POLIOMYELITIS UPDATE   from PDG Lindsay Ford / D9910 Polio Chair

Ethiopia

A polio outbreak on the Horn of Africa has spread to Ethiopia.

An 18-month-old child in the Warder district [in Somali state] of Ethiopia is the country's 1st polio case since 2008, Warder district is just across the border from Somalia, where 108 polio cases have been reported this year [2013].

"It's not surprising that the virus is spreading. This area has been considered high risk because of its proximity to Somalia,

A Somali refugee camp in Kenya has also seen 12 cases of the paralysing disease this year [2013], the outbreak began in Somalia in May [2013], when a 2-year-old girl came down with the disease, the country's 1st since 2007

Nigeria, Pakistan and Afghanistan are the last 3 countries where the poliovirus is still endemic.

Unfortunately, the concerns that the ongoing outbreak of polio in Somalia and the Dadaab region of Kenya (where there are Somali refugees) would potentially spread to Ethiopia were valid, as the 1st case of wild poliovirus (WPV) associated disease has been confirmed in a child in Ethiopia living in a district on the border with Somalia.

The population movement in the Horn of Africa has seen prior WPV outbreaks involving Somalia, Ethiopia, Kenya and extension to Yemen; hence the major concerns about continued spread and transmission of the WPV, the involved areas have a high percentage of incompletely vaccinated children, thereby leading to pools of susceptible where the WPV can be easily transmitted.

Africa, Asia - eradication challenges

The global effort to eradicate polio, a disease that has been on the brink of extinction for years, is facing serious setbacks on 2 continents. The virus is surging in Somalia and the Horn of Africa, which had been largely free of cases for several years. And a new outbreak has begun in a part of Pakistan that a warlord declared off limits to vaccinators 14 months ago.

The African outbreak began in May [2013] with just 2 cases of polio paralysis: one in Mogadishu, Somalia's capital, and another in the huge Dadaab refugee camp in Kenya, where thousands of Somalis have fled fighting between Islamic militants, clan militias, government troops and African peacekeepers.

Now there are 121 cases in the region; last year [2012], there were only 223 in the world.

The new Pakistan outbreak is in North Waziristan, near the frontier with Afghanistan. It is in an area where a warlord banned polio vaccinations after it was disclosed that the CIA [Central Intelligence Agency] had staged a hepatitis vaccination campaign in its hunt for Osama bin Laden. The warlord, Hafiz Gul Bahadur, banned all efforts until American drone strikes ended.

Although only 3 North Waziristan children have suffered polio paralysis since then, even one case shows that the virus is in the area and could spread.

The new outbreaks may delay a recently announced USD 5.5 billion plan to eradicate polio by 2018. Nonetheless, public health officials still believe that, with enough local political will and donor money, they can prevail by using techniques that have worked before.

To prevent the disease from reaching Mecca during next month's hajj, Saudi Arabia has tightened its rules. Pilgrims from any country with polio cases must be vaccinated at home and again on arrival. Last year [2012], nearly 500 000 pilgrims were vaccinated on arrival.

The Pakistan outbreak is particularly frustrating because eradication had been going steadily forward despite the killings in December [2012] of 9 vaccinators.

Public health officials had counted themselves lucky that despite simultaneous vaccination bans in North and South Waziristan, no polio virus was known to be circulating in the 250 000 children in those areas. Vaccination posts were set up on nearby highways and on buses and trains. Urban hospitals packed the vaccine on ice for families willing to smuggle it back to neighbours. But it was not enough.

"The equation is simple, where you can immunize, the virus goes away. Where you can't, the virus gets in, and it will paralyse these poor kids."

Before the Waziristan outbreak, Pakistan had seen only 24 cases this year [2013], about as many as it had at the same point in 2012. Most were around Karachi and Peshawar, where last year's [2012] killings of the vaccinators took place and where resistance to vaccines is highest.

The Somali outbreak is different. There is little opposition to the vaccine itself.

 In several Muslim countries, including Pakistan, the drive has been hurt by rumours that the vaccine sterilizes girls or contains the virus that causes AIDS or pork products, many cases are in areas south of Mogadishu where the Shabab, a militant group, operate. The group opposes mass campaigns because it believes the sight of thousands of vaccinators going house to house would undercut its claim to rule those areas, Instead, the campaign negotiates with local chiefs and midlevel Shabab members to hold small drives.

