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Progress Toward Poliomyelitis Eradication -- Eastern Mediterranean Region, 1996-1997

In 1988, the Regional Committee of the Eastern Mediterranean Region (EMR) * of the World Health Organization (WHO) adopted a resolution to eliminate poliomyelitis from the region by 2000. This report summarizes progress toward this goal in EMR countries through June 30, 1997 (1), and indicates that nearly all countries in the EMR are conducting National Immunizations Days (NIDs) ** and that surveillance for acute flaccid paralysis (AFP) is improving rapidly.

Routine vaccination coverage. In 1996, a total of 21 of 23 member countries reported routine vaccination coverage; among all reporting countries combined, routine coverage with at least three doses of oral poliovirus vaccine (OPV3) by age 1 year was 85% (range: 49%-100%), an increase compared with coverage during 1993-1995 (79%, 78%, and 80%, respectively). OPV3 coverage was greater than or equal to 90% in 17 (73%) countries. However, reported OPV3 coverage was 80% in Sudan, 79% in Pakistan, 54% in Yemen, and 49% in Djibouti. Coverage data were not available for Afghanistan and Somalia, where estimated OPV3 coverage was less than 50%.

Supplemental immunization activities. NIDs were conducted in two countries (Egypt and Syria) in 1993, five countries (Egypt, Iran, Pakistan, Sudan, and Syria) in 1994, and 18 countries in 1995. During 1996 and early 1997, except for Cyprus and Somalia, all countries in the region conducted NIDs; these included NIDs in Yemen, the first national campaigns in Afghanistan and Djibouti, and resumption of NIDs in Sudan. During the 1996-1997 NIDs, 13 countries reported achieving coverage rates of greater than or equal to 95% in each round, and two countries (Djibouti and United Arab Emirates) reported coverage rates of less than 90% in each round. In addition to coordinated campaigns in countries within EMR subregions, NIDs in several countries have been coordinated with countries in the European Region under "Operation MECACAR," and the last NIDs in Pakistan were coordinated with the campaigns in Southeast Asia (2,3).

Surveillance. By 1996, all member countries (except Afghanistan, Somalia, and Yemen) had established AFP surveillance. From 1995 through June 1997, eight countries (Bahrain, Iran, Jordan, Kuwait, Oman, Saudi Arabia, Syria, and Tunisia) have achieved or exceeded the WHO-established minimum AFP reporting rate indicative of a sensitive surveillance system ( greater than or equal to 1 nonpolio AFP case per 100,000 children aged less than 15 years) (Table_1). Egypt and Morocco are approaching the minimum level of sensitivity. The regional average rate for nonpolio AFP in 1996 was 0.7 cases per 100,000 population (range: 0-1.6), compared with 0.2 in 1993 when AFP surveillance was initiated in the region. During 1997, a total of 11 countries, including Cyprus, Iraq, and Palestine, have reached or exceeded the expected rate of nonpolio AFP. From 1996 through June 30, 1997, two adequate stool samples *** were collected from 63% of the reported AFP cases in EMR, compared with 45% in 1995 (Table_1). During 1996 and 1997, Bahrain, Cyprus, Egypt, Jordan, Oman, and Palestine achieved the WHO-recommended target of two adequate stool specimens collected from at least 80% of AFP cases.

EMR laboratory network. The EMR laboratory network comprises 12 laboratories (eight national and four regional reference laboratories). During 1996, AFP cases from 17 of the 20 EMR countries also were investigated in the laboratory. Of all the AFP cases reported during 1996, 92% were investigated in a network laboratory, compared with 75% in 1995. The regional average nonpolio enterovirus (NPEV) isolation rate (an indicator of the adequacy of laboratory technique and specimen handling) increased from 1995 (11%) to 1996 (12%), compared with 7% in 1994 (the WHO-recommended target is an NPEV isolation rate of at least 10% from stool specimens). Four laboratories (the regional reference laboratory in Egypt and national laboratories in Iran, Sudan, and Syria) achieved the target in 1996. Of the 10 laboratories that underwent proficiency testing during 1996, nine rated a passing score (80%), compared with seven of the 10 laboratories in 1995. Laboratory results were reported on time (within 28 days of receipt of specimen) for 53% of stool specimens during 1996, compared with 46% during 1995.

Incidence of polio. From 1988 to 1996, the number of confirmed cases of polio reported in the EMR decreased 77%, from 2342 to 532. Of 23 EMR countries, 15 reported zero cases during 1996 (Table_1), including two (Saudi Arabia and Syria) that reported zero cases for the first time. Pakistan continued to report the largest number of cases of any country and, during 1995 and 1996, accounted for approximately two thirds of all cases in the region. In addition to Pakistan, during 1996, five other countries reporting cases included Egypt (19%), Sudan (10%), Iraq (4%), Iran (2%), and Yemen (1%). However, during 1996, reports were not received for all periods from Afghanistan, Somalia, and Yemen, and information provided by nongovernmental organizations and other sources suggests that wild poliovirus may be widely endemic in these countries.

