Ministers of Health from Africa, the Eastern Mediterranean, Europe and South-East Asia have come together at Regional Committee meetings of the World Health Organization (WHO) to discuss urgent measures to interrupt the remaining chains of polio transmission in the world.
Convening on 30 August in Equatorial Guinea, the Ministers of Health from 46 African countries agreed to a concrete plan of action to grasp this rare opportunity to end polio in Africa. In response to multi-country epidemics which ravaged west, central and the Horn of Africa just 12 months ago, the leadership of Heads of State and Ministers of Health oversaw an unprecedented international outbreak response, featuring new strategic approaches to more rapidly boost population immunity levels. This resulted in a 98% decline in cases in Nigeria (previously the global epicentre of poliovirus), and the significant curbing of epidemics ranging from Senegal to Somalia. Concluding that an unprecedented epidemiologic opportunity currently existed to rapidly deliver a polio-free Africa, the Ministers endorsed a new Resolution, committing to provide the necessary leadership to implement the new strategies and ensure no African child will ever again be crippled for life by polio. Concurrently, however, experts cautioned that Angola and the Democratic Republic of the Congo (DR Congo), which combined have reported 48 of Africa’s 58 cases in the past six months (as of 20 October), posed the greatest threat to a polio-free African continent. And confirmation of new cases in Liberia and Uganda underscore the danger residual, ongoing low-level transmission pose to children everywhere.
Addressing the Regional Committee, WHO Director-General Dr Margaret Chan commended Africa’s progress against polio: “With your collaboration, we now have an aggressive new strategic plan to complete polio eradication. It also introduces accountability at the sub-national level.” Dr Chan was joined by WHO’s Regional Director for Africa, Dr Luís Gomes Sambo, in congratulating countries: “May I hail the immense efforts made by some countries in the implementation of corrective strategies aimed at eradicating polio. Indeed, at the end of July 2010, the number of polio cases dropped by 86% compared to the number of cases recorded in 2009.”
The African Regional Committee Meeting set the tone for the South-East Asia Regional Committee on 7 September. Meeting in Bangkok, Thailand, Health Ministers discussed the sharp downturn of polio cases in India in 2010, particularly the significant progress achieved in the two remaining endemic states of Uttar Pradesh and Bihar. However, the Ministers acknowledged that reaching mobile populations in India was an ongoing challenge that threatened the vision of a polio-free South-East Asia.
Meeting in Moscow, in the Russian Federation, on 13 September, Ministers of Health of the European Region expressed alarm at the recent spread of virus, with this Region, which has been certified polio-free, being re-infected with its first wild poliovirus since 2002. Discussions occurred as confirmation was received that an outbreak which had begun in Tajikistan, had spread to Turkmenistan, Kazakhstan, and the Caucasus region of the Russian Federation. Experts cautioned that Uzbekistan and neighbouring countries remained at extremely high risk of reinfection.
To urgently address the threat this outbreak poses, Dr Zsuzsanna Jakab, WHO Regional Director for Europe, convened an emergency meeting in the margins of the Regional Committee with the Ministers of Health of Russia, Tajikistan, Turkmenistan and Uzbekistan and formulated concrete plans to stop the outbreak before the end of 2010. A series of multi-country immunization campaigns and mop-ups around cases will be conducted across all infected and high-risk areas of these countries, to rapidly stop the outbreak and prevent it from spreading further.
At the Regional Committee for the Eastern Mediterranean on 3 October in Cairo Egypt, Ministers of Health commended the work of the polio infrastructure in Pakistan, which played a critical role in assisting WHO’s flood-relief work by rapidly assessing health facilities, establishing early warning systems for outbreaks and implementing a wide range of immunization services. At the same time, however, experts expressed concern at the ongoing vaccination coverage gap in high-risk areas of North West Frontier Province (now known as Khyber-Pakhtoonkhwa) and Federally Administered Tribal Areas (FATA).
