EXECUTIVE SUMMARY

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WORLD HEALTH ORGANIZATION Regional Office for Africa

Brazzaville • 2014

2013

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WHO/AFRO Library Cataloguing – in – Publication Annual Polio Report 2013

1. Poliomyelitis- prevention & control 2. Poliomyelitis-epidemiology 3. Poliomyelitis-transmission 4. Poliomyelitis-economics

5. Disease Eradication- organization and administration 6. Vaccination

I. World Health Organization. Regional Office for Africa ISBN: 978 929 023251 3 (NLM Classification: WC 555)

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Abbreviations

AFP Acute Flaccid Paralysis

AFRO WHO Regional Office for Africa

ARCC African Regional Certification Commission

AVW African Vaccination Week

bOPV Bivalent Oral Polio Vaccine

CDC US Centers for Disease Control and Prevention cVDPV Circulating vaccine-derived polio virus

DPT3 Third dose of Diphtheria Pertussis and Tetanus vaccine EMRO WHO Regional Office for the East Mediterranean Region ERC Expert Review Committee on Polio Eradication and

Routine Immunization, Nigeria

EOC Emergency Operations Centre for Polio Eradication GAVI Global Alliance for Vaccines and Immunization

GIS Geographic Information Systems

GPEI Global Polio Eradication Initiative

GVAP Global Vaccine Action Plan

Hep Hepatitis Vaccine

Hib Hemophilus Influenza Type B Vaccine

HMIS Health Management Information System

HOA Horn of Africa

ICC Immunization Coordination Committee

IDSR Integrated Disease Surveillance and Response IMCI Integrated Management of Childhood Illnesses

IM Independent Monitoring

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IMB Independent Monitoring Board of the Global Polio Eradication Initiative

IPV Inactivated Polio Vaccine

IST Inter-country Support Team

IVE Immunization, Vaccination and Emergencies Cluster

LGA Local Government Area

LQAS Lot Quality Assurance Sampling

NCC National Certification Committee

NID National Immunization Day

NPEC National Polio Expert Committee

NTF National Task Force on Containment

OPV Oral polio Vaccine

PIRI Periodic Intensification of Routine Immunization

PV Poliovirus

RED Reaching Every District

RI Routine Immunization

SIA Supplemental Immunization Activities

SNID Sub-national immunization Days

TAG Technical Advisory Group

TFI Task Force for Immunization in Africa tOPV Trivalent Oral Polio Vaccine

UNICEF United Nations Children’s Fund

VDPV Vaccine Derived Polio Virus

WHA World Health Assembly

WHO World Health Organization

WPV Wild Polio Virus

WR WHO Health Organization Representative

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FOREWORD

The priority areas of action identified for Polio Eradication in the Africa region at the end of 2012 included interruption of wild poliovirus and circulating vaccine derived poliovirus transmission, strengthening of routine immunization, resource mobilization and management of existing resources as well as preparation for certification and containment.

Progress has been made in each of the priority areas. The African Region registered a 40% decline in cases due to wild poliovirus infection and a 67% reduction in cases due to circulating vaccine derived poliovirus. The last case of WPV3 reported in the region was in November 2012. The decline in intensity of cases is also associated with decline in geographical and genetic diversity of the circulating poliovirus.

Several countries in the Region have registered improvements in routine immunization coverage. The improved reported routine immunization coverage however often masks large disparities at sub-national level.

In 2013, I reconstituted the Task Force on Immunization in Africa (TFI) as well as the African Regional Certification Commission (ARCC). Both bodies provide valuable technical orientation to the Regional Office as well as the member states in our region.

Despite the overall progress in the region, a number of key challenges remain.

In 2013, insecurity adversely affected implementation of programme activities in several countries in the region. Thirteen health workers and volunteers in Nigeria were tragically killed during polio eradication campaigns.

An increasing number of countries in the region experienced polio outbreaks following importation of wild poliovirus. Transmission of circulating vaccine derived poliovirus persists in areas with insecurity and very difficult terrain.

I wish to express appreciation to national Governments in the region for their commitment to the goal of polio eradication. Innovative and appropriate strategies continue to be implemented to overcome the remaining barriers in the highest risk areas to achieving interruption of poliovirus transmission in our region.

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The generous technical, financial and material support provided by partners and donors, to ensure timely and effective implementation of appropriate strategies and activities is very much appreciated indeed.

Dr Luis Gomes Sambo Regional Director

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EXECUTIVE SUMMARY

In September 2011, the 61ST Session of the Regional Committee for Africa urged all member states where poliovirus continued to circulate or was newly detected to declare the presence of polio a national public health emergency and undertake necessary actions to interrupt transmission as rapidly as possible. In May 2012, the World Health Assembly declared the completion of polio eradication a programmatic emergency.

Member states in the WHO African Region, with support provided by the World Health Organization and other Global Polio Eradication Initiative Partners, continue to implement recommended activities aimed at ensuring that interruption of transmission of all poliovirus is achieved within the shortest time possible.

The 2013-2018 Polio Eradication and Endgame Strategic Plan provided the overall framework for implementation of polio eradication activities in the region in 2013. Inter-regional collaboration between the WHO African (AFR) and Eastern Mediterranean (EMR) Regions of WHO was enhanced in 2013 particularly in relation to control of outbreaks affecting countries in both regions.

In 2013, the WHO African Region experienced continued transmission of wild poliovirus type 1 (WPV1) as well as circulating vaccine derived poliovirus (cVDPV).

