Concerns as polio cases surge globally
*Africa Regional Certification Commission begins verification visit to Nigeria
Nigeria’s quest to be certified polio-free by the World Health Organisation (WHO) has been shifted from December 2019 to June 2020. The country was supposed be certified polio free after not reporting any case of wild poliovirus (WPV) for three years- since August 2016.
But the target is threatened and the date shifted by the impact of circulating Vaccine-Derived Polio Virus type 2 (cVDPV2), poor rountine immunization, insecurity is some parts of northern Nigeria, and rise in cases of polio in the remaining polio endemic countries- Pakistan and Afghanistan- and some parts of Africa.
In West Africa and the Lake Chad sub-region, a cVDPV2 outbreak originating from Jigawa state, Nigeria, continues to spread. Following detection of this outbreak in Cameroon, Ghana, Benin and the Republic of Niger earlier this year and in 2018, the virus has now been detected in Chad, Togo and Côte d’Ivoire.
However, the Africa Regional Certification Commission (ARCC) for poliomyelitis eradication has kicked off, a two-week visit to Nigeria on December 9, 2019, to conduct critical analysis and verify the accuracy of the certification documents prepared by the Nigerian Government.
The independent commission has already accepted the documentation of 43 African countries as part of the process to certify the African Region free from all types of wild poliovirus, with only Cameroon, Central African Republic, Nigeria, and South Sudan remaining.No wild poliovirus has been detected anywhere in Africa since 2016. This stands in stark contrast to 1996, a year when wild poliovirus paralysed more than 75,000 children across every country on the continent.
The last wild poliovirus-caused paralysis was on detected on August 21 2016 in Nigeria, while the last environment sample with traces of the wild poliovirus was detected in Kaduna State from a sewage sample collected on May 5, 2014.Executive Director of National Primary Health Care Development Agency (NPHCDA), Dr. Faisal Shuaib, said: “The ARCC has invited Nigeria to present its final documentation to receive a wild polio-free status in June 2020. In this light, the ARCC has planned two field verification visits. The first is to the Southern States from 9 to 20 December 2019 and the second is to the Northern States, from 2 to 13 March 2020.”
The ARCC for Polio Eradication was appointed by the WHO African Regional Director to serve as the principal advisory body that reviews country-level certification reports submitted to it, and formulates recommendations for regional/country certification. ARCC members are charged with reviewing certification documentation from all 47 countries in the WHO African Region and verifying the absence of poliovirus in the presence of certification-standard surveillance. The commission meets biannually to review certification documentation and updates from countries in the region.
The primary requirements for the region’s certification include that no wild poliovirus transmissions are detected for a minimum of three consecutive years in all the region’s countries, coupled with having a high quality certification standard acute flaccid paralysis surveillance, a clinical symptom of poliomyelitis, in all countries for those three years. Other considerations include that countries maintain high immunization coverage for oral polio vaccine, as well as maintaining a robust national polio outbreak preparedness and response plan and a functional National Polio Certification Committee.
During the verification visit to Nigeria, nine ARCC members will assess the strides made so far in the fight against polio and deliberate on key resolutions in view of Nigeria’s polio status.The WHO Nigeria Team Lead, Expanded Programme on Immunization (EPI), Dr. Fiona Braka, said: “Having achieved the milestones of primary requirements, the ARCC will first review the complete documentation report of the interruption of wild poliovirus type 1 and then proceed to conduct field verification visits to select states in the south of Nigeria.
“If the ARCC is satisfied with the national documentation and field verification after both visits in December 2019 and March 2020, the WHO African Region could be certified to have eradicated polio by mid-2020.”
Meanwhile, according to the latest update from the Global Polio Eradication Initiative (GPEI), countries experiencing recent polio outbreaks saw no letup in activity, with Pakistan reporting five new wild poliovirus type 1 (WPV1) cases and four African nations, Pakistan, and the Philippines reporting more cVDPV2 cases.The WHO said the risk of further spread within Pakistan is high, due to population movement and low population immunity against type 2 poliovirus. It added that detection of the strain underscores the importance of maintaining high levels of routine polio vaccine coverage.
Regarding cVDPV2 in east and southern Africa, the WHO described the investigation into Zambia’s first cVDPV2 outbreak, which stands at one case, though two community contacts have tested positive. It notes that routine IPV coverage in children under age one was estimated at 36 per cent in 2018.