All Regional Committees also discussed the urgent need for the continued support of the international development community. Globally, the Global Polio Eradication Initiative continues to face a US$810 million three-year funding gap, against a US$2.6 billion budget for the 2010-2012. A critical lack of resources has forced the cutting of both supplementary immunization and surveillance activities in key high-risk areas, and given the epidemiological opportunity which presents itself to complete polio eradication globally by 2013, this is a risk the world can not afford to take.
In response to a lengthy and growing polio outbreak in Angola, leaders at national and provincial levels were out in force during the country’s nationwide vaccination campaign last weekend. The Minister of Health, as well as the Governor and Vice-Governor of Luanda province, toured neighbourhoods where vaccinators were going door to door, immunizing 5.6 million children under five years old. While it is too early to determine the impact of the leadership’s engagement on the coverage achieved during the campaigns, it is clear that the programme is being scrutinized by sub-national leadership. In all countries, it is leadership at this level which has been essential to eradicating polio. The Government is supported by civil society – the Angola Red Cross, Rotary International, religious groups, other NGOs and the business community.
To finish the outbreak, which began in April 2007, vaccination coverage gaps must be filled: data from previous campaigns indicate that some 30% of children are still missed in Luanda, for example. Outbreak response strategies work only if all children are vaccinated, and Angola itself has stopped several importations of polio before this current one.
Earlier this year, the public engagement of the Head of State in Chad turned around a similar situation in that country. In turn, the visible commitment from Angolan leadership, from national, to provincial to municipalities and communes, can bring swift change. Sustaining the leadership demonstrated this year with clear instructions to all Municipality administrators to provide personal oversight and actively supervise the polio campaigns, can end polio in Angola again.
Angola was polio-free for three years until it became re-infected with multiple poliovirus importations from northern India.
Improved vaccination coverage critical to halt Africa’s only expanding polio outbreak
Today, the Government of Angola launches vaccination campaigns aimed at delivering polio vaccine to all children under five years of age over the next three days. The campaigns – to be followed by a second round at the end of the month – are viewed as crucial to stopping an outbreak of polio which has paralyzed 24 children this year alone.
Angola’s inability to put an end to the prolonged outbreak, which began in 2007, is due to the poor quality of vaccination campaigns. Polio can only be stopped if every child is given the oral polio vaccine, and campaigns to date have sometimes missed more than a third of children in critical transmission areas such as Luanda. The outbreak has international consequences, in that it is the only expanding outbreak in all of Africa, spreading both within Angola and into the Democratic Republic of Congo. The spread is in stark contrast to progress in other parts of Africa, notably a 99% decline in polio in Nigeria (the only country in Africa that has never stopped polio), the end of an outbreak in the Horn of Africa and the waning of a west African epidemic. The situation in Angola is a growing risk to the global goal of ensuring that no child is paralyzed by polio.
Experience in polio eradication globally shows that vaccination campaign quality depends significantly on leadership at a local, district level in the planning, implementation and monitoring of activities. It is individuals at this level, with the support of provincial or state-level authorities, who can ensure that communities are aware of vaccination campaigns and that the full power of government machinery is behind the campaign. .
Given the fact that the population size and density in Angola are relatively low compared to such challenging areas as northern Nigeria or northern India, the outbreak can be stopped when vaccination campaigns successfully reach all children. For the outbreak to end by the end of this year, campaign quality would need to increase dramatically and rapidly.
Experts have expressed concern about possible further spread throughout the region and the high cost of conducting emergency response campaigns at a time when the global funding shortfall already tops US$810 million for the next three years. Given the upsurge in cases, now more than ever, ownership of immunization campaigns at all levels and the involvement of all stakeholders will be the only way to achieve success.
From 1-3 October, more than 7 million doses of oral polio vaccine will be used to reach 5.6 million children under the age of five years, nationwide.
Vaccination campaigns delayed or curtailed to minimize funding risk
After several rounds of intense vaccination campaigns to end a polio outbreak in west Africa, which saw heads of state, movie stars and football heroes advocate for the eradication of polio, funding shortfalls are forcing a reprioritization of further planned activities. Demand for oral polio vaccine (OPV) has recently gone up, following an outbreak in Tajikistan and resultant activity in that country and its neighbours. Together with the continued needs for supplementary immunization activities in West Africa, this demand has absorbed much of the flexible funding held for emergencies. While additional funds are expected later in the third quarter, activities planned for July and August in particular may require some adjustments.
