 asymptomatic so it means that virus circulating, so it is very serious,” Jasarevic [WHO spokesman] said…….’

Poliomyelitis

Key facts

• Polio (poliomyelitis) mainly affects children under 5 years of age.
• 1 in 200 infections leads to irreversible paralysis. Among those paralyzed, 5% to 10% die when their breathing muscles become immobilized.
• Polio cases have decreased by over 99% since 1988, from an estimated 350 000 cases then, to 37 reported cases in 2016. As a result of the global effort to eradicate the disease, more than 16 million people have been saved from paralysis.
• As long as a single child remains infected, children in all countries are at risk of contracting polio. Failure to eradicate polio from these last remaining strongholds could result in as many as 200 000 new cases every year, within 10 years, all over the world.
• In most countries, the global effort has expanded capacities to tackle other infectious diseases by building effective surveillance and immunization systems.

Polio and its symptoms

Polio is a highly infectious disease caused by a virus. It invades the nervous system, and can cause total paralysis in a matter of hours. The virus is transmitted by person-to-person spread mainly through the fecal-oral route or, less frequently, by a common vehicle (for example, contaminated water or food) and multiplies in the intestine. Initial symptoms are fever, fatigue, headache, vomiting, stiffness of the neck and pain in the limbs. 1 in 200 infections leads to irreversible paralysis (usually in the legs). Among those paralyzed, 5% to 10% die when their breathing muscles become immobilized.

People most at risk

Polio mainly affects children under 5 years of age.

Prevention

There is no cure for polio, it can only be prevented. Polio vaccine, given multiple times, can protect a child for life.

Global caseload

Polio cases have decreased by over 99% since 1988, from an estimated 350 000 cases in more than 125 endemic countries then, to 37 reported cases in 2016.

Of the 3 strains of wild poliovirus (type 1, type 2, and type 3), wild poliovirus type 2 was eradicated in 1999 and no case of wild poliovirus type 3 has been found since the last reported case in Nigeria in November 2012.

WHO Response

Launch of the Global Polio Eradication Initiative

In 1988, the Forty-first World Health Assembly adopted a resolution for the worldwide eradication of polio. It marked the launch of the Global Polio Eradication Initiative (GPEI), spearheaded by national governments, WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, and supported by key partners including the Bill & Melinda Gates Foundation. This followed the certification of the eradication of smallpox in 1980, progress during the 1980s towards elimination of the poliovirus in the Americas, and Rotary International’s commitment to raise funds to protect all children from the disease.

Progress

Overall, since the GPEI was launched, the number of cases has fallen by over 99%.

In 1994, the WHO Region of the Americas was certified polio-free, followed by the WHO Western Pacific Region in 2000 and the WHO European Region in June 2002. On 27 March 2014, the WHO South-East Asia Region was certified polio-free, meaning that transmission of wild poliovirus has been interrupted in this bloc of 11 countries stretching from Indonesia to India. This achievement marks a significant leap forward in global eradication, with 80% of the world’s population now living in certified polio-free regions.

More than 16 million people are able to walk today, who would otherwise have been paralysed. An estimated 1.5 million childhood deaths have been prevented, through the systematic administration of vitamin A during polio immunization activities.

Opportunity and risks: an emergency approach

The strategies for polio eradication work when they are fully implemented. This is clearly demonstrated by India’s success in stopping polio in January 2011, in arguably the most technically-challenging place, and polio-free certification of the entire South-East Asia Region of WHO occurred in March 2014.

Failure to implement strategic approaches, however, leads to ongoing transmission of the virus. Endemic transmission is continuing in Afghanistan, Nigeria and Pakistan. Failure to stop polio in these last remaining areas could result in as many as 200 000 new cases every year, within 10 years, all over the world.

Recognizing both the epidemiological opportunity and the significant risks of potential failure, the “Polio Eradication and Endgame Strategic Plan 2013-2019” was developed, in consultation with polio-affected countries, stakeholders, donors, partners and national and international advisory bodies. The new Plan was presented at a Global Vaccine Summit in Abu Dhabi, United Arab Emirates, at the end of April 2013. It is the first plan to eradicate all types of polio disease simultaneously – both due to wild poliovirus and due to vaccine-derived polioviruses.

Future benefits of polio eradication

Once polio is eradicated, the world can celebrate the delivery of a major global public good that will benefit all people equally, no matter where they live. Economic modelling has found that the eradication of polio would save at least US$ 40–50 billion between 1988 and 2035, mostly in low-income countries. Most importantly, success will mean that no child will ever again suffer the terrible effects of lifelong polio-paralysis.

WHO

In the Democratic Republic of the Congo (DRC), two separate circulating vaccine-derived poliovirus type 2s (cVDPV2s) have been confirmed. The first cVDPV2 strain has been isolated from two acute flaccid paralysis (AFP) cases from two districts in Haut-Lomami province, with onset of paralysis on 20 February and 8 March 2017. The second cVDPV2 strain has been isolated from Maniema province, from two AFP cases (with onset of paralysis on 18 April and 8 May 2017) and a healthy contact in the community.

Public health response

The Ministry of Health, supported by WHO and partners of the Global Polio Eradication Initiative (GPEI), has completed a risk assessment, including evaluating population immunity and the risk of further spread.

Outbreak response plans are currently being finalized, consisting of strengthening surveillance, including active case searching for additional cases of AFP, and supplementary immunization activities (SIAs) with monovalent oral polio vaccine type 2 (mOPV2), in line with internationally-agreed outbreak response protocols.

