WHO: Poliovirus (cVDPVs) in South Sudan and Madagascar

Photo Credit WHO

 

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In my lifetime we’ve gone from seeing Polio as among the worst of the childhood scourges to nearly seeing it vanquished around the globe, thanks to nearly 60 years of vaccination efforts.  But the Poliovirus – which just a few short years ago seemed on the verge of global eradication – has been making a bit of a comeback of late. 

 

So much so that last May we saw the WHO Declare Polio Spread A Public Health Emergency Of International Concern. 

 

Most of this backsliding is due to inadequate vaccination – particularly in war torn regions of the world, such as in Syria and Pakistan. But very rarely, as an unintended side effect of the oral polio vaccine (OPV), we’ll see a few cases of circulating vaccine-derived polioviruses (cVDPVs) show up.

 

The oral (Sabin) polio vaccine contains three attenuated (weakened) polio virus strains, that activates an immune response in the body, and for a few weeks causes the weakened virus to be shed in the feces.  This is considered a `good’ side effect, for in areas with poor sanitation, this vaccine-virus can spread in the community for a limited time onveying extra immunity.

 

But, as the WHO explains, every once in awhile this can go awry.

 

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 paralyse – this is what is known as a circulating vaccine-derived poliovirus (cVDPV).

<SNIP>

Since 2000, more than 10 billion doses of OPV have been administered to nearly 3 billion children worldwide. As a result, more than 10 million cases of polio have been prevented, and the disease has been reduced by more than 99%. During that time, 20 cVDPV outbreaks occurred in 20 countries, resulting in 758 VDPV cases.

 

Statistically, a drop in the bucket.  But for Polio to be completely eradicated, experts have warned that the use of the OPV must be eventually phased out, and the final push completed using the older inactivated Salk vaccine (see Nature Vaccine switch urged for polio endgame).

Unlike the oral vaccine which has been the workhorse of the global polio eradication initiative, the inactivated vaccine must be delivered via an injection, and by a trained healthcare professional.  It is also 10 times more expensive than the OPV.

 

Today the WHO reports on two rare, but  separate detections of cVDPV in South Sudan and Madagascar.

 

 

Poliovirus in South Sudan and Madagascar

Separate circulating vaccine-derived polioviruses confirmed in South Sudan and Madagascar

Disease outbreak news
14 November 2014

In separate and unrelated events, circulating vaccine-derived polioviruses (cVDPVs) have been confirmed in South Sudan and Madagascar.

South Sudan

In South Sudan, 2 cases due to cVDPV type 2 (cVDPV2) have been confirmed. The strains were isolated from 2 acute flaccid paralysis (AFP) cases in Unity state, with onset of paralysis on 9 September and 12 September 2014, respectively. In Unity state, as many as 33% of children remain under-immunized against poliovirus. Both cases are from an internally-displaced persons camp in Unity state. Unity state has been affected by civil unrest, leading to population displacements and declining vaccination coverage in most of the areas.

In 2014, South Sudan has been participating in regional Horn of Africa outbreak response, given the risk posed by an ongoing wild poliovirus type 1 (WPV1) outbreak affecting the region (with cases in 2014 in parts of Somalia and Ethiopia). Two National Immunization Days (NIDs) were conducted in April (with trivalent oral polio vaccine – OPV) and May (with bivalent OPV). In response to confirmation of the cVDPV2, NIDs were held on 4 November with trivalent OPV and further Subnational Immunization Days (SNID) covering the 3 states with civil unrest (Unity, Upper Nile and Jonglei) are planned for 2 December 2014 and January 2015 with trivalent OPV. The objective is to rapidly stop the cVDPV2 in the internally-displaced persons camp and prevent further spread, while further boosting immunity to type 1 polio and minimize risk of re-infection from other parts of the Horn of Africa.

Madagascar

In Madagascar, cVDPV type 1 (cVDPV1) has been confirmed after the virus was isolated from 1 case of AFP (onset of paralysis on 29 September 2014) and 3 healthy contacts. The most recent supplementary immunization activities in Madagascar were conducted in December 2011/January 2012. SNIDs are planned for December, with NIDs to be held in January 2015. An estimated more than 25% of children remain under-immunized against poliovirus in the country. Madagascar was previously affected by a cVDPV2 outbreak in 2001/2002 (resulting in 5 cases) and in 2005 (resulting in 5 cases). A VDPV was also isolated during a research study among healthy children in Toliara I in 2011. Concerted outbreak response each time rapidly stopped those events. However, repeated emergence of separate cVDPV events underscores the risk of these events occurring in populations which are not fully immunized and of the importance of maintaining high levels of vaccination coverage.

WHO risk assessment

Circulating VDPVs are rare but well-documented strains of poliovirus which can emerge in some populations which are inadequately immunized. Due to the small risk of cVDPVs, use of OPV must be stopped to secure a lasting polio-free world. OPV will be withdrawn in a phased manner, beginning with the removal of type 2-containing OPV. The type 2 component contained in trivalent OPV accounts for 90% of all cVDPV cases.

In South Sudan, given that the cases detected are in an internally-displaced persons camp which can be accessed for vaccination, the World Health Organization (WHO) assesses the risk of international spread of the cVDPV2 from South Sudan to be low. However, the risk of international spread would increase if other areas are infected by the cVDPV2. With regard to Madagascar, given the history associated with previous cVDPVs, WHO assesses the risk of international spread from Madagascar to be low.

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 travelers 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.

PNAS: A Vaccine Evading Variant Poliovirus

Photo Credit WHO

 

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For those born after 1960, it is probably difficult to understand the kind of fear that Polio generated in the United States and around the world during the 1950s.  While only one infection in a hundred resulted in paralysis or death, polio was extremely infectious, and the United States routinely saw between 18,000 and 25,000 paralytic cases each year – mostly among young children.

 

Hospital wards were filled with paralyzed children trapped in iron lungs (a grim technology many younger adults have no memory of), which were used to keep them alive. The following short film clip may be hard for some to look at, but is a reminder of how things were . . . not so very long ago.

 

 

 

In 1954  the first major field trials of the Salk vaccine took place, and the following year – after review of the data - a national vaccination campaign was launched. By 1957, after two years of vaccination - the number of new polio cases in the United States dropped to under 6,000, and by 1964 that number had dropped to just 121 cases.

 

There was suddenly tremendous optimism that modern science had within its power to eliminate even the worst childhood scourges, and indeed over the next decade tremendous progress was made against the lesser threats of measles, mumps, pertussis and chickenpox.

 

But, as we’ve seen with the recent resurgence of measles, mumps, and pertussis – and the steady decline in the effectiveness of once powerful antibiotics – mankind’s victories over diseases are sometimes fleeting.

 

Polio – which just a few short years ago seemed on the verge of global eradication – has also made a comeback.  So much so that last May we saw the WHO Declare Polio Spread A Public Health Emergency Of International Concern. 

 

As a result, new, strict polio vaccination requirements are being implemented for those countries with `active polio’.

