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Published Date: 2012-12-03 15:18:26
Subject: PRO/EDR> Poliomyelitis - worldwide (14): Pakistan, Afghanistan, cVDPV2
Archive Number: 20121203.1435756

POLIOMYELITIS - WORLDWIDE (14): PAKISTAN, AFGHANISTAN, CIRCULATING VACCINE DERIVED POLIOVIRUS TYPE 2
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In this update:
[1] Pakistan, Afghanistan: cVDPV2
[2] Pakistan (Balochistan): cVDPV2
[3] Global update: Polio Eradication Initiative

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[1] Pakistan, Afghanistan: cVDPV2
Date: Mon 3 Dec 2012
Source: Dawn [edited]
http://dawn.com/2012/12/03/polio-outbreak-in-balochistan-sets-off-alarm-bells/

Polio outbreak in Balochistan sets off alarm bells
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The outbreak of a hitherto unknown strain of polio virus in Qilla [or Killa] Abdullah and Pishin has set alarm bells ringing and prompted the centre to ask the Balochistan government to launch an anti-polio campaign in the province within 30 days.

Over the past 3 weeks, 10 cases of the new virus, named "Sabin-like type 2 poliovirus", were reported in 2 Pakhtun-dominated districts of the province. "The districts are frequented by people from the troubled areas of Fata [Federally Administered Tribal Areas]. The situation is grim because of refusal by parents to get their children vaccinated against the crippling disease as the areas are under the influence of extremist groups opposed to the anti-polio drive.

"The extremists belonging to Lashkar-i-Jhangvi and Tehrik-i-Taliban Pakistan have established their cells in Balochistan and warn people against vaccination of their children," Zohra Yusuf, chairperson of the Human Rights Commission of Pakistan (HRCP), told Dawn.

She said an HRCP team had visited Pishin and Qilla Abdullah in May [2012] to meet the local people and it was revealed that extremists had established their camps and were involved in killing people from Punjab. She said the people mostly coming from Khyber Pakhtunkhwa and other tribal areas brought the virus with them.

The Prime Minister's Office has also declared 'red alert' against the poor state of polio eradication drive in Balochistan and asked the administration to launch an emergency campaign in the province.

In a letter addressed to the chief secretary of Balochistan, copy of which is available with Dawn, Special Assistant to the Prime Minister Shehnaz Wazirali has conveyed the utter disappointment of the highest office in response to the way polio eradication drive is being carried out in Balochistan.

"The situation in Quetta block, which includes Killa Abdullah and Pishin, is aggravated by the continued resistance to and intransigence of the district health authorities and supervisory cadre of vaccinators," it said.

The letter said the new polio virus had not only affected 10 children in Pakistan but also paralysed 2 children in Afghanistan's Kandahar province. "I want to draw your attention to the reporting of Sabin-like polio virus cases in Qilla Abdullah and 2 from neighbouring Afghanistan," Shehnaz Wazirali said in the letter.

The PM Office also expressed concern over the low level of routine immunisation and asked the provincial government to immediately hold three rounds of anti-polio campaign in Qilla Abdullah beginning from the second week of December. "Highest quality should be ensured with strict monitoring and zero tolerance for under performance."

The letter called for urgent steps to institute the WHO's direct disbursement mechanism across the board for payment to the polio team staff. Measures should also be taken to improve the routine immunisation coverage in Qilla Abdullah on an emergency basis with clear targets and milestones given to district health teams.

"Stubbornness of the provincial health department and government supervisors for polio eradication in Balochistan is one of the biggest reasons behind dismal performance of the polio programme that has resulted in detection of new strain of poliovirus in Pakistan and threatens to impose travel restrictions on citizens that may put the country in an extremely embarrassing situation in the near future," the letter said.

WHO Team: A special 6-member international delegation of the World Health Organisation, led by polio eradication expert Dr Mohammed Mohammedi, is currently holding discussions with officials of the Balochistan government on ways of combating the new strain of poliomyelitis virus.

Dr Mohammedi told Dawn that the delegation was holding brainstorming sessions with the provincial officials to control the situation. "We had a fruitful session with the provincial chief secretary today and recommended for holding 3 emergency anti-polio campaigns in Quetta, Qilla Abdullah, and Pishin districts in 30 days to control the spread of the virus to other parts of the country," he said, adding that it was decided that the 1st emergency polio round in the province would be launched on [10 Dec 2012.

