Poliomyelitis - worldwide (12): Asia, Africa

International Society for Infectious Diseases
< http://www.isid.org>

In this update:
Asia
[1] India
[2] Afghanistan
[3] Bangladesh

Africa
[4] Ethiopia & Somalia
[5] Nigeria

******
[1]
Source: One World South Asia [edited]
<http://southasia.oneworld.net/article/view/139175/1/1893>

Polio outbreak in India: Annan expresses concern
--------------------
India was meant to be polio free by 2005. Instead
it is facing a sharp upsurge in polio cases, worrying global leaders.

UN Secretary General Kofi Annan has now written
to Prime Minister Manmohan Singh, expressing
concern over the large number of polio cases reported this year.

Calling it an outbreak, Annan said many
countries, which have completely eradicated the
disease, face the threat of getting re-infected.

Global concern

"There is global concern about the outbreak in
Uttar Pradesh, which has spread the wild virus to
other polio-free parts within the country and
other countries including Nepal, Bangladesh,
Angola and Namibia and I urge you to ensure all
possible means to contain this outbreak," said Annan.

"We have come to know about Mr Annan's concerns,"
said Sobhan Sarkar, Consultant, Pulse Polio Programme.

While last year, Uttar Pradesh reported 27 cases,
the number of cases has shot up phenomenally to 255 this year.

Overall in India, there were just 66 cases. This
year has seen 283 cases, 90 per cent of these in
western UP - the epicentre of polio.

(Source: National Polio Eradication Programme Government Of India)

"We did not give enough attention to the
immunisation process at the beginning of this
year. That's why there are so many cases," said
Mukesh Kumar Meshram, District Magistrate, Meerut.

Eradicating the virus

Unlike Uttar Pradesh, the rest of India's record
has been excellent with 33 states and union
territories having completely eradicated the virus.

However, what's worrying agencies like the United
Nations is that the UP virus is being exported
through people migrating and re-infecting
polio-free states like Haryana and Maharashtra
and even countries like Nepal and Angola.

"The virus has spread to other states because
children affected by the virus travel from Uttar
Pradesh to other states," added Meshram.

Since Uttar Pradesh is one of the few places
where the wild polio virus still exists, there is
enormous pressure on the government to increase immunisation efforts.

A concerned director general of the World Health
Organisation (WHO) has now decided to convene a
high-level meeting of top Indian officials in
Geneva this week to tackle the current crisis.

"The latest in a series of mass polio
immunization campaigns was launched on 30 July
2006 in the remaining polio-infected areas of
India. For 4 days, hundreds of thousands of
health workers and volunteers went house-to-house
in western Uttar Pradesh and Bihar states, to
reach more than 32 million children under the age
of 5 years with polio vaccine.

The campaign comes amid fears that a new outbreak
centred around Moradabad district, in western
Uttar Pradesh, could cause epidemics of
international scale. Western Uttar Pradesh has
experienced a spike in new polio cases in 2006,
suffering a 4-fold increase in new disease over
the same period last year. Alarmingly, Moradabad
and its surrounding areas form the only place in
the world that is actively exporting poliovirus
to other countries - polio originating from this
area has recently been detected in a number of
previously polio-free countries, including as far
away as Namibia, the Democratic Republic of the
Congo (DR Congo), Bangladesh and Nepal.

The task of eradicating polio in western Uttar
Pradesh is daunting, due to extremely high
population density and low sanitation
infrastructure. With a population of more than
180 million people, and 500,000 children born
each month, the conditions are ideal for polio to
transmit among communities across the state. The
increase in polio transmission has been
attributed to a marginal increase in 'missed'
children during immunization activities in late
2005, which led to a surge in poliovirus transmission in 2006."


******
[2] Afghanistan
Source: Polio Eradication website [edited] [18 Aug 2006, accessed 12 Sep 2006]
<http://www.polioeradication.org/content/general/LatestNews200608.asp#AFG >

Polio outbreak in Southern Afghanistan - 18 Aug 2006
-------------
Afghanistan has seen a 6-fold rise in the number
of polio cases over last year (25 cases confirmed
in 2006, compared to 4 cases in the same period
in 2005). All but one of these cases is in the
southern region of the country, where the current
security situation has made it nearly impossible
for health teams to reach children.

The polio eradication campaign is one of the few
public health initiatives still maintaining some
degree of operations in the southern region of
the country. Tribute must be paid to health
workers on the ground, who are operating under
extremely difficult and dangerous conditions,
risking their lives in efforts to reach every child with polio vaccine.

The transmission of virus is made easier by
frequent population movements into and from
neighbouring Pakistan, one of the 3 other
polio-endemic countries. This "corridor of
transmission" stretches from the Southern Region,
into Pakistan's Balochistan and northern
Sindh/southern Punjab. In response, Afghanistan
and Pakistan continue to synchronize
Supplementary Immunization Activities (SIAs).