 

In 2010 there was a particularly severe outbreak of polio in the Republic Of Congo (ROC), primarily in and around the port city of Pointe Noire (see WHO GAR update).  This outbreak was unusual in several respects:

• The median age of victims was 20 (not under 5 as is normally the case)
• The fatality rate – normally in the single digits – was 47%
• Cases occurred among previously vaccinated adults

 

Yesterday, the journal PNAS published a study by an international group of researchers (including such familiar names as Christian Drosten  and Marion Koopmans) that examined this particular strain of polio, and found genetic changes in it that allowed it to evade the protective effects of the inactivated polio vaccine.

 

Robustness against serum neutralization of a poliovirus type 1 from a lethal epidemic of poliomyelitis in the Republic of Congo in 2010

Jan Felix Drexler, Gilda Grard, Alexander N. Lukashev, Liubov I. Kozlovskaya, Sindy Böttcher, Gökhan Uslu, Johan Reimerink, Anatoly P. Gmyl, Raphaël Taty-Taty, Sonia Etenna Lekana-Douki, Dieudonné Nkoghe, Anna M. Eis-Hübinger, Sabine Diedrich, Marion Koopmans, Eric M. Leroy, and Christian Drosten

Significance

In 2010, a large outbreak of poliomyelitis involving 445 laboratory-confirmed cases occurred in the Republic of Congo. The 47% case-fatality rate was unusually high. Outbreak severity was attributed to low immunization coverage but vaccine-mediated immunity against the outbreak virus was never investigated. We isolated the poliovirus type 1 responsible for the outbreak and located its evolutionary origins to Southeast Asia. Fatal cases showed evidence for previous vaccination against polioviruses and the outbreak virus was refractive against neutralization by monoclonal and vaccine-derived antibodies. This pointed to immune escape contributing to the severity of the outbreak. Sustained vaccination regimens in polio-free regions, together with clinical and environmental poliovirus surveillance will be necessary to combat antigenetically variant polioviruses in the poliomyelitis eradication endgame.

 

While people who had previously received the weaker inactivated poliovirus vaccine (IPV) were more vulnerable to this variant poliovirus, those who had recently received the live-attenuated Oral Polio Vaccine (OPV) were still protected. 

 

This discovery – of essentially a `mutated’ strain of polio – shows that the poliovirus can evolve over time.  While this particular variant appears to have been stamped out, the authors worry that more variants could appear in the future, complicating attempts to eradicate this virus.

 

In the battle against infectious diseases we’ve seen many wonderful advances made over the past century: Vaccines, antibiotics, even monoclonal antibodies. But no matter how sophisticated our response, the old adage – that nature always bats last – carries with it more than just a grain truth.  

 

A reminder that a loss of focus, or a break in vigilance, and even once defeated enemies can come back to bite us.

MMWR: CDC Interim Guidance On Polio Vaccination For Travelers To/From Countries With WPV

Credit MMWR

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Two months ago (May 5th) the World Health Organization -  after convening a meeting of their Emergency Committee on the recent spike in polio cases in the Middle East and parts of Africa- Declared  Polio Spread A Public Health Emergency Of International Concern (PHEIC).

 

A month later, the CDC published a HAN (Health Alert Network) Advisory with New Vaccination Requirements For Travel To Countries With Active Polio.

 

Yesterday the MMWR fleshed out these new vaccine requirements in an early release called:

 

Interim CDC Guidance for Polio Vaccination for Travel to and from Countries Affected by Wild Poliovirus

Early Release

July 7, 2014 / 63(Early Release);1-4

Gregory S. Wallace, MD1, Jane F. Seward, MBBS1, Mark A. Pallansch, PhD1 (Author affiliations at end of text)

(Excerpt)

Vaccine Recommendations and Requirements

Advisory Committee on Immunization Practices (ACIP) and CDC recommendations are evidence-based and provide public health recommendations to the general public on the basis of the best available epidemiological and scientific data to prevent poliovirus infection. This includes recommendations for travelers visiting countries with WPV circulation in the last 12 months or countries and provinces where they will be in situations with a high risk for exposure to persons with imported poliovirus infection.

Three countries are still endemic for polio (Afghanistan, Nigeria, and Pakistan). Countries where WPV has circulated during the previous 12 months include those endemic countries and those with polio outbreaks or environmental evidence of active WPV circulation during this time (Cameroon, Ethiopia, Equatorial Guinea, Iraq, Israel, Somalia, and Syria). Travelers working in health-care settings, refugee camps, or other humanitarian aid settings in these and neighboring countries might be at particular risk for exposure to WPV.

Recommendations for vaccination under the International Health Regulations differ from ACIP and CDC recommendations and include exit requirements for proof of polio vaccination when leaving the country at borders or through airports. If implemented by a country, these requirements could be mandatory and are intended to prevent exportation of WPV.

Vaccine Recommendations for Travelers to Countries with WPV Circulation

Persons at greatest risk for acquiring polio are unvaccinated persons. In the United States, infants and children should be vaccinated against polio as part of a routine immunization series. Before traveling to areas with WPV circulation, all travelers should ensure that they have completed the recommended age-appropriate polio vaccine series and have received a booster dose, if necessary.*

Infants and Children

In the United States, all infants and children should receive 4 doses of IPV at ages 2, 4, and 6–18 months and 4–6 years (10). The final dose should be administered at age ≥4 years, regardless of the number of previous doses, and should be given ≥6 months after the previous dose. A fourth dose in the routine IPV series is not necessary if the third dose was administered at age ≥4 years and ≥6 months after the previous dose (11). Infants and children traveling to areas where there has been WPV circulation in the last 12 months should be vaccinated according to the routine schedule. If the routine series cannot be administered within the recommended intervals before protection is needed, an accelerated schedule can be used as follows: 1) the first dose should be given to infants aged ≥6 weeks, 2) the second and third doses should be administered ≥4 weeks after the previous doses, and 3) the minimum interval between the third and fourth doses is 6 months.

If the age-appropriate series is not completed before departure, the remaining IPV doses to complete a full series should be administered when feasible, at the intervals recommended for the accelerated schedule. If doses are needed while residing in the affected country, the polio vaccine that is available (IPV or OPV) may be administered.

Adults

Adults, who are traveling to areas where there has been WPV circulation in the last 12 months and who are unvaccinated, incompletely vaccinated, or whose vaccination status is unknown should receive a series of 3 doses: 2 doses of IPV administered at an interval of 4–8 weeks; a third dose should be administered 6–12 months after the second. If 3 doses of IPV cannot be administered within the recommended intervals before protection is needed, the following alternatives are recommended:

• If >8 weeks are available before protection is needed, 3 doses of IPV should be administered ≥4 weeks apart.
• If <8 weeks but >4 weeks are available before protection is needed, 2 doses of IPV should be administered ≥4 weeks apart.
• If <4 weeks are available before protection is needed, a single dose of IPV is recommended.

If <3 doses are administered, the remaining IPV doses to complete a 3-dose series should be administered when feasible, at appropriate intervals, if the person remains at increased risk for poliovirus exposure. If doses are needed while residing in the affected country, the polio vaccine that is available (IPV or OPV) may be administered.