Other tactics have changed, too: children of any age, and sometimes adults, get the drops, and drives are held twice a month instead of every 3 months.

Refugee camps face other obstacles. Large ones often have lawless areas on their fringes where vaccinators may fear to work because of predatory criminals, few children born in the last 5 years had been immunized.

The outbreak could be beaten because it echoed the one that plagued the region from 2005 to 2007. It also began in Mogadishu, and it spread as far as Yemen and Eritrea and paralysed about 700 children before multiple mass vaccination rounds snuffed it out. Kenya, Yemen and Ethiopia are already planning those with help from Geneva.

Somalia is so dangerous for health workers that Doctors Without Borders pulled out of the country this month [August 2013] after 22 years there. But polio officials hope their campaign will not be targeted, largely because it creates thousands of temporary paying jobs for "volunteer" vaccinators.

In Mogadishu in July [2013], President Hassan Sheik Mohamud publicly took polio drops at an event encouraging parents to vaccinate.

[A 38-year-old] mother of 4 changed her attitude. "I was thinking the vaccine might sicken our children," she said. "I realized later that it was good."

[A 26-year-old woman] said she accepted it "because I don't want this serious disease to cripple my children."

But [another woman], in a different Mogadishu neighbourhood, said her husband had forbidden vaccination, believing it causes "a mysterious disease."

The common themes in this article are the challenges faced by the polio eradication initiative related to areas of insecurity for vaccination efforts to reach the target population for vaccinations, and the politicization of the vaccination efforts. While the rumours that are circulating in the various areas are different, the outcome of these rumours is the same -- suspicion on the part of the population that the vaccines are being used to harm the children rather than to help the children; and the fact that this type of rumour mongering activities has been ongoing in the endemic countries on 2 different continents -- Africa (Nigeria) and Asia (Afghanistan and Pakistan).

I remember the days when both sides of warring factions would lay down their arms to permit national vaccination efforts to occur, and would help out in making sure the vaccinators could reach their target populations. Today's environment is the opposite, where warring factions spread rumours to disrupt activities, and threaten the safety of individuals in the area, both the safety of the healthcare workers and that of the population that might choose to get vaccinated, a very sad and sorry state of affairs that is difficult to understand.

Global Polio Eradication Initiative update as of 21 Aug 2013

Wild poliovirus (WPV) cases

Total cases: Year-to-date 2013 / Year-to-date 2012 / Total 2012

Globally: 192 / 123 / 223

- In endemic countries: 71 / 118 / 217

- In non-endemic countries: 121 / 5 / 6

Case breakdown by country

Countries: 2013 WPV1 / WPV3 / W1W3 / Total 2013 / 2012 WPV1 / WPV3 /

W1W3 / Total year-to-date 2012 / Total 2012 // Date most recent case

Pakistan: 24 / 0 / 0 / 24 // 26 / 2 / 1 / 29 / 58 // 13 Jul 2013

Afghanistan: 4 / 0 / 0 / 4 // 17 / 0 / 0 / 17 / 37 // 23 Jul 2013

Nigeria: 43 / 0 / 0 / 43 // 57 / 15 / 0 / 72 / 122 // 23 Jul 2013

Somalia: 108 / 0 / 0 / 108 // 0 / 0 / 0 / 0 / 0 // 10 Jul 2013

Ethiopia: 1 / 0 / 0 / 1 // 0 / 0 / 0 / 0 / 0 // 10 Jul 2013

Kenya: 12 / 0 / 0 / 12 // 0 / 0 / 0 / 0 / 0 // 14 Jul 2013

Chad: 0 / 0 / 0 / 0 // 5 / 0 / 0 / 5 / 5 // 14 Jun 2012

Niger: 0 / 0 / 0 / 0 // 0 / 0 / 0 / 0 / 1 // 15 Nov 2012

Total: 192 / 0 / 0 / 192 // 105 / 17 / 1 / 123 / 223 Total in endemic countries: 71 / 0 / 0 / 71 // 100 / 17 / 1 / 118 /

217

Total outbreak: 121 / 0 / 0 / 121 // 5 / 0 / 0 / 5 / 6

Highlights of this week:

- In Ethiopia, a case of WPV1 has been detected in an 18-month-old child from the Somali Region (Warder District).