As the situation in southern Afghanistan is
rapidly evolving, it is difficult to plan complex
operations. The immediate goals of the polio
eradication programme are to ensure the safety of
staff working in the field and to maintain the
highest levels of continuity of operations
possible under the circumstances, in order to
make sure that polio transmission does not spread out of Southern Region.

To this end, the polio teams in the country are
working with all sectors of society at the
district, state and national level to negotiate
increased access to children. More local
community members are being recruited as
vaccinators and supervisors. Teams are also
taking advantage of any windows of opportunity
when areas can be accessed to conduct rapid and
focused mop-up activities, in addition to the planned large scale SIA rounds.

Large-scale SIAs are continuing in all other
areas of the country to prevent spread of polio
out of the southern region. Other antigens such
as Vitamin A are also distributed during
activities, and the active Acute Flaccid
Paralysis (AFP) surveillance network is used to
help identify other diseases of public health importance.

In total this year [2006], 3 National
Immunization Days have been held (5 Mar, 2 Apr
and 20 Aug), and 4 sub-national activities
(sNIDs: 22 Jan , 7 May , 4 June and 19 July).
Thanks to these efforts, geographical spread of
polio has largely been restricted to the southern
region of the country. However, the risk of
spread remains high, and Afghanistan's 7.1
million children under the age of 5 are vulnerable.

More activities are planned in the second half of
the year, for which USD 700 000 is needed for
campaign operations and disease surveillance.

Experience in other countries of civil conflict
shows that polio eradication strategies work even
in the most challenging settings, as the disease
has been eradicated from such countries as Sierra
Leone, Côte d'Ivoire and Liberia. Ultimately,
however, political ownership must be strong at
all levels and across political lines in order to
secure access to all communities.

******
[3] Bangladesh
Source: Polio Eradication Website [4 Aug 2006 accessed 12 Sep 2006]
<http://www.polioeradication.org/content/pressreleases/20060804press.asp>

New cases of polio prompts further immunization drive in Bangladesh
------------------
Only one month after completing the 3rd polio
National Immunization Days (NIDs), the Government
of Bangladesh has ordered a further 3 polio NIDs
this year in response to at least 10 new cases of
polio detected in the country.

The 1st of these new NIDs will be held on Sunday
6 Aug [2006] and aims to immunize 22 million
children under the age of 5. In November and
December this year [2006] the Government will hold 2 more polio NIDS.

The Government has also announced that there will
be 4 rounds of polio NIDs in 2007 and 2 rounds
each year after that until bordering India is polio-free.

"The decision of the Government of Bangladesh to
continue the rounds of NIDs in response to the
importation of the poliovirus and the occurrence
of new polio cases is in line with WHO's
recommendation for polio eradication. Global and
regional experience over the past 2 years has
shown that additional rounds are required to feel
confident of having stopped the circulation of
the virus," said Dr Duangvadee Sungkhobol, World
Health Organization (WHO) Representative to Bangladesh.

Bangladesh had been polio-free for 5 years before
the 1st case was confirmed in March of this year
[2006]. That one case sparked the 3 NIDS which
reached 96 percent of the 22 million children
aged under 5. This, however, has not stopped the
outbreak with a further 10 cases being confirmed
in the past month [July 2006].

The Government of Bangladesh, along with partners
including WHO, UNICEF, Rotary International and
the US Centers for Disease Control and Prevention
(CDC), decided further NIDs were necessary. Each
NID will be followed by a 4 day house-to-house
search for any children that may have missed out.

"As disappointing as it is that the first 3 NIDS
didn't stop the spread of polio in Bangladesh, it
is an achievement that the Government and the
Global Polio Eradication Initiative can work
together to launch another 3 national
immunization days in a short period of time. We
are committed to working together until
Bangladesh is once again polio-free," said
Louis-Georges Arsenault, UNICEF Representative to Bangladesh.

The Global Polio Eradication Initiative (GPEI)
works with governments around the world to
eradicate polio and is spearheaded by WHO, Rotary
International, the US Centers for Disease Control
and Prevention (CDC) and UNICEF. The GPEI has
reduced the incidence of polio by more than 99
percent since its launch in 1988, from 350 000
annual cases to 1950 cases in 2005.

As in the previous campaigns GPEI will help
procure 22 million doses of vaccine and will be
involved in the massive preparations which
include orienting and training health workers and
field-based volunteers. It will also be
instrumental in raising awareness through the
electronic media, interpersonal communication,
distribution of communication materials and
door-to-door searches for left out children.


******
[4] Ethiopia & Somalia
Source: WHO Epidemic &amp; Pandemic Alert & Response (EPR) [8 Sep 2006]
<http://www.who.int/csr/don/2006_09_08/en/index.html>

Poliomyelitis in Ethiopia and Somalia 8 Sep 2006
--------------------
Polio-free for almost 3 years, Somalia became
re-infected last year. To date, there are a total
of 215 confirmed cases, and 14 out of Somalia's
19 regions have been infected. Since its
re-infection in December 2004, Ethiopia has
reported a total of 37 polio cases with 4 out of
11 regions infected. The high-risk areas remain
the cross-border region of Somali, Ethiopia and
north/central areas of Somalia. Kenya has been
polio-free for the last 22 years.

