Remaining polio-free beyond July 2017

The die is cast. Nigeria is now in a make-or-mar situation in the quest for polio elimination. The country is now 11 months away from a possible polio free certification by the Global Polio Eradication Initiative (GPEI) led by the World Health Organisation (WHO).
CHUKWUMA MUANYA, Assistant Editor (Science and Technology), with publications from the GPEI, writes on what must be done for Nigeria to remain polio-free beyond July 24, 2017.

To be certified polio free, Nigeria needs to have had no case of wild polio for three consecutive years in the presence of high quality Acute Flaccid Paralysis (AFP) surveillance systems. The last wild poliovirus (WPV) type 3 case had onset of paralysis on November 10, 2012 and the last WPV type 1 case had onset on July 24, 2014. WPV type 2 has been eradicated globally after the last case reported from India had onset of paralysis on 24 October 1999.

However, no single country can be certified as polio-free; certification can only occur on a WHO regional basis. With four of six WHO regions already certified polio- free, only the Eastern Mediterranean and African regions remain to be certified in the path towards global eradication, and hence constitute a key priority for the GPEI.

The GPEI is a public-private partnership led by national governments and spearheaded by the WHO, Rotary International, the United States Centers for Disease Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF). Its goal is to eradicate polio worldwide.

July 24, 2016, marked two years with no case of wild poliovirus in Nigeria – a milestone for the polio eradication programme and an important step toward a polio-free world.

But critics insist that there is much still to be done. Nigeria and the African region need to protect the gains made and tackle continuing challenges to eliminate the risk of polio.

Last month marked the longest Nigeria has ever gone without a case of wild poliovirus, with the country taken off the list of polio-endemic countries in September 2015. Thanks to the hard work of the government, partners, community leaders, health workers and donors, this is the closest the country, and the world, has ever been to ending polio. This important milestone leaves the global community cautiously optimistic that ending polio in Nigeria, and the whole African continent, is within our grasp.

According to the latest edition of the Weekly Polio Update published by the GPEI, “no WPV1 cases have been reported in 2016. The most recent WPV1 case had onset of paralysis on July 24, 2014 in Sumaila Local Government Area (LGA), southern Kano state.

“No new environmental samples of circulating vaccine-derived poliovirus type 2 (cVDPV2) were reported this week. The most recent positive sample (and the only one in 2016) was collected in Maiduguri district of Borno state on March 23.

“Genetic sequencing of the isolated strain indicates it is most closely linked genetically to a cVDPV2 detected in 2013 in Borno, and was initially found in Chad in 2012.

“In Nigeria a series of large-scale outbreak response supplementary immunisation activities (SIAs) using monovalent oral polio vaccine type 2 (mOVP2) was initiated, following authorization and release of the vaccine from the global stockpile by the Director General of the WHO. The third vaccination round took place from July 9–16.”

The GPEI said a campaign using fractional dose inactivated polio vaccine (IPV) is planned for September 17 to 22, 2016, in high risk areas of Borno, to further boost immunity against all virus types including type 2.

According to the GPEI, the detection of the Borno isolate suggests that this cVDPV2 strain has circulated without detection for a prolonged period somewhere in the sub-region – either in Nigeria or in adjacent countries of the Lake Chad region. Due to this, synchronised Supplementary Immunisation Activities using mOPV2 taking place in Cameroon, Chad and Niger on 19–21 August and 9–11 September. The Director General of WHO approved release of the vaccine from the mOPV2 stockpile for these campaigns. This aims to boost immunity against type 2 VDPVs across the broader Lake Chad region as well as within Nigeria.

Also, Subnational Immunization Days (SNIDs) are planned for the 15-18 October 2016, in the north of Nigeria, using bOPV.

Indeed, innovation has underpinned the strong progress seen against polio in Nigeria, including novel strategies and the incredible commitment of tens of thousands of health workers. One hundred and fourteen mobile health teams, developed to access children in the most remote areas, now reach nearly 7,000 settlements across ten states with polio vaccines and other primary health care services. There must be a sustained focus on innovative solutions to issues such as accessibility that continue to leave children in remote areas vulnerable to retransmission of the virus.

The GPEI, however, cautioned that while two years with no wild polio in Nigeria is cause for celebration, it must not be a cause for complacency. The recent meeting of the Expert Review Committee (ERC) in Abuja highlighted that there is still a long way to. Polio eradication needs to be kept top of the priority list in Nigeria until the job is done completely and the entire African region certified polio-free.

