Statement of the Twenty-Seventh Polio IHR Emergency Committee - World Health Organization

by who.int 02/19/2021

The twenty-seventh meeting of the Emergency Committee under the International Health Regulations (2005) (IHR) on the international spread of poliovirus was convened by the WHO Director-General on 1 February 2021 with committee members and advisers attending via video conference, supported by the WHO Secretariat.  The Emergency Committee reviewed the data on wild poliovirus (WPV1) and circulating vaccine derived polioviruses (cVDPV).  The following IHR States Parties provided an update at the video conference on the current situation in their respective countries: Afghanistan, Burkina Faso, the Republic of the Congo, Côte d’Ivoire, Egypt, the Islamic Republic of Iran, Liberia, Madagascar, Mali, Sierra Leone and Pakistan and Tajikistan.Wild poliovirusThe committee noted that the rising incidence of global WPV1 cases seen since 2019 may have peaked with 140 cases with onset of illness in 2020 as at 21 January 2021 compared to the 137 cases that had occurred in 2019 as reported at 21 January 2020.  While in Pakistan the number fell from 111 cases to 84, it is not clear that this is going to be sustained, while the number in Afghanistan had more than doubled from 26 to 56.  Transmission persists in the core reservoirs of Karachi and Quetta Block in Pakistan and in Southern Afghanistan and has expanded to previously polio-free areas such as North Sindh and South Punjab in Pakistan and the Western and Northern regions in Afghanistan. The increase in Afghanistan is likely due to the growing cohort of missed children throughout the country due to local vaccination bans and the effect of COVID-19. The number of positive environmental samples has increased from 463 in 2019 to 503 so far in 2020. The Committee noted that based on results from sequencing of WPV1 since the last committee meeting in October 2020, there were further instances of international spread of viruses from Pakistan to Afghanistan.  The ongoing frequency of WPV1 international spread between the two countries and the increased vulnerability in other countries where routine immunization and polio prevention activities have both been adversely affected by the COVID-19 pandemic are two major factors that suggest the risk of international spread may be at the highest level since 2014.  While border closures and lockdowns may mitigate the risk in the short term while in force, this would be outweighed in the longer term by falling population immunity through disruption of vaccination and the resumption of normal population movements.Circulating vaccine derived poliovirus (cVDPV) The committee was very concerned that cVDPV2 continues to spread rapidly.  The number of cases in 2020 is 1009 (year to date), 254% higher than the total for 2019.  As in all the years following 2016 when OPV2 was withdrawn, the number of cVDPV2 cases globally has been greater than the number of WPV1 cases. The Global Polio Laboratory Network routinely analyzes and tracks vaccine derived polioviruses just as it does wild polioviruses, to assist the polio program identify the patterns of spread and thereby provide opportunities to limit or prevent the circulation.  In the most recent quarterly routine analysis (July to September 2020) there has been evidence of exportation of cVDPV2 from:Pakistan to AfghanistanSudan to EgyptAfghanistan to IranCôte D’Ivoire to MaliBenin to NigeriaAfghanistan to PakistanChad to SudanChad into CameroonCôte D’Ivoire and Togo to Burkina FasoSomalia to EthiopiaBurkina Faso to MaliAngola to Republic of CongoChad and Sudan to Republic of South SudanEthiopia to SomaliaMore recently, in addition to the exportation of cVDPV2 to Egypt and the Republic of the Congo mentioned above, in West Africa, cVDPV2 that has been circulating in Côte d’Ivoire has now been found in sewage in Liberia, and similarly cVDPV2 previously found in Guinea has now caused an outbreak with at least three cases so far in Sierra Leone.  Following the earlier event in September 2020 where virus circulating in Darfur in Sudan was detected in sewage in Giza, Cairo, a second exportation has been detected in sewage in Alexandria in Egypt with links to the cVDPV2 found in the River Nile state in Sudan, and one detection in each of Anwan and Qena in southern Egypt linked to Alexandria.  The cVDPV2 virus causing the large outbreak in Afghanistan has now been detected in Sistan and Baluchistan province of the Islamic Republic of Iran, where it has been found in sewage in two districts on three separate occasions.  It has also been detected in two AFP cases in Tajikistan.However, the number of lineages detected so far in 2020 is 35, compared to 44 for the whole of 2019, and the number of newly emerged viruses is only 13 so far in 2020, compared to 38 during 2019.  This reduction may reflect refinement and modification of cVDPV2 outbreak management to lessen the risk of seeding new emergences. The committee noted that novel OPV2 (nOPV2) has received an interim recommendation for use under WHO’s Emergency Use Listing procedure (EUL) to enable rapid field availability, and potential wider rollout of the vaccine.  