Decisions to delay or curtail some activities are being made based on epidemiology, protecting activities in highest-risk areas (endemic countries and those with re-established transmission). In order to meet the first milestone in the new strategic plan for polio eradication (ending outbreaks which started in 2009), activities are now planned in June for Burkina Faso, Gambia, Guinea, Liberia, Mali, Mauritania and Senegal . On the other hand, Somalia and Ethiopia in the Horn of Africa (a region without a case since July 2009), may delay vaccination campaigns into later in the year. In the Democratic Republic of the Congo, campaigns in July may be cut to cover the highest-risk districts only. Partners in the Global Polio Eradication Initiative are examining every possible option to manage the cash flow and minimize any threat to progress made across the countries with importations of polio.
Campaign aims to leave no child unvaccinated in 19 countries
More than 85 million children under five years old will be immunized against polio in 19 countries across west and central Africa in a massive example of cross-border cooperation aimed at stopping a year-long polio epidemic.
Over 400 000 volunteers and health workers will take part in the campaign, which is part of an ongoing response to the epidemic that first spread from polio-endemic Nigeria to its polio-free neighbours in 2008 and is still paralysing children in west and central Africa. Nine countries – Burkina Faso, Cameroon, Chad, Guinea, Liberia, Mali, Mauritania, Senegal and Sierra Leone – are considered to have active outbreaks of polio (i.e. cases within the last six months). The campaign kicks off on March 6 in these countries as well as Nigeria, Ghana, Benin, Central African Republic, Gambia, Cape Verde and Guinea Bissau. Niger, Togo and Cote d’Ivoire will join at a later date due to political transitions or elections.
This complex logistical operation is largely made possible by US$ 30 million in extraordinary funding released by Rotary International, a major partner in the global effort to stop polio.
WHO Regional Director for Africa, Dr Luis Gomes Sambo, said the synchronized campaign showed Africa’s determination to be free of polio. “From the top leadership to local district administrators in every country,” he said, “we are each accountable to the African child – to vaccinate every child and achieve high coverage.”
A previous round of campaigns in 2009 did not stop the outbreak completely, as not enough children were vaccinated to stop polio transmission. After years with no polio cases, some countries lacked the necessary skills and experience to respond adequately to the outbreak. New approaches being introduced this year include standardized, independent monitoring of whether children have been reached, better training for vaccinators to carry out the plans fully and appropriate deployment of experienced staff.
UNICEF’s Regional Director for West and Central Africa, Dr Gianfranco Rotigliano noted: “With better coverage that leaves no child unvaccinated, these campaigns can succeed in making West and Central Africa polio-free.”
Getting real-time campaign coverage data
The Global Polio Eradication Initiative is implementing new approaches to improve the quality and impact of eradication strategies. One critical step is to obtain complete and rapid data on supplementary immunization activities (SIAs), so that mid-course corrections can be made if any gaps are found.
To this end, the GPEI is exploring the feasibility of consolidating internationally-available independent monitoring data within 10-14 days of an SIA. The WHO Regional Office for Africa has seized the opportunity of the recent campaigns in west Africa for this pilot. The report focuses on six countries of west Africa which are currently experiencing an outbreak following importation of wild poliovirus of Nigerian origin.
While some of the low numbers of missed children demonstrate that refinements are needed, the basic elements of a real-time independent monitoring report are present. These include the number and source of independent monitors, the number of children monitored, the percentage whose fingers were marked to prove they were vaccinated and the proportion of districts monitored.
Once reviewed, adjusted and endorsed by the Advisory Committee on Poliomyelitis Eradication in November, this process will be adapted for scale-up beyond the pilot phase. Real-time, independent monitoring data will reliably answer the question, “How many children did we reach with vaccine?” and allow course corrections rapidly to cover missing children and stop polio transmission more swiftly.