The WHO warned that risk of further spread in Africa remains high, due to cross-border movements, immunity gaps, inadequate surveillance, and waning mucosal immunity type 2 polio.But Shuaib said the cVDPV2 is not going to affect Nigeria’s journey to be certified polio free. He explained: “The reason why we have few cVDPV is because of poor routine immunisation and this is why our effort should quickly address that as we begin to move for results.
We need to stop open defecation because it leads to poor environmental sanitation. Open defecation leads to all round infection. So this is why the cVDPV is still here. Environmental sanitation is particularly poor, personal hygiene is suboptimal. This is why some types of infections are terrible.”
Does being certified polio free mean the end of polio? Shuaib said: “Without any shadow of doubt, certification means no more polio in Nigeria, what it means is that no child born in Nigeria would ever face the threat of being paralysed or killed by the wild poliovirus. So it is a significant milestone that we as Nigeria have been able to achieve…”
“We still have a few months before the documentation to officially certify Nigeria by 2020 as polio free. Of course there is lot of work that needs to be done and we will continue to face threat from other countries like Afghanistan and Pakistan that have not yet eradicated polio, but there is no more polio virus that will threaten our children forever, that is why at the Federal Ministry of Health (FMoH), we are excited. And we are counting down to when we will be certified polio free.
“We want to recognise that many years have gone by since we any case. We had journalist against polio, the media practitioners that were helping us fight those that said the polio vaccines were fake, it causes infertility and all of that, the media was very strong in helping us counter those misconceptions, and all other drugs that have been handled in the last few decades have brought us closer to success and we need to be proud of the work we have done in those years.
“When we are finally certified polio free, we want to assure you that each and everyone of you would be invited to that party at Aso Villa.”It is also feared that complacency could delay the final push to eradicate polio. Great strides have been made in the global effort to eradicate polio. Reported cases of wild poliovirus have decreased by over 99 percent from an estimated 350,000 cases in 1988 to 33 in 2018.
Polio is a highly infectious disease caused by a virus that invades the nervous system, and can cause total paralysis in a matter of hours. It is spread mainly through food and water that are contaminated with faecal matter. The goals to eradicate polio by 2000, then 2018, were both missed.
There are three strains of wild poliovirus: type 1, type 2 and type 3. Wild polio virus type 2 was eradicated in 2015. Most recently, the WHO announced that type 3 poliovirus had been eradicated. The goal of ending all three types of the virus is within reach. Only two countries, Afghanistan and Pakistan, still have poliovirus circulating in the environment and causing disease in patients.
Today it is easy to forget how common this disease once was and how it changed and ended lives. The danger in this is that complacency sets in and the strategies that were successful in fighting the disease – such as vaccination – are no longer followed. This has happened with other diseases. For example, measles has begun to recur in several countries even though it can be prevented through vaccination.
Steps are being taken to ensure that this does not happen with polio. Global leaders recently pledged US$2.6 billion as part of the first phase of the funding needed to eradicate the disease by 2023.
But it will take more than money to contain and eradicate it. It also requires constant vigilance.As the number of cases falls to near zero, the quantity of resources needed to eradicate it may appear disproportionate to the risk. But any breakdown in control efforts will undermine all achievements over the previous decades by leaving open the chance that a small number of cases becomes a large number again. This catastrophic scenario should be avoided. Maintaining polio-free status and going further to eradicate polio still requires considerable efforts from countries and regions.
Reducing polio to zero new cases in several regions of the world took decades of a global synchronised effort. A similar global effort resulted in the eradication of smallpox by 1979.Because polio is highly contagious, a single case in one country can undo decades of progress. It can spread across a country as well as across regions where it had previously been eliminated. The most important intervention to stop this from happening is to ensure high vaccination coverage.
Countries can be in danger of losing their polio free status if they are not vigilant. Take the case of South Africa as an example. The country was declared polio-free in 2006 but this was rescinded in 2017 as a result of challenges with several aspects of polio control. There were particular problems with surveillance and vaccination coverage. After these were addressed, South Africa regained its polio-free status in 2019.
To achieve polio eradication, all countries must reinforce disease surveillance and strengthen their immunisation programmes. The vaccines used for polio control are safe and effective but no less than 95 per cent of the population needs to be vaccinated.The GPEI co-ordinates the polio endgame strategy and has outlined the steps that should lead to polio eradication and subsequently maintain a polio-free world.
Tremendous resources are required to execute this strategy. When a disease is not highly visible, it is not always easy to convince stakeholders that the investment is worth it.But, building on lessons learned from the elimination of types 2 and 3 polioviruses as well as the eradication of smallpox in the 1970s, the dream of achieving a polio-free world is possible.