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Poliomyelitis Eradication in the Eastern Mediterranean Region
Progress Report 2002

Highlights of poliomyelitis eradication activities in countries of the Region

Endemic or recently polio-free countries

Egypt

As one of only seven still-endemic countries in the world in 2002, Egypt is a high priority for the Global Polio Eradication Initiative. Although the Ministry of Health is implementing different polio eradication activities, circulation of poliovirus has persisted in several provinces as evidenced by both AFP and environmental surveillance.  

During 2002, seven cases were reported. One case was from Assiut, Upper Egypt. Two cases were from Giza, near Cairo. Four cases were from governorates of Lower Egypt (one from each of Alexandria and Menofia and two from Sharkia). All cases were of type 1 and had onset in September or later, after intensification of surveillance activities, which started in July 2002.

Egypt is reporting high levels of routine immunization, has conducted many rounds of supplementary immunization and is maintaining the surveillance for cases of acute flaccid paralysis (AFP) up to the certification standard. However, as shown by the continuing occurrence of clinical cases and the widespread detection of type 1 wild polioviruses in the environment, final achievement of eradication of all wild polioviruses has been delayed beyond expectation.

The reported routine OPV3 coverage in 2002 was 97%. Immunization campaigns with OPV have been conducted in Egypt since 1976. Annual national immunization days (NIDs) have been conducted since 1989. The quality of these campaigns has improved particularly recently by shifting to house-to-house vaccine delivery in urban areas as was being done in rural areas. This shift to urban house-to-house vaccination started in Upper Egypt and high-risk areas and slums in Lower Egypt several years ago. In Fall 2002 the three rounds of NIDs were implemented house-to-house in all areas of Egypt including main cities such as Cairo and Alexandria. In addition these NIDs have involved for the first time volunteers from outside the Ministry of Health, from different national sectors such as universities and nongovernmental organizations, particularly the Red Crescent Society, the Scouts Movement and the Rotary Clubs. There is evidence that the SNIDs carried out in Spring 2002 and the NIDs carried out in Fall 2002 were of good quality with marked increase in the number of vaccination teams and intensified supervision and monitoring. 

AFP surveillance was initiated in Egypt in the early 1990s. Surveillance quality, as measured by non-polio AFP rates and the completeness of collection of adequate stool specimens, has continued to improve over the past 5 years to reach the required level of performance at the national level. There were however several practices performed until recently which have worked against full transparency of surveillance activities. One of these was the punitive action taken in response to the detection of polio cases. These actions had established a pervasive “culture of fear” among health workers discouraging the rapid reporting of suspect AFP cases and leading to the possible suppression of wild poliovirus reporting. These practices were gradually overcome almost completely starting two years ago. Testing of all stool samples is carried out at the laboratories of VACSERA, Cairo, which is accredited by the WHO as a regional reference lab. 

Due to the delay in the interruption of wild virus transmission beyond expectation a Technical Advisory Group (TAG) was established early in 2002 to review the situation of polio in Egypt and provide recommendations. In response to the recommendations of the TAG a comprehensive plan of action for polio eradication was developed for the second half of 2002. The AFP surveillance system has improved markedly with the development of standard operating procedures, and recruitment of national consultants by WHO to support activities in different governorates. With all these improvements the AFP rate for the second half of 2002 was above 3.5 compared to 1.2 in 2001.  A recent surveillance review has indicated that since mid 2002 significant improvement in the performance of the surveillance system has occurred, including reduction, although perhaps not complete elimination, of the “culture of fear”.  However, the review concluded that the AFP system is not yet complete, and it is likely that some cases of AFP with wild poliovirus continue to be missed in some governorates, primarily because of continued existence of important “silent areas” and inadequate involvement of other non-MOH health facilities in the surveillance system.  

In summary it is believed that the programme in Egypt is progressing well towards achieving the eradication goal. However, sustaining these high quality activities will be crucial for achieving interruption of virus transmission in this challenging situation.