| 05 Mars 2015
The fourth meeting of the Emergency Committee under the International Health Regulations (IHR) (2005) regarding the international spread of wild poliovirus in 2014 - 15 was convened via teleconference by the Director-General on 17 February 2015. The following IHR States Parties submitted an update on the implementation of the Temporary Recommendations since the Committee last met on 13 November 2014: Cameroon, Equatorial Guinea, Pakistan and the Syrian Arab Republic.
The Committee noted that the international spread of wild poliovirus has continued with one new exportation from Pakistan into neighbouring Afghanistan documented after 13 November 2014. Although there is seasonal decline in the number of reported cases in Pakistan, transmission is ongoing in each of the four provinces and the Federally Administered Tribal Areas. The Committee assessed the risk of international spread from Pakistan to be sustained. The Committee appreciated that Pakistan has prepared a new robust ‘low season’ vaccination plan, established national and provincial emergency operations centres, and resumed campaigns in South and North Waziristan. Nonetheless, the principle factors underpinning the international spread of wild poliovirus from Pakistan have not yet changed sufficiently since the date of the third meeting of the Emergency Committee on 13 November 2014.
There has been no other documented international spread of wild poliovirus since March 2014. Although the risk of new international spread from the nine other infected Member States appears to have declined, the possibility of international spread still remains a global threat worsened by the expansion of conflict-affected areas, particularly in the Middle East and Central Africa. Furthermore, countries affected by conflict inevitably experience a decline in health service delivery that leads to deterioration of immunization systems in a number of such at-risk countries
The Committee assessed that the spread of polio still constitutes a Public Health Emergency of International Concern and recommended the extension of the Temporary Recommendations for a further 3 months. The committee considered the following factors in reaching this unanimous conclusion:
1. The continued international spread of wild poliovirus through 2014;
2. The risk and consequent costs of failure to eradicate globally one of the world’s most serious vaccine preventable diseases;
3. The continued necessity of a coordinated international response to stop the international spread of wild poliovirus and to prevent new spread with the onset of the high transmission season in May/June 2015;
4. The serious consequences of further international spread for the increasing number of countries in which immunization systems have been disrupted by armed conflict and complex emergencies. Populations in these fragile states are vulnerable to infection and outbreaks of polio which are exceedingly difficult to control;
5. The importance of a regional approach and cooperation as much international spread of polio occurs over land borders.
The Committee sincerely appreciated the efforts that all countries have made in response to the temporary recommendations and reviewed the progress against the criteria previously established by the Committee for countries to respond to under the IHR. The Committee remains concerned that implementation of the Temporary Recommendations is incomplete in all affected countries, many of whom are affected by regional conflicts.
The Committee provided the Director-General with the following advice aimed at reducing the risk of international spread of wild poliovirus, based on an updated risk stratification of the 10 countries that had earlier met the criteria for ‘States currently exporting wild poliovirus’ or ‘States infected with wild poliovirus but not currently exporting ‘. A third risk category has been added by the Committee for ‘States no longer infected by wild poliovirus, but which remain vulnerable to international spread’. The committee also noted the feedback from the four exporting countries that highlighted the challenges of implementing polio eradication measures in situations where there is significant cross-border population movement, often across long borders and common epidemiological blocks. The committee therefore recommended that countries apply a regional approach and develop joint immunisation strategies with neighbouring countries.
States currently exporting wild poliovirus
Cameroon (until 11 March), Equatorial Guinea (Until 4 April), Syrian Arab Republic (until 17 March) and Pakistan should:
• Officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency; where such declaration has already been made, this emergency status should be maintained.
• Ensure that all residents and long-term visitors (i.e. > 4 weeks) receive a dose of OPV or inactivated poliovirus vaccine (IPV) between 4 weeks and 12 months prior to international travel;
• Ensure that those undertaking urgent travel (i.e. within 4 weeks), who have not received a dose of OPV or IPV in the previous 4 weeks to 12 months, receive a dose of polio vaccine at least by the time of departure as this will still provide benefit, particularly for frequent travellers;
• Ensure that such travellers are provided with an International Certificate of Vaccination or Prophylaxis in the form specified in Annex 6 of the International Health Regulations (2005) to record their polio vaccination and serve as proof of vaccination;
• Intensify cross-border coordination to enhance surveillance for prompt detection of poliovirus and substantially increase vaccination coverage among refugees, travellers and cross-border populations;
• Maintain these measures until the following criteria have been met: (i) at least 6 months have passed without new exportations and (ii) there is documentation of full application of high quality eradication activities in all infected and high risk areas; in the absence of such documentation these measures should be maintained until at least 12 months have passed without new exportations.
The committee noted that by 11 March, 17 March and 4 April 2015, 12 months would have elapsed since any documented exportation from Cameroon, Syria and Equatorial Guinea, respectively 1. On these dates, should no further exportations occur, Cameroon and Equatorial Guinea will meet the criteria for States infected with wild poliovirus but not currently exporting and would be subject to the recommendations for this category of risk. Syria will meet the criteria for ‘States no longer infected by wild poliovirus, but which remain vulnerable to international spread’.