Adults who have completed a routine series of polio vaccine are considered to have lifelong immunity to poliovirus, but data are lacking (12). As a precaution, persons aged ≥18 years who are traveling to areas where there has been WPV circulation in the last 12 months and who have received a routine series with either IPV or OPV in childhood should receive another dose of IPV before departure. For adults, available data do not indicate the need for more than a single lifetime booster dose with IPV.

(Continue . . . )

 

WHO: Environmental Surveillance Detects WPV1 (Polio) In Brazil

Child receiving Polio Vaccine – CDC PHIL

 

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Although it may be not the most glamorous public health job at the World Cup in Brazil, the sampling of sewage for the poliovirus is an important part of the surveillance effort, since only 1 person in 100 who becomes infected actually develops the acute flaccid paralysis (AFP) we normally associate with the disease.

 

Everyone who is infected, however, sheds large quantities of the virus in their feces for weeks, making environmental sampling of sewage an efficient method of determining the presence of the virus in the community.

 

In January of 2013, you may recall, we saw a report (see Polio Virus Detected By Environmental Surveillance In Egypt) where this type of surveillance had detected Wild Poliovirus type 1 (WPV1) in sewage samples taken in Cairo, Egypt, and they closely matched those found in Pakistan.

 

Today, it has been announced that environmental surveillance has detected WPV1 in sewage samples taken from São Paulo, from an area where previous sampling has failed to produce positive results. This suggests a recent importation of the virus.  Genetic analysis shows this virus is a close match to strain recently detected in Equatorial Guinea.

 

There is no indication at this time that anyone has been infected in Brazil, and given the high level of local immunity due to regular immunization drives, the risks of forward transmission are considered low.

 

  This from the World Health Organization.

 

Detection of poliovirus in sewage, Brazil

Disease outbreak news
23 June 2014

On 18 June 2014, the National IHR Focal Point for Brazil reported the isolation of wild poliovirus type 1 (WPV1) from sewage samples collected in March 2014 at Viracopos International Airport, in Campinas municipality in the State of São Paulo, Brazil. Virus has been detected in the sewage only; sewage samples collected from the same site subsequent to the detection of WPV1 have been either negative or only positive for Sabin strains or non-polio enteroviruses; to date no case of paralytic polio has been reported. The isolate was detected through routine environmental surveillance testing of sewage water; there is no evidence of transmission of WPV1.

Genetic sequencing indicated a close match with a strain of WPV1 that was recently isolated from a case of polio in Equatorial Guinea. Additional epidemiological investigation is ongoing.

The Americas Region has been free of indigenous WPV transmission since 1991 and Brazil since 1989. There is no indigenous transmission of wild poliovirus reported in Brazil since 1989.

Brazil health authorities have enhanced their surveillance activity aimed to detect transmission of WPV1 and potential cases of paralytic polio as well as for any un-immunized persons. The vaccination coverage against polio in São Paulo State and Campinas municipality have been higher than 95% in the routine immunization program. The last national OPV campaign was conducted in June 2013. The campaign for this year is planned in November 2014 at the national level and the target group is children 6 months to less than 5 years of age with OPV.

Specimens collected through environmental surveillance at this and other sites in Brazil since 1994 have consistently tested negative for the presence of WPV.

Given the high levels of population immunity indicated by the high routine immunization coverage and implementation of periodic vaccination campaigns in the area — no evidence so far of WPV1 transmission and the response being implemented — the World Health Organization (WHO) assesses the risk of further international spread of this virus from Brazil as very low.

Given the ongoing WPV1 outbreak in Equatorial Guinea, low national routine immunization coverage, and the inconsistent quality of the initial outbreak response vaccination campaigns, WHO assesses the risk of additional exportation from Equatorial Guinea as high.

WHO note

Brazil was not re-infected with WPV; the country was exposed to a poliovirus importation.

The environmental surveillance system had the capacity to detect the poliovirus in sewage samples and the high immunity appears to have prevented transmission.

WHO travel recommendations

WHO’s International Travel and Health recommends that all travellers to and from polio-affected areas be fully vaccinated against polio. Brazil has detected a poliovirus importation event. Based on current evidence, the country is not considered polio-affected.

 

With hundreds of thousands of people flocking to Brazil for the World Cup from all corners of the world, one of public health concerns has revolved around what diseases might be imported into  (or exported from) Brazil during this month-long event. 

 

The sample being reported today was collected in March, long before the start of  FIFA World Cup, and is presumably not connected to that event.

 

Still, international travel carries with it the risk of acquiring or spreading infectious diseases, and so the WHO/PAHO have called for visitors to be vaccinated against a variety of diseases, including Polio (see The ECDC Risk Assessment On Brazil’s FIFA World Cup).

 

Vaccination coverage should include:

• all diseases included in the immunisation schedule of all EU Member States: poliomyelitis, diphtheria, tetanus, pertussis, measles, mumps and rubella;
• all diseases included in the immunisation schedule of some EU Member States: tuberculosis, pneumococcal disease, meningococcal disease, human papilloma virus (HPV) and chickenpox;
• diseases with an increased risk of acquisition for visitors to Brazil: hepatitis A, yellow fever, rabies, and typhoid fever; and
• one disease which could be re-introduced to Brazil: cholera.

WHO Declares Polio Spread A Public Health Emergency Of International Concern

Photo Credit WHO

 

 

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The recent resurgence of Polio in the Middle East (see WHO: WPV1 (Polio) Risks In Israel Remain Moderate to High)  and in Africa (see WHO: Polio Outbreak In Horn Of Africa), along with the continued threat of infection in the three remaining polio-endemic nations (Afghanistan, Nigeria and Pakistan), has highlighted the fragility of the global polio-eradication efforts.

 

Fearing that three decades of progress in eradicating the disease might be at risk, the World Health Organization  convened an expert committee over the weekend, and determined that the recent rise in cases constitutes a Public Health Emergency Of International Concern (PHEIC), and has announced immediate steps to  address the situation.

 

Below you’ll find a link to the announcement:

 

WHO Statement on the Meeting of the International Health Regulations Emergency Committee Concerning the International Spread of Wild Poliovirus

The Emergency Committee convened by the Director-General under the International Health Regulations (2005) [IHR (2005)] was held by teleconference on Monday 28 April 2014 from 13:30 to 17:30 Geneva time (CET) and on Tuesday 29 April 2014 from 13:30 to 19:00 Geneva time (CET).

Members of the Emergency Committee and expert advisors to the Committee met on both days of the meeting[1].  The following affected States Parties participated in the informational session of the meeting on Monday 28 April 2014: Afghanistan, Cameroon, Equatorial Guinea, Ethiopia, Israel, Nigeria, Pakistan, Somalia and the Syrian Arab Republic.

During the informational session, the WHO Secretariat provided an update on and assessment of recent progress in stopping endemic and imported polioviruses and the international spread of wild polioviruses in 2014 as of 26 April.  The above affected States Parties presented on recent developments in their countries.