When contacted, Noorul Haq Baloch, Additional Secretary of Health in Balochistan, painted a rosy picture and said only 4 cases of polio had been detected this year as compared to 74 cases last year. "Polio cases have been on decline in Balochistan," he claimed.

He said Sabin-like polio virus was a new disease and the provincial health department was planning to conduct 3 rounds on [10 and 23 Dec 2012] and [7 Jan 2013] on the directives of the chief secretary.

Mr Baloch disclosed that some health officials had expressed reservations over the new system of payment to the officials involved in the campaign, but said things would improve in the coming days.

He rejected a perception that the constant movement of people from the troubled areas of Fata to Killa Abdullah was one of the major reasons for the spread of polio and said most of the cases ware detected in areas where people were poor and illiterate.

Shahnaz Wazir Ali told Dawn on Sunday [2 Dec 2012] that most refusal cases came from Pushto-dominated areas of Killa Abdullah. "The main cause of refusal is illiteracy and ignorance," she said.

She expressed concern over the children in Khyber Pakhtunkhwa consistently being missed during anti-polio campaigns. She said Karachi's polio cases also revealed that a child contracted the virus from Khyber Pakhtunkhwa.

"In Balochistan, the problem also occurs due to zonal health supervisors as they want to include their own people in the campaign. We have no objection but we want work," she said.

[Byline: Aamir Yasin]

[For the interactive HealthMap/ProMED map of Pakistan, see http://healthmap.org/r/1iGJ.

For the interactive HealthMap/ProMED map of Afghanistan, see http://healthmap.org/r/1CnW. - Mod.MPP

--
Communicated by:
Gert van der Hoek
Senior Moderator
FluTrackers
http://flutrackers.com

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[2] Pakistan (Balochistan): cVDPV2
Date: Mon 3 Dec 2012
Source: The Express Tribune [edited]
http://tribune.com.pk/story/473980/new-polio-strain-from-pakistan-hits-afghanistan/

New polio strain from Pakistan hits Afghanistan
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Officials say newly-discovered Sabin-Like ([type]2) [polio virus that is genetically similar to the oral polio vaccine is referred to as a vaccine-derived poliovirus -- VDPV, and when there are 2 or more cases of the same genetically lined virus, it is considered to be a circulating vaccine derived poliovirus -- cVDPV) poliomyelitis originated in Balochistan.

With the Independent Monitoring Board recommending travel restrictions on polio endemic countries, reports of the transmission of a newly-discovered poliovirus strain from Pakistan to Afghanistan is likely to complicate an already tough situation for Islamabad.

Two Afghan children, living close to the border with Pakistan, have been paralysed by the Sabin Like (2) poliomyelitis [cVDPV2], officials in the Polio Programme told The Express Tribune. The cases were reported from Afghanistan's Kandahar province 2 days ago -- one in Panjwai district and the other in Spin Boldak, they added. The World Health Organisation (WHO) has confirmed the 2 new cases.

According to the officials, genetic sequencing has confirmed the new polio strain originated in Balochistan's Killa Abdullah district. They said Sabin Like (2) [cVDPV2] poliomyelitis develops in children with an extremely poor record of routine immunisation -- a situation rampant in Balochistan.

Since 2006, polio vaccination teams have repeatedly missed an estimated 50 000 children in Killa Abdullah, derailing efforts to eradicate the virus in the country. This is not the 1st case of poliovirus transmission from Pakistan to a neighbouring country either. Last year [2011], 16 children in China's Xinjiang province were paralysed after being infected by a polio strain originating in Pakistan.

"The paramedic association and health department of Balochistan continues to hold the polio-eradication campaign hostage in Killa Abdullah through unfair demands... It has now resulted in embarrassment for Pakistan before the world community," an official of the Expanded Programme on Immunisation (EPI) told The Express Tribune on condition of anonymity.

WHO senior coordinator for polio eradication Dr Elias Durry said the organisation was monitoring the situation in Balochistan closely.

"We are seriously concerned about the new poliovirus strain and are recommending urgent steps to the provincial government to contain the outbreak," said Dr Durry. The only way to contain the spread of the virus is by conducting 3 to 4 high-quality polio vaccination rounds in the infected districts and their nearby areas," he said.