Through June 30, 1997, cases of polio have been confirmed in Pakistan (37), Iraq (20), Iran (15), Egypt (seven), and Sudan (two). In Iran, 27 virologically confirmed cases were detected from April 1996 through April 1997; however, some of these cases have been linked to importation of wild virus from neighboring countries with endemic polio.

Although wild poliovirus type 2 was not isolated in EMR during 1995 and 1996, isolates have been identified in three cases associated with an outbreak in Pakistan in 1997. Of the 146 wild poliovirus type 1 isolates reported in 1996, 92 were from Egypt, 37 from Pakistan ****, 11 from Iran, and six from Sudan. Wild poliovirus type 3 isolates were reported from these countries, including Egypt (eight), Pakistan (two), and Iran (one).

Reported by: Expanded Program on Immunization, Regional Office for the Eastern Mediterranean Region, Alexandria, Egypt. Global Program for Vaccines and Immunization, World Health Organization, Geneva, Switzerland. Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Polio Eradication Activity, National Immunization Program, CDC.

Editorial Note

Editorial Note: Because of persistent problems with routine vaccination delivery, increased reliance has been placed on high-quality supplementary vaccination campaigns to rapidly interrupt wild poliovirus transmission in several EMR countries. As of June 1997, all countries in EMR, except Cyprus and Somalia, have conducted NIDs, with reported coverage rates of greater than or equal to 90% in nearly all countries. During 1996-1997, NIDs also were conducted in Afghanistan, Sudan, and Yemen despite ongoing civil unrest and/or substantial logistical constraints. Subnational immunization days targeting children in the accessible parts of northern Somalia are planned for late 1997.

The quality of AFP surveillance in most EMR countries has improved substantially since 1993. The most rapid progress occurred during 1995 and 1996, especially in Egypt, Iran, Iraq, Pakistan, Saudi Arabia, and Syria. The EMR laboratory network is well established and is able to provide virologic information to the national immunization programs for targeting prevention and control activities.

The incidence of polio is at record low levels in EMR, and polio-free zones are beginning to emerge in the western part of north Africa, the Arab Gulf subregion, and the Middle East. However, the risk for importations of wild poliovirus continues to challenge those countries in EMR and geographically contiguous areas that have either become polio-free or have reduced virus transmission to very low levels. Interregional and intercountry activities are ongoing to coordinate and synchronize surveillance and vaccination campaigns in key border areas and in countries with similar patterns of poliovirus transmission (2,3). However, despite several years of NIDs in Egypt and Pakistan, widespread circulation of wild poliovirus persisted in 1996, and in Pakistan, two outbreaks of polio were identified during 1997; in these two countries, cases occurred primarily among undervaccinated or unvaccinated children.

The governments of EMR countries have provided the largest share of the resources needed for polio eradication in the region. In addition, critical technical and financial support have been provided by WHO; United Nations Chidren's Fund (UNICEF); and other partner agencies, especially CDC, Rotary International, the government of Japan, ODA (government of the United Kingdom), and DANIDA (government of Denmark).

EMR priorities to achieve polio eradication by 2000 include 1) ensuring that high-quality NIDs are conducted in countries with persistent wild poliovirus circulation and low vaccination coverage, particularly in countries experiencing ongoing armed conflict and/or with severe political and administrative constraints; 2) establishing and strengthening sensitive and effective AFP surveillance systems in Afghanistan, Somalia, and Yemen and other EMR countries where these systems remain rudimentary; 3) implementing coordinated AFP surveillance and supplementary vaccination activities among key border area populations; 4) strengthening political commitment to ensure that NIDs are continued annually in countries that have become polio-free and that the sensitivity and quality of AFP surveillance continues to improve in all EMR countries; 5) maintaining and strengthening the political commitment of governments for polio eradication; and 6) consolidating support of donor governments and partner agencies for the financial and human resources needed to successfully implement polio-eradication strategies in the region.

References

  1. CDC. Progress toward poliomyelitis eradication -- Eastern Mediterranean Region, 1988-1994. MMWR 1995;44:809-11,817-8.

  2. CDC. Update: mass vaccination with oral poliovirus vaccine -- Asia and Europe, 1996. MMWR 1996;45:911-4.

  3. CDC. Update: progress toward poliomyelitis eradication -- South East Asia Region, 1995-1997. MMWR 1997;46:468-73.

* Member countries are Djibouti, Egypt, Libya, Morocco, Somalia, Sudan, and Tunisia in northern and eastern Africa; the Arab Gulf states of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen; Iraq, Jordan, Lebanon, Syria, and the Palestinian people in the Middle East; Afghanistan, Iran, and Pakistan in Asia; and Cyprus. 

