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

Syria - Credit Wikipedia

# 8393

 

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.

WHO: Update On Polio Detection In Syria

Syria - Credit Wikipedia

# 8012

 

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: 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: 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.