A total of 80 cases of paralytic disease due to WPV1 were confirmed in 4 countries while 13 cases due to cVDPV were confirmed from 4 countries in the region. There was close to 40% decline in cases due to WPV in the Region in 2013 compared to 2012, while a decline of 67% in confirmed cases due to cVDPV was observed in 2013 compared to 2012. The last confirmed case of WPV3 in the region was in November 2012.

The declining incidence of poliovirus in the region is a result of increasing coverage of immunization activities in the region. By end of 2013, 33 countries in the region reported a national coverage of at least 80% OPV3. An increasing number of high risk districts in infected and high risk countries also registered coverage of at least 80% during immunization campaigns.

The main factors that contribute to the improving coverage and quality of polio eradication activities in the WHO African Region and the declining intensity of poliovirus transmission include:

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• High commitment to the goal of polio eradication by Political leaders and Government authorities at national and sub-national level;

• Effective engagement of community leaders, religious leaders as well as influential members of civil society in polio eradication activities, particularly in the highest risk areas;

• Technical, material and financial resources provided for implementation of Polio Eradication activities by national Governments, international partners and donors;

• Effective implementation of appropriate strategies to enhance (a) local ownership and accountability amongst key programme stake-holders in the remaining infected and high risk areas (b) service delivery by front- line vaccination teams and (c) community engagement and demand for immunization services;

• Implementation of appropriate innovations to overcome local barriers including increasing insecurity in infected and high risk areas.

The progress made in Polio Eradication in the region in 2013 remains fragile because of gaps in population immunity and surveillance as well as increasing insecurity affective programme operations in several countries in the region.

In 2013, three countries in the region experienced polio outbreaks following importation of poliovirus from remaining polio reservoir. It is key that progress made in 2013 is consolidated and intensified so that interruption of transmission is achieved within the shortest time possible. Priority actions to to ensure that other key targets and milestones as elaborated in the 2013-2018 Polio Eradication and Endgame strategic plan have been identified.

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1. BACKGROUND

Implementation of intensified polio eradication activities in the African Region continue to be guided by resolutions on Polio Eradication by the World Health Assembly and the WHO Regional Committee for Africa.

The Polio Eradication and Endgame Strategic Plan 2013-2018, discussed by the 66th World Health Assembly in May 2013 provided the overall framework for implementation of Polio Eradication Activities in the WHO African Region in 2013.

This report will provide an update on progress towards the attainment of three of the four main objectives of this Strategic Plan, namely:

• Poliovirus detection and interruption

• Strengthening Immunization Systems

• Containment and certification

Work on the fourth objective of the Strategic plan, Polio Legacy Planning in the WHO African region, will begin in earnest in 2014.

Member states in the WHO African Region continue to implement the resolutions of the 61st session of the Regional Committee that called on infected states to systematically engage all leaders at national and local levels to ensure highest quality immunization campaigns and achieve interruption of the last chains of transmission within shortest time possible.

The 63^rd session of the WHO Regional Committee for Africa, that took place in Brazzaville in September 2013, discussed progress in the implementation of the Regional Immunization Strategic Plan 2009-2013, the Global Vaccine Action Plan (GVAP) and the Polio Endgame. Recommendations made during this session include the need for member states to (a) use recent lessons learned in improving routine immunization coverage to further improve coverage and achieve targets as laid out by GVAP (b) enhance cross-border collaboration on public health issues including immunization and (c) develop a plan to strengthen routine immunization and accelerate the withdrawal of OPV2 and the introduction of IPV.

Global, Regional, Sub-Regional and country-specific Technical Advisory Groups on Polio Eradication and Immunization Systems Strengthening provide important technical orientation to WHO/AFRO and countries in the region. These groups

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include the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative, the Strategic Advisory Group of Experts (SAGE), the Task Force on Immunization in Africa, African Regional Certification Commission (ARCC), as well as sub-regional and country-specific Technical Advisory Groups (TAGs).

The Regional Directors of the WHO African and Eastern Mediterranean Regions continued to foster close collaboration and coordination with regards to Polio Eradication activities. In line with orientation from both RDs, a sub-regional outbreak response plan covering all AFRO and EMRO countries in the Horn of Africa was elaborated in June 2013. The implementation of this plan was closely monitored by both Regional Directors.

The WHO Regional Director for Africa, WHO Country Representatives (WRs) from polio-priority countries as well as immunization technical staff from the Regional office and Country Offices, meet each quarter to review progress towards the attainment of Polio eradication milestones in the WHO African Region. These meetings also provide a forum for discussions on how WHO can enhance the support it provides to the member states in the region in terms of polio eradication and strengthening of routine immunization.

Priorities for Polio Eradication in the WHO African Region identified at the end of 2012 included interruption of poliovirus (both wild poliovirus as well as circulating vaccine derived poliovirus) transmission, strengthening routine immunization, improving resource mobilization and management of resources as well as preparation for certification and containment^1.

This third edition of the Annual Polio Report outlines the evolving status of poliovirus transmission in the African Region, poliovirus surveillance in the region, actions taken to interrupt poliovirus transmission, certification and research activities, resources used as well as well as future PRIORITY actions for Polio Eradication in the African Region.

2. STATUS OF POLIOVIRUS TRANSMISSION

In 2013, 80 cases of paralytic disease due to wild polioviruses were confirmed from 4 countries in the WHO African region. This represented an almost 40% decline compared to the 128 cases of paralytic disease due to wild polioviruses confirmed from 3 countries in the region in 2012.