After discussion and deliberation on the information provided, and in the context of the global polio eradication initiative, the Committee advised that the international spread of polio to date in 2014 constitutes an ‘extraordinary event’ and a public health risk to other States for which a coordinated international response is essential.  The current situation stands in stark contrast to the near-cessation of international spread of wild poliovirus from January 2012 through the 2013 low transmission season for this disease (i.e. January to April).  If unchecked, this situation could result in failure to eradicate globally one of the world’s most serious vaccine preventable diseases.  It was the unanimous view of the Committee that the conditions for a Public Health Emergency of International Concern (PHEIC) have been met.

(Continue . . . )

 

WHO: GAR On Polio Spread From Syria – Confirmed Case in Iraq

Syria - Credit Wikipedia

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The discovery last October of a cluster of 22 cases  of Acute Flaccid Paralysis (AFP) in  Syria (see WHO: Reports Of Suspected Polio In Syria) – later confirmed to be Polio (WPV1) – set off alarm bells in the International public health community, as only 1%-2% of those infected develop paralysis.

 

Meaning that 22 AFP cases are simply the tip of a much larger viral iceberg, and could involve more than 2,000 additional infections.

 

In November of 2013, the WHO announced an ambitious plan to vaccinate 20 million children in Syria and surrounding countries (see WHO/UNICEF: Polio Vaccination Response For Syria & Neighboring Countries) in an attempt to contain the outbreak.  

 

The recent resurgence of Polio in the Middle East (see WHO: WPV1 (Polio) Risks In Israel Remain Moderate to High)  and in Africa (see WHO: Polio Outbreak In Horn Of Africa), along with the continued threat of infection in the three remaining polio-endemic nations (Afghanistan, Nigeria and Pakistan), has highlighted the fragility of the global polio-eradication efforts.

 

Between civil war in Syria, a war in Afghanistan,  attacks on polio workers in Pakistan (see Pakistan: 3 More Polio Workers Killed), and a deep seated distrust of vaccines in Nigeria, the hoped-for final elimination of this scourge remains elusive.

 

Overnight the World Health Organization posted the following GAR update on Polio in the Middle East, including details on the first case detected in Iraq since the year 2000.

 

 

Update of polio outbreak in the Middle East – ongoing transmission in Syria with international spread

21/03/2014

 

Polio outbreak response in the Middle East is continuing to urgently stop an outbreak affecting the region. As of 20 March 2014, in the Syrian Arab Republic, a total of 37 wild polio virus type 1 (WPV1) cases have been reported:

• 25 cases by the Syrian Arab Republic Ministry of Health, and 12 cases from contested areas (Aleppo, Edleb and Deir Al Zour) not yet reflected in official figures.
• The most recent case had onset of paralysis on 17 December 2013, from Edleb.

Further evidence of regional spread was confirmed this week by notification of a WPV1 case from Iraq, the first polio case in the country since 2000. The case, a six-month old boy from Baghdad who had not been immunized, developed paralysis on 10 February 2014. Genetic sequencing indicates the virus is most closely related to virus detected in Syria.

 

WPV1 was also isolated from the child’s three-year old sister, who did not develop symptoms.

 

Prospects for rapidly controlling this event are positive, as Iraq has been part of a regional Middle East emergency outbreak response since confirmation of polio in the Syrian Arab Republic was received in October 2013. In response, all countries of the WHO Eastern Mediterranean Region, in a joint resolution, declared polio eradication to be an emergency, calling for support in negotiating and establishing access to those children who are currently unreached with polio vaccination. In Iraq, since October 2013, two nationwide immunization campaigns and three subnational campaigns have been conducted, achieving overall high quality.

Approximately 95 percent of children were reported to have been reached during each campaign, though coverage has varied by area. WHO and UNICEF estimates from 2012 put routine immunization levels in Iraq at 70 percent. Routine immunization levels in Baghdad are estimated to be 81 percent.

As part of outbreak response, efforts have been ongoing to strengthen subnational surveillance sensitivity to ascertain the full extent of transmission, particularly in the Syrian Arab Republic. Subnational surveillance gaps persist, particularly in areas of Damascus, Aleppo, Homs, Lattakia, Quneitra and Al Raqa. Surveillance quality has improved in other governorates of north-eastern Syria, including in Deir Al Zour.

Phase 1 of the planned regional outbreak response is now being completed. Since October 2013, 24 supplementary immunization activities (SIAs) have been conducted across the region to reach more than 22 million children with multiple doses, in:

• Egypt (2 nationwide SIAs; 1 subnational SIA); Iraq (2 nationwide SIAs;
• 3 subnational SIAs); Jordan (3 nationwide SIAs); Lebanon (3 nationwide SIAs); Syria (5 nationwide SIAs); Turkey (3 subnational SIAs);
• and, West Bank and Gaza Strip (2 SIAs).

Phase 2 is being launched on 1 April 2014, with nationwide campaigns in:

• Egypt (1-3 April);
• Syria and Iraq (both on 6-10 April) and Lebanon (April), to be followed by further campaigns across the region in May.

In Israel, WPV1-positive samples continue to be detected through environmental surveillance. In total, 186 positive samples have been collected since 3 February 2013, the most recent of which on 16 February 2014.

In West Bank and Gaza Strip, 3 WPV1-positive samples have been detected by environmental surveillance, the most recent of which was detected in January 2013.

No cases of polio paralysis have been detected in Israel, West Bank or Gaza Strip; WPV1 has been isolated from sewage samples only. A surveillance alert remains in place for the region, calling on countries to actively search for additional potential cases in addition to implementing the recommended SIAs with OPV. The risk of further international spread across the region remains high.

WHO’s International Travel and Health recommends that all travellers to and from polio-affected areas be fully vaccinated against polio.

Pakistan: 3 More Polio Workers Murdered

 

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This headline is sadly becoming all too common, as once again attacks on polio workers have claimed multiple lives in Pakistan.  This report from The Hindu.

 

Updated: January 21, 2014 20:00 IST

Three polio workers killed in Karachi

Armed men on motorcycles opened fire on a polio team in Karachi fatally injuring three members including two women, in Qayyumabad area in Karachi East on Tuesday.

The polio vaccination drive had entered its second day today and now the members are unwilling to go ahead with the drive, according to unofficial sources. The polio team comprising four people was targeted while they were administering the oral polio vaccine in a crowded area of the city.

Sindh province reported six cases of the total 91 in 2013 and four of them were from Karachi. The polio drive was aimed at immunising over seven million children and was to continue for a couple of days.

(Continue . . .)

 

The campaign against immunization by the Taliban began eight years ago, but appears to have gained greater ferocity after it was disclosed that a sham hepatitis vaccination campaign was used as a CIA cover in the pursuit of Osama Bin Laden  (see Maryn McKenna’s Update: Pakistan, Polio, Fake Vaccines And The CIA).

 

Additionally, many believe that vaccinations are part of a Western plot to sterilize Muslims, a notion that some local clerics have helped foster.

 

The recent detection of Polio in Syria (see WHO: Update On Polio Detection In Syria) has been genetically linked to a  poliovirus circulating in Pakistan, making the containment and eradication of this virus in that country a global concern.

