The motivation of this post comes after speaking to a researcher at the WHO working on polio, who tells me that polio remains a challenge for the world. It is particularly active in Pakistan, Afghanistan, Nigeria and India. I asked him how the campaign Kick Polio out of Africa was going, and we chatted a bit. I then did a search and found this African Union statement following a meeting of the Ministers of Health, 4 – 8 May 2009 and the meeting of experts 4-6 May 2009, where this status report on polio was made public.
POLIO ERADICATION IN AFRICA: STATUS REPORT
POLIO ERADICATION IN AFRICA –
- Since 1988 when the GPEI was launched, the GPEI has reduced the global incidence of polio by more than 99%. As a result, indigenous poliovirus has been eliminated from all countries except four countries: India, Nigeria, Pakistan and Afghanistan. Polio is on the verge of eradication. However, many countries continue to experience re-infections that result in polio outbreaks.
- The Global Polio Eradication Initiative (GPEI) has reduced the global incidence of polio by more than 99 percent – from 350,000 cases per year in 125 countries in 1988, to 1660 cases in 18 countries in 2008.
- The “Kick Polio Out of Africa” campaign launched by President Mandela in 1996, and supported by the OAU and the AU, is an integral part of the success of GPEI.
- 91% of the polio cases in the world in 2008 were from just the four polio-endemic countries of Nigeria (northern states), India (2 northern states), Pakistan, and southern provinces of Afghanistan. The rest of the cases were from countries that were re-infected with poliovirus importations from either Nigeria or from India.
- Since the launch of GPEI in 1988, nearly five million people are today walking, who would otherwise have been paralysed by the disease. An estimated more than 250,000 polio-related deaths have been prevented, in addition to more than 1.2 million childhood deaths averted by the systematic distribution of Vitamin A during polio supplementary immunization activities (SIAs).
- The polio eradication infrastructure and staff on the ground have also provided broader benefits for the health systems by supporting the delivery of various other critical health interventions, establishing a robust disease surveillance network, establishing cold chain and logistics systems for vaccine distribution, scaling up communication and social mobilization efforts to increase awareness of the benefits of immunization, and training a large cadre of health workers in the field.
- The continued leadership of the AU and sustained and intensified effort by the polio-infected AU Member States to reach and vaccinate all children will contribute to the ultimate success of this historic effort to deliver a polio-free world.
II. African Union and Polio Eradication – 2008:
- 57% (946) of all polio cases in the world were reported in AU member States in 2008, with Nigeria alone contributing to 49% (806) of the global polio cases.
- Of the 14 countries that reported polio outbreaks after re-infections in 2008, 13 are members of the African Union (Angola, Benin, Burkina Faso, Central African Republic, Chad, Cote d’Ivoire, Democratic Republic of Congo, Ethiopia, Ghana, Mali, Niger, Sudan, and Togo).
- Importations of poliovirus of northern Nigerian origin are responsible for the ongoing circulation of imported viruses in 11 of 13 re-infected AU member states in west, central and Horn of Africa (viruses of Indian origin are circulating in the other 2 AU states).
- The persistent polio outbreaks in Angola and Chad that have been ongoing for a number of years are a major global concern.
III. African Union and Polio Eradication – 2009 (data as of March 25, 2009):
- 87% (147) of all polio cases in the world in 2009 were reported in AU member States, with Nigeria alone contributing to 53% (90) of the global polio cases.
- A major polio outbreak in south Sudan has now spread into Kenya and Uganda, threatens other countries in the Horn of Africa, and is a matter of grave concern that should be treated as a matter of international public health emergency.
- All the 10 countries that have reported polio outbreaks after re-infections in 2009 are members of the African Union (Angola, Benin, Burkina Faso, Cote d’Ivoire, Kenya, Mali, Niger, Sudan, Togo and Uganda).
Polio Cases in 2008 and 2009 in AU Member States (as of 25 March, 2009)
|5||Central African Republic (CAR)||3||0|
|8||Democratic Republic of Congo (DRC)||5||0|
IV. Technical Feasibility of Polio Eradication Affirmed by Scientific Bodies
At this meeting, the GPEI stakeholders launched the intensified polio eradication effort.
WHO Executive Board calls for Independent Evaluation by May, 2009
- On 26 January, 2009 WHO’s governing body called for Afghanistan, India, Nigeria, and Pakistan to make polio eradication their top operational priority in 2009 and to report to the World Health Assembly in May on their progress. Member states supported the Director-General’s proposal to conduct an independent review of program implementation in the endemic countries to determine the remaining barriers to stopping transmission. The Board called for the Director-General to provide an initial report on the findings of the independent review and how they will guide next steps for the polio eradication initiative at the WHA in May. The Board also highlighted concerns about reinfection of polio-free countries and called for additional measures to prevent the importation of cases.