Meanwhile, a special WHO delegation, led by internationally acclaimed polio eradication expert Dr Mohammed Mohammedi, has reached Balochistan and is holding in-depth discussions with the provincial government over ways to combat the outbreak.

"We have asked the provincial government to hold 3 emergency polio campaigns each in Quetta, Killa Abdullah, and Pishin districts during a span of 30 days to control the spread of the virus to other parts of the country," said Dr Mohammedi, adding that the 1st campaign in the 3 districts was scheduled for [10 Dec 2012].

Pakistan has reported a total of 56 polio cases this year [2012] so far. A massive 181 cases were reported in 2011.

[Byline: Sehrish Wasif]

--
Communicated by:
Gert van der Hoek
Senior Moderator
FluTrackers
http://flutrackers.com

******
[3] Global update: Polio Eradication Initiative
Date: Wed 28 Nov 2012
Source: Global Polio Eradication Initiative [excerpted, edited]
http://polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

Global Polio Eradication Initiative update as of 27 Nov 2012
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Total cases
Year-to-date 2012 / Year-to-date 2011 / Total in 2011*
Globally: 202 / 553 / 650
- in endemic countries: 197 / 265 / 341
- in non-endemic countries: 5 / 288 / 309

Case breakdown by country
Country: Year-to-date 2012 WPV1 / WPV3 / W1W3 / Total // Year-to-date 2011 WPV1 / WPV3 / W1W3 / Total // Total in 2011* / Date of most recent case
Pakistan: 53 / 2 / 1 / 56 // 159 / 2 / 0 / 161 // 198 / 10 Nov 2012
Afghanistan: 31 / 0 / 0 / 31 // 58 / 0 / 0 / 58 // 80 / 9 Nov 2012
Nigeria: 92 / 18 / 0 / 110 // 36 / 9 / 0 / 45 // 62 / 4 Nov 2012
India: 0 / 0 / 0 / 0 // 1 / 0 / 0 / 1 // 1 / 13 Jan 2011
Chad: 5 / 0 / 0 / 5 // 114 / 3 / 0 / 117 // 132 / 14 Jun 2012
DR Congo: 0 / 0/ 0 / 0 // 87 / 0 / 0 / 87 // 93 / 20 Dec 2011
Angola: 0 / 0 / 0 / 0 // 5 / 0 / 0 / 5 // 5 / 7 Jul 2011
Niger: 0 / 0 / 0 / 0 // 1 / 1 / 0 / 2 // 5 / 22 Dec 2011
CAR: 0 / 0 / 0 / 0 // 2 / 0 / 0 / 2 // 4 / 8 Dec 2011
China: 0 / 0 / 0 / 0 // 18 / 0 / 0 / 18 // 21 / 9 Oct 2011
Guinea: 0 / 0/ 0 / 0 // 0 / 3 / 0 / 3 // 3 / 3 Aug 2011
Kenya: 0 / 0 / 0 / 0 // 1 / 0 / 0 / 1 // 1 / 30 Jul 2011
Cote d'Ivoire: 0 / 0 / 0 / 0 // 0 / 36 / 0 / 36 // 36 / 24 Jul 2011
Mali: 0 / 0 / 0 / 0 // 0 / 7 / 0 / 7 // 7 / 23 Jun 2011
Congo: 0 / 0 / 0 / 0 // 1 / 0 / 0 / 1 // 1 / 22 Jan 2011
Gabon: 0 / 0 / 0 / 0 // 1 / 0 / 0 / 1 // 1 / 15 Jan 2011
Total: 181 / 20 / 1 / 202 // 492 / 61 / 0 / 553 // 650
Total in endemic countries: 176 / 20 / 1 / 197 // 254 / 11 / 0 / 265 // 341
Total outbreak: 5 / 0 / 0 / 5 // 238 / 50 / 0 / 288 // 309

*Data in WHO as of 29 Nov 2011 for 2011 data and 27 Nov 2012 for 2012 data.