Pakistan: 3 More Polio Workers Killed

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Via Radio Free Europe/Radio Liberty, we get the sad news that another series of attacks has killed three Polio workers and/or their protection details in Pakistan.  Over the past year we’ve seen a number of horrific coordinated attacks made against aid workers, either involved with or associated with the Polio Vaccination drives in Pakistan.

 

Friday, December 13, 2013

Pakistan

Three Killed After Pakistan Resumes Antipolio Campaign

At least three people have been killed in Pakistan's tribal areas after the resumption of an antipolio campaign.

RFE/RL's Radio Mashaal reports that gunmen shot and killed two police officers assigned to protect a team of polio-vaccination workers in northwestern Pakistan.

The incident occurred north of Peshawar, the capital of Khyber Pakhtunkhwa Province, on December 13.
Reports said the attackers fled the scene.

There was no immediate claim of responsibility.

In a second incident, Esmattulah Wazir, a political administrator in the tribal areas, said unknown assailants shot dead a polio worker named Yousef in his home.

(Continue . . . )

The campaign against immunization by the Taliban began eight years ago, but appears to have gained greater ferocity after it was disclosed that a sham hepatitis vaccination campaign was used as a CIA cover in the pursuit of Osama Bin Laden  (see Maryn McKenna’s Update: Pakistan, Polio, Fake Vaccines And The CIA).

 

Additionally, many believe that vaccinations are part of a Western plot to sterilize Muslims, a notion that some local clerics have helped foster.

 

The recent detection of Polio in Syria (see WHO: Update On Polio Detection In Syria) has been genetically linked to a  poliovirus circulating in Pakistan, making the containment and eradication of this virus in that country a global concern.

WHO: Update On Polio Detection In Syria

Syria - Credit Wikipedia

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The World Health Organization has announced the detection of an additional two cases of polio in Syria, one each in rural Damascus and Aleppo, which confirms the ongoing spread of the virus.  Earlier this month 13 cases of AFP (Acute Flaccid Paralysis) in Syria were confirmed due to the WPV1 polio virus (see WHO: Polio Update In Syria – Nov 11th).

 

 

Polio in the Syrian Arab Republic - update

Disease outbreak news

26 November 2013 - A total of 17 cases due to wild poliovirus type 1 (WPV1) have been confirmed in the Syrian Arab Republic. In addition to 15 cases confirmed in Deir Al Zour province, two additional cases have been confirmed, one each in rural Damascus and Aleppo, confirming widespread circulation of the virus. The case with most recent onset developed paralysis on 8 October 2013.

 

A comprehensive outbreak response continues to be implemented across the region. Seven countries and territories are holding mass polio vaccination campaigns targeting 22 million children under the age of five years. In a joint resolution, all countries of the WHO Eastern Mediterranean Region have declared polio eradication to be an emergency, calling for support in negotiating and establishing access to those children who are currently unreached with polio vaccination. WHO and UNICEF are committed to work with all organizations and agencies providing humanitarian assistance to Syrians affected by the conflict to ensure all Syrian children are vaccinated no matter where they live.

 

It is anticipated that outbreak response will need to continue for at least six to eight months, depending on the area and based on evolving epidemiology.

 

Given the current situation in the Syrian Arab Republic, frequent population movements across the region and subnational immunity gaps in key areas, the risk of further spread of wild poliovirus across the region is considered to be high. A surveillance alert has been issued for the region to actively search for additional potential cases in addition to implementing the recommended supplementary immunization activities with oral polio vaccine.

WHO Updates The Polio Outbreak In The Middle East

 

 

# 7970

 

We’ve been following the outbreak of Polio in Syria, and the detection of the polio virus in environmental surveillance in Israel and Egypt, for quite some time.  Most recently in WHO: Polio Update In Syria – Nov 11th and WHO/UNICEF: Polio Vaccination Response For Syria & Neighboring Countries.

Today the World Health Organization released the following statement on the ongoing eradication efforts.

 

 

WHO update on polio outbreak in Middle East

 

UNICEF13 November – A comprehensive outbreak response continues to roll out across the Middle East following confirmation of the polio outbreak in Syria.

Seven countries and territories are holding mass polio vaccination campaigns with further extensive campaigns planned for December targeting 22 million children; in a joint resolution all countries of the WHO Eastern Mediterranean Region have declared polio eradication to be an emergency and called on Pakistan to urgently access and vaccinate all of its children to stem the international spread of its viruses. The countries also called for support in negotiating and establishing access to those children who are currently unreached with polio vaccination.

WHO and UNICEF are committed to working with all organizations and agencies providing humanitarian assistance to Syrians affected by the conflict. This includes vaccinating all Syrian children no matter where they are, whether in government or contested areas, or indeed outside Syria.

The first priorities are to resupply and reactivate the required health infrastructure, including redeploying health workers to deliver vaccine in worst-affected areas, and moving vaccine across conflict lines where necessary and possible. The government has committed to reach all children; information on which areas are not reached will guide corrective actions and planning for the next rounds. All parties are working to find solutions for conflict-affected areas.

Dr Jaouad Mahjour, Director of Communicable Diseases Prevention and Control at the WHO Regional Office for the Eastern Mediterranean, stressed the necessity of reaching all children inside Syria and in neighbouring countries. "WHO and UNICEF are coordinating the vaccination campaign with all concerned parties to make sure that all children are vaccinated no matter where they are located."

A larger scale outbreak response across the Syrian Arab Republic and neighbouring countries will continue, to last for at least six to eight months depending on the area and based on evolving epidemiology.

WHO: Polio Update In Syria – Nov 11th

Syria - Credit Wikipedia

 

# 7961

 

The World Health Organization release the following update this morning on the Polio outbreak situation in Syria (see WHO/UNICEF: Polio Vaccination Response For Syria & Neighboring Countries for earlier reports). 

 

Below that you’ll find a link to Helen Branswell’s terrific report from yesterday on recent gains made against one of the two remaining wild strains of polio; WPV3.

 

Polio in the Syrian Arab Republic - update

Disease outbreak news

11 November 2013 - Thirteen cases of wild poliovirus type 1 (WPV1) have been confirmed in the Syrian Arab Republic. Genetic sequencing indicates that the isolated viruses are most closely linked to virus detected in environmental samples in Egypt in December 2012 (which in turn had been linked to wild poliovirus circulating in Pakistan). Closely related wild poliovirus strains have also been detected in environmental samples in Israel, West Bank and Gaza Strip since February 2013. Wild poliovirus had not been detected in the Syrian Arab Republic since 1999.

 

A comprehensive outbreak response continues to be implemented across the region. On 24 October 2013, an already-planned large-scale supplementary immunization activity was launched in the Syrian Arab Republic to vaccinate 1.6 million children against polio, measles, mumps and rubella, in both government-controlled and contested areas. Implementation of a supplementary immunization campaign in Deir Al Zour province commenced promptly when the first ‘hot’ acute flaccid paralysis (AFP) cases were reported. Larger-scale outbreak response across the Syrian Arab Republic and neighbouring countries will continue for at least 6-8 months depending on the area and based on the evolving situation.

