REGIONAL COMMITTEE Sixty-first Session SEARO, New Delhi 8–11 September 2008
Provisional Agenda item 18.2 SEA/RC61/18 16 July 2008
FOLLOW-UP ACTION ON SELECTED RESOLUTIONS/ DECISIONS OF THE LAST THREE YEARS: CHALLENGES IN POLIO ERADICATION Despite major challenges, the polio eradication efforts in India successfully eliminated subtype P1 polio cases from western Uttar Pradesh (UP). Furthermore, the lowest number of P1 cases were recorded due to sustained efforts with the use of mOPV1 in successive rounds of supplemental immunization in the two endemic states, i.e Bihar and UP. However, this strategy also led to lowering of population immunity in UP and Bihar against the type 3 poliovirus that had led to a P3 outbreak in 2007. Fortunately, with the aggressive use of monovalent type 3 vaccine (mOPV3) in the last few months of 2007 and in early 2008, the outbreak was brought under control. Intensified efforts are under way to achieve the goal of sequential elimination of subtype P1 poliovirus in 2008, and P3 in 2009. However, appropriate rounds with sufficient size for mop-ups are essential to keep the pressure on the virus in India, particularly in UP and Bihar. In all countries, efforts to sustain high-level acute flaccid paralysis (AFP) surveillance are crucial to ensure timely detection of any case of polio and for appropriate response when a case, either indigenous or imported, is detected. Also, to sustain the gains of polio eradication, it is critical that countries achieve and sustain high routine coverage for all antigens, particularly against poliomyelitis. This paper was discussed at the Meeting of the Advisory Committee (ACM) held in SEARO, New Delhi from 30 June to 3 July 2008. The ACM made the following recommendations: Action by Member States (1) (2) Scale up the routine OPV coverage in countries where OPV3 coverage is still less than 80%; and High quality surveillance for AFP should be maintained, including in countries that are polio-free.
Action by WHO/SEARO (1) Enhance support to Member States to eradicate poliomyelitis where it is still endemic, and to sustain polio-free status in countries that have already eradicated polio; and
Provide technical guidance to Member States on OPV cessation and future options to maintain population immunity against polio including the possibility of IPV use and its cost implications for national programmes. The paper is now submitted to the Sixty-first Session of the Regional Committee for its consideration. (2)
SEA/RC61/18
1. The WHO Regional Committee for South-East Asia adopted resolution SEA/RC60/R8 at its sixtieth session in Thimpu, Bhutan in 2007 urging Member States to strengthen their immunization programmes to ensure the highest coverage and highest standard of surveillance for vaccine-preventable diseases. The resolution also requested the Regional Director to support Member States in this endeavour. Further, the resolution also required WHO to report on the progress made in polio eradication to the Regional Committee on an annual basis till the Region acquires polio-free status. This report briefly summarizes the progress made and the challenges that still remain in strengthening routine immunization and polio eradication. 2. Most countries have made considerable improvement in enhancing routine immunization coverage, but as a Region South-East Asia’s overall picture is far from the ideal. Bangladesh, Indonesia and India are three among the top 10 countries of the world in terms of the population of unimmunized children. Bangladesh achieves very high routine coverage but due to the size of the birth cohort, even a small percentage missed translates into significant numbers. Indonesia is making steady progress and a survey of coverage in the provinces has recently been completed to reach out to areas where enhanced efforts are needed. India is home to the largest number of children that are unimmunized. According to WHO/UNICEF estimates, of the 26.1 million children who did not receive DTP3 globally in 2006, about 13.2 million are in India alone. 3. Along with the colossal efforts to eradicate polio, India has also made significant progress in addressing the issue of routine immunization. More money is now available to the states through the National Rural Health Mission and a new cadre of social activists at the community level, known as “ASHA”, has been created that is motivating local leaders to address integrated child health needs, including that of immunization. Furthermore, almost 80% of unimmunized children live in just seven states, with the states of Bihar and Uttar Pradesh (UP) contributing the maximum. Along with other partners and nongovernmental organizations (NGOs), WHO is also supporting the Government of India to strengthen routine immunization services. WHO extends financial support for four state-level immunization medical officers, in addition to eight district immunization medical officers in western UP. They, along with other Surveillance Medical Officers particularly in UP and Bihar, support the local government to improve micro-planning, tracking newborns and monitoring immunization sessions. Despite these efforts, huge challenges towards improving routine immunization still remain in India. 