V. Key Challenges to Polio Eradication in AU Member States:
Nigeria: progress in overcoming operational challenges must be systematically applied across all northern states
- These ongoing vaccination coverage gaps present a unique risk to the global polio eradication effort, as type 1 polio from northern Nigeria in 2008 spread and re-infected seven countries in West Africa.
- The ACPE concluded: “Nigeria will continue to pose a high risk to international health until the new, top political commitment is translated into field level improvements in campaign quality.”
- In February 2009 a landmark public commitment was signed on behalf of Nigeria’s 36 state Governors by the Ministry of Health and the Chairman of the Executive Governors’ Council has pledged to hold Local Government Authorities (LGAs) accountable for the performance of their eradication programs. In 2008, the New England Journal of Medicine reported that if 90% of children under five in Nigeria each received three polio vaccine doses, polio transmission would be stopped. On 2 February in Abuja, with Bill Gates Jr. in attendance, the Governors recognized the urgent need to tackle the ongoing coverage gaps, signing the historic “Abuja Commitments to Polio Eradication in Nigeria” in a public pledge to mobilize the state and LGA civil administrations to reach the necessary 90% coverage target.
Re-infected countries: stopping prolonged outbreaks and minimizing the risk of renewed international spread
Chad & Angola
- In 2008, 37 cases have been reported in Chad and 29 in Angola. Chad is affected by widespread geographic transmission of both type 1 and type 3 poliovirus, including in the east of the country (bordering Sudan), the south (bordering CAR) and the west (bordering Cameroon and Nigeria).
- With suboptimal outbreak response activities implemented in 2008 (in quality, scope and timeliness), and subnational surveillance gaps, the risk of further spread of polio within Chad, within Angola, and bordering countries is high.
The key remains to urgently improve the quality of operations, as upwards of 40% of children were regularly missed during activities in 2008 in Chad. Full political engagement, beginning with the Office of H.E. the President, is urgently needed.
- These prolonged outbreaks represent a risk of further international spread across Africa.
- The confirmation of new polio cases in Benin, Burkina Faso, Cote d’Ivoire, Ghana, Mali, Niger and Togo underscores the fact that west Africa continues to be at risk of international spread of polio from northern Nigeria. The risk of further circulation or additional importations into these western African countries depends fully on the quality of polio campaigns in northern Nigeria and of the outbreak response activities in the re-infected countries themselves.
- Seven-country synchronized cross-border campaigns were conducted in February and March in the re-infected countries, in coordination with Nigeria. More than 28 million children from Benin, Burkina Faso, Côte d’Ivoire, Mali, Niger and Togo joined the 25 million children being immunized with mOPV1 in 15 states in Nigeria.
- It is important that countries across West Africa strengthen disease surveillance for acute flaccid paralysis (AFP), in order to rapidly detect any poliovirus importations and facilitate a rapid response.
Horn of Africa and Sudan outbreak raises alarm:
- An outbreak of wild poliovirus type 1, previously restricted to southern Sudan and western Ethiopia, has spread to northern Kenya, northern Uganda and northern Sudan (Khartoum and Port Sudan). The report of a case in Port Sudan is particularly concerning, given it was from this port city that an outbreak spread to Saudi Arabia, Indonesia, Somalia and Yemen in 2004-06, resulting in 1,200 cases and requiring more than US$150 million in international emergency outbreak response costs.
- WHO has informed its Member States of the high risk of international spread of the disease. Locally, detection of the case has sparked urgent and immediate outbreak response activities in the affected areas and heightened surveillance in countries at risk.
- On 26-27 February, the HOA Technical Advisory Group met to urgently address the polio outbreak in the region. The TAG noted that all countries in the HOA were at significant risk of outbreak, and called upon the Governments of HOA countries to make polio eradication a top priority until the current outbreaks were stopped and the risk of further spread gone. The TAG stressed that every effort must be made to improve the quality and reach of SIA rounds, and that co-ordination between countries was critical to an effective response.
- To minimize the risk of international spread of polio, preventive SIAs will be conducted and heightened attention to strengthening routine immunization levels given in highest-risk areas (e.g. those bordering endemic areas).
VI. African Union leadership and next steps for polio eradication in Africa:
- The continued public support of the African Union for completing polio eradication in Africa will be critical to ensure that all polio-affected AU member states are fully engaged in this historic effort. There is an urgent need for enhanced commitment and public involvement by the leaders of the polio-affected countries to help engage all sectors of the Government and improve the quality of polio eradication activities so that every child is reached and vaccinated against polio. At least 90% of the children need to be vaccinated in the polio immunization activities in order to stop polio in Africa.