President Muhammadu Buhari called for a reinvigoration of polio eradication efforts whilst receiving WHO representatives earlier this month, emphasizing that ‘‘… we have not recorded any case of polio in the last two years, but we should not be complacent. The breakdown of law and order in the North East has posed challenges to regular immunization. This vigilance at the highest level is paramount in ensuring that no child is forgotten in the fight against polio in Nigeria.”

Stakeholders insist that improving the scope of surveillance and immunization activities is vital if Nigeria is to be kept polio-free. At least one more year must pass without a case of wild poliovirus in order for the WHO African region to be certified polio-free.

The ERC highlighted the steps that need to be taken to progress towards certification. Investing in strengthening routine immunization must now be the priority of the government and partners in order to sustain the gains of the polio eradication programme and protect children against other vaccine-preventable diseases. It is imperative that these steps are taken in order to make sure that no child is left vulnerable and without adequate immunization

The GEI noted that eradicating polio in Nigeria is already benefitting the health of children across the country more broadly, and has the potential to do even more in the future. The Hard-to-Reach project, operating in high-risk states in Nigeria, exemplifies the wider health benefits that polio eradication efforts bring. The camps are built on the polio infrastructure but offer other services such as antenatal care, routine vaccines, basic medicines, screening for malnutrition and health education, targeting families that lack basic access to healthcare.

The GPEI said the celebration of two years without a case of wild polio in Nigeria must constitute a call to action to maintain momentum and ensure a polio free Nigeria. This is imperative, with the entire African region drawing closer to possibly being certified polio-free in 2017. “Ending polio in Nigeria will be a victory for the country and for children everywhere,” the GPEI noted.

Meanwhile, with nearly two years since the last case of wild polio on the continent, the Africa Regional Certification Commission has met to review progress.

The annual meeting of the Africa Regional Certification Commission (ARCC) for the Eradication of Polio took place in Algeria from June 27– July 1, 2016 to assess progress towards the certification of the African region as polio-free. A Secretariat comprised of representatives of the WHO from the African region chaired the meeting of 47 African Member states, represented by National Polio Committees.

The meeting marked good progress towards certifying the region free of wild poliovirus, with complete documentation submitted by Niger, Chad and Mozambique. This indicates that these countries can provide certification standard evidence of three consecutive years without transmission of the virus and have strong surveillance networks in place. The remaining countries are scheduled to submit documentation in the year ahead. The meeting also reviewed progress reports from Algeria, Cape Verde, Gabon and Ethiopia.

The ARCC commended the successful switch from trivalent to bivalent OPV, and the timely submission of validation reports that highlight the progress made at a national level towards meeting the criteria of the ARCC for immunisation and surveillance activities. However, the Commission expressed concern over the global shortage of the inactivated poliovirus vaccine (IPV), an ongoing issue that the WHO and its partners are working to resolve.

Despite the high number of countries that have successfully submitted their documentation to the ARCC, major challenges remain. The ARCC flagged the inadequate surveillance quality and sub-optimal population immunity assessed though vaccination coverage in some countries, which need to be resolved in order for certification to be achieved.

While progress has been made in improvements to routine immunisation coverage at the national level, concerns remain about low population immunity and surveillance gaps in more vulnerable areas at the sub national levels. Overcoming these challenges requires urgent action from Member States, alongside the continuing support of partners from across the Global Polio Eradication Initiative. It is not just for certification that momentum must be maintained; it is imperative to prevent Africa being re-infected by the virus spreading from Pakistan or Afghanistan, again paralysing children in Africa. We must redouble our efforts to reach every child in the African region so as to avoid setbacks in the progress made against the virus so far.

The ARCC highlighted the steps necessary to build on the progress towards certifying Africa polio-free. It is imperative that countries that have yet to be certified continue to drive momentum towards polio eradication, and are diligent in the submission of the comprehensive national documentation required. The Commission stressed that in light of the recent switch to bivalent OPV, countries must redouble efforts to strengthen immunization system, particularly at subnational levels where coverage is lower. Containment most also remain a top priority to support the certification process; countries must finalise the second phase of containment according to GAP III, the WHO Global Action Plan to minimize poliovirus facility-associated risk after the eradication of certain types of wild polioviruses and the phasing out of oral polio vaccine use.

The GPEI insists that with nearly two years since the last case of wild polio on the African continent, there is still much to do in order to certify the Region. Only by vaccinating every last child and finding every last virus even in the countries no longer with endemic poliovirus will we reach the goal of being polio-free across the African continent.