 

Given the current situation in the Syrian Arab Republic, frequent population movements across the region and the immunization level in key areas, the risk of further international spread of wild poliovirus type 1 across the region is considered to be high. A surveillance alert has been issued for the region to actively search for additional potential cases.

 

WHO’s International Travel and Health recommends that all travellers to and from polio-infected areas be fully vaccinated against polio.

 

 

One of 2 remaining types of polio viruses may be wiped out; not seen in a year

By Helen Branswell The Canadian Press

TORONTO – The effort to rid the world of polio is too often a journey of one step forward and two steps back, with the heartbreaking news that polio is crippling toddlers in war-ravaged Syria the most recent evidence of that stuttering progress.

Still, there is some good news on the polio front.

Sunday marks one year since Type 3 polio viruses have been found, suggesting vaccination efforts may – heavy stress on may – have wiped out the second of three strains of polio.

If the Type 3 viruses are indeed gone, it will mean that only Type 1 polio viruses remain to be vanquished before the long-overdue goal of polio eradication can be realized.

(Continue . . . )

WHO/UNICEF: Polio Vaccination Response For Syria & Neighboring Countries

 

Photo Credit WHO

 

# 7951

 

The recent resurgence of Polio in the Middle East (see WHO: Confirmation Of Polio In Syria & WHO: WPV1 (Polio) Risks In Israel Remain Moderate to High)  has prompted the World Health Organization and UNICEF to announce a monumental polio vaccination drive to be held in Syria and neighboring countries.   The plan is to immunize 20 million children.

 

The announcement was made simultaneously via the @WHO twitter account (see above), and an emailed statement (see  below).

 

Over 20 million children to be vaccinated in Syria and neighbouring countries against polio, say WHO and UNICEF

A week after the Middle East declared a polio emergency in the region, mass vaccination against polio and other vaccine-preventable diseases is under way in Syria, its neighbouring countries and beyond

Geneva, New York, 8 November – The largest-ever consolidated immunization response in the Middle East is under way to stop a polio outbreak, aiming to vaccinate over 20 million children in seven countries and territories repeatedly.

Emergency immunization campaigns in and around Syria to prevent transmission of polio and other preventable diseases have vaccinated more than 650,000 children in Syria, including 116,000 in the highly-contested north-east Deir-ez-Zor province where the polio outbreak was confirmed a week ago.
In a region that had not seen polio for nearly a decade, in the last 12 months poliovirus has been detected in sewage samples from Egypt, Israel, the West Bank and Gaza Strip. The outbreak of paralytic polio among children in Syria has catalysed the current mass response. The first polio outbreak in the country since 1999, it has so far left 10 children paralyzed, and poses a risk of paralysis to hundreds of thousands of children across the region. Preliminary evidence indicates that the poliovirus is of Pakistani origin and is similar to the strain detected in Egypt, Israel, the West Bank and Gaza Strip.

Dr. Ala Alwan, the World Health Organization Regional Director for the Eastern Mediterranean noted, “The Middle East has shown exactly the coordinated leadership needed to combat a deadline virus: a consolidated and sustained assault on a vaccine-preventable disease and an extraordinary commitment to a common purpose.”

UNICEF has procured 1.35 billion doses of oral polio vaccine (OPV) to date in 2013 and by the end of the year will have procured up to 1.7 billion doses to meet increased demand. Global supply of OPV was already under constraint with vaccine manufacturers producing at full capacity. The new outbreak in Syria is adding further pressure to the supply but WHO, UNICEF and manufacturers are working to secure sufficient quantities to reach all children.

"The polio outbreak in Syria is not just a tragedy for children; it is an urgent alarm -- and a crucial opportunity to reach all under-immunized children wherever they are,” said Peter Crowley, UNICEF’s Chief of Polio. “This should serve as a stark reminder to countries and communities that polio anywhere is a threat to children everywhere.”

The unprecedented response to polio virus circulation in the region includes plans for a six-month sustained effort of intense immunization activity. Equally important is heightened disease surveillance until the global eradication of polio, to find cases which may have been missed in an environment which was until recently polio-free.

Multiple mass immunization efforts are aimed at protecting as many children as possible. Inside Syria, the campaign is targeting 1.6 million children with vaccines against polio, measles, mumps and rubella. In Jordan over 18,800 children under the age of five were vaccinated against polio in a campaign in the past few days targeting all children at Za’atari camp and a nationwide campaign is currently underway to reach 3.5 million people with polio, measles and rubella. In Iraq, a vaccination campaign has started in the west of the country, with another campaign planned in the Kurdistan Region in the coming days. Lebanon’s nationwide campaign begins later this week and Turkey and Egypt by mid-November.

Syria’s immunization rates have plummeted from more than 90% before the conflict to currently 68%.

NOTES for the Editor:

The seven countries and territories in the consolidated emergency response to the polio outbreak are: Egypt, Iraq, Jordan, Lebanon, the West Bank and Gaza, Syria, Turkey.

The polio virus usually infects children in unsanitary conditions through faecal-oral transmission associated with close person to person contact and consumption of food and drink contaminated with faeces. It attacks the nerves and can kill or paralyse, spreading widely and unnoticed before it starts crippling children. For every one case of polio, 200 children can be infected. There is no cure for polio – it can only be prevented through immunization.

 

Since 1988, vaccination has reduced polio by more than 99% worldwide, and the disease is slated for complete eradication.

Contacts:
Geneva: Marixie Mercado, UNICEF, +41 79 756 7703; Sona Bari, WHO, +41 79 475 5511; Oliver Rosenbauer, WHO, +41 79 500 6536
New York: Sarah Crowe, UNICEF, +1 646 209 1590.

WHO: Stepped Up Polio Immunizations For Travelers To And From Infected Areas

Photo Credit WHO

#7937

 

The recent resurgence of Polio in the Middle East (see WHO: Confirmation Of Polio In Syria & WHO: WPV1 (Polio) Risks In Israel Remain Moderate to High)  and in Africa (see WHO: Polio Outbreak In Horn Of Africa), along with the continued threat of infection in the three remaining polio-endemic nations (Afghanistan, Nigeria and Pakistan), has highlighted the fragility of the global polio-eradication efforts.

Between civil war in Syria, a war in Afghanistan,  attacks on polio workers in Pakistan, and a deep seated distrust of vaccines in Nigeria, the hoped-for final elimination of this scourge remains elusive.

 

Today the World Health Organization announced stepped up efforts to prevent the further spread of this disease, by boosting vaccination of travelers. 

 

 

Un- or under-immunized travellers from polio-infected areas to receive polio vaccine boost

05-11-2013

The current poliomyelitis (polio) outbreak in the Syrian Arab Republic and remaining polio-endemic countries (Afghanistan, Nigeria and Pakistan), as well as frequent population movements and vaccination gaps in some European countries, increases the risk of the international spread of wild poliovirus. As long as the virus is circulating in the world and vaccination coverage is not optimal, polio threatens to return to the WHO European Region.

