Polio eradication in the African Region on course despite public health emergencies.

The World Health Organization, African Region is heading toward eradication of the three types of wild polio virus, from the Region. Cases of wild poliovirus (WPV) types 2 and 3 (WPV2 and WPV3) were last reported in 1998 and 2012, respectively, and WPV1 reported in Nigeria since July 2014 has been the last in the entire Region. This scenario in Nigeria, the only endemic country, marks a remarkable progress. This significant progress is as a result of commitment of key partners in providing the much needed resources, better implementation of strategies, accountability, and innovative approaches. This is taking place in the face of public emergencies and challenges, which overburden health systems of countries and threaten sustainability of health programmes. Outbreak of Ebola and other diseases, insecurity, civil strife and political instability led to displacement of populations and severely affected health service delivery. The goal of eradication is now within reach more than ever before and countries of the region should not relent in their efforts on polio eradication. WHO and partners will redouble their efforts and introduce better approaches to sustain the current momentum and to complete the job. The carefully planned withdrawal of oral polio vaccine type II (OPV2) with an earlier introduction of one dose of inactivated poliovirus vaccine (IPV), in routine immunization, will boost immunity of populations and stop cVDPVs. Environmental surveillance for polio viruses will supplement surveillance for AFP and improve sensitivity of detection of polio viruses.

Polio Eradication Initiative (PEI) contribution in strengthening public health laboratories systems in the African region.

BACKGROUND: The laboratory has always played a very critical role in diagnosis of the diseases. The success of any disease programme is based on a functional laboratory network. Health laboratory services are an integral component of the health system. Efficiency and effectiveness of both clinical and public health functions including surveillance, diagnosis, prevention, treatment, research and health promotion are influenced by reliable laboratory services. The establishment of the African Regional polio laboratory for the Polio Eradication Initiative (PEI) has contributed in supporting countries in their efforts to strengthen laboratory capacity. On the eve of the closing of the program, we have shown through this article, examples of this contribution in two countries of the African region: Côte d'Ivoire and the Democratic Republic of Congo. METHODS: Descriptive studies were carried out in Côte d'Ivoire (RCI) and Democratic Republic of Congo (DRC) from October to December 2014. Questionnaires and self-administered and in-depth interviews and group discussions as well as records and observation were used to collect information during laboratory visits and assessments. RESULTS: The PEI financial support allows to maintain the majority of the 14 (DRC) and 12 (RCI) staff involved in the polio laboratory as full or in part time members. Through laboratory technical staff training supported by the PEI, skills and knowledge were gained to reinforce laboratories capacity and performance in quality laboratory functioning, processes and techniques such as cell culture. In the same way, infrastructure was improved and equipment provided. General laboratory quality standards, including the entire laboratory key elements was improved through the PEI accreditation process. CONCLUSION: The Polio Eradication Initiative (PEI) is a good example of contribution in strengthening public health laboratories systems in the African region. It has established strong Polio Laboratory network that contributed to the strengthening of capacities and its expansion to surveillance of other viral priority diseases such as measles, yellow fever, Influenza, MERS-CoV and Ebola. This could serve as lesson and good example of laboratory based surveillance to improving diseases prevention, detection and control in our middle and low income countries as WHO and partners are heading to polio eradication in the world.

Polio Eradication Initiative: Contribution to improved communicable diseases surveillance in WHO African region.

