Presentation from the European Scientific Conference on Applied Infectious Disease Epidemiology (ESCAIDE), published by the European Centre for Disease Prevention and Control (ECDC)

1. Polio elimination in Europe: Strategies to prevent re-emergence
Donato Greco
WHO EU Regional Polio Certification Commission

2. The Global Polio Eradication Initiative (GPEI)
•Began in 1988
•By 2006 Wild polio Virus trasmission in all but 4 countries (Afghanistan, India, Nigeria and Pakistan)
•The GPEI plan 2010-12 :
–End outbreaks of 2009 by mid 2010
–End outbreaks of 2010 by mid 2010

3. The Global Polio Eradication Initiative (GPEI) HOW
•high infant immunization coverage with four doses of oral poliovirus vaccine (OPV) in the first year of life;
•supplementary doses of OPV to all children under five years of age during SIAs;
•surveillance for wild poliovirus through reporting and laboratory testing of all acute flaccid paralysis (AFP) cases among children under fifteen years of age;
•targeted “mop-up” campaigns once wild poliovirus transmission is limited to a specific focal area.

4. The Global Polio Eradication Initiative (GPEI)
•More than five million people who would otherwise have been paralysedare walking today because they have been immunized against polio since the initiative began in 1988.
•By preventing a debilitating disease, the Global Polio Eradication Initiative is helping to reduce poverty, and is giving children and their families a greater chance of leading healthy and productive lives.
•By establishing the capacity to access children everywhere, more than two billion children worldwide have been immunized during SIAs, demonstrating that well-planned health interventions can reach even the most remote, conflict-affected or poorest areas

5. The last Euro Region polio case : Turkey 1998

7. First import-related polio outbreak in the European Region since declaredpolio-free in 2002
Third region declared polio-free
To remain polio-free:
–improve population immunity
–increase capacity to rapidly detectany remaining transmission or new importation of wild poliovirus
–implement polio importation preparedness plans if required
7

8. Groups involved in certification of polio eradication at global, regional, and country levels
8

9. Roles of National Certification Committees (NCCs) and Regional Certification Commission (RCC)
9NCCs submit an annual progress reportAttesting that they are polio-free, and stating that they would be able to detect importations of wild poliovirus with an Action Plan for such events. RCC reviews the statements from NCCs on why the NCC believes the country is polio free; RCC evaluates countries as to their risk for transmission if a wild poliovirus was introduced (High, Intermediate, Low) using pre-agreed criteria. It is the RCC that will decide when a country is free of polio, not a country.

10. Requirements for regional certificationAbsence of wild polioviruses isolated from cases of acute paralytic poliomyelitis for three years, demonstrated through the following surveillance methodologies: Acute Flaccid Paralysis at 1/100,000 children below 15 years with compliance with virological investigation criteria; Surveillance of representative numbers of samples of faecal or CSF specimens for enteroviruses without wild polioviruses being detected; Environmental sampling that is sensitive, specific and from representative populations with an action plan for further investigations if wild polioviruses are detected. Any samples containing wild polioviruses must be destroyed or contained securely.
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11. Risk of transmission following importation of wild poliovirus: WHO European Region, 2009
111
3
241-Bosnia & Herzegovina2-Turkey (Eastern) 3-Georgia4-Tajikistan

12. RCC conclusions 2009: TajikistanSIAs in the border areas of Tajikistan will be very important for preventing the introduction of wild poliovirus into the Region. Routine polio immunization coverage is below desired levels. Continued low coverage will result in the accumulation of a cohort of susceptible children that may eventually pose a risk for the entire Region.
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13. po
Poliomilelitys in Tagikistan 2010
Donato Greco
7 giugno 2010

14. Genetic relationship of 2010TJK35325
isolate to recent Indian SOAS PV1
strains
ERC
A new poliovirus entered the country

15. 600 paralized children !

