REGIONAL COMMITTEE Sixty-seventh Session Dhaka, Bangladesh 9–12 September 2014
Provisional Agenda item 9.3 SEA/RC67/16 28 July 2014
Progress reports on selected Regional Committee resolutions: Challenges in polio eradication (SEA/RC60/R8) On 27 March 2014, the Regional Certification Commission for Polio Eradication (RCCPE) certified the South-East Asia Region as being polio-free. However, the Region is faced with the risk of importation and spread of poliovirus from polio-infected countries and the challenge of complacency on becoming polio free. In order to overcome these challenges and mitigate associated risks, (1) the South-East Asia Regional Certification Commission for Polio Eradication (SEA-RCCPE) and the National Certification Committee in every Member State need to remain operational at least until the global certification of polio eradication; and (2) Member States need to (i) maintain high population immunity and highperformance surveillance for acute flaccid paralysis (AFP); (ii) conduct regular risk assessment at regional and country levels, and risk-mitigation activities, including introduction of vaccination for travellers to and from polio-infected countries; (iii) be prepared to deal with poliovirus importation and conduct periodic simulation exercises of the preparedness and response plan; (iv) continue containment activities for polioviruses based on the Global Action Plan. Although the last case in the world due to type-2 wild poliovirus was reported from India in 1999, polio cases due to type-2 circulating vaccine-derived polioviruses (cVDPV2) will continue to pose a risk as long as countries use trivalent oral polio vaccine (tOPV). Risk mitigation against the emergence of cVDPV2 will require countries that are using tOPV to switch to bivalent OPV (bOPV). The switch should happen synchronously across the world by 2016. In order to maintain population immunity against all three types of wild polioviruses, at least one dose of inactivated polio vaccine (IPV) should be administered in the routine immunization schedule prior to the vaccine switch. The High-Level Preparatory (HLP) Meeting held in the Regional Office in New Delhi, India, from 14 to 17 July 2014, reviewed the attached working paper and made the following recommendations:
Actions by Member States (1) (2) High-quality AFP surveillance and polio immunization should be sustained throughout every Member State. Regular risk assessment and risk mitigation activities, including laboratory containment, simulation exercises of the polio outbreak response and preparedness plans, should be conducted. National certification committees should continue their role till global certification.
(3)
Actions by the WHO Regional Office (1) (2) (3) The Regional Office should continue to support Member States in risk assessment and planning for risk mitigation activities. Technical support should be provided to Member States to develop national plans for vaccination for travellers to and from polio-infected countries. Member States should be supported in planning for IPV introduction and a timeline for vaccine switch.
The working paper and the HLP recommendations are submitted to the Sixty-seventh Session of the Regional Committee for its consideration.
SEA/RC67/16
Introduction 1. The South-East Asia Region was certified polio-free on 27 March 2014, thus making it the fourth WHO Region to be certified polio-free 12 years after the European Region. As long as poliovirus circulates anywhere in the world, the risk of importation to any polio-free country, followed by spread, remains. Risk assessments conducted at regional and country levels in early 2014 show that India, Indonesia, Myanmar and Timor-Leste are at high risk for polio outbreaks following importation. The risk status underscores the need to avoid complacency and continue all efforts by Member States to maintain population immunity through both routine and supplemental immunization, as may be necessary, and high-performance surveillance for acute flaccid paralysis (AFP).
Current situation and strategic issues 2. The Polio Eradication and Endgame Strategic Plan 2013–2018 was prepared in response to the declaration at the sixty-fifth World Health Assembly in May 2012 that completion of poliomyelitis eradication is a programmatic emergency for global public health. The plan has four objectives: (1) detect and interrupt all poliovirus transmission; (2) strengthen immunization systems and withdraw oral polio vaccine; (3) contain poliovirus and certify interruption of transmission; and (4) plan for the polio legacy. This Region has achieved the first objective. Work is ongoing to achieve the remaining objectives. 3. Globally, the last case due to type-2 wild poliovirus was reported from India in 1999. However, polio cases due to type-2 circulating vaccine-derived polioviruses (cVDPV2) have proved and continue to pose a risk as long as countries use trivalent oral polio vaccine (tOPV). Risk mitigation against the emergence of cVDPV2 will require a switch from the current use of trivalent oral polio vaccine (tOPV), which contains types 1, 2 and 3 polio viruses, to bivalent oral polio vaccine (bOPV), which contains only types 1 and 3 polio viruses. This switch should be globally synchronized and completed by 2016. 4. In order to protect against the emergence of cVDPV2 boost immunity against all three types of wild polioviruses, and prevent the occurrence of vaccine-associated paralytic polio (VAPP), at least one dose of inactivated polio vaccine (IPV) should be administered in the routine immunization schedule with the third dose of DTP at least six months prior to the vaccine switch. 5. Member States also need to develop a national policy and plan for vaccination against polio for travellers to and from polio-infected countries as outlined in WHO’s updated international travel and health guidelines. Specifically, the guidelines recommend that , “Before travelling abroad, persons of all ages residing in polio-infected countries and long-term visitors to such countries should have completed a full course of vaccination against polio in compliance with the national schedule. All travellers are advised to carry their written vaccination record (patient-retained record) in the event that evidence of polio vaccination is requested for entry into countries being visited.” In the South-East Asia Region, India has already established polio vaccination requirements for travellers to and from polio-endemic and -infected countries.
SEA/RC67/16 Page 2
6. All Member States of the South-East Asia Region have completed phase-1 laboratory containment activities and documentation. In the entire Region, only the Global Specialized Laboratory at the Enterovirus Research Centre, Mumbai, India, stores wild poliovirus material, and 68 other biomedical facilities store potentially infectious material. All Member States of the South-East Asia Region need to continue phased implementation of the Global Action Plan and destroy all poliovirus-infected material or potentially infectious material.
The way forward 7. Two major challenges need to be continually addressed: (i) risk of importation and spread of poliovirus from polio-endemic and polio-infected countries; and (ii) complacency on becoming polio free. In view of the ongoing risk and to implement the Polio Eradication and Endgame Strategic Plan 2013–2018, the following steps are proposed:
The RCCPE and National Certification Committees should remain active until global certification. High population immunity and AFP surveillance should be maintained in every country. Regular risk assessment and risk mitigation activities should be conducted. Countries should be adequately prepared to deal with importation of polioviruses and conduct periodic simulation exercises of the preparedness and response plans. Containment activities of polioviruses based on the Global Action Plan should be continued and all poliovirus-infected material and/or potentially infected material destroyed to eliminate the risk of spread. Introduction of polio vaccination should be considered for travellers to and from polioendemic and -infected countries to mitigate the risk of importation, and all travellers should carry a written vaccination record (patient-retained record) as per the International Travel and Health Guidelines. One dose of IPV should be introduced in the routine immunization schedule in line with the Polio Eradication and Endgame Strategic Plan 2013–2018, and all countries should plan for switch from tOPV to bOPV in 2016.