INTRODUCTION: Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, there has been a tremendous progress in the reduction of cases of poliomyelitis. The world is on the verge of achieving global polio eradication and in May 2013, the 66th World Health Assembly endorsed the Polio Eradication and Endgame Strategic Plan (PEESP) 2013-2018. The plan provides a timeline for the completion of the GPEI by eliminating all paralytic polio due to both wild and vaccine-related polioviruses. METHODS: We reviewed how GPEI supported communicable disease surveillance in seven of the eight countries that were documented as part of World Health Organization African Region best practices documentation. Data from WHO African region was also reviewed to analyze the performance of measles cases based surveillance. RESULTS: All 7 countries (100%) which responded had integrated communicable diseases surveillance core functions with AFP surveillance. The difference is on the number of diseases included based on epidemiology of diseases in a particular country. The results showed that the polio eradication infrastructure has supported and improved the implementation of surveillance of other priority communicable diseases under integrated diseases surveillance and response strategy. CONCLUSION: As we approach polio eradication, polio-eradication initiative staff, financial resources, and infrastructure can be used as one strategy to build IDSR in Africa. As we are now focusing on measles and rubella elimination by the year 2020, other disease-specific programs having similar goals of eradicating and eliminating diseases like malaria, might consider investing in general infectious disease surveillance following the polio example.

Coordination as a best practice from the polio eradication initiative: Experiences from five member states in the African region of the World Health Organization.

BACKGROUND: As part of the efforts to eradicate polioviruses in the African Region, structures were put in place to ensure coordinated mobilization and deployment of resources within the framework of the global polio eradication initiative (PEI). The successes of these structures made them not only attractive to other public health interventions, but also caused them to be deployed to the response efforts of other diseases interventions, without any systematic documentation. This article documents the contributions of PEI coordination units to other public health interventions in the African Region of World Health Organization METHODS: We reviewed the contributions of PEI coordination units to other public health interventions in five countries in the African Region. RESULTS: The analysis identified significant involvement of PEI coordination structures in the implementation of routine immunization programs in all the countries analyzed. Similarly, maternal and child health programs were planned, implemented, monitored and evaluation the Inter-Agency Coordination Committees of the PEI programs in the different countries. The hubs system used in PEI in Chad facilitated the efficient coordination of resources for immunization and other public health interventions in Chad. Similarly, in the Democratic Republic of Congo PEI led coordination activities benefited other public health programs like disease control and the national nutrition program, the national malaria control program, and the tuberculosis control program. In Nigeria, the polio Expert Review Committee effectively deployed the Emergency Operation Center for the implementation of prioritized strategies and activities of the National Polio Eradication Emergency Plan, and it was utilized in the response to Ebola Virus Disease outbreak in the country. CONCLUSIONS: The PEI-led coordination systems are thus recognized as having made significant contribution to the coordination and delivery of other public health interventions in the African Region.

Epidemiological and Surveillance Response to Ebola Virus Disease Outbreak in Lofa County, Liberia (March-September, 2014); Lessons Learned.

Ebola Virus Disease (EVD) outbreak was confirmed in Liberia on March 31st 2014. A response comprising of diverse expertise was mobilized and deployed to the country to contain transmission of Ebola and give relief to a people already impoverished from protracted civil war. This paper describes the epidemiological and surveillance response to the EVD outbreak in Lofa County in Liberia from March to September 2014. Five of the 6 districts of Lofa were affected. The most affected districts were Voinjama/Guardu Gbondi and Foya. By 26th September, 2014, a total of 619 cases, including 19.4% probable cases, 20.3% suspected cases and 44.2% confirmed cases were recorded by the Ebola Emergency Response Team (EERT) of Lofa County. Adults (20-50 years) were the most affected. Overall fatality rate was 53.3%.  Twenty two (22) cases were reported among the Health Care Workers with a fatality rate of 81.8%. Seventy eight percent (78%) of the contacts successfully completed 21 days follow-up while 134 (6.15%) that developed signs and symptoms of EVD were referred to the ETU in Foya. The contributions of the weak health systems as well as socio-cultural factors in fueling the epidemic are highlighted. Importantly, the lessons learnt including the positive impact of multi-sectorial and multidisciplinary and coordinated response led by the government and community.  Again, given that the spread of infectious disease can be considered a security threat every effort has to put in place to strengthen the health systems in developing countries including the International Health Regulation (IHR)'s core capacities. Key words:  Ebola virus disease, outbreak, epidemiology and surveillance, socio-cultural factors, health system, West Africa.