- In Israel, WPV1 has been detected in 68 sewage samples collected from [3 Feb 2013] to [16 Aug 2013] from 24 sampling sites.

- In Somalia, 8 new WPV1 cases have been reported this week from previously infected districts.

Afghanistan

- No new WPV case was reported in the past week.

- All 4 WPV cases this year [2013] were reported from Eastern Region.

The most recent WPV1 case had onset of paralysis on [23 Jul 2013] from Kunar province. In the high-risk Southern Region, no WPV cases have been reported since November 2012.

- No WPV3 has been detected in Afghanistan since April 2010. - No new circulating vaccine-derived poliovirus type 2 (cVDPV2) cases were reported in the past week. The total number of cVDPV2 cases in 2013 remains 3. The most recent cVDPV2 case had onset of paralysis on [13 Mar 2013] (from Kandahar, Southern Region).

- Subnational immunization days (SNIDs) were held on [1-3 Jul 2013], with resources focusing on Southern and Eastern Regions. Planning is underway for nationwide SIAs in late August [2013].

Nigeria

- No new WPV case was reported in the past week. The total of WPV1 cases for 2013 remains 43. The most recent WPV1 case in the country had onset of paralysis on [23 Jul 2013] (from Borno).

- The most recent WPV3 detected in Nigeria was in November 2012.

- No new cVDPV2 cases were reported in the past week. The total number of cVDPV2 cases for 2013 remains one (with onset of paralysis on [6 Jun 2013] from Borno).

- Nearly half of all WPV1 cases in the country this year are from Borno and Yobe state. As many as 35 precent of children in these states remain under-immunized. In comparison, in other high-risk states of northern Nigeria (such as Kano, Jigawa, Katsina and Kaduna), fewer than 20 precent of children remain under-immunized.

- Targeted approaches are being implemented in those LGAs of Borno and Yobe where access is hampered due to insecurity.

- Across all areas, strengthened efforts are being made to track the direct engagement and oversight of eradication activities by LGA Chairpersons, and traditional and religious leaders.

- The next subnational Immunization plus Days (IPDs) are planned across northern states in September [2013].

Pakistan

- No new WPV cases have been reported in the past week. The total number of WPV1 cases for 2013 is 24. The most recent WPV1 case in the country case is from North Waziristan, and had onset of paralysis on [13 Jul 2013].

- No new WPV3 has been detected in the country since April 2012.

- 1 new cVDPV2 case was reported in the past week from a new district, Mohmand, in FATA [Federally Administered Tribal Areas] with the onset of paralysis on [13 Jul 2013]. The total number of cVDPV2 cases for 2013 is 12.

- FATA remains the major poliovirus reservoir in Pakistan and in Asia, both due to WPV1 and cVDPV2.

Chad, Cameroon and Central African Republic

- In Chad, no new WPV cases were reported in the past week. The most recent WPV case had onset of paralysis on [14 Jun 2012] (WPV1 from Lac).

- No new cVDPV2 cases were reported in the past week. The total number of cVDPV2 cases for 2013 remains 4 (the most recent cVDPV2 case had onset of paralysis on [12 May 2013] from Ennedi).

- The 4 cVDPV2 cases were reported from various parts of the country, indicating widespread transmission. In some areas, only one immunization round has been conducted in response. A more comprehensive outbreak response to these cVDPV2 cases must be planned and implemented. The risk of further spread within Chad and further international spread remains high (cVDPV2 circulating in Chad has also been detected in Cameroon and Nigeria).

- In Cameroon, no new cVDPV2 cases were reported in the past week. The total number of cVDPV2 cases for 2013 remains 2. The most recent

CVDPV2 case had onset of paralysis on [27 May 2013] (from Extreme-Nord).

- Central African Republic (CAR) continues to be at serious risk of re-infection due to proximity with Chad, ongoing insecurity and humanitarian crises, and destruction of health infrastructure. To minimize the risk and consequences of potential re-infection, 2 subnational immunization campaigns were conducted in June and July [2013]. A SNID is planned for September [2013] and a NID for October [2013].

