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Background

The Eastern Mediterranean Region is currently the only region in the world reporting wild poliovirus. In 2015, only two countries, Pakistan and Afghanistan, have reported cases. In these two countries, lack of safe access to children in conflict-affected areas and inconsistent improvement in the quality and coverage of supplementary immunization activities have hampered eradication efforts. However, the governments and their partners have developed robust emergency plans for 2015, the implementation of which is achieving results.

Key achievements & progress in 2015

As of 26 August, 37 polio cases have been reported globally in 2015 from just 2 countries, Pakistan (29) and Afghanistan (8). This represents more than a 70% reduction in the number of polio cases reported globally compared to the same period of 2014, and a 65% reduction in cases overall in these two endemic countries, although Afghanistan case numbers are roughly similar to 2014.

Access in key areas of Pakistan has improved considerably in 2015, and the number of inaccessible children in the Federally Administered Tribal Areas has been greatly reduced. However, many challenges remain. In Afghanistan large numbers of children were unreached in the southern and eastern regions in the first half of 2015 due to security challenges and local bans on immunization, and circulation of wild poliovirus continues in the remaining pockets of inaccessible children in Pakistan. Quality improvement in the delivery of immunization to children even in accessible areas has been uneven, with significant numbers of children still being missed due to inadequate training of vaccinators, inadequate microplans, poor supervision and weak oversight. Emergency Action Plans in both countries have introduced innovative measures in 2015 to address the challenges in accessing children and improving quality, including the recruitment of female community workers, community protected campaigns, permanent polio vaccination teams, vaccination at the transit points, and introduction of IPV in difficult to access and high-risk areas. Political commitment in both countries is growing. The establishment of emergency operations centres (EOCs) has given governments the opportunity to demonstrate leadership and to coordinate more effectively with partners, which has provided new momentum and impetus to the programme.

The outbreaks of polio in the Middle East and Horn of Africa in 2013–2014 have been successfully controlled, and large multi-country epidemics have been prevented as a result. It is now more than 16 months since the date of onset of the most recent case from the Middle East (April 2014 in Iraq) and 12 months since the most recent from the Horn of Africa (August 2014 in Somalia).

AFP surveillance quality is largely being maintained across the Region, and certification documentation and containment reports submitted by countries were reviewed by the Regional Commission for the Certification of Poliovirus Eradication in April 2015. All national, reference and specialized poliovirus laboratories in the Region have been fully accredited.

Technical support to polio endemic, outbreak, and at-risk countries has been accelerated through the recruitment of national and international WHO staff supported by consultants, including short-term Stop Transmission of Polio (STOP) consultants seconded from the United States Centers for Disease Control and Prevention. In addition, teams of experts constituting technical advisory groups provide technical support to the national programmes on strategic directions.

The first meeting of the Islamic Advisory Group (IAG) was held in February 2014 in Jeddah, and the Jeddah Declaration reasserted the compatibility of polio vaccines with Islamic sharia and tenets, strongly condemned the killing of health workers, and approved a plan of action to support polio eradication activities in areas of conflict and vaccination bans. The second global IAG meeting in Cairo on 6 May 2015 endorsed a comprehensive action plan for 2015 and 2016, focusing on the priority areas in the endemic countries and countries at risk of polio importation.

The polio eradication endgame strategic and legacy plan is progressing. A major objective of the plan is the withdrawal of oral polio vaccine (OPV) in a phased manner, starting with type 2-containing OPV. Progress is being made with the introduction of at least one dose of inactivated poliovirus vaccine (IPV) into routine immunization schedules in the Region, and the target for the switch from trivalent to bivalent oral poliovirus vaccine for all OPV use is currently April 2016, although the final date will be proposed by the Scientific Advisory Group of Experts (SAGE) following their meeting in October 2015.

In priority countries (Afghanistan, Pakistan and Somalia), plans are being implemented to achieve the optimal use of Global Polio Eradication Initiative assets to improve and sustain routine immunization. A legacy planning process is being undertaken to derive lessons from the global polio eradication initiative that are of relevance for other critical health initiatives, and where possible to harness the polio eradication infrastructure to support delivery of other programmes.

The way forward

Stopping transmission of poliovirus in the few remaining endemic foci in Afghanistan and Pakistan is the challenge that must be overcome in order to achieve global polio eradication. Achieving access to all children, and ensuring high quality immunization campaigns, is vital to success, and this requires tight monitoring and stronger partnerships, coordinated through emergency operations centres at national and subnational levels. Due to the long border and extensive population movement between Pakistan and Afghanistan, there is a clear need for well-coordinated activities to stop poliovirus transmission in the residual endemic foci in both countries.

The status of the outbreaks in the Middle East and Horn of Africa is assessed at regular intervals through formal reviews. With both outbreaks in the final stages of control, the next phase plans will have a strong focus on re-building routine immunization services. The strong working relationship among polio partners has been a critical factor in responding effectively to outbreaks, and this relationship must continue to be fostered.

In the polio-free countries of the Region, the priority is to maintain high population immunity, certification-standard AFP surveillance, and to develop robust polio importation preparedness plans. Preventive vaccination campaigns will continue to be conducted in selected high-risk countries, and all countries should ensure that high-risk population pockets (including refugees, migrants and internally displaced persons) are identified and immunized. POL EMRO will continue conducting regular risk assessments to share with Member States and encourage them to conduct subnational risk assessments and take corrective measures. Member States should also prepare carefully for the introduction of at least one dose of inactivated polio vaccine into routine immunization schedules, and the switch from trivalent to bivalent Oral Poliovirus Vaccine.

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¹This article is an abridgement of the progress report “Progress report on eradication of poliomyelitis” presented at the Sixty-second session of the WHO Regional Committee for the Eastern Mediterranean in Kuwait 5–8 October 2015 (EM/RC62/INF.DOC.1). The full report is available on the Regional Office web site at: http://applications.emro.who.int/docs/RC_technical_papers_2015_Inf_Doc_1_16467_EN.pdf?ua=1