WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 103rd Session Provisional agenda item 3 EB103/7 27 November 1998
Poliomyelitis eradication Report by the Director-General
BACKGROUND 1. In 1988 the Health Assembly established a goal to eradicate poliomyelitis globally by the year 2000.1 Recognizing that a focused eradication goal could facilitate the development of health care systems, the Health Assembly specified that poliomyelitis eradication should be conducted within the Expanded Programme on Immunization (EPI) and the context of primary health care. 2. Routine immunization systems are now delivering poliomyelitis vaccine and other EPI antigens to 80% of the world’s infants. National immunization days for poliomyelitis eradication have been conducted in all endemic countries with the exception of the Democratic Republic of the Congo and Liberia. Eightynine countries will conduct national immunization days in 1998, targeting an estimated 470 million children, approximately three-quarters of the world’s population aged less than five years. Many immunization days are being internationally coordinated either within or between WHO regions, including the “Kick Polio Out of Africa” campaign, Operation MECACAR (Eastern Mediterranean and European regions), and the simultaneous immunization days among countries of the South Asian Association for Regional Cooperation. Surveillance of acute flaccid paralysis has been established in all poliomyelitis endemic countries, fully integrated in a global network of 133 poliomyelitis laboratories. Truces have been declared for immunization campaigns in Afghanistan, El Salvador, Peru, Philippines, Sri Lanka, Sudan, and Tajikistan. 3. If the current rate of progress is maintained, poliomyelitis can be eradicated globally by the year 2000 or shortly thereafter. Since 1988 the number of cases reported by WHO Member States has fallen by 85%. Poliomyelitis eradication was certified in the Region of the Americas in 1994, three years after the last case occurred in Peru. In the Western Pacific Region the last case occurred in Cambodia in March 1997. As of mid-1998, only 50 countries were still considered to be polio-endemic, mainly in South Asia and sub-Saharan Africa (Annex). 4. Eradication of poliomyelitis will benefit the world by preventing hundreds of thousands of cases of paralysis each year, and producing direct savings of US$ 1.5 thousand million each year after immunization is stopped. The eradication initiative has already revitalized immunization programmes in many countries, helping to re-establish the cold chain and improve routine coverage. Improved integrated
1
Resolution WHA41.28.
EB103/7
surveillance systems, trained health staff and the global virology laboratory network are additional legacies. In 43 countries, the distribution of vitamin A during national immunization days has prevented blindness and reduced deaths from measles and other infectious diseases. Because of the “slack” in many health systems, combined with the availability of new funding, there has not been a major disruption in other health services or diversion of funds. The eradication of poliomyelitis in the Western Hemisphere has led the Region of the Americas to adopt a measles elimination target.
ISSUES 5. The poliomyelitis eradication initiative is now in a crucial phase, with some of the most difficult countries still remaining endemic. Six countries (Bangladesh, Ethiopia, India, Nepal, Nigeria and Pakistan) are major reservoirs of poliomyelitis, where large populations, high birth rates, crowded areas with poor sanitation and insufficient routine immunization facilitate poliovirus transmission. Implementing eradication activities is especially challenging in seven countries affected by conflict (Afghanistan, Angola, Liberia, Sierra Leone, Somalia, Sudan and Tajikistan). The Democratic Republic of the Congo is a unique challenge, a major reservoir affected by conflict. 6. During the initial phases of poliomyelitis eradication, countries paid 80% to 90% of the total cost. However, the lower levels of infrastructure and health resources available in the remaining poliomyelitisendemic countries mean that a high percentage of the eradication cost has to be paid from external sources. Political will and financial resources are urgently needed to accelerate the eradication initiative and to avoid delays that would both threaten the success to date and substantially increase the overall cost. Such support also needs to continue in those countries that are now poliomyelitis-free, as the quality of surveillance and immunization has already started to decline in some areas. 7. As more countries become free of the disease, the risk posed by laboratory stocks of wild poliovirus increases substantially. If wild poliovirus were inadvertently released after immunization is stopped, circulation could be re-established. WHO has drawn up a global action plan and timetable for safe handling and maximum laboratory containment of wild polioviruses and potentially infectious materials. This plan calls for countries to inventory laboratory stocks of wild polioviruses, destroy stocks of no scientific value and move the remaining stocks to interim repositories starting in 1999.
FUTURE ACTION 8. Eradication activities must be accelerated in the 14 most difficult countries, with additional rounds during national immunization days in many areas. Data deriving from surveillance of acute flaccid paralysis must be improved in order to identify accurately areas where wild polioviruses continue and to target large scale house-to-house “mopping-up” immunization to halt transmission. Truces for immunization need to be secured in countries affected by conflict. All countries must ensure that highquality immunization days reach all children aged less than five years. 9. WHO’s advocacy is needed to secure the political support and funds necessary to conduct these activities. WHO estimates that a total US$ 700 million is needed from external sources over the next three years, the current shortfall being US$ 350 million. An emergency fund is needed to permit a rapid and effective response when windows of opportunity open in countries that are affected by conflict or are politically isolated.
2
EB103/7
10. Implementation of WHO’s plan of action for containment of wild polioviruses should start in 1999. A coordinating group needs to be set up, with the authority to oversee the process, provide guidance to WHO, and report formally to the Global Commission for the Certification of the Eradication of Poliomyelitis.
ACTION BY THE EXECUTIVE BOARD 11. The Executive Board is invited to consider the following draft resolution: The Executive Board, Noting the report of the Director-General on the global eradication of poliomyelitis, RECOMMENDS to the Fifty-second World Health Assembly the adoption of the following resolution: The Fifty-second World Health Assembly, Reaffirming WHO’s commitment to the global eradication of poliomyelitis by the end of the year 2000; Recognizing that substantial progress has been made towards eradication of poliomyelitis, with large geographic areas of the world now free of poliomyelitis, and a fall of 85% in annually reported cases since global eradication began in 1988; Noting, however, that as of May 1999 a number of countries of south Asia and subSaharan Africa remain poliomyelitis-endemic, some of which are either affected by conflict or constitute densely populated wild poliovirus “reservoirs”, 1. URGES poliomyelitis-endemic Member States to accelerate eradication activities by conducting additional immunization rounds each year, on either a national or subnational basis; to improve the quality of national immunization days by ensuring that every child is reached; to implement house-to-house “mopping-up” campaigns; and to enhance surveillance by ensuring that all cases of acute flaccid paralysis are detected and promptly investigated; 2. URGES poliomyelitis-free Member States to sustain high levels of immunization coverage and poliovirus surveillance until eradication is certified globally; 3. URGES all Members States: (1) to mobilize the human and financial resources necessary to accelerate eradication in poliomyelitis-endemic countries; (2) to begin in collaboration with WHO, the process leading to the laboratory containment of wild poliovirus; 4. REQUESTS the Director-General: 3
EB103/7
(1) to urge all partners to facilitate acceleration of the initiative to eradicate poliomyelitis during the critical period 1999 to 2001; (2) to collaborate with other organizations of the United Nations system and other international bodies in arranging truces in countries affected by conflict for eradication and facilitating activities; (3) to help mobilize the necessary financing to implement eradication activities, including establishment of an emergency fund to meet the needs of countries affected by conflict, countries classified as major wild poliovirus reservoirs, and other countries in particularly difficult circumstances; (4) to collaborate with Member States in the establishment of a mechanism for overseeing the process of laboratory containment of wild poliovirus.
4
EB103/7
ANNEX COMPARISON OF “KNOWN OR PROBABLE” WILD POLIOVIRUS TRANSMISSION IN 1988 AND BY JANUARY 1998
=
=
=
5