- A robust discussion at the 4th AU Conference of Ministers of Health on the polio eradication efforts, challenges, and risks in the African continent will assist in recognizing the urgent need to enhance polio eradication efforts in the AU to protect the significant gains achieved in the continent. The adoption of a Decision on Polio Eradication at the Conference will further strengthen the commitment of the polio-affected AU member states, and help engage the Heads of State in this historic effort. It will also boost donor confidence to continue to support eradication efforts in Africa.
- Only Nigeria remains as the last polio-endemic country in Africa, though a growing number of previously polio-free countries have now become re-infected due to polio importations from Nigeria and India.
- Again, this demonstrates that with strong leadership, the outbreak response strategies succeeded in rapidly again stopping the spread of poliovirus across the continent.
- At the same time, efforts must continue to be intensified in Nigeria. Until Nigeria eradicates polio, all countries across Africa will remain at risk of re-infection.
- The recommendations are included in the annexed Draft Decision for the next Session of the AU Assembly of Heads of State and Government.
draft Decision on Completing Polio Eradication in Africa
1. TAKES NOTE of the Sixty-First World Health Assembly resolution on Polio Eradication (WHA61.1) adopted on 24 May 2008 that highlights the risk of international spread of poliovirus;
2. CONCERNED that there is continued intense poliovirus transmission in the one last polio-endemic Member State in Africa, that there has been international spread of the disease from this region to seven other Member States in West Africa thereby imposing great humanitarian and economic burden on these States, and that a few Member States have not succeeded in stopping poliovirus outbreaks following re-infections more than a year ago;
3. RECALLS the Yaoundé Declaration on Polio Eradication in Africa adopted by the Heads of State and Governments of the Organization of African Unity (OAU) (1996), the Lungi Declaration on Polio Eradication in West African sub-region adopted by the Governments of the Economic Community of West African States ( ECOWAS) (2001), the Decision on Polio Eradication in Africa adopted by the Conference of African Ministers of Health (Tripoli, 2003), the Executive Council Decision on Polio Eradication in Africa ( Maputo, 2003);
4. ACKNOWLEDGES the unprecedented success of the “Kick Polio Out of Africa,” initiative that resulted in the launching of national and continent-wide polio campaigns that by end 2008 has restricted endemic poliovirus transmission to just one Member State, and polio re-infections in 13 Member States;
5. REAFFIRMS its previous commitments towards interrupting the final chains of poliovirus transmission in Africa, and preventing the international spread of poliovirus to polio-free areas within Africa and beyond;
6. REITERATES that polio eradication is an African socio-economic development priority and that success in this historic effort will provide the necessary confidence and financial support to tackle other complex public health challenges;
7. NOTES WITH APPRECIATION the technical assistance received from all the partners of the Global Polio Eradication Initiative, and the financial support received for polio eradication from all public and private development partners, in particular the G8 Members, Rotary International, and the Bill and Melinda Gates Foundation;
8. COMMENDS the sustained efforts and leadership of the WHO, UNICEF, CDC, Rotary International and other partners, towards completing polio eradication;
9. URGES all polio-affected Member States:
- To engage all levels of political and civil society to conduct intensified eradication activities that ensure all children are vaccinated with oral poliomyelitis vaccine;
- To provide the highest level of political oversight and visible leadership in support of intensified polio eradication activities so as to ensure that all children are consistently reached and vaccinated in every polio campaign;
- To mobilize the resources of all Government Ministries to assist in reaching and vaccinating children; and ,
- To engage traditional and religious leaders and civil society to enhance community support;
10. CALLS UPON all Member States:
- to sustain international quality polio surveillance in the country to rapidly detect and respond to poliovirus cases,
- and to strengthen routine immunization services to protect populations from the consequences of poliovirus importations into polio-free areas;
11. ALSO URGES all polio-affected Member States to urgently allocate domestic resources to implement polio eradication activities, and calls on all development partners, including the G8, to maintain their financial and/or technical support to facilitate the achievement of a polio-free Africa;
12. REQUESTS the Chairperson of the African Union, and the President of the African Union Commission to undertake high-level advocacy with the last remaining polio-affected Member States, and provide visible support by launching polio eradication activities;
13. FURTHER REQUESTS the African Union Commission to submit to the Assembly an annual Progress Report on Polio Eradication efforts in the continent, until Africa is certified to be polio free.