1. WHO Regional Office for Africa. Annual Polio Report 2012.sembly on 24 and 25 September, 2013. The Rio+20 Declaration.

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Nigeria is the only endemic country in the Africa region as it is the only country that has not been able to interrupt indigenous wild poliovirus. The other countries in the region with confirmed polio cases due to wild poliovirus, have imported this transmission from remaining endemic poliovirus reservoirs².

For the very first time in the history of Polio Eradication, only one serotype of wild poliovirus, WPV1, was reported in the region in 2013. The last confirmed WPV3 reported in the African Region was in November 2012 from Yobe State, in Northern Nigeria.

Figure 1: Confrmed wild poliovirus cases in the African Region, 2008-2013

Paralytic polio disease due to circulating vaccine derived poliovirus (cVDPV) continues to be confirmed in the African Region. In 2013, a total of 13 cases of paralytic polio cases due to cVDPV were confirmed in 4 countries in the African Region. This represented an approximately 68% decline in cases of cVDPV in the region when compared to the 40 cases reported from 4 countries in 2012 (annex 9.1).

Nigeria: In 2013, poliovirus transmission in Nigeria was confirmed from virological analysis of stool specimens from children with Acute Flaccid Paralysis (AFP) as well as from systematic assessment of environmental samples collected from designated sites.

2. In 2013, endemic wild poliovirus reservoirs remained in only 3 countries globally i.e. Afghanistan, Pakistan and Nigeria. All cases of wild poliovirus importation in the African region in 2013 were genetically linked to the endemic reservoir in Nigeria.

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Figure 2: Confirmed poliovirus cases (wild and circulating vaccine-derived) in Nigeria, 2013

The number of children para-lysed following infection with wild poliovirus declined from 798 cases in 2008 to 122 cases in 2012 (a 85% decline) (Annex 9.1). In 2013, Nigeria had a total of 53 confirmed cases of paralytic disease due to wild poliovirus compared to the 122 cases confirmed in 2012.

The declining intensity of wild poliovirus transmission in Nigeria is associated with declining geographical extent of transmission. In 2012, a total of 13 states had confirmed wild poliovirus while in 2013, nine states had confirmed wild poliovirus cases. Close to 48% (17/53) of the confirmed 2013 wild poliovirus cases in Nigeria were from two states: Borno and Yobe. These states were at the epicentre of insecurity experienced in Northern Nigeria in 2012-2013.

In 2013, wild poliovirus and circulating vaccine-derived poliovirus were detected by environmental surveillance but not from any acute flaccid paralysis case in one state in Nigeria: Sokoto.

The declining number and geographical extent of transmission of wild poliovirus in Nigeria has also been associated with declining genetic diversity of the virus.

The reported number of circulating genetic clusters of WPV1 declined from 11 in 2011 to 8 in 2012 and then to only 2 in 2013.

Nigeria has had persistent outbreak of paralytic polio disease due to cVDPV since 2005. The two cases of paralytic disease due to cVDPV s reported in 2013 is the lowest number of cases due to this virus over the last five years.

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Figure 3: Confirmed poliovirus cases (cVDPV) in Nigeria, 2008-2013

The factors that have contributed to the progress in reducing transmission of poliovirus in Nigeria are discussed in detail in Chapter 4 of this report.

Outbreak countries: The proportion of confirmed WPV cases from countries in the WHO African Region that experienced outbreaks following importation increased by close to 80% in 2013 compared to 2012. In 2013, a total of 27 confirmed WPV cases were reported from four previously polio-free countries in the Region that experienced wild poliovirus importation, namely Cameroon (four WPV cases), Ethiopia (nine cases) and Kenya (14 cases). In 2012, the WHO African Region had six WPV cases from two previously polio-free countries, namely Chad (five cases) and Niger (one case).

The 2013 wild poliovirus transmission in the Horn of Africa, Ethiopia and Kenya,³ was genetically linked to wild poliovirus transmission in Northern Nigeria in 2013.

Genetic analysis of the 2013 WPV1 in Cameroon confirmed that this transmission was genetically linked to WPV1 last detected in Chad in 2011. The WPV1 in Chad had earlier being imported from the endemic reservoir in Northern Nigeria.

Countries previously classified as re-established transmission countries: In 2010, three previously polio-free countries in the African Region, namely Angola, Chad and Democratic Republic of the Congo, had experienced persistent poliovirus transmission following importation from endemic reservoir for more than three

3. The Horn of Africa outbreak also affected Somalia, which reported a total of 195 confirmed polio cases in 2013. This is not described in this report as Somalia is a member of the WHO Eastern Mediterranean Region.

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years. These countries were then classified as countries with re-established transmission. In 2013, not a single case of confirmed wild poliovirus was reported from any of these three countries. The last confirmed WPV in Angola and Democratic Republic of the Congo was reported in 2011 while the last confirmed WPV in Chad was reported in 2012.

Circulating vaccine-derived poliovirus transmission in 2013: Four countries that share common international borders around Lake Chad, namely Cameroon, Chad, Niger and Nigeria, had confirmed circulating vaccine-derived poliovirus in 2013.

Figure 4: Confirmed cases of cVDPV in the WHO African Region, 2013

3. POLIOVIRUS SURVEILLANCE

Acute flaccid paralysis (AFP) surveillance is the primary strategy for the detection of poliovirus. Environmental surveillance, which is the systematic sampling of sewage for poliovirus, is a complementary strategy for the detection of poliovirus.

Surveillance for poliovirus provides critical information to guide polio eradication activities including the intensification of immunization activities in polio-infected areas.