Afghanistan
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- One new WPV case was reported in the past week (one WPV1 from Khost), bringing the total number of WPV cases for 2012 to 31. It is the most recent case in the country and had onset of paralysis on [9 Nov 2012].
- Khost province is on the country's eastern border with Pakistan. Though Khost is not an endemic area, a case was reported in September [2012] as well. Both cases are linked to virus circulating in Quetta, capital of Balochistan province in Pakistan.
- The Independent Monitoring Board has stated that Afghanistan has made progress, but too slowly, and that too many children in southern Afghanistan are missed not just due to insecurity but also due to remaining managerial challenges. As with each of the 3 endemic countries, the IMB [Independent Monitoring Board] recommends 'absolute ownership' by leaders at all levels.
- The Technical Advisory Group (TAG) met in Kabul earlier this week [week of 28 Nov 2012], to review impact of the national polio emergency action plan and discuss additional tactics to address ongoing immunity gaps in known high-risk districts.
- Management trainings of polio staff continue, to address managerial and administrative obstacles in the programme.
- To further boost immunity levels in security-compromised areas, special strategies continue to be implemented including the vaccination of populations moving in and out of such areas. Supplementary immunization activities (SIAs) took place last week, with the next activity planned for December [2012].

Nigeria
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- 6 new WPV cases were reported in the past week (5 WPV1s from Katsina and one WPV1 from Borno), bringing the total number of WPV cases for 2012 to 110. A WPV1 from Katsina is the most recent in the country and had onset of paralysis on [4 Nov 2012].
- Katsina has now had 32 cases, and represents nearly one-third of all of Nigeria's cases this year [2012]. The state has the most intense transmission of wild poliovirus in the world at the moment, accounting for more than 15 percent of all polio cases globally this year [2012].
- The new case in Borno is the first since August [2012]. Insecurity in Borno continues to complicate operations, and the state's proximity to Chad is cause for concern. Historically, polio from Borno has spread east into Chad and from there onwards.
- Another area of concern is Sokoto, as in the past polio has spread from Sokoto into neighbouring countries of West Africa. While immunity levels are improving, overall the population is under-immunized, with approximately 60 percent of children having received greater than 3 doses of OPV (compared to a 80 percent national average). Operational challenges in the state continue to hamper basic implementation. However, under the leadership of the State Governor, there is a renewed effort to address these, including by continuing to review and strengthen micro-plans to more clearly identify missed settlement areas; reviewing workloads of individual vaccination teams; and increasing supervision and accountability at the Local Government Area (LGA) level and the ward-level. [For more on this see http://www.polioeradication.org/tabid/461/iid/258/Default.aspx. This press release from the Polio Eradication Initiative discusses the concerns in Sokoto -- a good summary is seen in the following quote: "And while Sokoto has reported a deceptively low 8 cases so far this year [2012], environmental surveillance regularly detects wild poliovirus and the state has reported a case of circulating vaccine-derived poliovirus type 2 -- sure signs that too few children are immunized." - Mod.MPP]
- The Independent Monitoring Board has stated that Nigeria's programme could be on the brink of a breakthrough, but that it continues to represent a risk to other countries. The IMB report concludes that success in Nigeria, and all of Africa, lies in the hands of the Nigerian programme -- "from President to vaccinator." As with each of the 3 endemic countries, the IMB recommends 'absolute ownership' by leaders at all levels.
- Immunization Plus Days (IPDs) were concluded last week [week of 19 Nov 2012]. The activity had been delayed by one week, to allow additional preparatory time.
- In December [2012], trivalent OPV will be added to planned Child Health Days (with meningitis vaccine) on [1-10 Dec 2012], and subnational IPDs will be conducted using bivalent OPV ([15-18 Dec 2012]). This will be an opportunity to administer 2 additional doses of OPV to children in highest-risk areas, within the space of a single month.

Pakistan
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- 2 new WPV cases were reported in the past week (WPV1s from Khyber Pakhtunkhwa -- KP, and Federally Administered Tribal Areas -- FATA), bringing the total number of WPV cases for 2012 to 56. The WPV1 from FATA is the most recent case in the country and had onset of paralysis on [10 Nov 2012].
- Additionally, 2 new cVDPV2 cases were reported in the past week, bringing the total number of cVDPV2 cases to 7 (all from the greater Quetta area of Balochistan).
- The Independent Monitoring Board has stated that Pakistan's chances of success have greatly improved over last year [2011], but that next year's [2013] elections and a complex security situation are major risks in 2013. As with each of the 3 endemic countries, the IMB recommends 'absolute ownership' by leaders at all levels.
- Preparations are underway for the next Subnational Immunization Days, scheduled for mid-December [2012], in high-risk areas across the country using bivalent OPV.