** Mass campaigns over a short period (days to weeks) in which two doses of oral poliovirus vaccine are administered to all children in the target age group (usually age less than 5 years) regardless of previous vaccination history, with an interval of 4-6 weeks between doses. 

*** Two stool specimens collected at an interval of at least 24 hours within 14 days of onset of paralysis. 

**** Complete data on characterization of polioviruses isolated during 1996-1997 in Pakistan are pending, including all type 3 strains from 1997.



    Table_1
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    TABLE 1. Number of reported cases of acute flaccid paralysis (AFP) and confirmed poliomyelitis* and key surveillance indicators, by country -- Eastern
    Mediterranean Region, World Health Organization, 1996-June 1997
    =========================================================================================================================================================================================
                                                             1996                                                                               1997
                          ------------------------------------------------------------------------------     --------------------------------------------------------------------------------
                                                                                     % AFP cases with                                                                   % AFP cases with two
    Country               No. AFP cases    No. confirmed cases   Nonpolio AFP rate+  two stool specimens &   No. AFP cases   No. confirmed cases  Nonpolio AFP rate @      stool specimens
    -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Afghanistan                  2                    NR **                NR                  NR                NR                    NR                  NR                      NR
    Bahrain                      2                     0                  1.0                100%                 1                     0                 1.0                    100%
    Cyprus                       1                     0                  0.4                100%                 3                     0                 3.0                      NR
    Djibouti                     0                   100                    0                   0                NR                    NR                  NR                      NR
    Egypt                      309                    12                  0.9                 85%                76                     7                 0.6                     86%
    Iran                       472                    21                  1.6                 66%               193                    15                 1.3                     69%
    Iraq                        59                     0                  0.4                 39%                95                    20                 1.7                     75% ++
    Jordan                      20                     0                  1.0                 85%                15                     0                 1.6                     87%
    Kuwait                      10                     0                  1.6                 60%                 8                     0                 2.6                     38%
    Lebanon                      5                     0                  0.4                 60%                 2                     0                 0.3                     50%
    Libya                        2                     0                  0.1                 50%                 2                     0                  NR                      NR
    Morocco                     76                     0                  0.8                 42%                36                     0                 0.7                     38%
    Oman                        10                     0                  1.6                 90%                 5                     0                 1.6                    100%
    Pakistan                   546                   341                  0.3                 56% ++            402 ++                 37                  NR                     58% ++
    Palestine                    8                     0                  0.6                 75%                 7                     0                 1.1                     85%
    Qata                         1                     0                  0.5                   0                 3                     0                 3.0                       0
    Saudi Arabia                75                     0                  1.0                 60%                48                     0                 1.3                     63% ++
    Somalia                     NR                    NR                   NR                  NR                 1                     1                  NR                      NR
    Sudan                       54                    51                 <0.1                 35%                15                     2                <0.1                     57%
    Syria                       76                     0                  1.2                 67%                47                     0                 1.5                     62%
    Tunisia                     41                     0                  1.4                 44%                18                     0                 0.9                     61%
    United Arab                  0                     0                    0                   0                NR                    NR                  NR                      NR
    Emirates
    Yemen                        7                     7                    0                   0                NR                    NR                  NR                      NR
    
    Total                     1776                   532                  0.7 &&              63%               977                    82               0.9@@                     64% ***
    -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    *   A confirmed case of polio is defined as AFP and at least one of the following: 1) laboratory-confirmed wild poliovirus infection, 2) residual
        paralysis at 60 days, 3) death, or 4) no follow-up investigation at 60 days.
    +   Number of AFP cases per 100,000 population aged <15 years. Minimum expected rate is one case of nonpolio AFP per 100,000 per year.
    &   Two stool specimens collected at an interval of at least 24 hours within 14 days of paralysis onset from 80% or more of AFP cases.
    @   Annualized nonpolio AFP rate.
    **  Not reported.
    ++  Based on quarterly reports from the Regional Reference Poliovirus Laboratory in Pakistan.
    &&  Excludes from denominator the expected nonpolio AFP cases from Afghanistan, Somalia, and Yemen.
    @@  Excludes from denominator the expected nonpolio AFP cases from Pakistan since final classification of most cases is pending.
    *** Countries that did not report surveillance indicator data are excluded from the denominator.
    =========================================================================================================================================================================================
    

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