16. Distribution of laboratory-confirmed polio cases by district*, Tajikistan, Feb,2010

17. Distribution of laboratory-confirmed polio cases by district, Tajikistan, March,2010

18. Distribution of laboratory-confirmed polio cases by district*, Tajikistan, April,2010

19. Distribution of laboratory-confirmed polio cases by district*, Tajikistan, May,2010

20. Distribution of laboratory-confirmed polio cases by district*, Tajikistan, June,2010

21. Local movement to/from Tajikistan to neighbouring countries

22. Laboratory confirmed polio cases, AFP cases negative for poliovirus, and AFP cases pending results by date of paralysis onset, Tajikistan, 2010
Data as of 21 October 2010
Source: Weekly AFP reporting to WHO European Region
Total 706 AFP Cases (including 458 confirmed wild poliovirus type1)
SIA
Round 1
SIA
Round 2
SIARound 3
SIA
Round 4Mop-upSIARound 613-17 Sep mOPV34 districts(98-100%)
Accounts for 73%of all
global polio cases
in 2010, to date

23. -2
0
2
468
10
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28/02/190029/02/190001/03/1900
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06/04/1900
Cases of AFP in Tajikistan 2010 at 6 june 2010 by age groupmore 6
less 6

24. Distribution of laboratory confirmed polio cases by week of paralysis onset, Tajikistan, 2010
Data as of 21 October 2010
Source: Weekly AFP reporting to WHO European Region
Total 458 confirmed wild poliovirus type1
1224511121320117211223231417373326333512311126101213221723132811414441110102030405060708090 5312345678910111213141516171819202122232425262728293031323334 Week of onset (ISO week number) Number of cases 15+ years6-14 years1-5 yearsUnder 1

25. How susceptible the tajik ?
•Assuming 200 infected per case
•At least 150.000 individuals were infected
•In many districts paralitic polio incidence was bigger than 100/100.000
•1child over 3 below 1 year was not protected
•1 child over 5 below 6 years was not protected
•1 adolescent (6-15) over 10 was not protected
How is in your country ??

26. •This suggests that poor immunization coverage is not a very recent issue. A proportion of Tajik children has not been vaccinated or has received incomplete vaccination systematically during the last 20 years, leading to a build-up of susceptible hosts that was conducive to the current outbreak.
•Summingsusceptiblescohorts

27. •We can only conclude that for the last 20 or more years there has been a regular, systematic deficiency in the vaccination services in Tajikistan. This is not an issue that concerns only “pockets” nor rural/Hard to Reach communities, but that affects a large part of the “normal” children population.

28. Why polio outbreak in Tajikistan?
Immunization coverage (susceptibility)
•Constraints in delivery of immunization through health system
•Accuracy of administrative coverage data
•Supplemental activities postponed due to lack of funding
AFP Surveillance (detection)
•Timely detection and transparent reporting
•Appropriate response actions
•Delay on diagnostics
Commitment and resources
•Feeling of “done”
•Funds for supplemental immunization
Geo-political context
28

29. 29
Direct flight routes departing Tajikistan, February 2009-February 2010
N=499,514 air travellers
Source data: CDC Division of Global Migration and Quarantine11,079 5,370 An infected healthy carrier can shed poliovirus for 3-6 weeks

30. Reported laboratory-confirmed polio cases: Russian Federation in 2010May
May -June
May -July
May -August
May -September