Large-scale immunization campaign in the Syrian Arab Republic

In response to the outbreak, the Syrian Arab Republic has launched large-scale supplementary immunization activities to vaccinate more than 1.3 million children against polio (and measles, mumps and rubella) in both government-controlled and contested areas. Further campaigns will be needed to interrupt transmission in infected areas during the next 6 months. Neighbouring countries, including Turkey, have begun planning and implementing supplementary immunization campaigns as part of a multicountry response to prevent the international spread of polio.

WHO’s travel and health advice for polio

WHO’s publication “International travel and health” recommends that all travellers to and from polio-infected areas be fully vaccinated against polio. Countries receiving travellers from polio-infected areas or accommodating people displaced by the Syrian Arab Republic’s conflict should identify anyone who is un- or under-immunized, or with unknown immunization status, and provide him/her with missing doses of polio vaccine according to the national schedule of the country of origin. High immunization coverage against polio across age groups and high-quality surveillance – i.e. acute flaccid paralysis (AFP), environmental or enterovirus (the group of viruses including the poliovirus) surveillance – are essential factors for early alert and all-population protection against polio.

As to resident populations, any vaccination gaps for polio should be checked and all missing vaccine doses provided. Only ensuring that every local community has high vaccination coverage can avert the risk of wide polio spread in case the virus is imported.

Annual review of polio status in the WHO European Region

The European Regional Commission for the Certification of Poliomyelitis Eradication, an independent panel of international public health experts, conducts annual reviews of the risk of local transmission and potential outbreak following importation of poliovirus in countries in the WHO European Region. The evaluation is based on the level of population immunity and ability to detect poliovirus, as well as other factors that indicate the capacity to detect and respond to importation in a timely manner. Releasing its latest report in May 2013, the Commission called for significantly greater efforts in the Region to maintain its polio-free status (declared in 2002) until global polio eradication is achieved.

WHO: Confirmation Of Polio In Syria

Syria - Credit Wikipedia

 

# 7915

 

 

The World Health Organization has posted a GAR (Global Alert & Response) update on the polio situation in Syria (see earlier blog BBC: Polio Confirmed In Syria – WHO) confirming the discovery of wild poliovirus type1 (WPV1) in Syria.

 

Polio in the Syrian Arab Republic

29 October 2013 - Following reports of a cluster of 22 acute flaccid paralysis (AFP) cases on 17 October 2013 in the Syrian Arab Republic, wild poliovirus type 1 (WPV1) has been isolated from ten of the cases under investigation. Final genetic sequencing results are pending to determine the origin of the isolated viruses. Wild poliovirus had not been detected in the Syrian Arab Republic since 1999.

 

Most of the cases are very young (below two years of age), and were un- or under-immunized. Estimated immunization rates in the Syrian Arab Republic declined from 91 percent in 2010 to 68 percent in 2012.

 

Even before this laboratory confirmation, health authorities in the Syrian Arab Republic and neighbouring countries had begun the planning and implementation of a comprehensive outbreak response. On 24 October 2013, an already-planned large-scale supplementary immunization activity (SIA) was launched in the Syrian Arab Republic to vaccinate 1.6 million children against polio, measles, mumps and rubella, in both government-controlled and contested areas.

 

Implementation of an SIA in Deir Al Zour province commenced promptly when the first ‘hot cases’ were reported. Larger-scale outbreak response across the Syrian Arab Republic and neighbouring countries is anticipated to begin in early November 2013, to last for at least six to eight months depending on the area and based on evolving epidemiology.

 

Given the current situation in the Syrian Arab Republic, frequent population movements across the region and subnational immunity gaps in key areas, the risk of further international spread of wild poliovirus type 1 across the region is considered to be high. A surveillance alert has been issued for the region to actively search for additional potential cases.

 

WHO’s International Travel and Health recommends that all travellers to and from polio-infected areas be fully vaccinated against polio.

 

 

 

 

BBC: Polio Confirmed In Syria - WHO

Syria - Credit Wikipedia

 

# 7912

 

While not surprising, given the reports last week (see WHO: Reports Of Suspected Polio In Syria & ECDC Risk Assessment : Suspected Polio In Syria),  this morning the BBC and Reuters are both reporting that the World Health Organization has announced positive poliovirus test results for 10 of the 22 AFD (acute flaccid paralysis) cases reported.  Test results are pending for the remaining cases.

 

While 22 cases may not seem like a lot, the reality is that only about 1%-2% of those infected develop paralysis. Meaning that 22 AFP cases are simply the tip of a much larger viral iceberg, and could involve more than 2,000 additional infections.

 

I expect we’ll get a formal announcement from the World Health Organization later today, but for now we have this from the BBC:

 

Syria polio outbreak confirmed by WHO

The World Health Organization (WHO) has confirmed 10 cases of polio in Syria - the first outbreak in the country in 14 years.

The UN body says a further 12 cases are still being investigated. Most of the 22 people who have been tested are babies and toddlers.

(Continue . . . )

ECDC Risk Assessment : Suspected Polio In Syria

Syria - Credit Wikipedia

# 7993

 

The discovery last week of a cluster of Acute Flaccid Paralysis (AFP) in Syria (see WHO: Reports Of Suspected Polio In Syria) has set alarm bells ringing both inside, and outside of that civil war torn country.  While there are other, non-polio causes of AFP, preliminary testing has indicated that at least 2 of the 22 cases were positive for wild poliovirus. 

 

Final testing is awaited, but the assumption is that they are dealing with `hot’ AFP cases, and an appropriate response is being planned.

 

While 22 cases may not seem like a lot, the reality is that only about 1%-2% of those infected develop paralysis. This from the New York Health Dept.  Poliomyelitis FAQ

 

Up to 95 percent of people infected with polio have no symptoms. However, infected persons without symptoms can still spread the virus and cause others to develop polio. About four to five percent of infected people have minor symptoms such as fever, muscle weakness, headache, nausea and vomiting. One to two percent of infected persons develop severe muscle pain and stiffness in the neck and back. Less than one percent of polio cases result in paralysis.

 

Meaning that 22 AFP cases are simply the tip of the viral iceberg, and could represent more than 2,000 additional infections.

 

Although Polio is believed to be endemic now in only 3 countries (Afghanistan, Nigeria and Pakistan), already this year we’ve seen reports of polio virus detection in the Middle East (see WHO: WPV1 (Polio) Risks In Israel Remain Moderate to High)  and in Africa (see WHO: Polio Outbreak In Horn Of Africa).  An wider outbreak in Syria would greatly complicate global eradication efforts.

 

The World Health Organization has warned that a `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’. 

 

The ECDC released a 5-page Rapid Risk Assessment of the situation, and the threat it may pose to EU countries, this morning.   First the link to the report, followed by some excerpts:

 

 

Suspected outbreak of poliomyelitis in Syria: Risk of importation and spread of poliovirus in the EU

24 Oct 2013

Available as PDF in the following languages

ENGLISH

This document is free of charge.