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3.1. Acute flaccid paralysis surveillance activities

Active surveillance for all cases of AFP remains the mainstay of poliovirus surveillance in the WHO African Region. Front line health workers and clinicians are regularly sensitized to report all cases of AFP. Trained health workers conduct full investigation of all reported AFP cases including the collection and transportation of stool specimens to WHO-accredited polio laboratories.

AFP surveillance is monitored through standard indicators for sensitivity as well as timeliness and completeness of case investigation. A non-polio AFP rate of at least two per 100 000 population under 15 years as well as at least 80% of AFP cases with adequate stool samples collected are the two main surveillance performance indicators used to assess quality of AFP surveillance.

Figure 5: AFP surveillance at subnational level in the WHO African Region, 2013

In 2013, 39 of the 46 countries in the WHO African Region achieved AFP surveillance indicators for sensitivity i.e non-polio AFP rate of at least two per 100 000 population under 15 years. Five island countries (Cape Verde, Equatorial Guinea, Mauritius, Sao Tome and Principe, Seychelles) and two mainland countries (Algeria and Gabon) did not meet the AFP surveillance sensitivity indicator in 2013.

Approximately 50% of the countries in the WHO African Region did not meet the indicator of at least 80% stools being adequate (see Annex 3).

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In 2013, countries implemented a number of key activities to ensure that the two main AFP surveillance performance indicators (non-polio AFP detection rate and proportion of AFP cases with two adequate stool samples) were attained and/or sustained. These activities included:

(a) refresher training of front line health workers and clinicians;

(b) close monitoring of active surveillance visits down to district level, with particular focus on districts with suboptimal surveillance performance indicators;

(c) implementation of quarterly surveillance review meetings to regularly assess performance and implement any required corrective measures;

(d) preparation and dissemination of national surveillance feedback bulletins.

Eight countries in the region conducted surveillance reviews in 2013. The surveillance reviews documented a number of factors that were compromising quality of surveillance. These included insufficient active surveillance visits;

challenges with transportation; and high turnover or insufficient number of trained surveillance staff.

Surveillance activities in special populations e.g. nomadic/pastoralist communities, nomadic communities, hard-to-reach communities, displaced/

refugee communities were found to be suboptimal in most instances. Some of the recommendations from surveillance reviews conducted in 2013 included the need for closer monitoring of active surveillance particularly in poor performing areas; regular refresher training of all front line health workers; regular analysis and feedback of surveillance performance indicators; and the expansion of surveillance networks to include key community informants.

3.2. Environmental surveillance

Environmental poliovirus surveillance (ES) is the monitoring of poliovirus (PV) transmission in human populations by screening environmental specimens assumed to be contaminated by human faeces. The rationale is based on the fact that persons infected with PV shed large amounts of PV in the faeces for several weeks. There are situations in which there are good reasons to suspect that negative results of AFP surveillance are not reliable, hence supplementary information is required in such situations and one approach for that is environmental surveillance. ES is complementary to AFP surveillance and can detect circulation of WPV, cVDPV or OPV-derived polioviruses in the population.

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The strategic plan for expansion of environmental surveillance in Africa is four- fold focusing on country selection, sample collection, ES expansion and laboratory capacity. Concerning country selection, environmental surveillance will provide information about endemic locations, polio-free districts adjacent to endemic districts, in the same or adjacent countries and also areas with recent or recurrent importation, re-establishment of transmission, or history of silent transmission in regard to adequate surveillance indicators. Concerning sample collection, ES will assess the feasibility of countries to concentrate samples in the field and transport them to a central laboratory for processing. With ES expansion, consideration is being given to the addition of specimen collection sites in Nigeria; starting specimen collection at designated sites in Luanda, Angola for local concentration;

and remote processing tentatively in South Africa. Additional locations in sub- Saharan Africa are under consideration because they are major transport hubs (Burkina Faso, Chad, Ghana, Mali, Niger) or are high-risk areas (Angola, Democratic Republic of the Congo, Kenya, Somalia, South Sudan). Laboratory capacity must first be sufficiently increased to be able to cope with the heavy workload.

In Africa, environmental surveillance started in July 2011 in Kano and expanded later to Sokoto, Lagos, Kaduna, Federal Capital Territory and Borno (states in Nigeria). In 2013, ES detected three cases of WPV1, (Kano 1 and Sokoto 2). A total of 18 cVDPV2 cases (Sokoto 9, Kano 1, and Borno 8) were also detected in Nigeria.

ES was started as a pilot project in Kenya in mid-2013. Two sites, Kamukunji and Kibera, were identified and sampled in 2013. In October 2013, a wild poliovirus was isolated from a sewage sample collected from the Kamukuji site.

Figure 6: Sampling sites selection in Nigeria (Source: Maiduguri Lab, in Nigeria)

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Environmental surveillance faces various challenges. Many areas lack proper planned sewage systems. Another common problem is the frequent refuse blockages along open drains; these interrupt the flow of sewage water.

Experiences from Nigeria confirm that ES can detect introduction and silent circulation of WPV and VDPV. Also, because ES incorporates more sensitivity than AFP surveillance, it can monitor ceasing PV.

3.3. Polio laboratory performance in the African Region

The Polio Laboratory Network in the African Region plays a critical role in the Global Polio Eradication Initiative. Timely, accurate laboratory results drive public health action and help shape policies.

The Polio Laboratory Network was established in 1993 with 16 laboratories assigned to perform poliovirus laboratory diagnosis. The three laboratories in Central African Republic, Ghana and South Africa are the regional reference laboratories;

the laboratory in South Africa performs polio sequencing for the entire Region.