31. 31
TJK-10-002-064-1504-Gissa-35503
TJK-10-003-022-0704-Kabad-35349
TJK-10-002-031-0804-Gissa-35291
TJK-10-003-015-3103-Kabad-35335
TJK-10-002-013-1003-Gissa-35411
TJK-10-002-018-1303-Gissa-35265
TJK-10-002-041-0804-Shajr-35311
TKM-10-008-005-Koytendag-37362
TJK-10-003-019-0304-Kabad-35343
TJK-10-003-023-0904-Kabad-35351
TJK-10-003-011-3003-Kabad-35327
TJK-10-002-040-1004-Gissa-35309
TJK-10-002-029-0904-Vahda-35287
TJK-10-002-026-0404-Gissa-35281
TJK-10-001-006-1804-Dusha-35444
TJK-10-002-067-2404-Rudak-35507
RUS-10-058-010-011-Sverdlovsk-36710
TJK-10-002-058-1904-Vahda-35494
RUS-10-058-010-010-Sverdlovsk-36229
RUS-10-075-003-002-Irkutskaya-35673
TJK-10-002-004-0103-Rudak-35393
TJK-10-002-002-0102-Rudak-35389
TJK-10-002-054-0804-Gissa-35487
TJK-10-002-061-1904-Gissa-35499
TJK-10-002-068-1904-Faiza-35509
TJK-10-002-014-1803-Rudak-35257
TJK-10-002-003-1202-Rudak-35391
RUS-ARI-STPETERSBURG-36796
TJK-10-002-010-0503-Gissa-35405
TJK-10-001-007-1304-Dusha-35445
TJK-10-002-042-1204-Varzo-35313
TJK-10-001-015-2404-Dusha-35461
TJK-10-002-044-1404-Rudak-35467
TJK-10-003-020-0404-Shart-35345
TJK-10-001-005-1004-Dusha-35255
TJK-10-002-035-0804-Gissa-35299
TJK-10-003-007-1503-Shart-35319
TJK-10-001-004-0104-Dusha-35253
TJK-10-002-048-1404-Vahda-35475
TJK-10-002-012-1303-Gissa-35409
TJK-10-002-008-0303-Rudak-35401
TJK-10-002-043-0504-Rudak-35315
TJK-10-002-063-2004-Gissa-35501
TJK-10-003-014-3003-Shart-35359
TJK-10-003-014-3003-Shart-35333
TJK-10-003-017-0504-Kabad-35339
TJK-10-001-012-2404-Dusha-35455
TJK-10-002-057-1604-Rudak-35491
TJK-10-002-059-2204-Vahda-35495
TJK-10-002-016-2103-Rudak-35261
TJK-10-003-036-0304-Bokht-35365
TJK-10-002-060-2204-Rudak-35497
KAZ-10-014-016-38375
RUS-UZB-10-016-006-011-Moscow-36815
RUS-10-048-001-002-Chechen Re-37706
RUS-10-048-001-003-Chechen Re-37708
TJK-10-002-039-0804-Gissa-35307
RUS-10-058-010-010CONTACT-Sverdlovsk-36674
RUS-10-043-016-007-Dagestan-37449
RUS-10043005012-Dagestan-38492
RUSTJKMOSCOWHEALTHY-35671
TJK-10-003-010-2803-Shart-35325
RUS-10-083-001-003-Khabarovsk-37251
RUS-10-059-012-002-Chelyabins-36648
TJK-10-003-034-0304-Djili-35361
TKM-10-008-004-Koytendag-37184
RUS-10-059-008-001-Chelyabins-36716
RUS-10-059-008-002-Chelyabins-36682
TKM-10-008-006-Koytendag-37364
TJK-10-001-014-2604-Dusha-35459
TJK-10-003-035-1004-Bokht-35363
TJK-10-003-037-0404-Bokht-35367
TJK-10-002-003-1202-Rudak-35391 2
TJK-10-002-025-0404-Rudak-35279
TJK-10-001-011-2604-Dusha-35453
TJK-10-003-026-0704-Shart-35357
UPSHA09153I09
UPFKB09180I09
all viruses are closely related
to the WPV1 SOAS genotype
from Northern India
outbreak is the result of a
single importation of WPV1 in the
Region
WPV1 isolates in the Russian
Federation, Turkmenistan
and Kazakhstan are genetically
related to those from Tajikistan

32. European Region outbreak response plan
Stop current outbreak
Prevent spread to neighbouring countries
Strengthen acute flaccid paralysis (AFP) surveillance in high risk areas
Demonstrate polio-free status to the Regional Certification Commission (RCC) on Poliomyelitis Eradication
Ensure long-term sustainability
Ensure preparedness
Increase and maintain population immunity
Maintain certification standard surveillance
32

33. Then what to do
•Over a total population of 7 million , 15 million OPV vaccination in Tajikistan in 4 months
•Targetting 0 to 5 kids and 6 –to 15 , but many young adults were vaccinated
•6 National immunization days (SIAs)
•Coverage well over 95%
•Somentimes bigger than 100 !!!! (denominator fallacies !!)