Given the continued risk of international spread, both Cameroon and Equatorial Guinea should give special attention to:
• Enhancing regional cooperation and cross border coordination to ensure prompt detection of wild poliovirus and vaccination of refugees and mobile population groups.
Pakistan should in addition:
• Restrict at the point of departure the international travel of any resident lacking documentation of appropriate polio vaccination. These recommendations apply to international travellers from all points of departure, irrespective of the means of conveyance (e.g. road, air, sea);
• Note that the recommendation stated previously for urgent travel remains valid (i.e. those undertaking urgent travel who have not received appropriate polio vaccination must receive a dose of polio vaccine at least by the time of departure and be provided with appropriate documentation of that dose);
• Continue to provide to the Director-General a report on the implementation by month of the Temporary Recommendations on international travel, including the number of residents whose travel was restricted and the number of travellers who were vaccinated and provided appropriate documentation at the point of departure.
• Recognising that the movement of people across the border with Afghanistan continues to facilitate exportation of wild poliovirus, Pakistan should intensify cross border efforts by improving coordination with Afghanistan to substantially increase vaccination coverage of travellers crossing the border and of high risk cross-border populations.
States infected with wild poliovirus but not currently exporting
Afghanistan, Nigeria, Somalia, Ethiopia (until 16 March), Iraq (until 19 May), and Israel (until 28 April), should:
• Officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency; where such declaration has already been made, this emergency status should be maintained.
• Encourage residents and long-term visitors to receive a dose of OPV or IPV 4 weeks to 12 months prior to international travel; those undertaking urgent travel (i.e. within 4 weeks) should be encouraged to receive a dose at least by the time of departure;
• Ensure that travellers who receive such vaccination have access to an appropriate document to record their polio vaccination status;
• Intensify cross-border coordination to enhance surveillance for prompt detection of poliovirus and substantially increase vaccination coverage among refugees, travellers and cross-border populations;
• Maintain these measures until the following criteria have been met: (i) at least 6 months have passed without the detection of wild poliovirus transmission in the country from any source, and (ii) there is documentation of full application of high quality eradication activities in all infected and high risk areas; in the absence of such documentation these measures should be maintained until at least 12 months without evidence of transmission.
• Given the continued risk of international spread, enhance regional cooperation and cross border coordination to ensure prompt detection of wild poliovirus and vaccination of refugees and mobile population groups.
The Committee noted that by 16 March, 28 April 2015 and 19 May, 12 months would have elapsed since the detection of wild poliovirus in Ethiopia, Israel and Iraq respectively. Should there be no further detection of wild poliovirus up to these dates, Ethiopia, Iraq and Israel will meet the criteria for ‘States no longer infected by wild poliovirus, but which remain vulnerable to international spread.’
States no longer infected by wild poliovirus, but which remain vulnerable to international spread
Should there be no further detection of wild poliovirus in Ethiopia by 16 March, in Syria by 17 March, in Israel by 28 April, and in Iraq by 19 May these countries will meet the criteria for this category of risk and should:
• Enhance surveillance quality to reduce the risk of undetected wild poliovirus transmission, particularly among high risk mobile and vulnerable populations;
• Intensify efforts to ensure vaccination of mobile and cross-border populations, Internally Displaced Persons, refugees and other vulnerable groups;
• Enhance regional cooperation and cross border coordination to ensure prompt detection of wild poliovirus and vaccination of high risk population groups;
• Maintain these measures with documentation of full application of high quality surveillance and vaccination activities for a period of 12 months.
Based on this advice, the reports made by affected States Parties and the currently available information, the Director-General accepted the Committee’s assessment and on 27 February decided to extend the declaration of the international spread of wild poliovirus a Public Health Emergency of International Concern (PHEIC). The Director-General endorsed the Committee’s recommendations for ‘States currently exporting wild polioviruses’, for ‘States infected with wild poliovirus but not currently exporting’ and for ‘States no longer infected by wild poliovirus, but remain vulnerable to international spread‘ and extended them as Temporary Recommendations under the IHR (2005) to reduce the international spread of wild poliovirus, effective 27 February 2015. The Director-General thanked the Committee Members and Advisors for their advice and requested their reassessment of this situation within the next 3 months, particularly the Committee’s advice whether the Temporary Recommendations should continue beyond the World Health Assembly in 2015 or Standing Recommendations would be required to more effectively reduce the risk of international spread of polio at that time.
1 The committee applied the following criteria to assess the 12 month period for detection of no new exportations and the 12 month period for detection of no new cases or environmental isolates of wild poliovirus:
States no longer exporting (detection of no new wild poliovirus exportation):
- Wild Poliovirus Case: 12 months after the onset date of the first case caused by the most recent exportation PLUS six weeks to account for case detection, investigation, laboratory testing and reporting period.
- Environmental isolation of exported wild poliovirus: 12 months after collection of the first positive environmental sample in the country that received the new exportation PLUS 4 weeks to account for the laboratory testing and reporting period.
States no longer infected (detection of no new wild poliovirus):
- Wild Poliovirus Case: 12 months after the onset date of the most recent case PLUS six weeks to account for case detection, investigation, laboratory testing and reporting period.
- Environmental isolation of wild poliovirus: 12 months after collection of the most recent positive environmental sample PLUS 4 weeks to account for the laboratory testing and reporting period.