The Network provides support to 47 WHO African Region (AFR) countries⁴ and two Eastern Mediterranean Region (EMR) countries. The Kenya lab processed samples from Somalia and Sudan, countries in the Eastern Mediterranean Region.

In 2013, all AFR laboratories were accredited⁵ with the exception of the National Polio Laboratory in the Central African Republic. Because of insecurity in the Central African Republic in 2013, the annual accreditation visit could not be held. This visit has been rescheduled to take place whenever the security situation allows.

In 2013, a total of 46 333 samples were received by the AFR Polio Laboratory Network for viral isolation (Figure 7). The Nigeria lab in Ibadan processed 12 000 samples, and the Kenya lab processed approximately 6000 samples. All labs managed to report the isolation results within 14 days turnaround time with the exception of labs in the Central African Republic and Kenya.

4. Includes South Sudan which moved from the Eastern Mediterranean Region to the African Region in 2013.

5. The 2013 accreditation visit to the Algeria Polio Laboratory was conducted in February 2014.

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Figure 7: Number of samples received from African polio laboratories for isolation in 2013

A total of 4631 samples were received for intratypic differentiation (ITD) (Figure 8), and approximately 26% were characterized by the Kenya lab. The ITD results were reported within the expected timeliness of 7 days and the 80% target was reached by all 16 labs.

Figure 8: Number of isolates received from African polio labs for ITD

In 2013, a total of 80 cases of wild poliovirus type 1 (WPV1) were identified (53 from Nigeria, 14 from Kenya, 9 from Ethiopia and 4 from Cameroon) and all with onset of paralysis in 2013. The wild poliovirus isolated in Ethiopia and Kenya were

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genetically linked to virus circulating in Northern Nigeria. A total of 16 cases of vaccine-derived polioviruses (VDPVs) were identified in Africa and classified into two categories: i) circulating vaccine-derived polioviruses (cVDPVs) and ii) ambiguous vaccine-derived polioviruses (aVDPVs).

The work-load in the laboratories serving outbreak countries increased as a result of the outbreaks. These laboratories received additional technical support from the Regional Office as well as surge personnel in some instances. Additional equipment was also provided to these laboratories. Daily teleconferences were instituted with some of these laboratories to identify and resolve bottlenecks including fast track specimen processing. Remote data analysis technical support was also provided by the Regional Laboratory coordinator in the WHO Regional Office for Africa.

All 16 laboratories are now competent in performing the ITD assay including the Algeria laboratory. The sequence capacity was increased in the Region by further training for the Ghana laboratory which consisted of 12 participants including two from India and Thailand (in the WHO South-East Asia Region).

In summary, the Polio Laboratory Network has maintained high standards of performance. The labs have significantly reduced the result turnaround time by

>50%. Genetic sequence information generated suggests regional progress in reducing the wild poliovirus (WPV) reservoir as evidenced by reduction in the number of circulating viruses. There remain surveillance gaps, and this is evident from the identified orphan viruses in countries with circulating WPV. Detection of cVDPVs in Africa points to low population immunity in the identified countries and the need to strengthen routine OPV immunization.

The AFR Polio Laboratory Network has supported the strengthening of laboratory networks for other diseases such as measles, yellow fever, rotavirus and influenza.

Support hs included shared technologies, shared human resources, joint planning and missions.

4. STOPPING POLIOVIRUS TRANSMISSION IN THE AFRICAN REGION

4.1. Overview of actions to stop poliovirus transmission

The operational approaches to stopping poliovirus transmission in the African Region are similar to those that have been successfully applied in other WHO regions and include actions aimed at i) rapid detection of all polioviruses; ii)

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attainment of high population immunity such that the poliovirus is unable to find enough susceptible individuals to infect and sustain transmission; and iii) rapid response to any new polio outbreaks.

Activities undertaken to ensure rapid detection of all polioviruses were described in Section 3 of this report.

Attainment and sustaining of high population immunity above the threshold required to interrupt transmission are achieved through improving coverage of routine immunization and supplemental immunization activities (SIAs) particularly in high-risk, risk and infected areas (see Annex 4).

Advocacy activities to ensure support for polio eradication at all levels by political, traditional and community leaders were undertaken particularly in infected and high-risk countries. These activities were crucial for ensuring effective mobilization of all communities to participate in immunization campaigns as well as obtaining financial and non-financial resources to support polio eradication activities.

Figure 9: Political and traditional leaders at polio eradication event in Chad Independent technical advisory

groups (TAGs) provided key technical guidance to countries regarding implementation of programmatic strategies aimed at stopping poliovirus transmission as well as sustaining polio-free status. In 2013, the Task Force on Immunization was reconstituted as the regional TAG.

TAG meetings held in 2013 included the newly reconstituted Task Force on Immunization in Africa, the Horn

of Africa TAG, TAGs for five countries in Central and South Africa,⁶ the Expert Review Committee on Polio Eradication and Routine Immunization Strengthening in Nigeria as well as the TAG for Chad. TAGs reviewed the status of implementation of strategies aimed at enhancing population immunity and achieving highest

6. Angola, Congo, Democratic Republic of the Congo, Namibia and Zambia.

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quality poliovirus surveillance the impact of these strategies on reducing risks for persistent or renewed poliovirus transmission. In addition, TAGs made appropriate recommendations for consideration by national authorities and partners.

Figure 10: Meeting of the Polio Eradication Technical Advisory Group for Chad, November 2013

Rapid outbreak response activities in the African Region in 2013 included implementation of at least three rounds of large-scale immunization campaigns, activities aimed at enhancing poliovirus sensitivity as well as activities aimed at improving routine immunization performance.