Abstract

Following the announcement by WHO of a cluster of cases of acute flaccid paralysis in Syria, ECDC conducted a risk assessment and concludes that this does pose a risk that polio might be imported to the EU. The Risk Assessment includes number of recommendations for EU Member States.

EXCERPTS

Main conclusions and recommendations

 
This cluster of cases of acute flaccid paralysis among Syrian citizens increases the risk for the importation of
wild polio virus to the EU/EEA and further re-establishment and transmission in the Member States.

 
Recommendations:

• Countries hosting Syrian citizens in designated areas (camps) should assess the level of transmission of wild poliovirus among them. Such assessments can be carried out through enhanced clinical surveillance, environmental surveillance, and systematic collection of stool samples from symptomatic and asymptomatic persons.
• EU Member States receiving refugees and asylum seekers from Syria should assess their vaccination status on arrival and provide polio vaccination and other vaccinations as needed.
• Regional and international efforts to assess the risk and provide vaccination and other public health services in Syria and to Syrian refugees hosted by neighbouring countries should be supported.
• This situation stresses the need for Member States to consider implementing the recommendations made in the ECDC risk assessment of wild-type poliovirus transmission in Israel [2] (see Annex).
• Countries should review their national preparedness plans, and ensure that items such as framework and responsibilities for outbreak response, enhanced activities and reporting timelines vaccine of choice for outbreak response, and are appropriately addressed.

 

ECDC threat assessment for the EU

 
The probability is very high that the cluster of cases of AFP in Deir Al Zour province in Syria is caused by wild-type poliovirus, and this risk assessment is based on the assumption that wild poliovirus will be confirmed. Confirmation of the polio outbreak in Deir Al Zour province would signal widespread transmission of poliovirus in Syria and possibly in the areas bordering Syria.

 
The likelihood of poliovirus spreading from Syria to neighbouring countries hosting Syrian refugees is high.

 

Large numbers of people are leaving Syria and it is expected that the number of asylum seekers, refugees and undocumented migrants entering the EU will probably continue to increase as the conflict evolves. If poliovirus is indeed circulating in Syria, it should be assumed that a proportion of Syrian refugees are also carrying the virus.

The risk will be highest among children born in Syria since 2011 because of the interruptions to vaccination
services. Further, refugees from Syria are more likely to mix with under-vaccinated populations living in poor
sanitary conditions. 

WHO: Reports Of Suspected Polio In Syria

# 7878

 

 

The World Health Organization has just released a GAR (Global Alert & Response) update on a cluster of AFP (Acute Flaccid Paralysis) detected in civil war-torn Syria.  While Polio is immediately suspected, there are other viral causes of AFP, including many of the non-polio enteroviruses like EV71 (see Australia: Acute Flaccid Paralysis & EV71), and Coxsackie virus A10, A16, and A24. 

 

There are also vector borne arboviruses known to cause AFP as well (eg. West Nile Virus, Japanese Encephalitis, etc.).

 

Disease outbreaks are always a concern during armed conflicts because of limitations in both surveillance and in mounting an effective response. With reports earlier this year of polio detection in the Middle East (see WHO: WPV1 (Polio) Risks In Israel Remain Moderate to High)  and in Africa (see WHO: Polio Outbreak In Horn Of Africa) - should this prove to be Polio - it would represent a serious development.

 

 

Report of suspected polio cases in the Syrian Arab Republic - 19 October 2013

 

19/10/2013

On 17 October 2013, the World Health Organization (WHO) received reports of a cluster of acute flaccid paralysis (AFP) cases in the Syrian Arab Republic. This cluster of ‘hot’ AFP was detected in early October 2013 in Deir Al Zour province and is currently being investigated.  Initial results from the national polio laboratory in Damascus indicate that two of the cases could be positive for polio – final results are awaited from the regional reference laboratory of the Eastern Mediterranean Region of WHO.  Wild poliovirus was last reported in Syria in 1999.

The Ministry of Health of the Syrian Arab Republic confirms that it is treating this event as a cluster of  ‘hot’ AFP cases, pending final laboratory confirmation, and an urgent response is currently being planned across the country.   Syria is considered at high-risk for polio and other vaccine-preventable diseases due to the current situation.

A surveillance alert has been issued for the region to actively search for additional potential cases.  Supplementary immunization activities in neighbouring countries are currently being planned.

WHO’s International Travel and Health recommends that all travelers to and from polio-infected areas be fully vaccinated against polio.

Pakistan: Bomb Attack On Polio Vaccination Protection Team Kills 2

 

# 7841

 

The violent campaign against the polio vaccination effort in Pakistan continues, with a fresh bomb attack in a Peshawar suburb on a van that killed two, and injured more than a dozen others.  Most of those injured appear to be police officers, or other members of the protection team.

 

This report from Aljazeera News.

 

 

Pakistan polio campaign disrupted by attack

Police van protecting polio vaccination team in Peshawar suburb hit by blast, killing two people and wounding 12 others.

Last Modified: 07 Oct 2013 09:02

A bomb hitting a police van protecting a polio vaccination team in northwest Pakistan has killed two people and wounded 12 others, police said.

The attack took place on the third and last day of a UN-backed vaccination campaign in a suburb of the city of Peshawar on Monday, police said, adding that a policeman was among the two dead.

Najeebur Rehman, a senior police official, said those killed were a police officer and a member of a volunteer peace committee. He said the bomb went off just as officers reached the village to provide security to polio teams administering anti-polio vaccine to local residents..

(Continue . . . )

 

Over the past ten months we’ve seen horrific coordinated attacks made against aid workers, either involved with or associated with the Polio Vaccination drives in Pakistan.

 

The first attack (see Pakistan: 6 Polio Workers Murdered) was reported on December 18th, the next day (see Pakistan: Fresh Attacks On WHO/UNICEF Polio Workers) we learned of 3 more deaths, and on January 1st  the headlines read : 7 More Aid Workers Killed In Pakistan.

 

Since then additional attacks have occurred, often resulting in temporary suspension of their vaccination efforts. Pakistan is one of 3 countries where the polio virus is still endemic (the others being Afghanistan and Nigeria).

 

The Pakistan attacks may be related to the Taliban’s condemnation of polio immunization campaigns after the use of a sham hepatitis vaccination campaign as a CIA cover in the pursuit of Osama Bin Laden (see Maryn McKenna’s Update: Pakistan, Polio, Fake Vaccines And The CIA).  Additionally, many believe that vaccinations are part of a Western plot to sterilize Muslims, a notion that some local clerics have helped foster.

 

In their GAR update of September 20th, 2013 on Poliovirus detected from environmental samples in Israel and West Bank and Gaza Strip  the World Health Organization advised:

 

It is important that all polio-free countries, in particular those with frequent travel and contacts with poliovirus-affected countries and areas, strengthen surveillance for cases of acute flaccid paralysis in order to rapidly detect any new virus importations 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 and from poliovirus-affected countries and areas be fully vaccinated against polio. Three countries remain endemic for indigenous transmission of wild poliovirus virus: Afghanistan, Nigeria and Pakistan. Additionally, in 2013, the Horn of Africa has been affected by an outbreak of wild poliovirus type 1.