34. Vaccination

35. SIAs –Tajikistan, May to November 2010mOPV1
mOPV3
bOPVtOPVRound 1: 04-08 May( 0-6 years / 99.4%) Round 2: 18-22 May( 0-6 years / 99.4%) Round 3: 01-05 Jun( 0-15 years / 98.8%) Round 4: 15-05 Jun( 0-15 years / 99.3%)
Round 5: 04-08 Oct
( 0-15 years)
Round 6: 08-12 Nov( 0-15 years) Mop-up Round 1 : 13-17 Sep34 districts ( 0-15 years) PlannedTo be corrected

36. SIAs –Turkmenistan, July to Oct 2010
mOPV1
mOPV3bOPVtOPVRound 1: 13-18 July( 0-5 years / 98.9%)Round 2: 26 Aug –05 Sep ( 0-15 years / 99.6%)
Round 3: 20-29 Sep
( 0-15 years / 99.6%)
Mop-up Round 1: 25 July -06 Aug( 0-15 years / 95.5%) To be corrected

37. SIAs –Kyrgyzstan, May to Oct 2010mOPV1
mOPV3
bOPVtOPVRound 1: 19-23 July( 0-5 years / 95.2%) Round 2: 23-27 Aug( 0-5 years / 95%)

38. SIAs –Kazakhstan, May to Oct 2010
mOPV1mOPV3bOPV
tOPV
Round 1: 06-10 Sept
( 0-5 years / 98.9%)
SNID Round 2: 1-10 Nov
( 0-15 years / ------%)
Planned

39. Are we safe from the poliomielitis risk ?

40. Malta12
3
45678
Risk of transmission following importation of wild poliovirus: WHO European Region, 2010
High risk
Intermediate riskLow risk1-Bosnia & Herzegovina2-Georgia3-Montenegro 4-Malta5-Turkey (Eastern) 6-Tajikistan 7-Ukraine 8-Uzbekistan40
Adding : Turkmenistan, Kirghistan, Afganistan, India, Nigeria, Congo

41. 23rdRCC conclusions 2010The European Region has reached a critical juncture. The polio-free status for the entire Region is in jeopardyThe gravity of the situation requires that all Member States reinforce their polio surveillance so that any spread will be detected rapidly and effective control measures instituted at the earliest possible moment. How many countries, represented in this room, have done this? RCC will be monitoring the situation closely. Failure to control polio within the European Region will jeopardize the global polio eradication initiative.
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42. 23rdRCC conclusions -2010Quality of polio surveillance is falling in many countries. Surveillance must be brought back to certification levels if the Region is to be certified as polio-free when global certification is considered. The reports from many National Certification Committees are not convincing and would be inadequate for the purposes of final certification. National Plans of Action must be completed and should be tested.
42

43. 43
Status of preparedness plans in the European Region, 2010
•37 Member States (MS) reported that preparedness plan or equivalent documents exist
•33 MS submitted their plans to WHO
–7/33 plans expired in 2008-2009
–5/33 plans end in 2010

44. Data in WHO HQ as of 02 Nov 2010Wild Poliovirus(1,2), 03 Nov 2009 –02 Nov 2010The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2010. All rights reservedCase or outbreak following importation (0 -6 months) Endemic countriesCase or outbreak following importation (6 -12 months) Wild virus type 1Wild virus type 3Wild virus type 1/3
1Excludes viruses detected from environmental surveillance and vaccine derived polioviruses. 1 WPV1 in Jammu and Kashmir, date of onset of 07 Feb 2010, does not appear on the map. 2Of the poliovirus cases reported from the Russian Federation, some may be attributed to other countries following full investigation.