4.2 Strengthening routine immunization

All countries in the Region implemented activities aimed at ensuring high routine immunization coverage. Specific interventions were implemented in districts that had suboptimal routine immunization coverage and high numbers of non immunized children. Some of the interventions implemented in these areas included:

(a) improving implementation of the Reaching Every District (RED) strategy including micro-planning as well as supportive supervision, monitoring of vaccination sessions (both fixed and outreach) and using data for action;

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(b) ensuring resources for immunization strengthening including prioritizing GAVI resources for immunization system strengthening (ISS) and health system strengthening (HSS) in the high-risk, low coverage districts;

(c) implementation of multi-antigen local campaigns;

(d) increased routine immunization activities during African Vaccination Week (AVW);

(e) increased social mobilization activities to stimulate community demand for routine immunization activities.

Immunization personnel in the WHO African Region, supported by polio eradication funding, continued to support national authorities to implement strategies to improve routine immunization performance.

In Nigeria, specific activities were implemented in LGAs with high numbers of non-immunized children as well as in LGAs with confirmed cVDPV transmission.

During the last quarter of 2013, supervisory visits were conducted by WHO Nigeria immunization personnel to at least 500 routine immunization service delivery sites each month. The proportion of planned sessions that were actually conducted as well as the quality of each of the sessions monitored was assessed and feedback provided to health workers as well as LGA authorities for appropriate action. A monthly summary of routine immunization supportive supervision findings was also provided to the national authorities and partners to mobilize their support for any appropriate action.

Figure 11: Reasons for failure to conduct planned routine immunization sessions in high-risk LGAs in Nigeria, Oct-Dec 2013

In Chad, Democratic Republic of the Congo, Ethiopia and Uganda implementation of integrated routine immunization strengthening and polio eradication plans was closely monitored by national authorities and partners.

By the end of 2013, a total of 33 of the 47 countries in the WHO African Region reported OPV3 coverage of at least 80%

(see Annex 2). Reported immunization coverage varies significantly between and

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within countries. Data quality in several countries in the Region remains suboptimal with significant discrepancies between reported administrative immunization coverage data and data from immunization coverage surveys.

4.3 Supplemental immunization activities

In 2013, 500 million doses of oral polio vaccine (OPV) were administered during 85 rounds of polio eradication campaigns conducted in 24 countries in the WHO African Region. As indicated in Figure 12, a higher number of rounds were conducted in countries with confirmed poliovirus transmission in 2013 and in countries with increased risk of poliovirus importation.

Figure 12: Polio eradication SIAs conducted in the African Region in 2013 National authorities with the support of

partners gave specific attention to ensuring that the SIAs were of the highest quality and attained the highest coverage possible.

These efforts included activities aimed at i) enhancing local ownership and accountability by key leaders and stakeholders particularly in infected and high-risk areas; ii) improving the performance of front line vaccination teams through strengthened micro-planning, selection of vaccination team members, supportive supervision and monitoring; iii) special strategies to cover hard-to-reach, underserved and mobile communities;

and iv) enhancing community demand for immunization.

In Nigeria, increased focus was given to overcoming the barriers to high immunization coverage in LGAs with chronic suboptimal immunization coverage as well as in areas affected by insecurity. The president of Nigeria personally chaired two meetings of the Presidential Task Force on Polio Eradication in 2013.

These meetings were attended by governors of high-risk states and other key stakeholders who assessed progress in improving the quality of polio eradication activities in the states and LGAs at highest risk. There was a steady increase in the quality of SIAs in the highest risk LGAs in Nigeria in 2013 as shown in Figure 13.

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The main strategies implemented in Nigeria to improve immunization coverage in the highest risk areas included enhancing the involvement and oversight of all local political, traditional and community leaders; implementing the polio eradication accountability framework; improving quality of micro-planning and supportive supervision of vaccination teams; and enhancing the monitoring of vaccination teams including through the use of Geographic Information Systems (GIS) technology.

In the states and LGAs affected by insecurity in Northern Nigeria, the main strategies used to improve quality of SIAs included implementation of low visibility immunization activities aimed at reducing exposure of personnel to potential threats. These activities include the deployment of low visible permanent vaccination teams (PVTs) in insecure areas and the pre-positioning of vaccines and other logistics close to the insecure areas to facilitate implementation of opportunistic campaigns whenever the level of insecurity declined, a strategy referred to as “hit and run”. In the last quarter of 2013, almost 350 000 children were vaccinated in Borno by PVTs while nearly 1.1 million children were vaccinated during hit and run campaigns. In the insecure areas, emphasis was placed on ensuring closer collaboration between vaccination teams, local security authorities, local leaders and stakeholders as well as on promoting community demand for immunization.

Figure 13: Proportion of local government areas accepted at 80% coverage by lot quality assurance surveys conducted in 85 very high-risk LGAs in Nigeria, 2013

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In 2013, national authorities and partners continued to focus on ensuring high quality SIAs in all high-risk countries including countries that previously had re- established transmission. In Chad, the President continued to chair meetings to monitor the quality of polio eradication and routine immunization activities.

Special strategies aimed at ensuring highest quality implementation of SIAs in areas identified by standard risk assessment tools to be at increased risk for re- emergence of wild poliovirus transmission. Areas identified to be at increased risk include hard-to-reach areas, areas with insecurity, and areas with mobile populations including border areas. Efforts to implement cross border activities were conducted across international borders particularly in the West Africa, Central Africa and Horn of Africa subregions.