The EUL involves careful and rigorous analysis of existing data to enable early, targeted use of unlicensed products for a Public Health Emergency of International Concern.  WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) endorsed accelerated clinical development of novel OPV2 and its assessment in October 2019.COVID-19The committee was concerned that COVID-19 continues to have an impact on polio eradication at many levels.  Many of the polio affected countries are currently experiencing a second wave of COVID-19, notably Malaysia, Pakistan and Nigeria. Although resumption of SIAs is now a major focus of the polio program the effect of the pause in 2020 and the current second wave will hamper this resumption. There are ongoing signs of the impact of COVID-19 on surveillance, particularly with slow shipment and handling and reporting of samples for polio testing.   All these factors serve to heighten the risk of polio transmission.The committee noted that since the beginning of the pandemic, the value of polio-funded staff and assets contributed to the COVID-19 response in more than 50 countries is estimated at USD $104 million. In view of the overwhelming public health imperative to end the COVID-19 pandemic, the POB has committed to the polio program’s continued support for the next phase of COVID-19 response, COVID-19 vaccine introduction and delivery, through existing assets, infrastructure and expertise in key geographies.ConclusionThe Committee unanimously agreed that the risk of international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC) and recommended the extension of Temporary Recommendations for a further three months.  The Committee recognizes the concerns regarding the lengthy duration of the polio PHEIC, but concludes that the current situation is extraordinary, with clear ongoing and increasing risk of international spread and ongoing need for coordinated international response. The Committee considered the following factors in reaching this conclusion: Rising risk of WPV1 international spread:  Based on the following factors, the risk of international spread of WPV1 appears to be currently very high:transmission in Pakistan and Afghanistan remains high noting that the small decrease in Pakistan is yet to be sustained, and in Afghanistan case numbers have doubled;expansion of WPV1 transmission into previously polio free areas in both countries and rising positive environmental samples in both endemic countries;the ongoing inaccessibility in many provinces of Afghanistan leading increasingly to highly susceptible populations which are and will continue to drive higher transmission; over 3 million children were missed in the October and November NIDs, and the cohort of missed children continues to grow quickly;ongoing vaccine hesitancy in Pakistan leading to higher numbers of missed children particularly in high risk districts;the fall in population immunity consequent on the four months pause in polio vaccination necessitated by the COVID-19 pandemic, leading to greater susceptibility to poliovirus importation and outbreaks in high risk countries; the complicated context of WPV eradication activities in Afghanistan and Pakistan created by the need to simultaneously respond to cVDPV2 and COVID-19;the second wave of COVID-19 that appears to be currently under way in many polio affected countries making interventions more difficult;the difficulties in supplying vaccines due to the pandemic (as is being seen in Yemen, for example). Rising risk of cVDPV2 international spread:Based on the following factors, the risk of international spread of cVDPV2 appears to be currently very high:The increasingly large number of cases, environmental detections and documented exportations across borders to both new countries and already infected countries;The ever widening gap in population intestinal mucosal immunity in young children since the withdrawal of OPV2 in 2016;The same factors regarding the COVID-19 pandemic as mentioned above;The population of inaccessible children in Afghanistan that appears to be driving intense transmission there.Other factors includeWeak routine immunization: Many countries have weak immunization systems that can be further impacted by various humanitarian emergencies including COVID19, and the number of countries in which immunization systems have been weakened or disrupted by conflict and complex emergencies poses a growing risk, leaving populations in these fragile states vulnerable to outbreaks of polio.Lack of access: Inaccessibility continues to be a major risk, particularly in several countries currently infected with WPV or cVDPV, i.e. Afghanistan, Nigeria, Niger, Somalia and Myanmar, which all have sizable populations that have been unreached with polio vaccine for prolonged periods.Population move


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