Polio Eradication in the African Region: Progress and Way Forward

In 2012 the declaration of global polio eradication as a programmatic emergency for public health targets resulted in the setting of objectives and a schedule for eradication. Innovative approaches were taken to address the polio situation in the African Region. Supplementary immunization activities; planning; monitoring and surveillance have all been stepped up; and technological advances such as GPS and the use of polio dashboards to monitor key performance data have been employed. Key priority countries (Angola; Chad; Democratic Republic of the Congo; Nigeria) and communities (including nomadic groups) have been targeted.Great progress has been documented; for example routine immunization has risen from less than10 in 1980 to 77 in 2013. However; there are still some challenges to overcome; notably wild poliovirus outbreaks and three remaining foci of transmission - Nigeria; the Central Africa subregion and the Horn of Africa. This article charts the steps taken and the continuing action needed to realise the aim of polio eradication

Overview of the WHO Polio Laboratory Network in the African Region

The Polio Laboratory Network has always played a critical role in diagnosing poliovirus disease (poliomyelitis) and the detection of poliovirus transmission. In the new millennium; the strength of the laboratory network is often a direct reflection of the success of the Polio Eradication Initiative (PEI) programme. The network has taken advantage of new technologies that provide speedy turnaround times for results reporting thus contributing to the success of the PEI programme. This article presents a brief overview of the work of the network

Polio eradication in the World Health Organization African Region, 2008-2012.

A renewed commitment at the regional and the global levels led to substantial progress in the fight for polio eradication in the African Region (AFR) of the World Health Organization (WHO) during 2008-2012. In 2008, there were 912 reported cases of wild poliovirus (WPV) infection in 12 countries in the region. This number had been reduced to 128 cases in 3 countries in 2012, of which 122 were in Nigeria, the only remaining country with endemic circulation of WPV in AFR. During 2008-2012, circulation apparently ceased in the 3 AFR countries with reestablished WPV transmission-Angola, the Democratic Republic of the Congo, and Chad. Outbreaks in West Africa continued to occur in 2008-2010 but were more rapidly contained, with fewer cases than during earlier years. This progress has been attributed to better implementation of core strategies, increased accountability, and implementation of innovative approaches. During this period, routine coverage with 3 doses of oral polio vaccine in AFR, as measured by WHO-United Nations Children's Fund estimates, increased slightly, from 72% to 74%. Despite this progress, challenges persist in AFR, and 2013 was marked by new setbacks and importations. High population immunity and strong surveillance are essential to sustain progress and assure that AFR reaches its goal of eradicating WPV.

Progress toward laboratory containment of poliovirus after polio eradication.

BACKGROUND: The first steps (phase 1) toward laboratory containment of poliovirus after eradication are a national survey of biomedical facilities and a global inventory of such facilities retaining wild poliovirus (WPV) infectious and potentially infectious materials. METHODS: We reviewed published reports on national laboratory surveys and inventories of WPV materials from each of the 3 polio-free World Health Organization (WHO) regions (the European Region, completed in 2006; the Western Pacific Region, completed in 2008; and the Region of the Americas, completed in 2010), as well as reports on progress in polio-free countries of the remaining 3 regions (the African Region, the Eastern Mediterranean Region, and the WHO South-East Asia Region). RESULTS: Containment phase 1 activities are complete in 154 of 194 WHO Member States (79%), including all countries and areas of the polio-free regions and most polio-free countries in the remaining 3 regions. A reported 227 209 biomedical facilities were surveyed, with 532 facilities in 45 countries identified as retaining WPV-associated infectious or potentially infectious materials. CONCLUSIONS: Completion of containment phase 1 global activities is achievable within the time frame set by the Polio Eradication and Endgame Strategic Plan 2013-2018.

Trend in proportions of missed children during polio supplementary immunization activities in the African Region: evidence from independent monitoring data 2010-2012.