4.4 Outbreak response activities

The three countries that experienced polio outbreaks in 2013 implemented several rounds of large-scale outbreak response campaigns. Efforts undertaken to ensure that these rounds were of the highest quality particularly in the infected and high-risk areas included advocacy to enhance political ownership, deployment of additional technical support to highest risk areas and elaboration of national emergency outbreak response plans. Additional strategies used in outbreak countries included close coordination and support of polio outbreak activities through the implementation of national and subnational coordination and command centres that brought together government and other partners.

Operational strategies to enhance the effectiveness of outbreak response activities included the implementation of expanded age-group campaigns and campaigns targeting either the whole population (north-eastern Kenya) or all children up to age 10-15 years (Cameroon, Ethiopia and Kenya). In north-eastern Kenya, a combined OPV-IPV campaign was successfully conducted in a refugee camp in late 2013.

Lessons from 2013 polio outbreaks in the African Region

• Involvement of high-level government officials with decision-making authority early on in developing the emergency outbreak response plan was instrumental in facilitating effective implementation of the outbreak response.

• Establishment of outbreak response coordination and command centres with participation of appropriate government and partner staff served as effective mechanisms for monitoring outbreak response activities.

• Collection and review of data on the quality of immunization response as well as surveillance strengthening activities in the form of user-friendly dashboards were very useful in guiding outbreak response activities.

• The deployment of additional technical support to infected and high-risk areas during outbreak response is an opportunity to help address gaps in routine immunization and surveillance.

• Locally designed strategies ensure that all communities and families are accessed by vaccination teams, including through detailed micro-plans, and that there is appropriate community demand for vaccination.

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5. CERTIFICATION AND CONTAINMENT

The African Regional Certification Commission (ARCC) is an independent body appointed by the WHO Regional Director for Africa to oversee the certification and containment process in the African Region. The ARCC is expected to certify the African Region as polio free once the Region interrupts poliovirus transmission and maintains certification standard AFP surveillance for at least three years.

Figure 14: Participants at the 11th meeting of the African Regional Certification Commission, October 2013

Following the resurgence of

wild poliovirus transmission in the WHO African Region in 2008-2009, certification activities being overseen by the ARCC were temporarily halted. With the progress made in 2012-2013 towards interruption of wild poliovirus transmission, certification activities were resumed in 2013 in the Region. ARCC has been renewed and its membership expanded from 9 active members to currently 17 members appointed by the Regional Director. ARCC membership includes full members from three other WHO regions (Eastern Mediterranean,

South-East Asia and Americas).

Based on set criteria, ARCC selects countries to present complete national documentation for a polio-free status. ARCC has received and reviewed complete national documentation from 29 countries, 25 of which have been accepted (2 in IST Central Africa, 9 in IST West Africa, and 14 in IST East and Southern Africa). Twelve of the 25 countries with complete national documentation accepted by ARCC suffered WPV importations.

Phase 1 laboratory containment activities have been conducted in only 11 countries.

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In 2013, the ARCC had two meetings in June and October. The June meeting provided orientation for the newly appointed ARCC members. The October 2013 meeting reviewed and adopted a 2014 certification and containment workplan.

6. RESEARCH

Research was prioritized as a tool in reaching the goals and targets set for the polio eradication initiative (PEI) in the African Region. Two capacity-building workshops on operational research were conducted for participants from five English-speaking countries⁷ and six French-speaking countries.⁸ Participants were Ministry of Health (MoH) staff and personnel from the WHO Country Offices of the respective countries. Participants developed research proposals addressing prioritized PEI operational issues in their respective countries. These proposals were reviewed for technical and ethical appropriateness and funding.

Some of the research projects conducted within the WHO African Region with PEI support are discussed briefly below.

(a) Self-perceptions of vaccinators and supervisors in National Immunization Days in Angola. Key findings from this study include:

o Children are missed because vaccinators assume another member of the team will or has already covered a specific house;

o Planning of activities is not efficiently coordinated with vaccinators;

o Supervision is focused on the number of tally sheets filled and not painted fingers and door-to-door control;

o Some vaccinators join the SIAs because it enables them to be seen as important in the community;

o Some vaccinators participate to obey the request from a key community leader though they are not interested which results in poor performance and missed children.

(b) Reasons and circumstance for late notification of acute flaccid paralysis cases in health facilities in Angola. Some of the key findings from this study include:

o Ignorance and wrong perception of the etiology of the cases as well as dissatisfaction with the health units were the major reasons for late reporting of AFP cases;

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o The first health-care choice, for those who can afford the cost, is usually alternative health care from traditional healers or spiritualists because people believe that the problem is spiritually induced;

o The few who make it to health units are faced with ill equipped rural health workers who often must wait for many days for the arrival of more qualified staff;

o Given the anxiety and threat to the lives of their children, parents often opt for the quick and more responsive alternative medicine approaches.

(c) Reasons for polio vaccine refusals by parents in Chad. The key findings from this study include:

o A number of inter-related factors form the basis for the refusal of vaccination by populations in Chad;

o Rumours about the unclear intentions of government and vaccination officials were not addressed;

o Misunderstandings about the repetition of polio vaccinations because some persons already vaccinated suffered paralysis of the limbs;

o People argued that they have traditional ways of ensuring protection against diseases and these are not different from modern vaccinations;

o Unprofessional conduct of some vaccinators was a source of concern.