Countries in the Horn of Africa are increasing
their level of planning, coordination and
streamlining their polio eradication strategies
to cut the corridor of transmission of the
poliovirus. Somalia, Ethiopia and Kenya will
simultaneously vaccinate millions of children
under 5 years of age from 9-12 September [2006]
in the largest ever synchronized vaccination campaigns in the Horn of Africa.

******
[5] Nigeria
Source: Polio Eradication Website [17 Aug 2006 accessed 12 Sep 2006]
<http://www.polioeradication.org/content/general/LatestNews200608.asp#AFG>

Update on Immunization Plus Days in Nigeria
--------------
Nigeria currently accounts for 70 percent of the
global cases of polio this year, and over 80
perceent of these cases are in 5 northern states of the country.

As one of only a handful of areas worldwide that
have never uprooted wild poliovirus, northern
Nigeria has been honing its immunization
campaigns to counter the intense transmission of
the virus. Analysis of the first Immunization
Plus Days(IPDs) shows a measurable improvement in
the proportions of children covered and an
increase in public demand for vaccination.

While country teams now report that the IPD
approach is working to curb the intensity of
poliovirus transmission, they also warn that this
improvement is uneven across the north and that
refinements in operations and timely funding are
required to handle the vastly more complicated
logistics of offering several health inputs at once.

Reaching more children

IPDs were introduced by the Government of Nigeria
in May as a refinement of the previous National
Immunization Days, which concentrated only on
polio vaccination. By bundling health
interventions to communities during polio
vaccinations – such as measles and other
immunizations, insecticide-treated bed nets or
de-worming tablets – it was hoped that community
engagement and turn-out would increase. Following
2 IPDs in May and June [2006], in 11 northern
states, teams in the field report that
communities are more eager to bring their
children for the variety of benefits offered and
many political and health leaders are
increasingly identifying themselves with the gains in immunization coverage.

Local ownership

One of the several innovations during the IPDs
was the formal engagement in dialogue with
community leaders before the campaigns were held.
These community dialogues, implemented in time
for the June IPDs, provided an opportunity for
the community to feed into the planning, and
created greater local ownership of the package of
health care interventions. Parents were then much
more interested in procuring vaccinations for
their children. One example of this is in the
Sandamu local government area (LGA) of Katsina
State, where the proportion of missed children
declined from 38 percent in the May IPDs to 7.5 percent in the June IPDs.

As a result of such initiatives, Katsina State
was able to achieve the intermediate goal of
reducing the proportion of missed children in the
June campaign to less than 10 percent. Similar
success stories of local solutions to the low
coverage rates in high risk districts were
reported from several other LGAs in other states.
It is expected that the impact of this increased
coverage will soon be confirmed by a decline in cases.

Added benefits

An added benefit to the IPDs has been stronger
and more reliable data on the number of children
reached. Unlike house-to-house NIDs, counting
children present at fixed vaccination sites has
yielded more credible numbers. Since trained
health workers are required to administer
vaccinations such as measles, data collection is
also of better quality. The improvement in data
quality is useful for all other child health interventions.

Timely funding is critical

An important improvement between the May and June
IPDs was the timely arrival of funds, allowing
for better planning, training and logistical arrangements.

However, in some LGAs, increased commitment from
local authorities is required in order to achieve
the levels of coverage necessary to interrupt
polio transmission. In Jigawa state, for example,
the proportion of children missed during the IPD was over 35 percent in June.

In the May and June IPDs, not all of the
additional health interventions were available in
all areas. This was due to a combination of short
planning time and a lack of necessary funds. For
the IPDs to reach the proportions of children
necessary to eradicate polio, funding must be in
place on time to ensure that the additional interventions are available.

The next round of IPDs, planned for September,
will cover a larger area of the north, including
the same high-priority states as the previous IPDs.

As of 5 Sep 2006 of the 1182 cases of polio
reported for 2006, 784 of the cases (66 percent)
were in Nigeria and 258 (22 percent) were in
India. The remaining cases were: 26 in
Afghanistan, 20 In Namibia, 16 in Pakistan,
Ethiopia (14), Bangladesh (11), Niger (10),
Democratic Repubic of Congo 8, Indonesia 2, Yemen
1, Nepal 1 and Angola 1. Nigeria, India,
Afghanistan and Pakistan are considered polio
endemic, all the remaining countries reporting
cases are considered to be importations from
endemic countries. < http://www.polioeradication.org/casecount.asp>.

In the above WHO announcement (see part [4]
Ethiopia, Somalia) there is mention of 215 cases
in Somalia and 37 in Ethiopia. These numbers
reflect cases since 1 Jan 2005 in Somalia, and
since December 2004 for Ethiopia. Case count by
year can be seen at the polio eradication website
< http://www.polioeradication.org/content/general/casecount.pdf>.

Clearly there remain challenges ahead to achieve
the goal of worldwide interruption of
transmission of wild poliovirus.