This is a comparative analysis of independent monitoring data collected between 2010 and 2012, following the implementation of supplementary immunization activities (SIAs) in countries in the three sub regional blocs of World Health Organization in the African Region. The sub regional blocs are Central Africa, West Africa, East and Southern Africa. In addition to the support for SIAs, the Central and West African blocs, threatened with importation and re-establishment of polio transmission received intensive coordination through weekly teleconferences. The later, East and Southern African bloc with low polio threats was not engaged in the intensive coordination through teleconferences. The key indicator of the success of SIAs is the proportion of children missed during SIAs. The results showed that generally there was a decrease in the proportion of children missed during SIAs in the region, from 7.94% in 2010 to 5.95% in 2012. However, the decrease was mainly in the Central and West African blocs. The East and Southern African bloc had countries with as much as 25% missed children. In West Africa and Central Africa, where more coordinated SIAs were conducted, there were progressive and consistent drops, from close to 20-10% at the maximum. At the country and local levels, steps were undertaken to ameliorate situation of low immunization uptake. Wherever an area is observed to have low coverage, local investigations were conducted to understand reasons for low coverage, plans to improve coverage are made and implemented in a coordinated manner. Lessons learned from close monitoring of polio eradication SIAs are will be applied to other campaigns being conducted in the African Region to accelerate control of other vaccine preventable diseases including cerebrospinal meningitis A, measles and yellow fever.

World Health Organization regional assessments of the risks of poliovirus outbreaks.

While global polio eradication requires tremendous efforts in countries where wild polioviruses (WPVs) circulate, numerous outbreaks have occurred following WPV importation into previously polio-free countries. Countries that have interrupted endemic WPV transmission should continue to conduct routine risk assessments and implement mitigation activities to maintain their polio-free status as long as wild poliovirus circulates anywhere in the world. This article reviews the methods used by World Health Organization (WHO) regional offices to qualitatively assess risk of WPV outbreaks following an importation. We describe the strengths and weaknesses of various risk assessment approaches, and opportunities to harmonize approaches. These qualitative assessments broadly categorize risk as high, medium, or low using available national information related to susceptibility, the ability to rapidly detect WPV, and other population or program factors that influence transmission, which the regions characterize using polio vaccination coverage, surveillance data, and other indicators (e.g., sanitation), respectively. Data quality and adequacy represent a challenge in all regions. WHO regions differ with respect to the methods, processes, cut-off values, and weighting used, which limits comparisons of risk assessment results among regions. Ongoing evaluation of indicators within regions and further harmonization of methods between regions are needed to effectively plan risk mitigation activities in a setting of finite resources for funding and continued WPV circulation.

An outbreak of wild poliovirus in the Republic of Congo, 2010-2011.

BACKGROUND: The Republic of Congo has had no cases of wild poliovirus type 1 (WPV1) since 2000. In October 2010, a neurologist noted an abnormal number of cases of acute flaccid paralysis (AFP) among adults, which were later confirmed to be caused by WPV1. METHODS: Those presenting with AFP underwent clinical history, physical examination, and clinical specimen collection to determine if they had polio. AFP cases were classified as laboratory-confirmed, clinical, or nonpolio AFP. Epidemiologic features of the outbreak were analyzed. RESULTS: From 19 September 2010 to 22 January 2011, 445 cases of WPV1 were reported in the Republic of Congo; 390 cases were from Pointe Noire. Overall, 331 cases were among adults; 378 cases were clinically confirmed, and 64 cases were laboratory confirmed. The case-fatality ratio (CFR) was 43%. Epidemiologic characteristics differed among polio cases reported in Pointe Noire and cases reported in the rest of the Republic of Congo, including age distribution and CFR. The outbreak stopped after multiple vaccination rounds with oral poliovirus vaccine, which targeted the entire population. CONCLUSIONS: This outbreak underscores the need to maintain high vaccination coverage to prevent outbreaks, the need to maintain timely high-quality surveillance to rapidly identify and respond to any potential cases before an outbreak escalates, and the need to perform ongoing risk assessments of immunity gaps in polio-free countries.