Surveillance and immunization activities are being strengthened in neighbouring countries.

WHO risk assessment

WHO assesses the risk of further national spread of these strains to be high, and the risk of international spread to be medium.

The detection of cVDPV2s underscores the importance of maintaining high routine vaccination coverage everywhere, to minimize the risk and consequences of any poliovirus circulation. These events also underscore the risk posed by any low-level transmission of the virus. A robust outbreak response as initiated is needed to rapidly stop circulation and ensure sufficient vaccination coverage in the affected areas to prevent similar outbreaks in the future. WHO will continue to evaluate the epidemiological situation and outbreak response measures being implemented.

WHO advice

It is important that all countries, in particular those with frequent travel and contacts with polio-affected countries and areas, strengthen surveillance for AFP cases in order to rapidly detect any new virus importation and to facilitate a rapid response. Countries, territories and areas should also maintain uniformly high routine immunization coverage at the district level to minimize the consequences of any new virus introduction.

WHO’s International Travel and Health recommends that all travellers to polio-affected areas be fully vaccinated against polio. Residents (and visitors for more than four weeks) from infected areas should receive an additional dose of OPV or inactivated polio vaccine (IPV) within four weeks to 12 months of travel. As per the advice of the Emergency Committee convened under the International Health Regulations (2005), efforts to limit the international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC). Countries affected by poliovirus transmission are subject to Temporary Recommendations. To comply with the Temporary Recommendations issued under the PHEIC, any country infected by poliovirus should declare the outbreak as a national public health emergency and consider vaccination of all international travellers.

WHO

A circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in the Deir Al Zour Governorate of the Syrian Arab Republic. There is evidence of genetic linkage among three isolates of type-2 vaccine-derived polioviruses (VDPV2) isolated in the stool specimens of two acute flaccid paralysis (AFP) cases with dates of onset of paralysis on 5 March and 6 May 2017, and the contact specimen of an AFP case collected on 17 April 2017. Al Mayadeen was also the epi-centre of the wild poliovirus type 1 (WPV1) outbreak in Syrian Arab Republic in 2013. Aggressive multi-country polio outbreak response effectively controlled the WPV1 outbreak and no WPV1 case has been reported in Syrian Arab Republic since 21 January 2014.

Public health response

Since the confirmation of the first VDPV2 during May 2017, AFP surveillance has been intensified in the Governorate, especially in the Al Mayadeen district. As of 6 June 2017, a total of 58 AFP cases have been reported from the Governorate this year. In addition to the two cases that have tested positive for VDPV2, a further 11 have tested negative for polioviruses, with the remaining samples being under process in the laboratories or being transported to the laboratories.

Subsequent to the confirmation of the cVDPV2 outbreak, outbreak response planning is underway, including planning for supplementary immunization activities (SIAs) with monovalent oral polio vaccine type 2 (mOPV2), in line with internationally-agreed outbreak response protocols.

Although access for vaccination is compromised due to prevailing insecurity in Deir Al Zour, the Governorate has been partially reached by several vaccination campaigns against polio and other vaccine-preventable diseases since the beginning of 2016. Most recently, two campaigns have been conducted in March and April 2017 using bivalent oral polio vaccine (bOPV). The most recent full trivalent oral polio vaccine (tOPV) round was conducted in October 2015; while tOPV rounds conducted in the first four months of 2016 only reached part of the target population of the Deir Al Zour Governorate. It is pertinent to mention that Syrian Arab Republic introduced two doses of inactivated polio vaccine (IPV) in the routine infant immunization schedule in 2008. Syrian Arab Republic switched from tOPV to bOPV for routine immunization on 1 May 2016.

A detailed risk analysis is currently being updated, including assessing overall population immunity levels and strengthening active searches for additional cases of AFP. Surveillance and immunization activities are being strengthened in neighbouring countries as well.

WHO risk assessment

The detection of cVDPV2 underscores the importance of maintaining high levels of routine vaccination coverage at all levels to minimize the risk and consequences of any poliovirus circulation. Such events also underscore the risk in areas or regions with continued substantial insecurity that hampers maintaining high population immunity through routine vaccination. A robust outbreak response is needed to rapidly stop the VDPV2 transmission. WHO will continue to evaluate the epidemiological situation and outbreak response measures being implemented.

WHO advice

It is important to complete the ongoing risk assessment as soon as possible to inform the vaccination response with mOPV2 and IPV. The geographical scale of the vaccination response will be in accordance with the findings of the risk assessment. It will be critical to achieve the highest possible coverage during the vaccination response. Given the difficult and challenging security situation in the area, appropriate strategies will be identified and utilized to implement the response. Intensified AFP surveillance should continue.

It is important that all countries, in particular those with frequent travel and contacts with polio-affected countries and areas, strengthen surveillance for AFP cases in order to rapidly detect any new virus importation and to facilitate a rapid response. Countries, territories, and areas should also maintain uniformly high routine immunization coverage at the district level to minimize the consequences of any new virus introduction.

WHO’s International Travel and Health recommends that all travellers to polio-affected areas be fully vaccinated against polio. Residents (and visitors for more than four weeks) from infected areas should receive an additional dose of OPV or IPV within four weeks to 12 months prior to the travel.

As per the advice of an Emergency Committee convened under the International Health Regulations (2005), efforts to limit the international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC). Countries affected by poliovirus transmission are subject to Temporary Recommendations. To comply with the Temporary Recommendations issued under the PHEIC, any country infected by poliovirus should declare the outbreak as a national public health emergency and consider vaccination of all international travellers.