(d) Polio vaccine perceptions: a comparative study of acceptors and non- acceptors in Sokoto State, Nigeria. Key findings from this study include:

o Perceptions of benefits of the vaccine and susceptibility to the virus were found to influence oral polio vaccine acceptance;

o The opinion of family members about the oral polio vaccine moderated the relationship between a number of social ties and vaccine acceptance;

o Oral polio vaccine acceptance was related to outbreaks of paralysis of any sort but not aggregate scores of other preventative health behaviours.

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(e) Sero-prevalence study in Kano State, Nigeria. This health facility based study aimed to identify immunity gaps by evaluating antibody concentrations below and above the age of 5 years. These ages represent those recently vaccinated during routine and supplementary immunizations and those who had been vaccinated some time earlier.

(f) A study of AFP awareness of clinicians and health workers in Sokoto State of Nigeria was conducted. More than 50% of the 352 health workers were not aware of the AFP case definition, investigation and reporting system. However, the majority of those unaware of AFP had never been trained and worked in private hospitals. This implies that the awareness campaign should be extended to private hospitals to mitigate against delay in reporting cases of AFP. All the study participants were subsequently trained on these parameters.

(g) A current study is investigating the impact of an automatic telephone short message service (SMS) on the rate of reporting of AFP cases in Sokoto State of Nigeria. If the results show that SMS is faster or cheaper than the conventional method, this reporting system could be extended to surveillance of other diseases such as measles.

7. RESOURCES

Financial resources: The total required financial resources for polio eradication activities in the WHO African Region for 2013 were US$ 508.34 million. The breakdown of the required resources is as follows:

(a) acute flaccid paralysis surveillance: US$ 28.45 million;

(b) social mobilization: US$ 47.14 million;

(c) technical assistance: US$ 98.76 million;

(d) oral polio vaccine: US$ 111.04 million;

(e) operational costs for SIAs: US$ 222 million.

The required financial resources are mobilized from international partners and donors as well as governments in the Region. In 2013, a total of US$ 308 million mobilized from international donors was channeled through the WHO Regional Office for Africa. The source of these funds is shown in Figure 15 while the

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utilization of these funds according to the different programme components is shown in Figure 16.

Human resources: Technical support for the implementation of priority polio eradication activities in the countries in the Region was provided by WHO and other PEI partners. WHO provided various components of technical support. This included 848 positions for polio-funded core staff, 65% of which were in Angola, Democratic Republic of the Congo, Ethiopia and Nigeria. WHO also supported 2449 positions for polio-funded human resources surge capacity to assist priority countries; 95% of these positions are in Nigeria.

WHO Country Offices in the African Region also hosted technical support provided by the US Centers for Disease Control and Prevention i.e. STOP Consultants.

Figure 15: Financial resources from PEI partners for the African Region, 2013

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Figure 16: Financial resources by operational area, 2013

8. CONCLUSIONS AND PRIORITY ACTIONS

8.1. Conclusions

The WHO African Region registered progress in the priority areas of action identified at the end of 2012:

(a) close to 40% decline in number of paralytic polio cases due to infection with wild poliovirus;

(b) absence of confirmed WPV3 for more than 12 months;

(c) declining geographical and genetic diversity of wild poliovirus transmission in the remaining polio endemic country in the Region;

(d) close to 67% decline in number of paralytic polio cases due to infection with circulating vaccine-derived poliovirus;

(e) reported national routine immunization OPV3 coverage of at least 80%

in 33 countries in the Region;

(f) resumption of certification and containment activities in the Region.

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The progress noted in the WHO African Region in 2013 remains fragile because of continued gaps in population immunity and surveillance in infected and high-risk countries. Increasing insecurity in several infected and high-risk areas continues to have a negative impact on efforts to close the identified gaps in several areas in the Region.

The population immunity gaps are often compounded by population movements across international borders. This migration subsequently has resulted in international spread of poliovirus and new outbreaks.

8.2. Priority actions for 2014

Major priority actions for polio eradication activities in 2014 in the WHO African Region are to:

(a) further accelerate progress being made in closing the remaining population immunity gaps in Northern Nigeria and achieve interruption of transmission within the shortest time possible;

(b) enhance capacity to respond effectively to polio outbreaks and stop any new polio outbreaks within the shortest time possible;

c) mobilize and deploy required technical, financial and material support required to strengthen AFP field surveillance, environmental surveillance and the African Polio Laboratory Network;

(d) implement recommendations of the Strategic Advisory Group of Experts to introduce inactivated poliovirus vaccine into the national routine immunization schedule as well as continue the programme of work to improve routine immunization coverage in highest risk districts;

(e) implement priority certification and containment activities as included in the 2014 plan of action approved by the African Regional Certification Commission in October 2013;

(f) initiate implementation of polio legacy planning activities in the WHO African Region.

EXECUTIVE SUMMARY

2013

Contents

Abbreviations

FOREWORD

EXECUTIVE SUMMARY

1. BACKGROUND

2. STATUS OF POLIOVIRUS TRANSMISSION

3. POLIOVIRUS SURVEILLANCE

3.1. Acute flaccid paralysis surveillance activities

3.2. Environmental surveillance

3.3. Polio laboratory performance in the African Region

4. STOPPING POLIOVIRUS TRANSMISSION IN THE AFRICAN REGION

4.1. Overview of actions to stop poliovirus transmission

4.2 Strengthening routine immunization

4.3 Supplemental immunization activities

4.4 Outbreak response activities

5. CERTIFICATION AND CONTAINMENT

6. RESEARCH

7. RESOURCES

8. CONCLUSIONS AND PRIORITY ACTIONS

8.1. Conclusions

8.2. Priority actions for 2014