4. In countries that are currently experiencing active polio transmission or that experienced it in the recent past, both surveillance indicators and immunization coverage with polio vaccines are very high, particularly at the national level. One of the milestones in 2007 set by the Global Polio Eradication Initiative was the attainment of parity in immunity levels between children in polio transmission zones and polio-free areas in polio-endemic countries. This milestone has been achieved in India, the only polio-endemic country of the Region. Studies have shown that the endemic states in India –UP and Bihar – attained population immunity level against type1 polio for the first time in 2007. 5. Countries that have maintained polio-free status for more than five years have recently been facing problems in maintaining adequate surveillance or immunization coverage or both. The fall in immunization coverage against polio in the absence of supplemental immunization activities as shown by increases in the number of unimmunized or underimmunized children among the non-polio AFP cases and low surveillance sensitivity in the same areas or countries is a matter of concern since an explosive outbreak is possible in case of importation of wild poliovirus in these countries.
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6. In 2008 the polio eradication programme in India has recorded the lowest number of P1 cases due to sustained efforts with the use of mOPV1 in successive rounds of supplemental immunization in the two endemic states. However, this strategy also led to lowering of population immunity in UP and Bihar against type 3 poliovirus that had led to a P3 outbreak in 2007. Fortunately, with the use monovalent type 3 vaccine (mOPV3) in the last few months of 2007 and early 2008 the outbreak seems to have been brought under control. Experts consider that the programme has the unique opportunity to mop-up whatever low level of type1 circulation is ongoing during this time in hard-to-reach areas of Bihar and parts of eastern UP with aggressive rounds of immunization using mOPV1. Attention to P3 eradication should be provided during the latter part of 2008 and in 2009 while maintaining a high level of population immunity against P1 to guard against P1 importation from other endemic regions. 7. Some of the other key activities carried out in response to resolution SEA/RC60/R8 of the Regional Committee are: •
The terms of reference and the composition of the Technical Consultative Group (TCG) on Polio and Immunization have been revised; the first meeting of the newly constituted SEA Region Immunization Technical Advisory Group (SEAR-ITAG) was held on 14-15 July 2008. Similarly the current International Certification Commission for Polio Eradication (ICCPE) has also been dissolved and the new membership roster is being revised. A meeting on the issue of transition from OPV to IPV was organized on 29-30 April 2008 in Bali, Indonesia. A cross-border meeting is planned as a multi-country activity for the last quarter of 2008. The value of projected resources needed for the SEA Region for polio eradication is about US$ 75 million, while US$ 34 million have been mobilized so far. This leaves a gap of 55% of the total projected need. Strenuous efforts are being made to narrow this gap.
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8.
Some of the challenges to polio eradication efforts in the SEA Region are: • • • • •
Continuation of transmission of P1 in Bihar with potential re-infection of UP, especially western UP. Importation of P1 from other endemic regions, especially from Nigeria, Africa, where there has been a recent upsurge in P1 cases. Continuation of P3 outbreak with further importations posing a threat to polio-free states in India and in its neighbouring countries. Emergence of circulating vaccine-derived poliovirus (cVDPV) transmission in pockets of low immunization coverage. Existence of funding gaps to support the response required to achieve eradication in India and for responding to importations of wild polio virus into other countries.
9. The SEA Region is on the verge of eradicating type-1 poliovirus. Having attained this, type3 eradication will then not be far away. The key to success remains appropriate and aggressive supplementary immunization activities in high-risk areas of India; extensive mop-up activities in line with the World Health Assembly resolution 59.1 of 2006 in case of importation of wild virus to polio-free areas; and maintenance of uniform high level of surveillance and routine immunization coverage at national and sub-national levels in polio-free countries.