Horn of Africa

- 11 new WPV1 cases were reported in the past week -- in previously infected districts in Kenya and Somalia, and in a previously unaffected country, Ethiopia. The total number of WPV1 cases for 2013 is 121 (108 from Somalia, 12 from Kenya, 1 from Ethiopia). The most recent WPV1 case in the region had onset of paralysis on [14 Jul 2013] (from Kenya).

- On [14 Aug 2013], a case of WPV1 was reported in a child living in Ethiopia with date of onset of paralysis of [10 Jul 2013]. The case is an 18-month old child from the Somali Region (Warder District) of Ethiopia who had never been vaccinated with oral polio vaccine (OPV).

- Because of the known routes of poliovirus spread in previous outbreaks in the Horn of Africa, the Somali region of Ethiopia had been considered at 'high risk', and since June [2013], 2 large-scale supplementary immunization activities (SIAs) had already been conducted as part of the broader Horn of Africa outbreak response.

- In Ethiopia, an immediate local immunization campaign is being conducted in the vicinity of the case, with a larger-scale SIA planned targeting 950 000 children under the age of 5 years. Additional SIAs are planned from September to November [2013]. Confirmation of the case in Ethiopia underscores the risk this outbreak continues to pose to countries across the region.

- Access in some areas of south-central Somalia remains a significant challenge. Analysis shows that as many as 70 precent of children in inaccessible areas are under-immunized. This compares to 20 precent in accessible areas of the country. Of the 108 cases reported from Somalia so far, 33 are from inaccessible or only partially-accessible areas; 75 cases are from accessible areas or accessible areas with security challenges.

- In Kenya, the priority remains on increasing immunity levels in the Dadaab area of North Eastern province. Nearly 50 precent of children in this area remains under-immunized (compared to less than 5 precent in Kenya on the whole).

Israel

- WPV1 has been detected in 67 sewage samples from 24 sampling sites in Israel, collected from [3 Feb 2013 to 4 Aug 2013]. Initially restricted to southern Israel, WPV1 has now also been detected in environmental sampling sites elsewhere in Israel, indicating widespread transmission throughout the country. No case of paralytic polio has been reported.

- To interrupt WPV1 transmission, a supplementary immunization activity (SIA) with bivalent oral polio vaccine (OPV) targeting children up to the age of 9 years was initiated in the southern district of Israel during the week of [5 Aug 2013]; since [18 Aug 2013], the SIA was expanded to the entire country. The objective of the SIA with OPV is to boost intestinal immunity in children vaccinated with IPV only in order to rapidly interrupt wild poliovirus transmission.

West Africa

- No new WPV cases were reported in the past week. The most recent case in the region was a WPV1 from Tahoua province in Niger with onset of paralysis on [15 Nov 2012].

- Multi-country immunization campaigns are planned in West Africa for mid-October [2013] and mid-November [2013], as well as subnational campaigns in Niger in September [2013].

[In the past week since the last global update (13 Aug 2013), the number of cases of confirmed WPV associated disease has increased from

181 to 192 (see Poliomyelitis update (19): Somalia, Israel, global 20130817.1884992). Unfortunately, all of the newly confirmed cases have been outbreak associated, with no new cases confirmed from the 3 endemic countries (Afghanistan, Nigeria, and Pakistan).

The number of WPV cases associated with the ongoing outbreak in the Horn of Africa (Somalia, Kenya and now Ethiopia) has increased from

110 to 121 in the past week, with 8 newly confirmed cases in Somalia,

2 in Kenya and one in Ethiopia. The report mentions that as many as 70 precent of children in inaccessible areas are under immunized. But only

33 of the 108 cases (30.6 precent) have been from these areas. The question that arises is if these areas are inaccessible, could there be more cases occurring in these areas that are not coming to the attention of the health sector. (The same question applies to the inaccessible areas in Afghanistan and Pakistan and other countries with ongoing civil unrest and difficult-to-access locations).

Another worrisome occurrence is the continued spread of WPV northward in Israel. On Tuesday (20 Aug 2013) there was an announcement that WPV had been isolated from sewage sampling in the north -- Baka al-Garbiyeh in the Haifa district .