Angola
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- No new cases were reported in the past week. No cases have been reported in 2012. The country reported a total of 5 cases in 2011, and the last case had onset of paralysis on [7 Jul 2011] in Uige in the country's north.

Chad
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- No new WPV cases were reported in the past week. The most recently reported WPV case occurred in the Lac region (WPV1) with onset of paralysis on [14 Jun 2012]. The total number of WPV cases for 2012 remains 5.
- To urgently stop an ongoing cVDPV2 outbreak (6 cases in N'Djamena and 2 cases close to the border with Sudan), while further boosting immunity to type 1 and type 3 poliovirus, a 2nd round of staggered Sub-national Immunization Days were held [23-25 Nov 2012] (in the south and east), to be followed on [7-9 Dec 2012] (in the north and west), using trivalent OPV.

Democratic Republic of the Congo (DRC)
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- No new WPV cases were reported in the past week. No WPV cases have been reported in 2012. The total number of WPV cases for 2011 is 93 (all WPV1). The most recent case had onset of paralysis on [20 Dec 2011] in Maniema province.
- Although the country has not reported a WPV case since December 2011, it has been affected by a cVDPV2 outbreak in Katanga province in 2012, with 17 cases reported (most recent case: [4 Apr 2012]). Efforts are focused on ensuring the cVDPV2 outbreak is fully stopped.
- Supplementary immunization activities are ongoing from [27-29 Nov 2012] using a combination of bivalent and trivalent OPV.

Horn of Africa
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- No further cases have been reported in the cVDPV2 outbreak in Kenya and parts of Somalia (in a Somali refugee camp in Dadaab, Kenya, and Kismayo, south-central Somalia).
- New tactics are being explored to further boost immunity levels in and around inaccessible areas of south-central Somalia and to improve integration of polio vaccination with humanitarian activities across the Horn of Africa.

West Africa
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- No new WPV cases were reported in the past week. No WPV cases have been reported in 2012. The total number of WPV cases for 2011 in West Africa remains 51 (36 from Cote d'Ivoire, 3 from Guinea, 7 from Mali, and 5 from Niger). The most recent case from the region (WPV1 from Niger) had onset of paralysis on [22 Dec 2011].
- Multi-country immunization campaigns took place from [23-26 Nov 2012] in 7 countries of West Africa, critical to further boosting immunity levels in areas at highest-risk of potential importations from northern Nigeria.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Confirmed cases of polio associated with infection with the wild poliovirus (WPV) are presently reported from the 3 remaining polio endemic countries (Afghanistan, Nigeria, Pakistan). With the confirmation of 2 cases of cVDPV2 in Afghanistan near the Pakistan border, the number of countries with cVDPV2 outbreaks in 2012 has increased from 6 to 7 (Afghanistan, Pakistan, Nigeria, Chad, Democratic Republic of the Congo, Kenya, and Somalia). Of note, there was a small outbreak of cVDPV3 in Yemen involving 2 cases earlier this year (2012) as well. The common denominator in both situations (WPV and cVDPV outbreaks) is persistent sub-optimal vaccination coverages with polio vaccine in these countries, and specifically with low coverages with the oral polio vaccine that uses an attenuated live virus, especially those containing the type 2 vaccine virus [for an interesting analysis of the impact of the cVDPV2, see the Update on activities of the 27 Oct 2011, Geneva, WHO/HQ SAGE members available at http://www.healthinternetwork.com/immunization_standards/vaccine_quality/update_sage_polio.pdf). As other countries in the world continue to have pockets of populations in which vaccination coverages are sub-optimal, the threat of re-introduction of WPV from one of the endemic countries (as has been seen in prior years and earlier this year (2012) in Chad) is ever present, as is the appearance of cVDPV associated polio cases in these countries.

For maps of countries with confirmed cases of WPV associated polio in 2012 and 2011 respectively, see http://www.polioeradication.org/Dataandmonitoring/Poliothisweek/Poliocasesworldwide.aspx.

For a map of countries with confirmed cases of cVDPV associated polio in the preceding 6 months (28 May 2012 - 27 Nov 2012], see http://www.polioeradication.org/Dataandmonitoring/Poliothisweek/Circulatingvaccinederivedpoliovirus.aspx. - Mod.MPP]]

See Also