45. Data in WHO HQ as of 02 Nov 2010
Wild Poliovirus infected districts(1,2), 03 May –02 Nov 2010District infected with wild polio virus type 1District infected with wild polio virus type 3
District infected with more than one type of wild poliovirus1Excludes viruses detected from environmental surveillance and vaccine derived polioviruses. 2Of the poliovirus cases reported from the Russian The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2010 All rights reservedStatusCountryDate of most recent type 1Date of most recent type 3EndemicPakistan19-Oct-1020-Sep-10Afghanistan11-Oct-10NANigeria27-Sep-1005-Oct-10India16-Sep-1031-Aug-10DRCongo13-Sep-1024-Jun-09Angola20-Aug-10NAChadNA10-May-10Active outbreakUganda28-Sep-10NARussian Federation25-Sep-10NAMali01-May-1017-Sep-10Liberia08-Sep-10NANepal30-Aug-10NAKazakistan12-Aug-10NATajikistan04-Jul-10NATurkmenistan28-Jun-10NARe-established transmission

46. Data in WHO HQ as of 02 Nov 2010
Data in WHO as of 02 Nov Wild Poliovirus 2000 -2010Country or territory2000200120022003200420052006200720082009200920062007200820092010Pakistan1991199010353284032117897510120-Sep-1019-Oct-10184812-Oct-10Afghanistan27111084931173138241911-Apr-1011-Oct-101227-Jul-09Nigeria285620235578283011222857983883821005-Oct-1027-Sep-10Uganda*000000000881NA28-Sep-10Russian Federation∞0000000000014NA25-Sep-10Mali*3000019300125417-Sep-1001-May-10India2652681600225134666768745597415283931-Aug-1016-Sep-102133321812-Aug-10DRC**280000013415333024-Jun-0913-Sep-10Liberia*00000000011102NA08-Sep-10Nepal**40000455600615-Oct-0830-Aug-10112-Jul-10Angola**55100010282929272517-Nov-0820-Aug-10Kazakhstan*000000000001NA12-Aug-10Tajikistan*00000000000458NA04-Jul-10Turkmenistan*000000000003NA28-Jun-10Chad**400252421223764241410-May-1018-Nov-08Senegal*0000000000018NA30-Apr-10Mauritania§0100000001305NA28-Apr-10Niger ***2634025101111121515201-Apr-1028-May-09Sierra Leone*0000000001121NA28-Feb-10Guinea*00007000042320NA03-Nov-09Burkina Faso*001119000615130NA25-Oct-09Cameroon*000213120032015-Oct-0906-Dec-06Burundi*000000000220NA12-Sep-09CAR**30013000031414009-Aug-0930-Dec-08Côte d'Ivoire**3100117000126270NA06-Aug-09Kenya*00000020019180NA30-Jul-09Sudan**41001282701264545016-Dec-0827-Jun-091109-Jan-09Benin**1002600062020001-Dec-0819-Apr-09Togo*000100003660NA28-Mar-09Ghana**100800008000NA08-Nov-08Ethiopia**31001221703000NA27-Apr-08Myanmar**2000000110000NA28-May-07Somalia**467300185358000006-Oct-0225-Mar-07Bangladesh**100000180000023-Oct-9922-Nov-06Namibia*0000001900000NA26-Jun-06Indonesia*00000303200000NA20-Feb-06Yemen*00000478100000NA02-Feb-06Eritrea*000001000000NA23-Apr-05Saudi Arabia*000010000000NA17-Dec-04Egypt45711000000007-Dec-0003-May-04230-Dec-08Botswana*000010000000NA08-Feb-04Lebanon*000100000000NA23-Jan-03Zambia*032000000000NA27-Feb-02Algeria*010000000000NA13-Oct-01Georgia*010000000000NA02-Sep-01Bulgaria*020000000000NA24-Apr-01Iran*300000000000NA18-Dec-00Cape Verde*1200000000000NA13-Dec-00Congo220000000000029-Sep-0028-Nov-00Iraq400000000000NA28-Jan-00Total71948319187841255197919971315165116041282753314352367Total wild virus type 13---3491744555104517161666321976482425679Total wild virus type 3---134174229210263331994675112285774Tot. in endemic countries702475191573299993418691208150512561009169Tot. in non-end countries1783522561045128107146348273584No. of countries23159151816171218232219No. of endemic countries20107666§§4444Countries highlighted in pale yellow are considered to have active transmission (i.e. within the previous 6 months) of an imported poliovirus. 1Data in WHO HQ on 03 Nov 2009 for 2009 data and 02 Nov 2010 for 2010 data. 2Wild viruses from environmental samples, contacts and other non-AFP sources. 3 In 2009: 1 case in Cote d'Ivoire was subsequently found to be sabin; 3 cases in Mali were subsequently reallocated to Guinea. 4Includes 2 cases in 2008 and 2006, 3 in 2009, 2007, 2005, 2004 and 2002, and 4 in 2001 with a mixture of W1W3 virus. *All cases are importation related. NA. Most recent case had date of onset prior to 1999. §2001 wild virus of unknown origin; 2009 viruses are importation related. **All cases from 2003 onward are importation related. ∞Some cases may be attributed to other countries following full investigation. ***All cases from 2005 onward are importation related. §§In 2005, no endemic circulation occurred in Egypt or Niger but their status remained endemic. --- Data not available. Countries highlighted in yellow are endemic. Date of most recent virus2010Wild virus confirmed casesTotal Wild virus reported from other sources201 Jan - 02 Nov1Date of most recent type 3Date of most recent type 1Total

47. Data in WHO HQ as of 02 Nov 2010
Wild Poliovirus Cases by Type 2009 & 2010 -Year to Date Comparison W1W3W1W3W1W3W1W3W1W3W1W3Pakistan6028151231802119-Oct-10Afghanistan1522115911811-Oct-10Nigeria*7531307330725505-Oct-10India796611664611162316-Sep-10Total22910243205800411257DRCongo0300330013-Sep-10Angola290027025020-Aug-10Chad064002401410-May-10Sudan45004500027-Jun-09Total746772275514Uganda800801028-Sep-10Russian Federation**0000014025-Sep-10Mali***200503117-Sep-10Liberia11001002008-Sep-10Nepal000006030-Aug-10Kazakhstan000001012-Aug-10Tajikistan00000458004-Jul-10Turkmenistan000003028-Jun-10Senegal0000018030-Apr-10Mauritania1300005028-Apr-10Niger11401140201-Apr-10Sierra Leone1100201028-Feb-10Guinea42003200003-Nov-09Burkina Faso15001300025-Oct-09Cameroon030020015-Oct-09Burundi200200012-Sep-09CAR01400140009-Aug-09Côte d'Ivoire***26002700006-Aug-09Kenya1901830-Jul-09Benin2002019-Apr-09Togo60628-Mar-09Total1763114430051230Global total4791122342185746797401Data in WHO/HQ as of 03 Nov 2009 for 2009 data and as of 02 Nov 2010 for 2010 data. *Nigeria later reclassified 2 W1W3 cases as W1 in 2009. **Some cases may be attributed to other countries following full investigation. ***In 2009 data: 3 cases reported from Mali were subsequently reallocated to Guinea; 1 case reported in Côte d'Ivoire was subsequently found to be sabin. OutbreakEndemicRe-established transmissionCountry classificationTotal 2009Date of most recent case01 Jan - 02 Nov120092010

48. Data in WHO HQ as of 02 Nov 2010Comparison of 2009 and 2010 DataYear to Date (01 Jan to 02 Nov) Data for 2009 as of 03 Nov 2009 and for 2010 as of 02 Nov 2010. >90 days200920102009201020092010200920102010African1219612342610112939616261756670as of 02 Nov wild virus as of 27 Oct Central248724977274213834323822 South/East319530582611926494611203 West65146787512375332789907445American127013100020334493288as of 29 OctEastern Mediterranean868789961441208560468848as of 01 NovEuropean10511794047608391380140as of 01 NovSouth East Asian4385448658528459196506652171726as of 01 NovWestern Pacific432047200033356437300as of 02 NovGlobal71378778201282753197208837789713172Data received in HQTotalPending Final ClassificationWHO regionAFP CasesWild VirusPolio Compatible

49. A medical student with the last texbook on Communicable diseases !
Where there is no chapter on
Poliomielitis !!!

50. case of Polio ?
•How many of You know what polio is ?
•How many of you have ever seen a case of polio ?
•How safe are you on the good protection against polio of your district, town, region, country ??

51. NO More POLIO deaths on our Globe !!

52. Video